Health inspection·January 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. Residents Affected - Some The facility failed to identify a chnge in condtion for 9 hour for Resident #1, across 2 shifts on 01/14.24. An Immediate Jeopardy (IJ) situation was identified on 01/23/24. While the Immediate Jeopardy was removed on 01/26/24 at 10:36 am, the facility remained out of compliance at a scope of pattern with no actual harm that is immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at increased risk of decline in physical health. Findings include: Record Review of Resident #1's admission record dated 01/19/24 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnose which included of parkinson's disease (chronic degenerative disorder of the central nervous system), dementia (decline in cognitive abilities), hemiplegia (paralysis of one side of the body), benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlargement) and COVID-19 (coronavirus 2019). Record review of the quarterly MDS dated [DATE] reflected Resident #1 had severe cognitive impairment, had no weight loss of 5% or more in the last month or loss of 10% or more in the last six months, and required extensive assistance by one person for eating. Record review of Resident #1's care plans, revised on 11/18/23 reflected Resident #1 was at risk for nutritional deficits and/or dehydration risks related to the disease process, dementia and parkinson's disease. Goals for focus area reflected Resident #1's weights would remain stable within plus or minus four pounds, target date 01/11/24 by the Dietary Manager. Interventions included. -to ask resident or his RP what he liked to eat and drink, initiated 09/19/23. -provide meals, snacks and fluids as ordered, initiated 09/19/23. Page 1 of 23 745000 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 -RD to evaluate and make recommendations PRN, initiated 09/19/23. Level of Harm - Immediate jeopardy to resident health or safety -Weigh monthly and PRN. Notify MD of significant weight changes noted, initiated 09/19/23. Residents Affected - Some -Offer an alternate meal or supplement if he ate less than 50% of food at each meal, revised on 11/18/23. -RD to evaluate and make diet changes recommendations, revised 11/18/23. -adaptive equipment as needed, initiated 09/28/23. -report to any nurse any difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth, shortness of breath, chocking, labored respirations, revised on 11/18/23. Record review of Resident #1's weight log reflected the following. 08/16/23 154.0 pounds standing 09/06/23 151.0 pounds in wheelchair 10/10/23 153.0 pounds in wheelchair 11/06/23 153.0 pounds in wheelchair 11/11/23 126.0 pounds with Hoyer lift 12/12/23 154.0 pounds in wheelchair 01/08/24 152.0 pounds in wheelchair Record review of Resident #1's meal intakes log reflected between 12/21/23 to 01/11/24. -Resident #1 ate 25% or less for eleven meals provided. -Resident #1 ate 51% to 75% for ten meals. -Resident #1 ate 76% to 100% for ten meals provided. - Resident #1 refused meals for five meals provided. Record review of the progress notes dated 01/05/24 at 1:00 pm reflected Resident #1 presented with fever temperature of 103.1 degrees Fahrenheit, signed by the DON. A change in condition was documented. Primary Care Provider responded to administer Tylenol prn. Resident#1's weight was 154 pounds. Record review of the progress notes, dated 01/05/24 reflected the facility nurse practitioner examined Resident #1 due to testing COVID-19 positive, new orders were provided, signed by LVN K. Record review of the progress notes dated 01/07/24 at 1:29 pm reflected resident in no distress, 745000 Page 2 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some consumed 70% of breakfast meal, including a strawberry shake and 80% of lunch meal, no further concerns noted, signed by LVN L. Record review of the progress notes dated 01/08/24 at 11:29 am reflected resident continues isolation precautions, ate 45% of breakfast meal, signed by LVN C. Record review of the progress notes dated 01/09/24 at 10:42 am reflected a change in condition due to altered mental status, with fever 97.9 degrees, decreased or unable to eat or drink, weight was 154 pounds, signed by the DON. Record review of the progress noted dated 01/09/24 at 8:00 pm reflected a chest x-ray done with no radiographic evident of acute disease). No new order, signed by the facility nurse practitioner. Record review of the progress notes dated 01/10/24 at 4:17 pm reflected new orders given by the facility nurse practitioner Dextrose-NaCI Solution 5-0.45% 75 ml/hr due to COVID-19 and decreased oral intake, signed by LVN F. Record review of the progress notes dated 01/10/24 at 5:45 pm reflected the resident had orders for bolus IV fluids but kept removing peripheral line. Notified facility nurse practitioner and received order to discontinue order for Dextrose. Will continue to monitor and notify physician if any complications arise, signed by RN M. Record review of the progress notes dated 01/11/20 at 5:50 pm reflected resident maintained afebrile (not feverish) during nightshift, temperature was 97.7, looks lethargic and refused feedings, signed by LVN N. Record review of the progress notes dated 01/12/24 at 4:27 pm reflected notified nurse practitioner about recent weight of 28 pound weight loss due to no appetite. New order from nurse practitioner to start on Mirtazapine 15 mg by mouth daily, house shake with meals three times a day for 60 days and biweekly weights to be obtained on Monday and Friday. signed by RN I. Record review of the progress notes dated 01/12/24 at 5:07 pm reflected result for COVID-19 was negative. Resident to come off droplet precautions as of 01/13/24, signed by RN I. Record review of the progress notes dated 01/13/24 at 6:15 pm reflected the nurse made aware resident refused medication administration, signed by MA O. Record review of the progress notes dated 01/14/24 at 3:00 am reflected resident noted with what looked like muscle spasms or tremors, appearing slightly agitated, signed by LVN Q. Record review of the progress notes dated 01/14/24 at 5:00 am reflected the resident noted with minor shaking, appearing calm, continues to make eye contact with verbal stimuli but continues to not respond, resident alert times three, signed by LVN Q. Record review of the progress notes dated 01/14/24 at 10:33 am reflected a change of condition for abnormal vital signs, low/high blood pressure, heart rate, respiratory rate and weight change and shortness of breath, signed by the DON. Record review of the progress notes dated 01/14/24 at 12:07 pm reflected resident noted with 745000 Page 3 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some labored breathing, tremors, and excessive sweating. New order to send patient to the hospital for hypoxia (absence of oxygen), post COVID, signed by LVN C. Record review of the progress notes dated 01/14/24 at 9:31 pm reflected the resident admitted to the hospital for severe sepsis, pneumonia, dehydration, and COVID-19 virus infection, signed by RN M. Record review of the hospital records dated 01/15/24 reflected Resident #1 was admitted to the hospital with diagnoses which included severe sepsis (suspected infection with systematic manifestations) severe hypernatremia (high sodium in blood), metabolic encephalopathy (a condition in which brain function is disturbed due to different diseases or toxins in the body), pneumonia (infection in the lungs that causes inflammation, fluid or pus in the air sacs), leukocytosis (a sign of an inflammatory response), COVID-19 virus infection, lactic acidosis (body produces too much lactic acid), UTI, dehydration, AKI and elevated troponin (a protein that appears elevated in the blood only when the heart muscle is damaged). Resident #1 was admitted to the Intensive Care Unit. Record review of the physician orders for Resident #1 dated 01/14/24 reflected the following: -regular diet, mechanical soft ground meat texture, thin/regular consistency, start