**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility neglected to notify the physician and seek medical treatment after a significant decline in condition for one of three residents (R1) reviewed for neglect in the sample of nine. These failures resulted in R1 significantly declining in condition for two weeks before the facility sought medical treatment and sent R1 to the hospital on 5/10/25 for evaluation where R1 was admitted to the ICU (Intensive Care Unit) and remains in the hospital currently for treatment of Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and Bacterial Pneumonia. These failures resulted in an Immediate Jeopardy. The immediate jeopardy started on 4/29/25 when R1 started declining and the physician wasn't notified and treatment wasn't obtained, resulting in R1 going two weeks without medical treatment and R1 being admitted to the to the ICU and remains in the hospital currently for treatment of Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and Bacterial Pneumonia.' V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 6/3/25 at 3:08 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 5/13/25, prior to the start of the survey and was therefore Past Noncompliance. Findings include: The facility's Acute Change of Condition Policy, dated 1/23/23, documents Purpose: To provide facility guidance when a change of condition occurs with a resident. Policy: This facility shall identify and treat residents with acute change of conditions. Policy Interpretation and Implementation: 2. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. 6. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status, history, current medications and SBAR (Situation, Background, Assessment, and Recommendation) in Point Click Care). 7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response. 8. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. 9. The nurse and physician will discuss and evaluate the situation. a. the physician should request information to clarify the situation. 10. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. 13. The physician and staff will identify relevant resident/patient wishes, including advance directives and POLST (Physician Orders for Life-Sustaining Treatment) orders related to life-sustaining treatments. 14. If it is decided, after sufficient review, that care or observation cannot reasonable be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting. The facility's Abuse Policy, dated 1/9/24, documents Purpose: To provide guidance and Procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse Policy: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Definitions: Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, person care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services. On 5/28/25 at 12:21 PM V4/Director of Rehab stated, (R1) was able to straighten both legs out and he was able to bend both legs by the time he finished physical therapy (2/14/25). (R1) was a little resistant, but with dementia techniques we were able to get him to participate. (R1) was 25% (percent) weight bearing due to his right hip fracture at that time. He could stand up straight but did not know his limitations with weight bearing limitations. On 5/29/25 at 9:22 AM V10/SSD stated, I had tried to contact (V8/R1's Family Member) a week or so prior to the call on 5/8/25 and 5/9/25 regarding (R1's) major decline. I was trying to reach out to (V8) regarding hospice. I left (V8) a message asking if he could call me back. When I finally spoke to (V8) and let him know that (R1) has been getting worse, has lost weight, not eating, and possibly (R1) needing a gastrostomy tube, (V8) would not give me an answer on Hospice and kept telling me he would have to speak to (V16/R1's Family Member). I did let (V8) know how bad (R1) was and told him he didn't have much time to decide about hospice. I did not call (V14/R1's Physician) regarding (R1's) condition and I am not aware if nursing notified (V14) of (R1's) condition. The nursing staff just tell me what to call the families over and they wanted me to consult with (V8) regarding (R1's) decline in condition. On 5/29/25 at 9:44AM V11/CNA (Certified Nursing Assistant) stated around two weeks prior to R1 being sent out to the hospital R1 started not being as active as he normally was. V11 stated, Usually I could talk to (R1) and (R1) would talk back. (R1) started sleeping all the