**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy and procedure reviews and interviews, the facility failed to ensure Resident #9, who was identified as nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring of nutritional status, physician notification of diet changes and discharge from hospice services, and implementation of nutritional interventions to prevent weight loss and honor the resident's right for food preferences. This resulted in Immediate Jeopardy and serious life-threatening harm beginning on 08/01/23 related to malnutrition/weight loss for Resident #9, who experienced a 9.47 percent weight loss in three months from 07/25/23 (92.9 pounds) to 10/31/23 (84.1 pounds), and a 12.91 percent weight loss in five months from 01/16/24 (85.2 pounds) to 06/02/24 (74.2 pounds) with a total weight loss of 22.38 percent of her body weight (a 19.8 pound weight loss) and a severely low body-mass index of 13.6 due to the facility's failure to address the resident's refusal to consume pureed foods, obtain hospice services/offer in-house palliative care or order comfort foods, negatively impacting the resident's psychosocial well-being due to not being able to participate in food related activities and evidence of continued weight loss. The resident was identified and/or observed during the survey to request money to obtain food from the facility vending machine and obtain food of regular consistency on her own to consume indicating she was hungry. This affected one resident (#9) of three residents reviewed for weight loss. The facility census was 77. On 06/27/24 at 5:18 P.M., the Administrator, Regional Director of Operations (RDO) and Regional Nurse were notified Immediate Jeopardy began on 08/01/23 when Resident #9's orders were changed from a regular diet with regular textures to regular diet with pureed textures which the resident refused to accept. Prior to and following this change in diet order the resident sustained a 9.47 percent (%) /8.8-pound weight loss in three months and continued to progressively lose weight, with another significant weight loss of 12.91% over five months resulting in admission to Hospice services on 03/22/24 with an admitting diagnosis of severe protein calorie malnutrition. On 03/24/24, hospice services and comfort foods were discontinued related to a clerical error which the facility failed to notify Registered Dietician (RD) #352, Certified Nurse Practitioner (CNP) #502, physician, or Resident #9's legal guardian of. The facility failed to follow-up with hospice and the resident's guardian or offer in-house palliative care and comfort foods until hospice services could be re-established. Additionally, the RD was not familiar with the facility policy related to comfort foods. The Immediate Jeopardy was removed on 06/27/24 when the facility implemented the following corrective actions: • On 06/27/24 at 5:45 P.M., the RDO and Regional Director of Clinical Services (RDCS) educated the facility Administrator on the Weight Assessment Interdisciplinary Interventions policy and Resident Dietary Preferences. • On 06/27/24 at 6:00 P.M., an emergency Quality Assurance Performance Improvement (QAPI) meeting was held with department heads including Dietary Manager #150, Unit Managers #440 and #330, Human Resource Director #200, Social Service Assistant #123, MDS Coordinator #101, Business Office Manager #108, Director of nursing (DON) and Medical Director (MD) #115 via telephone to discuss notification of Immediate Jeopardy and initiation of abatement plan for corrective action. • On 06/27/24 at 6:00 P.M., Transitions Hospice' Regional Care Coordinator #500 had communications with Resident #9 and her guardian to sign new consents to enter hospice care. • On 06/27/24 at 6:23 P.M., the facility Administrator contacted Resident #9's guardian to discuss Resident #9's wishes for comfort/pleasure foods due to Resident #9 disliking pureed food. A dietary waiver was emailed to Resident #9's guardian after a telephone conversation to obtain a signed dietary waiver. • On 06/27/24 at 6:31 P.M., the facility Administrator received a signed dietary waiver via email to change Resident #9's recommended diet to comfort foods. • On 06/27/24 at 7:24 P.M., Unit Manager #330 notified facility CNP #502 of new signed waiver for Resident #9 and a new order was received for comfort foods on 06/27/24. • On 06/27/24 at 7:28 P.M., the Administrator provided education to RD #352 regarding