date 08/24/23. -house shake with meals for recent weight loss for 60 days, start date, 01/12/24. -biweekly weight one a day every 2 weeks on Monday and Friday, start date, 01/15/24. -mirtazapine Oral tablet 15 mg, give one tablet by mouth once a day for appetite stimulant, start date 01/13/24. Record review of the MARs dated January 2024 for Resident #1 reflected the following: -Mirtazapine Oral Tablet 15 mg give one tablet by mouth one time a day for Appetite Stimulant, start date 01/13/24, was administered on 01/13/24 and once on 01/14/24. -House shake with meals for recent weight loss for 60 days, start date 01/12/24, was administered on one meal on 01/12/24, three meals on 01/13/24 and on three meals on 01/14/24. Record review of the Registered Dietitian Nutrition assessment dated [DATE], for Resident #1 reflected resident's weight was 154 pounds, 6.1 height and intake of meals was 51-75% of meals and 25-50% of supplements. Resident #1 was not at risk for malnutrition, signed by the Dietitian. Record review of the Dietary Manager Nutrition Tool for Resident #1 dated 11/18/23, reflected the resident's weight was 153 pounds and was 6.1 height. His appetite had not changed, and he had not experienced any weight loss. Care plan indicated a focus area for Resident #1 was at risk for nutritional deficits and/or dehydration risks r/t disease process/dementia, signed by the Dietary Manager. Record review of the Dietary Manager Nutrition Tool dated 01/11/24 reflected the resident's weight was 152 pounds and resident' height was 61 inches (5 feet .08 inches), had no changes in weight and his appetite had not changed. Focus area in care plan remained the same with no new interventions. Interview on 01/19/24 at 10:45 am with the Dietary Manager revealed she had reviewed the weights for Resident #1 in the clinical chart and they reflected he weighed 152 pounds on 01/11/24. The 745000 Page 4 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Dietary Manager completed her Nutrition Assessment form and completed this form with the data she saw on the clinical record. Later in the morning meeting that was held, she was informed Resident #1 had lost 28 pounds based on the correct weight of 126 poounds that should have been recorded in Resident #1's clinical chart. The Dietary Manager said she did not enter the weights into the resident's clinical because the DON or an assigned nurse would enter the weights provided by the staff who weighed the residents. The Dietary Manager said she had not reviewed the meal intakes documented by the staff that provided Resident #1 his meals because she overlooked that procedure. Interview on 01/19/24 at 4:37 pm with RN A revealed staff followed their guidelines and policies for weight management. Resident #1 was in isolation for COVID-19 from 01/05/24 to 01/12/24. Staff reported to charge nurses Resident #1 had low appetite and was refusing meals. The charge nurses provided Resident #1 house shakes during the dates he was in isolation because the CNAs were reporting to charge nurse Resident #1 was only eating 25% or less or refusing to eat. RN A said no other action was taken to address Resident #1's low appetite or refusal to eat, only house shakes. On 01/11/24, Resident #1 was re-weighted as per the facility nurse practitioner and the weight recorded of 152 pounds on his clinical chart was incorrect, from 152 pounds to 126 pounds. An IDT meeting was held, and new action was taken for the 28 pounds weight loss for Resident #1. Interview on 01/19/24 at 5:20 pm with the DON revealed Resident #1's weight loss had not been identified until an IDT meeting on 01/11/24 when Resident #1's Nurse Practitioner R decided to have Resident #1 be weighed. The Restorative Aide S would weigh all the residents monthly and as needed and would document the monthly weights on a pre-recorded log report with all the resident's names and three or four previously monthly weights. Restorative Aide S would log all the monthly weights into this log and would turn it to the DON. The DON would input the weights or have a designated staff enter the weights into the residents' clinical records. If nurses or Nurse Practitioner R needed a resident to be re-weighed, they would ask the Aide S to weigh the resident and Aide would write the weight on a piece of paper and text the DON with the results and the DON would enter the resident's weight on a piece of paper. The DON said Restorative Aide S gave to her the last monthly weight log to her and she inputted the data into the residents' clinical charts. Only the nurses and herself could input the weights into the residents' clinical charts, in the weights and vital section. The DON said she had not corrected Resident #1's weight on 01/08/24 in his clinical chart because she had forgotten to do so. The correct weight should have been 126 pounds. Interview on 01/19/24 at 5:32 pm with LVN C revealed staff reported to her Resident #1 refused some meals or was ating less than 25% on some meals. The staff were instructed to document in the meal intake for Resident #1 as needed. LVN C said she would provide a house shake to Resident #1 herself or have the CNAs provide the house shake to the resident. Resident #1 started to eat less than 25% or refused some meals during the time he was admitted to the isolation room when he was diagnosed with COVID-19. LVN C said she had not reported the weight loss to the DON or document in her progress notes that Resident #1 was not eating as normal. LVN C said she did not visibly observe Resident #1 had lost the significant weight loss of 28 pounds while he was in isolation from 01/05/24 to 01/13/24. Interview on 01/19/24 at 6:33 am with LVN D revealed Resident #1 had not wanted to eat or take his medications while the resident was in isolation. The resident looked very thin when he entered isolation on 01/05/24. LVN D said she would mix the medications with pudding so the resident would take his medications. LVN D said she did not document in the progress notes staff had reported he was not eating or eating less than 25% of his meals. LVN D said when she came back after being off for a few days, she did not notice Resident #1 had lost a significant amount of weight. 745000 Page 5 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 01/19/24 at 6:39 pm with CNA J revealed she worked the afternoon shift in Resident #1's hall. CNA J said she assisted Resident #1 with his meals before and during his isolation. Resident #1 ate his meals as he was also assisted by his RP. Resident #1 began to eat less or refused to eat while he was in isolation. CNA J said she documented his refusal to eat or less than 25% in his clinical chart and to the charge nurse. Interview on 01/20/24 at 9:51 am with the Dietitian Consultant revealed she would come into the facility once a month or as needed to review the resident's nutrition program. The Dietitian Consultant stated she reviewed Resident #1's weights and nutrition reports. She stated she was at the facility in December 2023 to review Resident #1's nutrition reports and found no evidence of concerns. Staff at the facility including the DON, ADON, charge nurses or Dietary Manager would document in the resident's clinical chart any concerns regarding nutrition, and she had access to the information on each resident's nutrition concerns that would trigger into the computer for each resident in the facility. The Dietitian Consultant said she would not review the charts for concerns until she came into the facility to review monthly weights. The Dietitian Consultant said she came to the facility on [DATE] and when she was verbally informed by the DON Resident #1 had sustained a significant weight loss while he was in isolation due to COVID. She was also informed that Resident #1 was admitted to the hospital on [DATE]. The Dietitian Consultant stated the resident was started on house shakes when he started to eat less or refused to eat. New orders by the Nurse Practitioner were implemented to address Resident #1's weight loss