time and wasn't eating as much. I did notice (R1's) urine was darker than usual with a little less output. I believe I reported (R1's) urine color and output to (V12/Licensed Practical Nurse). (R1's) pain was also getting worse prior to being sent out to the hospital. (R1) just started moaning in pain all the time. (R1's) lower legs were bent at the knees and (R1) was unable to straighten them out. (R1) use to be able to straighten his legs. On 5/29/25 at 9:55AM V12/LPN stated, At least a week (maybe two weeks) before (R1) went to hospital (R1) was having a decline in his condition. (R1) stopped eating and wouldn't let us get him out of bed. I don't remember anyone reporting (R1's) urine color or output to me, I don't typically monitor that the CNA's usually do. I was at least (R1's) nurse two to three times a week. I reported to (V10/SSD) about (R1's) decline in condition. I did not notify the doctor however and should have. I did not document on (R1's) decline because I was communicating with (V10) regarding hospice, I should have documented. If we notice a change in condition, we should notify the physician immediately. On 5/29/25 at 10:15 AM V13/LPN stated I went to (V10/SSD) regarding a hospice consult around a week or so prior to (R1) being sent to the local hospital. I noticed (R1) was not eating and was having failure to thrive. I did not notify (V7/Dietitian or V14/R1's Physician) of my concerns with (R1) not eating and should have. Typically, we would fill out an SBAR (Situation, Background, Assessment, and Recommendation) and would send it to the doctor. I just assumed (V14) had already seen (R1) recently. On 5/28/25 at 1:54 PM V6/Hospital Registered Nurse stated I was the admitting nurse when (R1) got admitted to the ICU (Intensive Care Unit) on 5/10/25. (R1) could not straighten his legs, they were incredibly contracted. (R1's) legs were both completely bent at the knees where (R1) could not straighten either leg out. I doubt (R1) will ever be able to walk again. (R1's) mouth and teeth were caked with black sludge that took me ten minutes and 12 different swabs to even try to get it out of his mouth. (R1) had a lack of oral care like no one ever cleaned his mouth. (R1) had a horrible smell, (R1's) private area was excoriated and had an (indwelling urinary catheter) and a lack of it being cleaned. (R1's) groin was very red everywhere. The head of (R1's) penis, from the catheter rubbing and not cared for was actually split. (R1) was in severe pain and all he could do was cry out. It was one of the worst things I have seen, I felt completely horrible for (R1). (R1) had to have been completely neglected for a while. I was able to give him a bath here and treat him without (R1) refusing any care. (R1) remains in the hospital at this time and is still being treated. On 5/29/25 at 11:27 AM V14/R1's Physician stated that the last time he had visited R1 was on 4/8/25. V14 verified he was not made aware of R1 repetitive refusals of eating and drinking his med pass, refusing weekly weights, R1's significant weight loss, or R1's decline. V14 stated, It's not right if the (local hospital) had emptied two liters of urine from (R1's) bladder when (R1) arrived at the hospital. I am not sure what orders the facility had to change the urinary catheter, but if the facility staff would have notified me, I would have referred (R1) to a Urologist to assist in caring for (R1's) urinary catheter. Not changing (R1's) urinary catheter since January 2025 could have contributed to (R1's) infection and being hospitalized . I was not made aware of (R1's) declining condition. I last saw (R1) on 4/8/25 and I do not have any record of the facility notifying me of (R1's) change in condition. I would have sent (R1) right to the hospital and not messed with doing anything in house if the facility would have notified me of his condition. On 5/29/25 at 2:54 PM V7/Dietitian verified the lack of R1 eating and drinking would have led to hypernatremia. On 5/31/25 at 11:36 AM V8/R1's Family Member stated, I would call and speak to (R1) a couple of times a week from the time of (R1's) admission until he was admitted to the hospital. (R1) wasn't all the way cognitively there, but he could hold a conversation. I would call the facility and speak with the nurses, and they would always tell me (R1) was doing good, and that some Nurse Practitioner would see (R1) every Tuesday and monitor his labs, vital