updates to the Weight Assessment Interdisciplinary Interventions Policy and Resident Dietary Preferences. • On 06/27/24 at 7:29 P.M., notification was made to Resident #9's guardian by Administrator of Resident #9's new orders. • On 06/27/24 at 8:34 P.M., Resident #9 and her guardian were notified of diet changes. • On 06/27/24 at 8:40 P.M., Unit Manager #440 notified the dietary department of the resident's diet change, and a diet slip was completed for Resident #9 to receive comfort food items. • On 06/27/24 at 8:45 P.M., Administrator developed an action plan for residents who voiced concerns regarding their diet type. The plan included for the interdisciplinary team (IDT) to meet with the resident(s) and guardian(s) to discuss diet concerns and changes per preference the resident may desire. The IDT would notify Speech and Occupational therapies for a need to screen resident to identify any physical conditions that may be causing the resident's refusal of diet. • On 06/27/24 at 9 P.M., Resident #9's care plan was updated by Unit Manager #330 to reflect changes to Resident #9's diet to regular/comfort food. • On 06/27/24 at 9:10 P.M., the facility policy for Weight Assessment and Interdisciplinary Intervention was updated by RDCS. • On 06/27/24 at 10 P.M., education was completed by the Administrator to the facility department heads via phone message per group chat. Employees responded back they received and read education which was documented by the Administrator with the date and time on an employee roster. A total of 103 staff members were notified of the education. Education included the updated policy for Weight Assessment and Interdisciplinary Interventions as well as resident preferences for diet. • On 06/27/24 at 10:30 P.M., the Administrator completed education to the facility staff on updated policy for Weight Assessments and Interdisciplinary Interventions as well as resident preferences for diet. 21 Licensed Practical Nurses (LPN) and six Registered Nurses (RN) were educated at this time. • On 06/27/24 at 10:40 P.M. Administrator, UM #440 and UM #330 assessed 76 residents for weight loss and identified nine additional residents with weight loss (Residents #51, #34, #65, #81, #28, #1, #57, #56 and #40) to ensure their weight loss was not due to psychosocial issues from dislike of their current diets. Interviews with identified residents provided no concerns with their current diets. If a resident was not interviewable, a legal representative was called. Care conference sheets were completed for the identified residents (#1, #9, #28, #34, #40, #51, #56, #57, #65 and #81) and conferences were completed in person or via phone. • On 06/27/24 at 10:50 P.M., care conferences were completed with residents or guardians to review weights, diets and preferences to ensure residents' psychosocial status is maintained. Care conferences were completed by Unit Managers #330 and #440, RDO, and Director of Business Development. • On 06/27/24 at 10:55 P.M., the Administrator implemented a plan to complete weekly audits for all residents for weight loss. This audit would be completed three times per week for two weeks, two times a week for two weeks, then weekly for four weeks. Any new residents with weight loss identified by the RD would be added to the audit list. Residents would be reviewed in QAPI for further need of monitoring or enhancement. Although the Immediate Jeopardy was removed on 06/27/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, unspecified psychosis not due to a substance or known physiological condition, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, adult failure to thrive, insomnia, and diverticulosis of large intestine without perforation or abscess without bleeding. An additional diagnosis of unspecified severe protein-calorie malnutrition was added on 09/13/21. Review of a Dietary Review completed on 06/08/23 by the RD revealed Resident #9 did not have a therapeutic diet order, received house shakes twice daily, had no swallowing concerns, no weight loss, a Body Mass Index (BMI) of less than 19, intakes met 26-75% of estimated needs, and the resident was independent for eating after set-up. Review of a progress note dated 07/02/23 at 5:39 P.M. by Registered Nurse (RN) #223 revealed Resident #9 was going to other resident's rooms using feet to knock at doors trying to get snacks and money from residents and was redirected. Review of Resident #9's weight records revealed