as identified on 01/11/24. The Dietitian Consultant said she had not been notified of Resident #1's weight loss until she came to the facility on [DATE] and found the alert in the resident's clinical chart on computer. Interview on 01/20/254 at 10:09 am with CNA E revealed she worked from 6 am to 2 pm. CNA E said she would assist Resident #1 with his meals before and during when he was placed in isolation. CNA E said Resident #1 started to eat less than 25% or refused to eat his meals. She said she would report this information to the charge nurse, LVN F. LVN F would give her house shake to feed to the resident and sometimes LVN F would help feed the house shake to the resident. CNA E said she documented in the resident's chart the resident refused to eat or ate less than 25%. CNA E said the resident refused to drink fluids while he was in isolation. Interview on 01/20/24 at 10:18 am with CNA G said she noticed Resident #1 was losing weight while he was in isolation. CNA G said she reported to LVN C and LVN F that resident was eating less than 25% and refused meals, not drinking fluids. CNA G said she also documented the resident's meal intakes. LVN C and LVN F would go and see Resident #1 and feed him house shakes or give her the house shakes to feed the resident. Interview on 01/20/24 at 11:30 am with CNA H revealed she weighed the residents in the facility after Restorative Aide S left at beginning of the month. Attempts to contact aide were unsuccessful. CNA H said she was trained on weighing residents by three different methods, the resident standing on scale, seated in a wheelchair and with a Hoyer lift. CNA H said she would weigh the residents monthly or as requested. When weighing the residents monthly, she would get the weight log from the DON and record the resident's weights and return to the DON. If a request was made to weigh the resident as needed, she said she would write the result on a piece of paper, and when done weighing the resident she would text the DON or call her on the phone and report the result of the resident's weight results. Interview on 01/20/24 at 12:05 pm with LVN F revealed staff reported to her Resident #1 refused meals or ate less than 25% while resident was in isolation due COVID. 745000 Page 6 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some LVN F said she provided Resident #1 with house shakes and IV fluids as per the Nurse Practitioner R. LVN F said she did notice Resident #1 was losing weight while he was in isolation. LVN F said she did not document the information into the progress notes or anywhere else. LVN F said she knew Nurse Practitioner R had been to see Resident #1 since 01/02/24. LVN F said the IDT knew Resident #1 was not eating, and they met every morning to discuss concerns with residents. Interview on 01/20/24 at 12:14 pm with RN I revealed she was the Clinical Education and IP and in December 2023 she was assigned to hall 100 as the Nurse Manager. Resident #1 was in hall 100. RN I said she was in charge of managing the floor charge nurses. RN I said she was out on leave from 12/28/23 to 01/09/24. On 01/09/24 she was informed Resident #1 was not eating well and had poor appetite. The charge nurses reported to her, the resident was started on IV fluids as ordered by the Nurse Practitioner R on 01/10/24 and they were also feeding the resident house shakes. RN I said she did not notice Resident #1 had lost significant weight while he was in isolation. On 01/11/24 staff was informed Resident #1 had lost 28 pounds in less than a month while he was in isolation. RN I said she had not documented in the progress notes or any other place in his clinical records resident was not eating or eating less than 25% or drinking fluids. RN I said she had not made any recommendations to address the low appetite. Interview on 01/20/24 at 12:35 pm with Nurse Practitioner R revealed Resident #1 became her resident in the facility on 01/02/24. She would go see the resident daily and check on how he was doing. On 01/05/24 Resident #1 was admitted to isolation due to COVID. Nurse Practitioner R said she reviewed she was informed that Resident #1 was not eating his meals or refusing to eat or drink fluids while he was in isolation. Nurse Practitioner R said she had not noticed Resident #1 had lost significant weight until 01/118/24 during an IDT meeting when she reviewed his weight chart and saw Resident #1 weighed 152 pounds. She did not think the resident had that much weight on him and she asked staff to re-weigh the resident. Nurse Practitioner R said she also wanted to verify his height because his medical records stated he was 6.1 and she did not think this was correct. Nurse Practitioner R said she contacted Resident #1's RP and she verified by the resident's driver license he was 5.6 inches tall, not 6.1. The Nurse Practitioner said she then started Resident #1 on house shakes, biweekly weights and mirtazapine, an appetite stimulant. Interview on 01/20/24 at 2:53 pm with the Dietitian Consultant revealed the Nutrition Tool form used by the facility did not indicate the IBW for the residents. The Dietitian Consultant said based on the resident's height, his IBW was 140 pounds. Interview on 01/20/24 at 4:38 pm with the DON revealed staff reported to charge nurses Resident #1 was not eating or drinking fluids. The charge nurses administered house shakes to address that Resident #1 was not eating as normal. The charge nurses did not document in clinical chart and in progress notes that he was consistently not eating or less than 25% while he was in isolation. During the IDT meeting on 01/11/24, the Nurse Practitioner R asked to re-weigh Resident #1. The weight documented on 01/08/24 was incorrectly made by Restorative Aide S. When the resident was weighed again on 01/11/24, it was discovered Resident #1 weighed 126 pounds. The Restorative Aide S had most likely incorrectly weighed Resident #1 on 01/08/24. Resident #1's weight should have been 126 pounds on 01/08/24. Resident #1 lost 28 pounds from 12/12/24 of 154 pounds to 01/11/24 of 126 pounds. The Nurse Practitioner R provided care to Resident #1 as of 01/02/24 and did not notice a significant weight loss of 28 pounds in less than one month. The charge nurses did not document in clinical chart, in progress notes Resident #1 was consistently refusing to eat or drink fluids. The DON said a review of residents in isolation with COVID at the same time as Resident #1 revealed their weights were correct for the date of 01/08/24 when they were re-weighed on 01/11/24. 745000 Page 7 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 01/22/24 at 10:10 am with Nurse Practitioner R revealed Resident #1's significant weight loss could have a negative effect on Resident #1's overall health status. Interview on 01/24/24 at 9:45 am with the DON revealed she did not have a step-by-step policy and procedure on weighing residents with the three methods, standing, on wheelchair and on Hoyer lift. This was determined to be an Immediate Jeopardy (IJ) on 01/23/24 12:13 pm. The Administrator was notified. The Administrator was provided with IJ template on 01/23/24 at 12:13 pm. The following Plan of Removal submitted by the facility was accepted on 01/24/24. Plan of Removal: Corrective Action: Resident #1 was noted with a change in condition on 01-05-24 related to Covid Dx. Nursing re-assessed resident and notified the NP of resident's status on 01-05-24. New orders were provided. The Charge Nurse assessed Resident #1, on 01-14-24 and notified NP and orders were received to send resident to the hospital for evaluation and treatment. Identification: Residents who are noted with cognitive impairment, dependency on others, and changes in condition with weight loss have the potential to be affected by the alleged deficient practice. Residents will be re-weighed to confirm current weight is accurate. Initiated: 1/23/24 Completed: 1/24/23 Any Residents noted with weight variance and or significant weight loss will be promptly assessed, PCP/NP/Dietitian/ RP will be notified, and interventions initiated. Initiated: 01/23/24 Completed: 1/24/24 Systematic Changes: Regional Nurse conducted re-education with DNS and nursing administration related to the proper process for obtaining, evaluating, and documenting resident weights to include that identified changes in conditions, weight loss and poor appetite or eating are promptly communicated to the NP/PCP/Dietician and RP. Notifications will be via phone and documented in the EHR. Process for collecting weight, obtaining necessary re-weights for any weight loss of more than 3 lbs. to confirm the variance. Process for monitoring PO intake alerts for residents eating less than 25% of meals to offer substitute. Process for IDT collaboration to ensure that all weight variances (loss) are addressed, and the 745000 Page 8 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some plan of care has been reviewed or updated in order to meet the resident's needs. Process for DNS/Designee to review all identified weight loss to ensure that the weights are inputted accurately into the EHR. Also, to ensure that appropriate documentation is in place. Initiated: 1/23/24 Completed: 1/13/24 DNS/Designee conducted re-education with all nursing staff prior to resuming scheduled shift, related to the proper process for obtaining, evaluating, and documenting resident weights to include that identified changes in conditions, weight loss and poor appetite or eating are promptly communicated to the NP/PCP/Dietician and RP. Notifications will be via phone and documented in the EHR. Process for collecting weight, obtaining necessary re-weights for any weight loss of more than 3 lbs. to confirm the variance. Process for monitoring PO intake alerts for residents eating less than 25% of meals to offer substitute. Process for IDT collaboration to ensure that all weight variances (loss) are addressed, and the plan of care has been reviewed or updated in order to meet the resident's needs. Process for DNS/Designee to review all identified weight loss to ensure that the weights are inputted accurately into the EHR. Also, to ensure that appropriate documentation is in place. Initiated: 1/23/24 Completed: 1/25/24 Director of Nursing/Assistant Director of Nursing/Designee conducted skills validations of obtaining accurate weights to those team members identified and assigned weight collection responsibility. Initiated: 1/23/24 Completed: 1/24/24 ADNS/Designee will be assigned the weight system and be responsible for documenting weights in the EHR. Lead CNA/designee will use Weight Entry Report print out form from EHR to document weights and provide to ADNS/designee for data entry into EHR. Weight Variance Report will be printed monthly after weights being entered into EHR to confirm any significant weight losses/percentages. DNS/ADNS/Designee will notify Dietician/NP/PCP of significant weight loss and initiate any interventions ordered. Residents with significant weight loss will continue to be monitored for percentage of daily meal intake and appropriate notifications and nursing/MD interventions initiated. Charge Nurses will review alerts in PCC for residents eating less than 25% of meals and appropriate action taken. Dietary Manager will review alerts in PCC for residents eating less than 25% of meals and appropriate action taken. Ad-Hoc QAPI/QAPI meeting will be conducted with community's Administrator/IDT and Medical Director to review the plan developed related to weight management system and oversight necessary to reach and maintain system compliance. Initiated 1/23/24 745000 Page 9 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 Completed: 1/24/24 Level of Harm - Immediate jeopardy to resident health or safety Monitoring: During morning meeting, ADNS/DNS/Designee will monitor PO intake alerts for residents eating less than 25% of meals and appropriate action taken. Residents Affected - Some ADNS/Designee will conduct random weight rounds 1 x week x 3 months consisting of return demonstration observation of the action of weighing residents. Maintenance Supervisor/Designee will calibrate scales 1x a month and as needed. DNS/Designee will monitor resident's PO intake alerts daily for any resident eating less than 25% to ensure appropriate interventions. DNS/Designee will conduct weekly random audits of resident weights and verify that follow up is complete for any variances. This audit process will take place over the next 3 months. Findings will be reported to the Administrator and reviewed with the QAPI committee identifying system compliance or need for further education and clinical oversight. The state surveyor confirmed the facility's Plan of Removal had been implemneted sufficiently to remove the Immediate Jeopardy that included: Verification: Interview on 01/25/24 at 3:00 pm with the DON revealed all the residents had been re-weighed on 01/23/24. The results of all residents were compared to the weights recorded on 01/08/24 and four residents (Resident # 5, Resident #6, Resident #7, and Resident #8 ) were found to have significant weight variances (loss). The DON said orders from doctors were received, for weekly weights for four weeks, a COC was completed, residents seen by the Dietitian Consultant, PA was called to approved recommendations, RPs were notified, and care plans were updated for the four residents that were found to have lost significant weight loss on 01/23/24. The following staff (from different shifts) were interviewed on 1/25/24 and revealed they were able to verbalize and/or perform procedures and were trained on 01/24/24 regarding proper obtaining, evaluating and documenting weight loss and changes in condition. All staff were aware and verbalized the procedures per the facility's policy and procedures. 1:05 PM - CNA U (6A-2P shift) 1:15 PM - CNA V (6A-2P shift) 1:27 PM - CAN DD (6A-2P shift) 1:35 PM - CNA EE (6A-2P shift) 2:00 PM - CAN FF (2P-10P shift) 2:13 PM - CNA GG (2P-10P shift) 2:22 PM - CNA HH (2P-10P shift) 745000 Page 10 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 2:28 PM - CNA II (10P-6A shift) Level of Harm - Immediate jeopardy to resident health or safety 2:33 PM - CNA JJ(10P-6A shift Residents Affected - Some 3:20 PM - LVN Q (11P-7A shift) 2:48 PM - LVN W (7P-7A shift) 3:32 PM- LVN X (7P-7A shift) 3:40 PM -LVN T (7A-3P shift) 3:56 PM -RN A (Weekend/PRN shift) 4:10 PM -LVN C (7A-3P shift) 4:29 PM -LVN AA (7A-3P shift) 4:40 PM -RN K (7P-7A shift) 4:57 PM - LVN Z (3P-11P shift) Record review of Resident #5 's clinical chart reflected Resident #5 had sustained a weight loss of 21 pounds from 01/08/24 to 01/23/24. Record review of Resident #6's clinical chart reflected Resident #6 had sustained a weight loss of 23 pounds from 01/08/24 to 01/23/24. Record review of Resident #7's clinical chart reflected Resident #7 had sustained a weight loss of 14 pounds from 01/08/24 to 01/23/24. Record review of Resident #8's clinical chart reflected Resident #8 had sustained a weight loss of 18 pounds from 01/08/24 to 01/23/24. Record review of the facility policy titled Nutrition and Weight Measurement dated January 2023, reflected The community ensures that each resident maintains acceptable parameters of nutritional status, bodyweight, and protein levels, unless the resident's clinical condition demonstrates that doing so is not possible. The community should collect a once-a-month weight, unless otherwise specified and the weight will be reviewed to determine the need for appropriate intervention. The following suggested parameters for evaluating significance of unplanned and undesired weight loss during varying time intervals. -1 month-Greater than 5%. -3 months-Greater than 7.5%. -6 months-Greater than 10%. The Administrator was informed the Immediate Jeopardy was removed on 01/26/24 at 10:36 am pm. The 745000 Page 11 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0684 facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 745000 Page 12 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance,unless the