signs, and condition. A few days after (R1) being sent to the hospital I received a call from (V10/SSD) suggesting that (R1) receive hospice care due to (R1) not eating, having a significant weight loss, and (R1's) decline. (V10) stated (R1) started to really decline around a few weeks prior to this where he was becoming super weak. I told (V10) I wanted to speak with (V16/R1's Family Member) before making any decisions because (R1) always wanted to be a full code. I was waiting for a call back from (V16) when I then received a call from (V2/Director of Nursing/DON). (V2) told that we really need to get (R1) on hospice. I asked (V2) if (R1) was going to die and (V2) stated Oh no, no, no (R1) is just declining food at this point. I told (V2) I wanted (R1) sent out to the hospital to be evaluated and (V2) told me if they would send (R1) out to the hospital, the hospital would just send him right back because there is nothing the hospital can do. The next day I received a call from (V15/Registered Nurse/RN) that (R1) was lethargic and barely moving so (V15) sent (R1) to the local hospital. (V15) told me she could not take it anymore with (R1's) condition and that her conscious got the best of her, so (V15) decided she needed to send (R1) to the emergency room. The hospital then reached out to me and told me what (R1's) condition was and told me that my dad was severely dehydrated, malnourished, and was neglected. (R1) was in critical condition and they didn't know if he was going to make it. (R1) remains in the hospital as of today still being treated for his medical conditions. On 6/2/25 at 9:59 AM V18/Hospital Physician stated, I was the admitting physician that admitted (R1) to the hospital on 5/10/25. I did (R1's) assessment. (R1) had an indwelling catheter. (R1's) urine looked very, very dirty and had a lot of sediment in the urine. (R1) appeared very dry looking, he was dehydrated, and his oral cavity had tons of sludge like material with crusting in his mouth. (R1) came in with Acute Kidney Injury and his creatine lab was five times over his baseline number of one, implying that (R1) was very dehydrated and had been dehydrated for a while. His creatine lab was 4.94 which indicates someone has been dehydrated for at least more than two days. (R1) appeared very malnourished. (R1) did not get like that in just one day. I felt (R1) should have been hospitalized well before he was sent to us. On 6/2/25 at 11:51 AM V2/Director of Nursing verified R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietician) being notified of R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, R1's decreased consumption of med pass between 5/1/25 through 5/9/25, or R1's nutritional care plan not being revised until 5-8-25. V2 stated, I know I spoke to (V8) on 5/9/25 to go over (R1's) decline again and possibly needing hospice services. (V10/SSD) had called (V8) regarding (R1) possibly needing a gastrostomy tube. (V8) had questions regarding that. (V8) did ask if (R1) needed to be sent out to the hospital and I did tell (V8) that if we did send him out, the hospital probably would not do anything and send him right back. I have no documentation of a physician being notified of (R1's) significant decline in condition from 4/29/25 through 5/10/25. (V14/R1's Physician) should have been notified right away when (R1) started not eating/drinking and started having his significant decline. R1's admission Record, dated 5/28/25, documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Type Two Diabetes Mellitus, Unspecified severe Protein-Calorie Malnutrition, Depression, Poly Osteoarthritis, Chronic Kidney Disease, Obstructive and Reflux Uropathy, Celiac Disease, and Hypertension. R1's Order Summary Report, dated 5/28/25, documents R1 is a full code, has an indwelling urinary catheter, and an order for weekly weights. R1's MDS (Minimum Data Set) Assessment, dated 1/17/25, documents R1 had no behaviors. R1's MDS Assessment, dated 4/18/25, documents R1 had other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R1's MDS Assessments, dated 1/17/25 and 4/18/25, did not document R1 had rejected cares, had a weight loss, or had any upper or lower impairments. R1's MDS Assessment, dated 5/10/25, documents R1 rejected cares and had a weight loss of five % (percent) or more in the last month or loss of ten % or more in the last six months. R1's Progress Note, dated 3/29/25 and signed by