**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident (R88) at high-nutritional risk (tube feeding/multiple wounds) was appropriately assessed and failed to implement interventions resulting in unidentified severe weight loss (10.6% in one month) for one out of three residents reviewed for high nutritional risk. The Immediate Jeopardy (IJ) started on 3/17/25 when R88, a resident at high nutritional risk due to a tube feeding and multiple wounds, was admitted into the facility, and the facility neglected to ensure R88 was appropriately assessed by a qualified nutritional professional and provided adequate nutrition to prevent a severe weight loss of 10.6% in one month. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/16/25 at 2:42 PM. The IJ was removed on 4/17/25, but noncompliance remains at a Level 2 due to sustained compliance that has not been verified by the State Agency. Findings include: On 4/14/25 at 7:56 AM, R88 was observed alert and lying in bed. R88 said he received pain medication but was still in a little pain. R88 was observed receiving a tube feeding of Promote 1.0 infusing at 55 cc/hour. On 4/15/25 at 9:55 AM, R88 was observed receiving a tube feeding of Promote 1.0 infusing at 55 cc/hour. During an interview on 4/15/25 at 1:05 PM, Licensed Practical Nurse (LPN) O said R88's family provided the nutrition formula, Promote 1.0. At 1:30 PM, R88 refused to be weighed and said it would cause him pain. LPN O said she would administer an as needed pain medication and check back with R88 in an hour to see if he would consent to be weighed. During an interview on 4/15/25 at 1:35 PM, Station 3 Unit Manager, LPN N reported that she put the order in for monthly weights on 4/8/25. During the previous four-week period, weekly weights were supposed to be obtained. LPN N identified two facility attempts to weigh R88. LPN N said R88 refused to be weighed once and once a clean sling (used with a mechanical lift to weigh a resident) was not available. A review of the clinical record did not reveal an effort to resolve R88's refusal to be weighed or an attempt to weigh R88 when a clean sling was available. A review of R88's April 2025 MAR (Medication Administration Record) revealed the administration of one tablet of hydrocodone-acetaminophen 5-325 (pain) at 12:52 PM on 4/15/25. On 4/15/25 at 2:42 PM, R88 allowed facility staff to obtain a weight. R88 weighed 177 lbs. R88 sustained a 10.6% weight loss from the admission weight of 198 lbs. obtained on 3/18/25. During an interview on 4/15/25 at 4:07 PM, CDM K said the facility has recently had a couple of different registered dietitians (RD). The newest RD, (RD J), started on 4/1/25. CDM K added that RD J works remotely on a part-time basis. CDM K said he had not had any direct contact with RD J about facility residents' clinical concerns. CDM K said residents receiving a tube feeding were at high nutritional risk and should be seen by the RD within the first week of their admission. CDM K acknowledged that he completed the Dietary Profile for R88 on 4/5/25. On the Dietary Profile, CDM K calculated R88's daily estimated caloric and protein needs as 2708 calories and 90 grams respectively. When the calories provided from R88's current tube feeding order was calculated at 1200 calories, CDM K stated, He's getting less than half of his caloric needs. CDM K stated if R88 had pressure ulcers, obviously he would need more grams of protein. CDM K acknowledged he did not factor pressure ulcers into the equation when determining R88's estimated daily protein requirement. CDM K said R88 should have been evaluated by an RD. Review of R88's clinical record revealed no progress notes or nutrition assessment had been completed by a RD. CDM K acknowledged that the Dietary Profile indicated that a dietitian referral was not appropriate and that the correct response should have been yes. CDM K said an affirmative answer would have triggered an RD referral. The registered dietitian is qualified to complete a nutrition assessment on such an individual. A review of the Transfer/Discharge Report for R88 revealed an admission date of 3/17/25 and diagnoses that included dysphagia, hemiplegia, and hemiparesis following cerebral infarction, sacral region pressure ulcer - stage 4, right buttock pressure ulcer - stage 3, left buttock pressure ulcer - stage 3, pressure-induced deep tissue damage of right and left ankles, and gastrostomy status (R88 had a tube inserted into the stomach to provide a means of feeding). A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and the presence of one stage-4 pressure ulcer and two unstageable pressure ulcers. An additional review of R88's clinical record documented in part the following: 1. Hospital discharge paperwork documented a body weight of 198 lbs. 10.2 ounces. 