resident's clinical condition demonstrated that this was not possible, or resident preferences indicate otherwise for one of nine residents reviewed for nutrition. Residents Affected - Some The facility failed to ensure Resident #1 did not sustain a significant weight loss of 18.18% in a 30-day period. An Immediate Jeopardy (IJ) situation was identified on 01/23/24. While the Immediate Jeopardy was removed on 01/26/24 at 10:36 am, the facility remained out of compliance at a scope of pattern with no actual harm that is immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at increased risk of decline in physical health. Findings include: Record Review of Resident #1's admission record dated 01/19/24 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnose which included of parkinson's disease (chronic degenerative disorder of the central nervous system), dementia (decline in cognitive abilities), hemiplegia (paralysis of one side of the body), benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlargement) and COVID-19 (coronavirus 2019). Record review of the quarterly MDS dated [DATE] reflected Resident #1 had severe cognitive impairment, had no weight loss of 5% or more in the last month or loss of 10% or more in the last six months, and required extensive assistance by one person for eating. Record review of Resident #1's care plans, revised on 11/18/23 reflected Resident #1 was at risk for nutritional deficits and/or dehydration risks related to the disease process, dementia and parkinson's disease. Goals for focus area reflected Resident #1's weights would remain stable within plus or minus four pounds, target date 01/11/24 by the Dietary Manager. Interventions included. -to ask resident or his RP what he liked to eat and drink, initiated 09/19/23. -provide meals, snacks and fluids as ordered, initiated 09/19/23. -RD to evaluate and make recommendations PRN, initiated 09/19/23. -Weigh monthly and PRN. Notify MD of significant weight changes noted, initiated 09/19/23. -RD to evaluate and make diet changes recommendations, revised 11/18/23. -Offer an alternate meal or supplement if he ate less than 50% of food at each meal, revised on 11/18/23. 745000 Page 13 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 -adaptive equipment as needed, initiated 09/28/23. Level of Harm - Immediate jeopardy to resident health or safety -report to any nurse any difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth, shortness of breath, chocking, labored respirations, revised on 11/18/23. Residents Affected - Some Record review of Resident #1's weight log reflected the following. 08/16/23 154.0 pounds standing 09/06/23 151.0 pounds in wheelchair 10/10/23 153.0 pounds in wheelchair 11/06/23 153.0 pounds in wheelchair 11/11/23 126.0 pounds with Hoyer lift 12/12/23 154.0 pounds in wheelchair 01/08/24 152.0 pounds in wheelchair Record review of Resident #1's meal intakes log reflected between 12/21/23 to 01/11/24. -Resident #1 ate 25% or less for eleven meals provided. -Resident #1 ate 51% to 75% for ten meals. -Resident #1 ate 76% to 100% for ten meals provided. - Resident #1 refused meals for five meals provided. Record review of the progress notes dated 01/05/24 at 1:00 pm reflected Resident #1 presented with fever temperature of 103.1 degrees Fahrenheit, signed by the DON. A change in condition was documented. Primary Care Provider responded to administer Tylenol prn. Resident#1's weight was 154 pounds. Record review of the progress notes, dated 01/05/24 reflected the facility nurse practitioner examined Resident #1 due to testing COVID-19 positive, new orders were provided, signed by LVN K. Record review of the progress notes dated 01/07/24 at 1:29 pm reflected resident in no distress, consumed 70% of breakfast meal, including a strawberry shake and 80% of lunch meal, no further concerns noted, signed by LVN L. Record review of the progress notes dated 01/08/24 at 11:29 am reflected resident continues isolation precautions, ate 45% of breakfast meal, signed by LVN C. Record review of the progress notes dated 01/09/24 at 10:42 am reflected a change in condition due to altered mental status, with fever 97.9 degrees, decreased or unable to eat or drink, weight was 154 pounds, signed by the DON. 745000 Page 14 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Record review of the progress noted dated 01/09/24 at 8:00 pm reflected a chest x-ray done with no radiographic evident of acute disease). No new order, signed by the facility nurse practitioner. Record review of the progress notes dated 01/10/24 at 4:17 pm reflected new orders given by the facility nurse practitioner Dextrose-NaCI Solution 5-0.45% 75 ml/hr due to COVID-19 and decreased oral intake, signed by LVN F. Residents Affected - Some Record review of the progress notes dated 01/10/24 at 5:45 pm reflected the resident had orders for bolus IV fluids but kept removing peripheral line. Notified facility nurse practitioner and received order to discontinue order for Dextrose. Will continue to monitor and notify physician if any complications arise, signed by RN M. Record review of the progress notes dated 01/11/20 at 5:50 pm reflected resident maintained afebrile (not feverish) during nightshift, temperature was 97.7, looks lethargic and refused feedings, signed by LVN N. Record review of the progress notes dated 01/12/24 at 4:27 pm reflected notified nurse practitioner about recent weight of 28 pound weight loss due to no appetite. New order from nurse practitioner to start on Mirtazapine 15 mg by mouth daily, house shake with meals three times a day for 60 days and biweekly weights to be obtained on Monday and Friday. signed by RN I. Record review of the progress notes dated 01/12/24 at 5:07 pm reflected result for COVID-19 was negative. Resident to come off droplet precautions as of 01/13/24, signed by RN I. Record review of the progress notes dated 01/13/24 at 6:15 pm reflected the nurse made aware resident refused medication administration, signed by MA O. Record review of the progress notes dated 01/14/24 at 3:00 am reflected resident noted with what looked like muscle spasms or tremors, appearing slightly agitated, signed by LVN Q. Record review of the progress notes dated 01/14/24 at 5:00 am reflected the resident noted with minor shaking, appearing calm, continues to make eye contact with verbal stimuli but continues to not respond, resident alert times three, signed by LVN Q. Record review of the progress notes dated 01/14/24 at 10:33 am reflected a change of condition for abnormal vital signs, low/high blood pressure, heart rate, respiratory rate and weight change and shortness of breath, signed by the DON. Record review of the progress notes dated 01/14/24 at 12:07 pm reflected resident noted with labored breathing, tremors, and excessive sweating. New order to send patient to the hospital for hypoxia (absence of oxygen), post COVID, signed by LVN C. Record review of the progress notes dated 01/14/24 at 9:31 pm reflected the resident admitted to the hospital for severe sepsis, pneumonia, dehydration, and COVID-19 virus infection, signed by RN M. Record review of the hospital records dated 01/15/24 reflected Resident #1 was admitted to the hospital with diagnoses which included severe sepsis (suspected infection with systematic manifestations) severe hypernatremia (high sodium in blood), metabolic encephalopathy (a condition in which brain function is disturbed due to different diseases or toxins in the body), pneumonia (infection in the 745000 Page 15 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety lungs that causes inflammation, fluid or pus in the air sacs), leukocytosis (a sign of an inflammatory response), COVID-19 virus infection, lactic acidosis (body produces too much lactic acid), UTI, dehydration, AKI and elevated troponin (a protein that appears elevated in the blood only when the heart muscle is damaged). Resident #1 was admitted to the Intensive Care Unit. Record review of the physician orders for Resident #1 dated 01/14/24 