V7/Dietitian documents R1's oral intake is typically 75 to 100% of meals per chart. R1's Nutritional Assessment, dated 4/21/25 and signed by V7/Dietitian documents R1 had no decrease in food intake. R1's Nutritional Risk Assessment, dated 4/29/25 and signed by V7/Dietitian documents R1 had a decrease in oral food intake and eats zero to 75% of meals. R1's Percentage of Meal, dated 4/29/25 through 5/9/25 does not document consistent meal percentages consumed. This forms documents in eleven days R1 consumed 26 to 50% of a meal four times and in eleven days consumed zero to 25% of a meal 15 times. This same form documents in eleven days R1 refused or did not receive a meal three times. R1's Medication Administration Record (MAR) does not document R1's Physician ordered weekly weights were completed from 3/1/25 through 5/10/25. R1's Contracture Risk Assessments, dated 1/1/25 and 4/14/25, document R1 does not have any contractures. These same assessments document R1 was at moderate to severe risk for contractures related to (R1's) diagnoses. R1's Physical Therapy Evaluation and Plan of Treatment, dated 12/23/25 and signed by V17/Physical Therapist, documents Initial Assessment/Current Level of Function and Underlying Impairments: Musculoskeletal System Assessment- Contracture: Functional Limitations Present due to Contracture= No. R1's Physical Therapy Evaluation and Plan of Treatment, dated 1/14/25 and signed by V17/Physical Therapist, documents Initial Assessment/Current Level of Function and Underlying Impairments: Musculoskeletal System Assessment- Contracture: Functional Limitations Present due to Contracture= No. R1's emergency room Summary, dated 5/10/25, documents Musculoskeletal: Comments: Chronically contracture (to the) lower extremities. R1's Behavior Log, dated March 2025, documents R1 refused care twice out of 31 days. R1's Behavior Log, dated April 2025, documents R1 refused care zero times out of 30 days. R1's Behavior Log, dated 5/1/25 through 5/10/25, documents R1 refused care one time out of ten days. R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietitian) being notified of R1's 13.9 % weight loss within six months as of 5/7/25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, and R1's decreased consumption of med pass between 5/1/25 through 5/9/25. R1's Electronic Health Record dated 4/28/25 through 5/10/25 (date of hospitalization) does not include documentation of the facility contacting V14 (R1's Physician) or seeking medical treatment for two weeks once R1 started to have a decrease in appetite, decrease in fluid consumption, increase in weakness, increase in behaviors, and rejecting cares. R1's Electronic Medical Record from admission [DATE]) through R1's discharge to the hospital (5/10/25) does not include evidence of the facility monitoring R1's fluid intake. R1's care plan, dated 5/20/25, documents (R1) is at high risk for urinary tract infection due to catheter use, related to indwelling catheter secondary to diagnosis of Obstructive Uropathy. Goal: (R1) will not experience any decline in mental status related UTI (Urinary Tract Infection) through review date. Interventions: Change catheter and drainage bag per medical doctor orders, empty catheter drainage collection bag every shift, ensure catheter tubing and drainage bag are properly positioned to prevent urinary backflow or contamination, observe for and notify doctor for fever, abdominal tenderness, flank pain, altered mental status, malodor (odor), hematuria (blood in urine) or abnormal urine clarity/consistency, provide catheter irrigation as ordered. This same care plan documents Date Initiated 12/23/2024: (R1) has potential for altered nutrition and hydration related to diagnoses of Type Two Diabetes Mellitus, Dementia, and Cancer. (R1) also limits himself on foods he eats. Gluten free, no red meat or pork. Goal: (R1) will have no signs or symptoms of altered nutrition/hydration through review date. Interventions dated 12/23/24: Monitor weights as ordered and notify Physician of significant Weight Change. R1's Care Plan does not include any revisions or nutritional interventions to address R1's seven pound weight loss within one week on 4/23/25, R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, or R1's decreased consumption of med pass between 5/1/25 through 5/9/25, until 5-8-25 (two days before R1 was admitted to the hospital). On 5-8-25 R1's Nutritional Care Plan