2. Facility admission body weight of 198.6 lbs. obtained on 3/18/25. 3. Physician orders: A. Order for nutrition consult dated 3/18/25. B. Enteral Feed Order. One time a day Enteral feeding: enteral feeding formula: Promote 1.0, amount: continuous, rate 20 mL/hr. Change tubing with each bottle change. Mechanism of administration: Pump. Auto Flush water: 250 ml every 4 hours. Mechanism of administration: Pump. Start date 3/18/25. End date: 3/21/25. C. Enteral Feed Order. One time a day Enteral feeding: enteral feeding formula: Promote 1.0, amount: continuous, rate 50 mL/hour. Change tubing with each bottle change. Mechanism of administration: Pump. Auto Flush water: 250 ml every 4 hours. Mechanism of administration: Pump. Start date 3/21/25. D. Juven Packet (nutrition supplement) one time a day for nutrition 2 packs. Start date: 3/19/25. End date 3/21/25. E. Juven Packet. Give 1 packet via PEG (Percutaneous Endoscopic Gastrostomy - a tube inserted into the stomach to provide a means of feeding) tube two times a day for Nutritional Supplement Dissolve in 8 oz of warm water. Start Date 3/21/25. F. Weigh weekly and record times 4 weeks one time a day every Tuesday for weight monitoring for 4 Weeks. Start Date 3/18/25. G. Weigh monthly every night shift starting on the 8th and ending on the 8th every month for weight monitoring. Start Date 4/8/25. 4. Dietary Profile, dated 4/5/25, completed by CDM K documented in part the following: Reason for the assessment: Admission Most recent weight: 198.6 lbs. Current diet order: NPO (nothing by mouth) Current nutrition supplement: Enteral feed Estimated calorie needs: 2708 calories Estimated protein needs: 90 grams Estimated fluid needs 2708 ml Pressure related skin condition: Yes. Additional risk factors: Pressure sore and tube feeding Based on this review, a dietitian referral is appropriate: No 5. eMAR (electronic Medication Administration Record) note of 4/8/25: No sling available waiting for laundry. 6. Care plan. Focus: On current diet order - at risk for aspiration. NPO (nothing by mouth). TF (tube feeding) Promote 1.0 formula, cam (sic) at 20 cc/hour to increase q (every) 4 hours until goal rate of 50 cc/hour continuous (around the clock). Initiated and revised on 3/18/25. Interventions: Provide diet as ordered. Registered Dietitian evaluation to make recommendation as needed. An interview was conducted on 4/16/25 at 10:24 AM with Physician L. When Physician L was queried about R88's current tube feeding order, he stated, We have a dietitian on board that makes the recommendations for a resident on a tube feeding. Physician L said that usually the tube feeding is managed by the facility dietitian. Physician L identified the RD as the nutrition expert regarding tube feeding formulas and would go with their recommendation. During an interview on 4/16/25 at 10:46 AM, RD J said she received a message on 4/15/25 indicating that R88 had experienced a weight loss and requested that she complete a nutrition assessment on the resident. RD J said upon admission R88 would be considered at high nutrition risk because he had wounds and was on a tube feeding J said she was unaware of the 3/18/25 order for a nutrition consult because she was not the RD at that time. RD J stated, It would have been good to be notified about R88's pending consult when she started on 4/1/25. RD J said the CDM should have referred the high-risk resident to the RD. RD J said upon admission the standard was to obtain weekly weights for four weeks and if stable, obtain monthly weights thereafter. For residents on a tube feeding weekly weights would help determine if the tube feeding was the right amount. Once the nutrition assessment was completed by the RD, RD J recommended a change in R88's tube feeding order because the current order (of insufficient caloric and protein needs that R88 was on for 28 days) was not meeting his estimated needs. RD J said the facility has contracted her to work (remotely) 40 hours a month. A Dietary Progress Note, completed by RD J dated 4/15/25 at 11:27 PM, revealed in part the following: Weight 177 lbs.; Diet: NPO; Feeding: Osmolite 1.5 70 ml/hour. Supplement: Liquid Protein 30 ml BID (twice a day), Juven 1 packet BID. Skin: Stage 3 pressure injury to right and left outer ankles, stage 4 pressure injury to sacrum (according to) 4-10-25 wound assessment. Nutrition Problem: At risk for malnutrition, increased protein needs and swallowing problem. admitted [DATE]. Current weight shows 21 lb. decrease from admission weight. Estimated kcal needs - 2011 - 2414 kcal. (25 - 30 kcal/kg). Estimated protein needs - 97 - 116 g protein (1.2 - 1.5 g/kg). Recommended feeding change to Osmolite 1.5 as resident had been on a 1.5 calorie formula in the hospital. 