reflected the following: Residents Affected - Some -regular diet, mechanical soft ground meat texture, thin/regular consistency, start date 08/24/23. -house shake with meals for recent weight loss for 60 days, start date, 01/12/24. -biweekly weight one a day every 2 weeks on Monday and Friday, start date, 01/15/24. -mirtazapine Oral tablet 15 mg, give one tablet by mouth once a day for appetite stimulant, start date 01/13/24. Record review of the MARs dated January 2024 for Resident #1 reflected the following: -Mirtazapine Oral Tablet 15 mg give one tablet by mouth one time a day for Appetite Stimulant, start date 01/13/24, was administered on 01/13/24 and once on 01/14/24. -House shake with meals for recent weight loss for 60 days, start date 01/12/24, was administered on one meal on 01/12/24, three meals on 01/13/24 and on three meals on 01/14/24. Record review of the Registered Dietitian Nutrition assessment dated [DATE], for Resident #1 reflected resident's weight was 154 pounds, 6.1 height and intake of meals was 51-75% of meals and 25-50% of supplements. Resident #1 was not at risk for malnutrition, signed by the Dietitian. Record review of the Dietary Manager Nutrition Tool for Resident #1 dated 11/18/23, reflected the resident's weight was 153 pounds and was 6.1 height. His appetite had not changed, and he had not experienced any weight loss. Care plan indicated a focus area for Resident #1 was at risk for nutritional deficits and/or dehydration risks r/t disease process/dementia, signed by the Dietary Manager. Record review of the Dietary Manager Nutrition Tool dated 01/11/24 reflected the resident's weight was 152 pounds and resident' height was 61 inches (5 feet .08 inches), had no changes in weight and his appetite had not changed. Focus area in care plan remained the same with no new interventions. Interview on 01/19/24 at 10:45 am with the Dietary Manager revealed she had reviewed the weights for Resident #1 in the clinical chart and they reflected he weighed 152 pounds on 01/11/24. The Dietary Manager completed her Nutrition Assessment form and completed this form with the data she saw on the clinical record. Later in the morning meeting that was held, she was informed Resident #1 had lost 28 pounds based on the correct weight of 126 poounds that should have been recorded in Resident #1's clinical chart. The Dietary Manager said she did not enter the weights into the resident's clinical because the DON or an assigned nurse would enter the weights provided by the staff who weighed the residents. The Dietary Manager said she had not reviewed the meal intakes documented by the staff that provided Resident #1 his meals because she overlooked that procedure. Interview on 01/19/24 at 4:37 pm with RN A revealed staff followed their guidelines and policies for weight management. Resident #1 was in isolation for COVID-19 from 01/05/24 to 01/12/24. Staff 745000 Page 16 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some reported to charge nurses Resident #1 had low appetite and was refusing meals. The charge nurses provided Resident #1 house shakes during the dates he was in isolation because the CNAs were reporting to charge nurse Resident #1 was only eating 25% or less or refusing to eat. RN A said no other action was taken to address Resident #1's low appetite or refusal to eat, only house shakes. On 01/11/24, Resident #1 was re-weighted as per the facility nurse practitioner and the weight recorded of 152 pounds on his clinical chart was incorrect, from 152 pounds to 126 pounds. An IDT meeting was held, and new action was taken for the 28 pounds weight loss for Resident #1. Interview on 01/19/24 at 5:20 pm with the DON revealed Resident #1's weight loss had not been identified until an IDT meeting on 01/11/24 when Resident #1's Nurse Practitioner R decided to have Resident #1 be weighed. The Restorative Aide S would weigh all the residents monthly and as needed and would document the monthly weights on a pre-recorded log report with all the resident's names and three or four previously monthly weights. Restorative Aide S would log all the monthly weights into this log and would turn it to the DON. The DON would input the weights or have a designated staff enter the weights into the residents' clinical records. If nurses or Nurse Practitioner R needed a resident to be re-weighed, they would ask the Aide S to weigh the resident and Aide would write the weight on a piece of paper and text the DON with the results and the DON would enter the resident's weight on a piece of paper. The DON said Restorative Aide S gave to her the last monthly weight log to her and she inputted the data into the residents' clinical charts. Only the nurses and herself could input the weights into the residents' clinical charts, in the weights and vital section. The DON said she had not corrected Resident #1's weight on 01/08/24 in his clinical chart because she had forgotten to do so. The correct weight should have been 126 pounds. Interview on 01/19/24 at 5:32 pm with LVN C revealed staff reported to her Resident #1 refused some meals or was ating less than 25% on some meals. The staff were instructed to document in the meal intake for Resident #1 as needed. LVN C said she would provide a house shake to Resident #1 herself or have the CNAs provide the house shake to the resident. Resident #1 started to eat less than 25% or refused some meals during the time he was admitted to the isolation room when he was diagnosed with COVID-19. LVN C said she had not reported the weight loss to the DON or document in her progress notes that Resident #1 was not eating as normal. LVN C said she did not visibly observe Resident #1 had lost the significant weight loss of 28 pounds while he was in isolation from 01/05/24 to 01/13/24. Interview on 01/19/24 at 6:33 am with LVN D revealed Resident #1 had not wanted to eat or take his medications while the resident was in isolation. The resident looked very thin when he entered isolation on 01/05/24. LVN D said she would mix the medications with pudding so the resident would take his medications. LVN D said she did not document in the progress notes staff had reported he was not eating or eating less than 25% of his meals. LVN D said when she came back after being off for a few days, she did not notice Resident #1 had lost a significant amount of weight. Interview on 01/19/24 at 6:39 pm with CNA J revealed she worked the afternoon shift in Resident #1's hall. CNA J said she assisted Resident #1 with his meals before and during his isolation. Resident #1 ate his meals as he was also assisted by his RP. Resident #1 began to eat less or refused to eat while he was in isolation. CNA J said she documented his refusal to eat or less than 25% in his clinical chart and to the charge nurse. Interview on 01/20/24 at 9:51 am with the Dietitian Consultant revealed she would come into the facility once a month or as needed to review the resident's nutrition program. The Dietitian Consultant stated she reviewed Resident #1's weights and nutrition reports. She stated she was at the facility 745000 Page 17 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in December 2023 to review Resident #1's nutrition reports and found no evidence of concerns. Staff at the facility including the DON, ADON, charge nurses or Dietary Manager would document in the resident's clinical chart any concerns regarding nutrition, and she had access to the information on each resident's nutrition concerns that would trigger into the computer for each resident in the facility. The Dietitian Consultant said she would not review the charts for concerns until she came into the facility to review monthly weights. The Dietitian Consultant said she came to the facility on [DATE] and when she was verbally informed by the DON Resident #1 had sustained a significant weight loss while he was in isolation due to COVID. She was also informed that Resident #1 was admitted to the hospital on [DATE]. The Dietitian Consultant stated the resident was started on