the resident's weight on 07/25/23 was 92.9 pounds. Review of a nursing note dated 07/26/23 at 11:42 A.M. by Licensed Practical Nurse (LPN) #227 revealed Resident #9 received a new diet order for mechanical soft foods and thin liquids. Review of a progress note dated 07/26/23 at 11:52 A.M. by Speech Therapist (ST) #321 revealed Resident #9's guardian was informed of Resident #9's new onset of choking and coughing with meals. Updated regarding new diet order with potential to downgrade to pureed if coughing continued. Record review revealed on 08/01/23 the resident's weight was 92.1 lbs. Review of a modified barium swallow study completed on 08/01/23 revealed Resident #9 exhibited intermittent pre-spill into the pharynx during the oral phase and displayed up to a two second swallow delay, intermittent flash penetration with thin liquids, and decreased epiglottic inversion with moderate vallecular residue with reflexive swallows able to clear in the pharyngeal phase. Recommendations included pureed diet, crushed medications or liquids medications, and noted the resident would benefit from speech therapy. Review of Speech Therapy information revealed the following: Review of a Speech Therapy (ST) Evaluation and Treatment plan revealed Resident #9 received services from 07/26/23 through 09/26/23. Review of a ST note dated 08/02/23 by ST #321 revealed Resident #9 stated she will not eat pureed food and declined to participate in therapy on this date. Review of a ST note dated 08/29/23 by ST #321 revealed staff requested allowance of cheese puffs to pureed diet due to very poor intake and weight loss. Review of the ST note dated 09/07/23 by ST #321 revealed staff reported concerns over poor intake of pureed food and risk for weight loss with request for soft food items such as beefaroni. Resident #9 did not like pureed diet. There was no documented evidence facility staff requests for Resident #9 to receive cheese puffs or soft food items such as beefaroni were addressed and these food additions implemented. Review of the physician's orders revealed Resident #9 had a diet order dated 08/01/23 for a regular diet with pureed textures, thin liquids, ice cream with lunch and dinner, and super cereal for breakfast. Review of a dietary note dated 08/08/23 at 12:34 P.M. by RD #352 revealed Resident #9's diet was downgraded to pureed on 08/01/23 and as a result, her by mouth intake had decreased. RD #352 stated Resident #9 received house shake twice daily with good intakes. Recommendations included offer milkshakes once or twice daily. Record review revealed on 08/15/23 the resident's weight was 90.2 lbs. On 09/10/23 the resident's weight was 92 lbs. On 09/19/23 the resident weighed 89.9 lbs. and on 09/26/23 she weighed 88.2 pounds. Review of a dietary note dated 09/26/23 at 9:48 A.M. by RD #352 revealed Resident #9 had an insignificant weight loss of 3.8 pounds, continued with poor appetite with 38% of meals consumed on average. Further weight loss was expected with poor appetite and refusal of supplements. Record review revealed no new interventions or changes made at this time. On 10/02/23 the resident weighed 88.6 lbs. which was noted to be a 4.3 pound weight loss from the weight of 92.9 lbs. on 07/25/23. Review of a quarterly Minimum Data Set (MDS) completed on 10/04/23 revealed Resident #9 had moderate cognitive impairment, no behaviors, required supervision for eating, had no signs of a swallowing disorder, had no significant weight loss, and received a mechanically altered diet. On 10/31/23 the resident weighed 84.1 lbs. On 11/01/23 the resident weighed 84.3 lbs. and on 11/06/23 she weighed 84.5 lbs., indicating a weight loss of 4.63% from 10/02/23 through 11/06/23. Review of a dietary note dated 11/07/23 at 11:16 A.M. by RD #352 revealed Resident #9 had a significant weight loss of 7.5 pounds in 60 days, 7.6 pounds in 90 days, and 8.5 pounds in 120 days, appetite remains poor, and Resident #9 was being noncompliant with diet order. Recommendations included adding ice cream with lunch. Review of a progress note dated 11/08/23 at 1:13 P.M. by LPN #227 revealed Resident #9 received a new order for speech therapy (ST) to evaluate and treat up to three times a week for three weeks for dysphagia management. Resident #9 and guardian aware of new order. Review of ST information revealed the following: Review of ST Evaluation and Treatment revealed Resident #9 received ST from 11/08/23 through 11/29/23. Review