70 ml/hour to provide about 2310 kcal., 96.6 g protein. (Based on 22 hour feeding which allows for time off feeding for ADL's [activities of daily living]). Recommended liquid protein 30 ml BID to provide additional 180 kcal. and 36 g protein to enhance wound healing. Requested weekly weights x 4 weeks. On 4/16/25 at approximately 12:00 PM, the NHA indicated that RD M (the RD at the time of R88's admission) was employed by the facility March 1, 2025, to March 31, 2025. During an interview on 4/17/25 at 12:48 PM, the DON said the facility was unable to provide Pivot 1.5 (the tube feeding formula R88 received while hospitalized ). The hospital registered dietitian (RD S) said it was okay to put R88 on Promote 1.0. The DON provided a communication between the hospital RD and the hospital case manager dated 3/17/25 that documented in part the following: - Contacted by CM, (Case Manager P), regarding discharge TF (tube feeding) order for patient as accepting facility unable to provide Pivot 1.5. Changing TF order to Promote 1.0 at goal rate 75 mL/hour + 2 packets Juven BID which accepting facility will be able to provide. - Orders placed this encounter: Enteral feed/tube feeding: Promote 1.0; Route: PEG; Administration: Continuous; Goal rate: 75 mL/hour around the clock + 2 packs Juven. The DON added that the facility's RD was expected to assess residents on a tube feeding upon admission and that was not done. The DON indicated the facility was aware that R88 could receive Promote 1.0 but was unaware that the infusion rate had changed. On 4/17/25 at 1:18 PM, the NHA and DON were asked if they had anything else to provide or add regarding this concern, and they said they did not. A review of a document titled, Certified Dietary Manager, undated but provided by the facility during the survey, revealed in part the following job description: - Coordinates all clinical/dietetic service under the limited direction of the Registered Dietician. - Performs and charts the initial resident assessment and quarterly summary. - Responsible for coordination and participation in the Nutrition at Risk or Wound Weight meeting. A review of a document titled, Consultant Dietitian Responsibilities, undated but provided by the facility during the survey revealed in part the following: - Assess the nutrition needs of clients who have been referred due to having a medical condition which puts them at nutritional risk. - Complete in-depth nutrition assessments for those residents at high risk including significant weight loss, tube feed residents, hemodialysis and pressure injuries. - Based on analysis of the data and input from the healthcare team, the dietitian will exercise clinical judgement to determine the best nutrition approach by recommending interventions appropriate to the individual. A review of a facility document titled, Nutrition Assessment, dated 2021, documented in part the following: - The consultant dietitian provides in-depth nutrition assessments for clients whose medical condition(s) may place them at nutrition risk. - The healthcare community and the dietitian work together in determining level of nutritional risk. Medical conditions which may place clients at nutrition risk includes: Enteral or parenteral tube feeding; Pressure injury; Dialysis; Significant weight loss. A review of the facility document that provides guidelines for weight monitoring, dated June 2021, revealed in part the following: All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. The Immediate Jeopardy that began on 3/17/25 was removed on 4/17/25 when the facility took the following actions to remove the immediacy. The IJ was removed on 4/17/25 based on the on-site verification of the facility's actions to remove the immediacy: 1. R88 was reviewed by the RD (Registered Dietitian) on 4/15/25 and new orders were initiated. Nutritional Assessment was performed on R88. Interventions were implemented including weekly weights and liquid protein. The facility implemented a process for notification of the RD when high nutritional risk residents (residents with tube feeding and multiple wounds) are admitted to the facility by the nurses and education began on 4/16/25. The facility assessment was updated. 