house shakes when he started to eat less or refused to eat. New orders by the Nurse Practitioner were implemented to address Resident #1's weight loss as identified on 01/11/24. The Dietitian Consultant said she had not been notified of Resident #1's weight loss until she came to the facility on [DATE] and found the alert in the resident's clinical chart on computer. Interview on 01/20/254 at 10:09 am with CNA E revealed she worked from 6 am to 2 pm. CNA E said she would assist Resident #1 with his meals before and during when he was placed in isolation. CNA E said Resident #1 started to eat less than 25% or refused to eat his meals. She said she would report this information to the charge nurse, LVN F. LVN F would give her house shake to feed to the resident and sometimes LVN F would help feed the house shake to the resident. CNA E said she documented in the resident's chart the resident refused to eat or ate less than 25%. CNA E said the resident refused to drink fluids while he was in isolation. Interview on 01/20/24 at 10:18 am with CNA G said she noticed Resident #1 was losing weight while he was in isolation. CNA G said she reported to LVN C and LVN F that resident was eating less than 25% and refused meals, not drinking fluids. CNA G said she also documented the resident's meal intakes. LVN C and LVN F would go and see Resident #1 and feed him house shakes or give her the house shakes to feed the resident. Interview on 01/20/24 at 11:30 am with CNA H revealed she weighed the residents in the facility after Restorative Aide S left at beginning of the month. Attempts to contact aide were unsuccessful. CNA H said she was trained on weighing residents by three different methods, the resident standing on scale, seated in a wheelchair and with a Hoyer lift. CNA H said she would weigh the residents monthly or as requested. When weighing the residents monthly, she would get the weight log from the DON and record the resident's weights and return to the DON. If a request was made to weigh the resident as needed, she said she would write the result on a piece of paper, and when done weighing the resident she would text the DON or call her on the phone and report the result of the resident's weight results. Interview on 01/20/24 at 12:05 pm with LVN F revealed staff reported to her Resident #1 refused meals or ate less than 25% while resident was in isolation due COVID. LVN F said she provided Resident #1 with house shakes and IV fluids as per the Nurse Practitioner R. LVN F said she did notice Resident #1 was losing weight while he was in isolation. LVN F said she did not document the information into the progress notes or anywhere else. LVN F said she knew Nurse Practitioner R had been to see Resident #1 since 01/02/24. LVN F said the IDT knew Resident #1 was not eating, and they met every morning to discuss concerns with residents. Interview on 01/20/24 at 12:14 pm with RN I revealed she was the Clinical Education and IP and in December 2023 she was assigned to hall 100 as the Nurse Manager. Resident #1 was in hall 100. RN I 745000 Page 18 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said she was in charge of managing the floor charge nurses. RN I said she was out on leave from 12/28/23 to 01/09/24. On 01/09/24 she was informed Resident #1 was not eating well and had poor appetite. The charge nurses reported to her, the resident was started on IV fluids as ordered by the Nurse Practitioner R on 01/10/24 and they were also feeding the resident house shakes. RN I said she did not notice Resident #1 had lost significant weight while he was in isolation. On 01/11/24 staff was informed Resident #1 had lost 28 pounds in less than a month while he was in isolation. RN I said she had not documented in the progress notes or any other place in his clinical records resident was not eating or eating less than 25% or drinking fluids. RN I said she had not made any recommendations to address the low appetite. Interview on 01/20/24 at 12:35 pm with Nurse Practitioner R revealed Resident #1 became her resident in the facility on 01/02/24. She would go see the resident daily and check on how he was doing. On 01/05/24 Resident #1 was admitted to isolation due to COVID. Nurse Practitioner R said she reviewed she was informed that Resident #1 was not eating his meals or refusing to eat or drink fluids while he was in isolation. Nurse Practitioner R said she had not noticed Resident #1 had lost significant weight until 01/118/24 during an IDT meeting when she reviewed his weight chart and saw Resident #1 weighed 152 pounds. She did not think the resident had that much weight on him and she asked staff to re-weigh the resident. Nurse Practitioner R said she also wanted to verify his height because his medical records stated he was 6.1 and she did not think this was correct. Nurse Practitioner R said she contacted Resident #1's RP and she verified by the resident's driver license he was 5.6 inches tall, not 6.1. The Nurse Practitioner said she then started Resident #1 on house shakes, biweekly weights and mirtazapine, an appetite stimulant. Interview on 01/20/24 at 2:53 pm with the Dietitian Consultant revealed the Nutrition Tool form used by the facility did not indicate the IBW for the residents. The Dietitian Consultant said based on the resident's height, his IBW was 140 pounds. Interview on 01/20/24 at 4:38 pm with the DON revealed staff reported to charge nurses Resident #1 was not eating or drinking fluids. The charge nurses administered house shakes to address that Resident #1 was not eating as normal. The charge nurses did not document in clinical chart and in progress notes that he was consistently not eating or less than 25% while he was in isolation. During the IDT meeting on 01/11/24, the Nurse Practitioner R asked to re-weigh Resident #1. The weight documented on 01/08/24 was incorrectly made by Restorative Aide S. When the resident was weighed again on 01/11/24, it was discovered Resident #1 weighed 126 pounds. The Restorative Aide S had most likely incorrectly weighed Resident #1 on 01/08/24. Resident #1's weight should have been 126 pounds on 01/08/24. Resident #1 lost 28 pounds from 12/12/24 of 154 pounds to 01/11/24 of 126 pounds. The Nurse Practitioner R provided care to Resident #1 as of 01/02/24 and did not notice a significant weight loss of 28 pounds in less than one month. The charge nurses did not document in clinical chart, in progress notes Resident #1 was consistently refusing to eat or drink fluids. The DON said a review of residents in isolation with COVID at the same time as Resident #1 revealed their weights were correct for the date of 01/08/24 when they were re-weighed on 01/11/24. Interview on 01/22/24 at 10:10 am with Nurse Practitioner R revealed Resident #1's significant weight loss could have a negative effect on Resident #1's overall health status. Interview on 01/24/24 at 9:45 am with the DON revealed she did not have a step-by-step policy and procedure on weighing residents with the three methods, standing, on wheelchair and on Hoyer lift. This was determined to be an Immediate Jeopardy (IJ) on 01/23/24 12:13 pm. The Administrator was 745000 Page 19 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety notified. The Administrator was provided with IJ template on 01/23/24 at 12:13 pm. The following Plan of Removal submitted by the facility was accepted on 01/24/24. Plan of Removal: Corrective Action: Residents Affected - Some Resident#1. was noted with a change in condition on 01-05-24 related to Covid Dx. Nursing re-assessed resident and notified the NP of resident's status on 01-05-24. New orders were provided. The Charge Nurse assessed Resident #1, on 01-14-24 and notified NP and orders were received to send resident to the hospital for evaluation and treatment. Identification: Residents who are noted with cognitive impairment, dependency on others, and changes in condition with weight loss have the potential to be affected by the alleged deficient practice. Residents will be re-weighed to