of a ST note dated 11/13/23 by ST #321 revealed extensive education was provided to Resident #9 regarding rationale for pureed diet. Review of a ST note dated 11/20/23 by ST #321 revealed Resident #9 was highly agitated and wanted a sandwich. There was no evidence the resident's right to consume foods other than pureed was considered or further pursued at this time. On 11/14/23 the resident weighed 85 lbs., on 11/20/23 she weighed 83 lbs., on 11/27/23 she weighed 84.2 lbs. and on 12/01/23 she weighed 82.4 lbs., indicating a weight loss of 3.06% from 11/08/23 through 12/01/23. Review of a progress note dated 12/06/23 at 1:34 P.M. by LPN #227 revealed Resident #9 had a new order for a dietary consult for low protein. Resident #9 and guardian were aware of new order. Record review revealed on 12/11/23 the resident weighed 84.4 lbs. Review of a nutrition note dated 12/12/23 at 10:19 A.M. by RD #352 revealed Resident #9's BMI was 15.4 and considered to be severely underweight. Resident #9 continued to receive a regular diet with pureed texture, fortified foods, and appetite was varying from 0-100% meals consumed on average. Resident #9 frequently refuses ONS (oral nutritional supplement) to aid in meeting nutritional needs and is a picky eater, does not like pureed diet, occasionally is noncompliant with diet texture. No new recommendations and the note indicated will monitor as needed. Review of a care plan dated 12/12/23 revealed Resident #9 had potential for behavior problems related to dementia, mood disorder, depression, psychosis, calls staff derogatory names, can be both physically and verbally aggressive towards staff, raises her voice at times, will refuse ADL care such as bathing, changing clothes and oral care; taking peers personal belongings for herself; going into rooms of others uninvited; confabulating stories about staff/residents; will attempt to assist other residents with ADLs; 07/31/23 asking other residents for money; 08/15/23 asking other residents for food/etc. since downgrade of her diet; 08/28/23 attempting to get ice herself from ice bucket; and 12/12/23 will often refuse medications. Interventions included redirecting Resident #9 when she asks others for money/snacks and reminding her she cannot ask others for food that is not on her diet. On 12/18/23 the resident weighed 81.8 lbs. which reflected an 11.1 pound weight loss since the weight on 07/25/23 of 92.9 lbs. Review of a nutrition note dated 12/19/23 at 11:09 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 2.6 pounds times one week, appetite was varying and overall poor with 0-50% of meals consumed on average. Record review revealed no new interventions or changes made at that time. On 12/28/23 the resident weighed 82.6 lbs., and on 01/01/24 the resident weighed 81.4 lbs. Review of a nutrition note dated 01/02/24 at 10:34 A.M. by RD #352 revealed Resident #9 triggered for a 7.2 lb. weight loss in 90 days and 11.6 lb. weight loss in 180 days. Resident #9 had a poor appetite with 0-75% of meals consumed on average with two meals consumed a day. No new interventions or recommendations were made at this time. Review of a quarterly MDS completed on 01/03/24 revealed Resident #9 had moderately impaired cognition, no behaviors, required supervision for eating, no signs of a swallowing disorder, had a weight loss of either five percent in the last month or loss of ten percent or more in the last six months and was not on a prescribed weight-loss regimen, and had a mechanically altered diet. Review of a Dietary Review completed on 01/04/24 revealed Resident #9 received a mechanically altered diet, house supplement twice daily, had no swallowing concerns, had a weight loss of five percent or more in the last month or loss of ten percent or more in the last six months without a prescribed weight-loss regimen, had a BMI of less than 19, intakes met 26-75% of needs, and was independent for eating after setup. Record review revealed no new interventions or recommendations were made at this time. Review of a care conference sheet dated 01/04/24 revealed Resident #9, her guardian via phone, Activities Director, Social Services Director, Dietary Manager, and another staff member were present. The sheet revealed Resident #9 was still on a pureed diet and the facility was having trouble getting her to eat, discussed her degenerative tongue issue, reviewed her weight, and the resident's guardian wanted to know if or when hospice