2. Education was provided immediately to nursing staff regarding notification of high nutritional risk residents (residents with tube feeding and multiple wounds) upon admission. 3. Education was provided to CDM (Certified Dietary Manager) to make a referral to the RD for any high nutritional risk resident (residents with tube feeding and multiple wounds) upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00135751 Based on observation, interview, and record review, the facility failed to implement interventions to ensure exit door alarms were properly functioning resulting in an immediate jeopardy when one cognitively impaired resident (R101) eloped from the facility unbeknownst to staff and without the exit door alarm sounding on 4/2/23 at approximately 10:40 AM. A visitor alerted facility staff that a resident had exited the facility. Staff observed R101 in his wheelchair on the sidewalk between the facility and the parking lot and returned R101 to the facility without incident. This deficient practice resulted in the likelihood of serious injury or death when R101 eloped from the facility's exit door without a coat that faced toward a two-lane, 45 mph road and the temperature was 42 F (Fahrenheit) degrees. The Immediate Jeopardy started on 3/23/23 when the facility became aware the exit door alarm system was not functioning properly and failed to implement interventions to provide a safe functional environment for the 33 additional residents that were identified as being at risk for elopement. Findings include: The State Agency received a Facility Reported Incident (FRI) dated 4/2/23 that R101 had self-propelled himself through the exit door of the facility and was returned to the facility without injury by staff. The Facility's Investigation Report (IR) dated 4/10/23 indicated R101 was assessed to have severe cognitive impairment and be 'at risk' for elopement. The IR included a progress note dated 4/2/23 at 11:19 AM by Registered Nurse A that indicated R101 went outside through the exit door next to his room, on Station 1 South (S1S) Door and the door alarm system did not go off. Staff brought guest (R101) back into the facility, writer checked alarm, key alarm on. On 4/19/23 at approximately 10:00 AM, during an interview, RN A described what occurred when R101 eloped from the facility, On 4/2/23 at approximately 10:30 AM, a visitor told CNA (certified nurse assistant) B that she felt a rush of cold air and thought that Station 1 South (S1S) exit door had been opened and no alarm went off. CNA B went outside the S1S exit door and found R101 in his wheelchair down the sidewalk about 25 feet from the facility. When I looked at the key alarm it was in the 'off' position, so I turned it back to the 'on' position. RN A could not say when or who had turned the key alarm system off and stated, We do not regularly check to see if the alarm system is on. On 4/19/23 at approximately 10:20 AM observation of the S1S door revealed two different alarm systems in place; 1) a 'badge-reader' alarm system that required a card to be swiped down the reader (like swiping a credit card) to disengage the alarm system which was located on the door jam and 2) a 'key' alarm system that required a notched key to be manually turned to either the 'on' or 'off' position at a switch plate which was located on the wall next to the door. RN A said, the badge-reader alarm system doesn't work. It hasn't been reliable for a while. It works on some of the doors and sometimes it doesn't, but it hasn't worked on the Station 1 doors for a long time. We use the key alarm for this door. When R101 eloped, I noticed the notch on the key alarm was in the 'off' position and not engaged. RN A could not say when the key alarm was shut off. We don't periodically check to see if the door alarm is on. It is hard to tell where the notch should be to turn the key alarm 'on' because it's so small (the notch). Observation of key alarm system revealed it was in the 'on' position. RN A demonstrated that the badge reader alarm did not work. A card was swiped down the badge reader and the green light