documents, 5-8-25 Encourage (R1) to eat all meals in the dining room and chart any refusals. Notify physician of any further increase in oral intake for appropriate intervention. Provide supplements as ordered-refer to MAR. Staff to provide supervision with cueing during mealtimes. R1's Electronic Medical Record, including R1's Progress Notes, Care Plan, and Treatment Administration Records from admission [DATE]) through R1's discharge to the hospital (5/10/25) does not include documentation of R1's urinary catheter being changed. R1's Treatment Administration Record (TAR), dated 4/1/25-4/30/25, does not document R1's urinary output on 4/20, 4/21, 4/24, 4/25, 4/30/25 dayshift amounts and on 4/18, 4/19, 4/23, 4/25 and 4/27/25 evening shift amounts, for a total of ten undocumented urine output recordings in the month of April. R1's TAR, dated 5/1/25-5/31/25, documents a total day shift urine output for R1 on 5/9/25 of 100 milliliters (ml) and a total evening shift urine output of 600 ml (for a total of 700 ml). This TAR does not document R1's urinary output on 5/3/25 dayshift or 5/7/25 evening shift. R1's Progress Note, dated 5/8/25 and signed by V10/SSD, documents (V10) left a message for (V8/R1's family Member) regarding the decline in (R1) and hospice services and new POLST (Physician Orders for Life-Sustaining Treatment). (V10) will follow up. R1's Progress Note, dated 5/9/25 and signed by V10/SSD documents (V10) contacted (V8/R1's Family Member) regarding the decline in (R1). (V10) talked about (R1's) significant weight loss, refusing to eat, and wounds. (V10) explained hospice care or gastrostomy for nutrition. (V8) stated he wanted to talk with (V16/R1's Family Member) first before deciding what to do. (V8) stated that the earliest he would be able to come from out of town would be around 6/1/25. (V10) told (V8) that he needs to make a decision before then. (V8) is going to call back once he speaks with (V16). (V10) will follow up. R1's Progress Note, dated 5/10/25 and signed by V15/RN (Registered Nurse), documents (R1) lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to responds and slurred speech, hypotension noted, Blood Pressure 66 systolic/44 diastolic. Emergency Contact (V16/R1's Family Member) notified and request (R1) be evaluated at Emergency Room. 911 called and Emergency Medical Transport arrived, paramedics placed on IV (Intravenous Fluids) at facility and administered EKG (Electrocardiogram). (R1) in route to (local hospital) at this time. R1's Local Hospital emergency room Note, dated 5/10/25, documents Chief Complaint: Dysuria- Per SNF (skilled nursing facility). (R1) has had a UTI (Urinary Tract Infection) for several days. Had antibiotic and has been completed. (R1) presents with purulent (thick, milky white, yellow, green, or brown discharge) drainage in (R1's) indwelling urinary catheter bag. (R1) alert to self per baseline. HPI (History of Present Illness): (R1) is a [AGE] year-old male presenting to the emergency department for sepsis. (R1) presents to the emergency department by ambulance from nursing home. (R1) has a history of dementia and is alert to self only at baseline. (R1) has a chronic indwelling urinary catheter. Staff reports that (R1) has been treated for UTI for the past several weeks. (R1) has been appearing to have lower abdominal pain. (R1's) catheter isn't having significant urine output but has been noted to have purulent appearing content in urinary catheter bag. (R1) has had blood around his urethra. Review of systems by age: Genitourinary: Positive for dysuria (painful urination). Constitutional: Appearance: (R1) is ill-appearing. Genitourinary: Hypospadias (urethra opening on the posterior of the penile shaft) with blood around urethra. Purulent drainage noted in indwelling bag without significant blood clots or gross blood. Medical Decision Making: (R1) presents to emergency department for concern of Sepsis/Urinary Infection. Nursing home staff reports that (R1) appeared to have lower abdominal discomfort as well as purulent drainage from his chronic indwelling catheter. (R1) had blood around the urethra and had hypospadias noted. Nursing staff replaced (R1's) urinary catheter and had immediate return of two liters (2,000 milliliters) of purulent appearing urine. (R1) has acute renal failure with creatinine greater than four as well as metabolic acidosis with lactic acidosis. (R1's) urinalysis appears