should step in and discussed potential of comfort foods. However, no further information was documented in the chart as a follow-up to this care conference. On 01/15/24 the resident weighed 81.3 lbs., and on 01/16/24 the resident weighed 85.2 pounds. Review of a nutrition note dated 01/16/24 at 11:52 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 11.6 pounds in 180 days. The note indicated to continue nutrition plan of care and will follow up as needed. No new interventions or recommendations were implemented at this time. On 02/08/24 the resident weighed 71 lbs., indicating a weight loss of 16.67% from previous weight of 85.2 lbs. on 01/16/24. Review of a nutrition note dated 02/12/24 at 10:14 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 10.4 pounds in 30 days, 13.3 pounds in 90 days, and 21.1 pounds in 180 days. No changes in diet or appetite documented, and RD #352 requested a re-weight to verify weight loss. Record review revealed no new interventions or recommendations were implemented at this time. On 02/20/24 the resident weighed 76.2 lbs. Review of a nutrition note dated 02/27/24 at 10:22 A.M. by RD #352 revealed Resident #9 triggered for a weight gain of 5.2 pounds in 12 days, a weight loss of 9 pounds in 30 days, loss of 8 pounds in 90 days and 15.9 pounds in 180 days, with a question of the accuracy of weight taken on 02/08/24. No new interventions were noted at this time. On 03/04/24 the resident weighed 74.2 lbs., and on 03/11/24 the resident weighed 74.6 lbs. Review of a nutrition note dated 03/12/24 at 10:33 A.M. revealed Resident #9 triggered for a significant weight loss of 1.8 pounds in seven days with a recommendation to increase ice cream to twice daily (with lunch and dinner) and add pudding as a snack. Review of a social services note dated 03/14/24 at 2:05 P.M. by Social Services Assistant (SSA) #123 revealed Resident #9's guardian gave permission to get a hospice consult due to weight loss with no preference for hospice provider. A referral was sent and an additional note at 2:09 P.M. revealed SSA #123 was awaiting a response regarding hospice consult from the hospice provider. Review of a progress note dated 03/15/24 at 11:38 A.M. by previous DON #160 revealed a referral was sent to a different hospice provider and the social worker was to come to facility at noon for intake paperwork. An additional note at 2:39 P.M. revealed hospice representative was present and received paperwork. Review of a progress note dated 03/15/24 at 2:47 P.M. by previous DON #160 revealed Resident #9's weights were reviewed for one, three and six months with a 10% weight loss noted in six months. Review of the progress note revealed no additional information related to the root cause of the weight loss and/or any new interventions to prevent additional weight loss/promote weight gain. Review of a progress note dated 03/18/24 at 3:47 P.M. by previous DON #160 revealed the facility was awaiting paperwork from the hospice provider. Review of a progress note dated 03/22/24 at 7:16 P.M. by RN #389 revealed Resident #9 was admitted to Hospice for severe protein calorie malnutrition, routine level of care, continue DNRCC (do not resuscitate-comfort care), and continue all current medications. The resident's diet plan was for comfort foods and a liberalized diet at this time. Review of written orders dated 03/22/24 revealed Resident #9 admitted to Hospice for severe protein calorie malnutrition/routine level of care. There was no documented evidence Resident #9 ever received a liberalized diet or comfort foods. Review of Resident #9's medical record revealed no documented evidence of a physician order to discontinue hospice services. However, medical record review revealed staff progress notes that identified Hospice services were discontinued on 03/24/24 for Resident #9 with no evidence of notification to the physician, resident or guardian at that time. In addition, there was no evidence of follow-up to resolve why services were discontinued at this time. On 03/25/24 the resident weighed 74.6 lbs. Review of a nutrition note dated 03/26/24 at 2:05 P.M. by RD #352 revealed Resident #9 recently admitted to hospice care, overall goal was for comfort and quality of life with hospice. The note did not include any additional information related to comfort foods/liberalized diet at this time. The note also failed to identify that although hospice services had recently been initiated, they were