did not change. RN A opened the S1S door, and a buzzer alarm sounded. RN A explained the buzzer sound was the 'key' alarm sounding off and not the 'badge reader' alarm. The 'badge reader' alarm is a beeping sound. The 'key' alarm is a buzzer sound. RN A said the maintenance director was aware of the door alarm system not working correctly. On 4/19/23 at approximately 10:45 AM the Director of Nursing (DON) confirmed that the alarm did not sound when R101 eloped through the S1S exit door. When asked what interventions the facility used to provide a safe environment for residents at risk for elopement the DON said the facility did not use a wander guard system (a bracelet worn by residents that triggers the door alarm to alert facility staff when a resident is near an exit door) and that facility staff relied solely on the facility's exit door alarm systems to alert staff if an unauthorized person or resident has opened an exit door. The DON confirmed that the facility had an issue with the doors alarm system during the State survey in March 2023. The back door on Station 2 (S2N) had not been working properly at that time but when the security company arrived to repair it, the door was working fine (3/23/23). The DON said after R101 eloped on 4/2/23 all the residents in the facility were assessed for the risk of elopement utilizing the facility's elopement risk assessment tool. Thirty-three residents had been identified to be at risk for elopement with 16 residents at 'high risk' for elopement. The DON confirmed that these residents were located throughout the facility and had the potential to access the facility exit doors. When asked if any additional interventions were implemented to ensure the facility provided a safe environment for residents who were at risk for elopement while the exit door alarm system was not fully functioning the DON said, The exit doors alarms were functioning properly. On 4/19/23 at approximately 11:00 AM during an interview with Maintenance Director (MD) G he said that during the State survey inspection the facility became aware the alarm system at the back entrance door (S2N) was not locking correctly and another door (S3N) was not alarming correctly. MD G said, I had the security system company come out to repair it. When the security company arrived, the back exit door (S2N) was locking properly but the S3N door wasn't alarming properly. Since then (3/23/23) I have been manually checking the exit doors to ensure they are fully closed and locked, and the key alarm is in the 'on' position. I do not actually open the door to check if the alarms work. I don't want to set off the alarm because the badge reader alarm system is still messed up. Sometimes the badge reader will continuously alarm until I reset it at the control panel. The security company said repeatedly resetting the badge reader alarm system at the control panel may be causing the issue. MD G referred to the work order from the security company. According to the security company's work order dated 3/23/23; MD G, called and said a couple of his back doors, one being an emergency door, are not locking even though they are supposed to be badge access only to unlock. There is no alarm going off either The first door he showed me that was non-functional was working properly on my arrival. The second door (S3N) was not sounding the piezo (electric alarm) in the ceiling when opening the door . The staff have been resetting the door alarms by using the reset button on the control panel not by using the card reader. It is suspected that using the reset button may be causing issues with the cards in the panel, and we would need to access the systems software The current system in place is out dated and no longer offers tech support. We wouldn't be able to access the software The customer was presented with a quote to replace the system, but since then the lead of maintenance has changed I recommend getting in touch with our office regarding the quote and to discuss further actions to solve the issue. During interview MD G said he had not received any further instruction or information regarding the facility's plan to repair the exit door alarm system. MD G presented an excel spread sheet labeled Daily Alarm Check initiated on 3/23/23 and said, Since 3/23/23 I have used this sheet to document that I checked all the exit doors. MD G said he put his initials to indicate the date the door checks had been completed. Review of the Daily