significantly concerning for infection. Urine culture was sent. CT (computed tomography) scan showed right-sided hydroureteronephrosis (ureters and kidneys are dilated due to a blockage or obstruction in the urinary tract) without obstructing stone. This same summary notes also documents Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Sepsis, Renal failure, and Cardiac failure. Clinical Impression: 1. Acute Renal Failure, Bladder Obstruction, Complicated UTI, Lactic Acidosis, Metabolic Acidosis, and Bacterial Pneumonia. R1's Hospital Progress Note, dated 5/10/25 and signed by V6/Hospital Registered Nurse documents (R1)'s mouth was caked with crusty sludge like material. It took over ten swabs to perform oral care. Was able to move the sludge from his mouth. (R1) was also noted to have a very crusty indwelling catheter at the penis. (R1) is very thin and dehydrated. Nose is crusty with dried mucous. (R1) has a very unwashed smell about him. This same note documents R1 is contracted and difficult to straighten legs. R1's Hospital Progress Note, dated 5/11/25 and signed by V18/Hospital Physician, documents Physical Exam: General- 78-years-old male poorly built, poorly nourished. Assessment and Plan: Acute Cystitis: (R1's) Urinalysis showed 3+ (three plus) blood, positive leukocyte esterase. Urine looked dirty in foley bag with sediment and cloudy urine. On Intravenous antibiotics currently. Acute Kidney Injury, Dehydration, and Chronic Kidney Disease Stage 2: (R1's) baseline creatine is around 1. Current creatinine is around 3.83 which improved from 4.9 with Intravenous fluids. (R1) severely dehydrated on arrival. (R1's) foley catheter was exchanged upon arrival. Concern with Osteomyelitis Pressure Wound on Right Thigh: Ordered x-ray right femur but (R1) has contracture and is not able to extend the right lower extremity due to ongoing pain. Medical Neglect: (R1) arrived at the hospital showing signs of neglect including severe dehydration with poor oral care, and poor foley catheter care. R1's Hospital History and Physical, dated 5/10/25 and signed by V18/Hospital Physician, documents Physical Exam: General- [AGE] year-old male poorly built, poorly nourished, appears to be in moderate distress. Lungs- rhonchi noted on the right lung. Assessment/Plan: Acute Metabolic Encephalopathy: (R1) is alert, not oriented to time, place or person. Not able to follow commands. Ordered computed tomography of brain as well. Encephalopathy is multifactorial likely from infection, dehydration, hypernatremia. Severe malnutrition: Concern for Refeeding Syndrome: (R1) appeared malnourished. BMI (Body Mass Index) is 18.4. Will consult dietitian once (R1) mentation improves. (R1) is at high risk for refeeding syndrome. Will monitor and replete electrolytes closely. The Immediate Jeopardy that began on 4/29/25 was removed and the deficient practice corrected on 5/13/25 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. R1 still remains in the hospital and will not be returning to the facility (as per family.) 2. On 5/13/25 resident chart reviews were conducted for the following areas: Change in condition, Significant Weight Change, Resident Exhibiting Signs/Symptoms of Dehydration, Hydration Status, and Foley Catheter Status by the clinical team and consulting team. 3. On 5/12/25 V30/Chief Executive Officer in-serviced the facility's interdisciplinary team on the Change in Condition Policy, Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Foley Catheter Policy, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 4. On 5/13/25 V2/Director of Nursing in-serviced all licensed nursing staff on the Change in Condition Policy, Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Foley Catheter Policy, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 5. On 5/13/25 V2/Director of Nursing in-serviced all CNA's on Foley Catheter Policy and Hydration Policy. 6. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date for any changes in condition. 7. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date to ensure they are receiving catheter care, physician orders to change catheters are in place, care plans are updated, and catheter output is documented. 8. On 5/15/25, 5/22/25, 5/29/25, and 6/5/25 the V1/Administrator held a quality assurance meeting where the results from the quality assurance audits were reviewed, and additional interventions were implemented. Completion Date: 5/13/25.