confirm current weight is accurate. Initiated: 1/23/24 Completed: 1/24/23 Any Residents noted with weight variance and or significant weight loss will be promptly assessed, PCP/NP/Dietitian/ RP will be notified, and interventions initiated. Initiated: 01/23/24 Completed: 1/24/24 Systematic Changes: Regional Nurse conducted re-education with DNS and nursing administration related to the proper process for obtaining, evaluating, and documenting resident weights to include that identified changes in conditions, weight loss and poor appetite or eating are promptly communicated to the NP/PCP/Dietician and RP. Notifications will be via phone and documented in the EHR. Process for collecting weight, obtaining necessary re-weights for any weight loss of more than 3 lbs. to confirm the variance. Process for monitoring PO intake alerts for residents eating less than 25% of meals to offer substitute. Process for IDT collaboration to ensure that all weight variances (loss) are addressed, and the plan of care has been reviewed or updated in order to meet the resident's needs. Process for DNS/Designee to review all identified weight loss to ensure that the weights are inputted accurately into the EHR. Also, to ensure that appropriate documentation is in place. Initiated: 1/23/24 Completed: 1/13/24 745000 Page 20 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some DNS/Designee conducted re-education with all nursing staff prior to resuming scheduled shift, related to the proper process for obtaining, evaluating, and documenting resident weights to include that identified changes in conditions, weight loss and poor appetite or eating are promptly communicated to the NP/PCP/Dietician and RP. Notifications will be via phone and documented in the EHR. Process for collecting weight, obtaining necessary re-weights for any weight loss of more than 3 lbs. to confirm the variance. Process for monitoring PO intake alerts for residents eating less than 25% of meals to offer substitute. Process for IDT collaboration to ensure that all weight variances (loss) are addressed, and the plan of care has been reviewed or updated in order to meet the resident's needs. Process for DNS/Designee to review all identified weight loss to ensure that the weights are inputted accurately into the EHR. Also, to ensure that appropriate documentation is in place. Initiated: 1/23/24 Completed: 1/25/24 Director of Nursing/Assistant Director of Nursing/Designee conducted skills validations of obtaining accurate weights to those team members identified and assigned weight collection responsibility. Initiated: 1/23/24 Completed: 1/24/24 ADNS/Designee will be assigned the weight system and be responsible for documenting weights in the EHR. Lead CNA/designee will use Weight Entry Report print out form from EHR to document weights and provide to ADNS/designee for data entry into EHR. Weight Variance Report will be printed monthly after weights being entered into EHR to confirm any significant weight losses/percentages. DNS/ADNS/Designee will notify Dietician/NP/PCP of significant weight loss and initiate any interventions ordered. Residents with significant weight loss will continue to be monitored for percentage of daily meal intake and appropriate notifications and nursing/MD interventions initiated. Charge Nurses will review alerts in PCC for residents eating less than 25% of meals and appropriate action taken. Dietary Manager will review alerts in PCC for residents eating less than 25% of meals and appropriate action taken. Ad-Hoc QAPI/QAPI meeting will be conducted with community's Administrator/IDT and Medical Director to review the plan developed related to weight management system and oversight necessary to reach and maintain system compliance. Initiated 1/23/24 Completed: 1/24/24 Monitoring: During morning meeting, ADNS/DNS/Designee will monitor PO intake alerts for residents eating less than 25% of meals and appropriate action taken. 745000 Page 21 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ADNS/Designee will conduct random weight rounds 1 x week x 3 months consisting of return demonstration observation of the action of weighing residents. Maintenance Supervisor/Designee will calibrate scales 1x a month and as needed. DNS/Designee will monitor resident's PO intake alerts daily for any resident eating less than 25% to ensure appropriate interventions. DNS/Designee will conduct weekly random audits of resident weights and verify that follow up is complete for any variances. This audit process will take place over the next 3 months. Findings will be reported to the Administrator and reviewed with the QAPI committee identifying system compliance or need for further education and clinical oversight. The state surveyor confirmed the facility's Plan of Removal had been implemneted sufficiently to remove the Immediate Jeopardy that included: Verification: Interview on 01/25/24 at 3:00 pm with the DON revealed all the residents had been re-weighed on 01/23/24. The results of all residents were compared to the weights recorded on 01/08/24 and four residents (Resident # 5, Resident #6, Resident #7, and Resident #8 ) were found to have significant weight variances (loss). The DON said orders from doctors were received, for weekly weights for four weeks, a COC was completed, residents seen by the Dietitian Consultant, PA was called to approved recommendations, RPs were notified, and care plans were updated for the four residents that were found to have lost significant weight loss on 01/23/24. The following staff (from different shifts) were interviewed on 1/25/24 and revealed they were able to verbalize and/or perform procedures and were trained on 01/24/24 regarding proper obtaining, evaluating and documenting weight loss and changes in condition. All staff were aware and verbalized the procedures per the facility's policy and procedures. 1:05 PM - CNA U (6A-2P shift) 1:15 PM - CNA V (6A-2P shift) 1:27 PM - CAN DD (6A-2P shift) 1:35 PM - CNA EE (6A-2P shift) 2:00 PM - CAN FF (2P-10P shift) 2:13 PM - CNA GG (2P-10P shift) 2:22 PM - CNA HH (2P-10P shift) 2:28 PM - CNA II (10P-6A shift) 2:33 PM - CNA JJ(10P-6A shift 2:48 PM - LVN W (7P-7A shift) 745000 Page 22 of 23 745000 01/26/2024 Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576

F 0692 3:20 PM - LVN Q (11P-7A shift) Level of Harm - Immediate jeopardy to resident health or safety 3:32 PM- LVN X (7P-7A shift) Residents Affected - Some 3:56 PM -RN A (Weekend/PRN shift) 3:40 PM -LVN T (7A-3P shift) 4:10 PM -LVN C (7A-3P shift) 4:29 PM -LVN AA (7A-3P shift) 4:40 PM -RN K (7P-7A shift) 4:57 PM - LVN Z (3P-11P shift) Record review of Resident #5 's clinical chart reflected Resident #5 had sustained a weight loss of 21 pounds from 01/08/24 to 01/23/24. Record review of Resident #6's clinical chart reflected Resident #6 had sustained a weight loss of 23 pounds from 01/08/24 to 01/23/24. Record review of Resident #7's clinical chart reflected Resident #7 had sustained a weight loss of 14 pounds from 01/08/24 to 01/23/24. Record review of Resident #8's clinical chart reflected Resident #8 had sustained a weight loss of 18 pounds from 01/08/24 to 01/23/24. Record review of the facility policy titled Nutrition and Weight Measurement dated January 2023, reflected The community ensures that each resident maintains acceptable parameters of nutritional status, bodyweight, and protein levels, unless the resident's clinical condition demonstrates that doing so is not possible. The community should collect a once-a-month weight, unless otherwise specified and the weight will be reviewed to determine the need for appropriate intervention. The following suggested parameters for evaluating significance of unplanned and undesired weight loss during varying time intervals. -1 month-Greater than 5%. -3 months-Greater than 7.5%. -6 months-Greater than 10%. The Administrator was informed the Immediate Jeopardy was removed on 01/26/24 at 10:36 am pm. The facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 745000 Page 23 of 23