Alarm Check sheet revealed it was initiated on 3/23/23 and identified seven facility exit doors: Station 1 South (S1S), Station 1 [NAME] (S1W), Station 2 [NAME] (S2W), Station 2 North (S2N), Station 3 North (S3N), Station 3 East (S3E), Golf door (GD). The spread sheet did not identify what the alarm check entailed, only dates and initials. MD G's initials were missing on 3/25/23, 3/26/23, and 4/1/23 (the day prior to R101's elopement). MD G confirmed that he did not check the doors on 3/25/23, 3/26/23, or 4/1/23. On 4/19/23 at approximately 11:15 AM with MD G the Station 2 exit door had an alarm sounding. Staff were attempting to swipe the badge reader alarm with their badge and the alarm would not shut off. The Station 2-unit manager, RN D said, A visitor opened the exit door and the badge reader isn't working again. I tried a couple different badges, and it won't shut off. Can you reset it? At this time MD G went to a utility closet on Station 2 and used the reset button on the control panel to shut the badge reader alarm off. RN D said, This is the main entrance and exit door for staff and visitors. The badge reader alarm system does not work right sometimes, so we have to reset it. RN D said there were no residents at risk for elopement on her station. On 4/19/23 at approximately 11:25 AM during observation of Station 3 exit doors with MD G and Unit Manager Licensed Practical Nurse (LPN) E the Station 3 East (S3E) door alarm did not function properly. The S3E door was opened. The badge reader alarm did not sound. The key alarm sounded but shut off when the door closed. LPN E said, the alarm is not supposed to automatically shut off when the door closes. The door alarm should continue to sound until a staff member inspects and secures the area, then manually turns the key to reset it. LPN E said that R102 was at high risk for elopement. R102's room was at the end of the Station 3 East Hall with her door next to the S3E exit door. R103 was also identified to be at high risk for elopement and resided near the S3E exit door. According to the facility's Elopement policy revised on 8/2022 the purpose of the policy is to provide guidance on elopement management. Guidelines: 5. Access doors on some units are alarmed so that staff can secure the environment rather than the resident and can intercede when a resident wants to leave the unit or safe area. 6. All facility staff are responsible for responding to a door/elevator alarm immediately. On 4/19/23 at 3:40 PM, the Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) that began on 3/23/23 when the facility failed to implement interventions to prevent elopement when they became aware the facility's exit door alarms were not functioning properly. Although the Immediate Jeopardy was removed on 4/19/23, the facility remained out of compliance at a scope of isolated with severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency. A written plan of removal for the immediate jeopardy was received and verified on 4/20/23. The facility removal plan documented the following: 1. Education will be provided immediately to the licensed nurses to ensure that they are aware of the door alarms being able to be turned off and that they should be turned on in order for the alarm to sound when opened. If they find a nonfunctioning alarm- they need to notify their supervisor- and will assign staff to monitor door to ensure resident safety and no resident exits facility from that door. 2. No licensed nurses will be allowed to work in the facility until completing the necessary education. 3. Maintenance educated on door alarm checks 4. Staff to monitor door exit by room [ROOM NUMBER]- to ensure resident safety and ensure no residents exits the facility from that door until replacement alarm is installed-expected to be installed on 4/21/23 1. A QA Tool was developed to ensure door alarms are alarming when door is opened and remains alarming until disarmed by staff. 2. Daily QA will continue until the door alarm is replaced to the exit door by room [ROOM NUMBER] 3. Once door alarm is replaced to the exit door by room [ROOM NUMBER], The QA tool will be completed 4x/weekly for the next 30 days to ensure compliance, this will continue to be completed until QAPI has identified facility remains in continued compliance X 4 weeks. 4. The QA Tool will be presented to QAPI and will be continued to be reviewed for on-going compliance and for any further recommendations and or resolutions.