not being provided as of this time. Review of a Nutritional Assessment Review completed by the RD on 03/26/24 revealed Resident #9's BMI was 13.6 and her goal weight was 110 lbs., she did not have swallowing issues, and her overall goal was for comfort and quality of life with hospice, expect decline in weight, skin integrity, and intakes as disease state progress. Recommendations included discontinuing weekly weights order due to hospice, consider discontinuing monthly weights due to hospice and monitor as needed. Review of a significant change MDS completed on 04/03/24 revealed Resident #9 had moderately impaired cognition, had no behaviors, required set-up help for eating, had no signs of a swallowing condition, had a weight loss of five percent or more in the last month or loss of ten percent or more in the last six months and was not on a prescribed weight-loss regimen, received a mechanically altered diet, and received hospice care. Review of a Dietary Review completed on 04/05/24 revealed Resident #9 received a mechanically altered diet, house supplement twice daily, had no swallowing issues, had a weight loss of five percent or more in the last month or loss of ten percent or more in last six months without a prescribed weight loss regimen, had a BMI of less than 19, intakes met 26-75% of estimated needs, and was independent for eating after set-up. Record review revealed no evidence of the resident receiving any type of comfort foods/liberalized diet at this time. Review of a social services note dated 04/09/24 at 2 P.M. by SSA #123 revealed a quarterly care conference was held with Resident #9, her guardian did not answer, and she would follow up as soon as guardian called back. Review of the care conference sheet revealed no additional information. There was no indication the resident's nutritional status, weight loss, diet order or hospice were discussed. On 04/16/24 the resident weighed 76 lbs. Review of a dietary note dated 04/16/24 at 10:40 A.M. by RD #352 revealed Resident #9 had a significant weight loss of 12.6 pounds in 180 days, she remained with varying appetite. At the time of this note, the RD documented the resident's overall rate of weight loss had slowed with a goal of comfort and quality of life with hospice. Review of a care plan dated 04/18/24 revealed Resident #9 was at risk for fluctuations in activity of daily living (ADL) ability related to current condition, diagnosis of psychosis, dementia, schizophrenia, on noted the resident was on hospice services at this time. The care plan also reflected the resident had communication problems and may need tasks explained. On 05/07/24 the resident weighed 74.8 lbs. Review of a dietary note dated 05/14/24 at 10:24 A.M. by RD #352 revealed no new recommendations regarding weight loss. Review of a dietary care plan dated 06/04/24 revealed Resident #9 was at risk for impaired nutritional status due to diagnoses including chronic obstructive pulmonary disease, anemia, hyperlipidemia, depression, ETOH abuse, hypertension, cataract, malnutrition. Underweight BMI and history of refusal of supplements, refuses to be weighed at times, need for mood-altering medications that may alter weight/appetite, and consistent weight loss in facility. On 03/25/24 the resident had been identified to have a significant weight loss in six months. Interventions included monitor intakes, monitor labs, monitor skin integrity, provide supplements as ordered, provide diet as ordered, provide medications as ordered, if meal was refused offer an alternative from the always available menu. On 06/02/24 the resident weighed 74.2 lbs. Review of a nutrition note on 06/11/24 at 11:38 A.M. by RD #352 revealed Resident #9 had a goal to clarify fortified foods. Fortified foods order discontinued and new order for super potatoes or super cereal once a day. Interview on 06/24/24 at 4:07 P.M. with Resident #9 revealed she refused to eat the facility food because they puree it. During the interview, Resident #9 was observed to have a bag of cool ranch Doritos and was observed to smash the chips into smaller pieces before eating them. No coughing was noted. Observation on 06/25/24 at 2:27 P.M. revealed Resident #9 had a pudding cup for a snack, and as she finished the pudding, she was scraping the sides clean trying to get as much of the pudding as she could from the cup to consume it. Interview on 06/25/24 at 2:31 P.M. with RN #223 revealed Resident #9 received mighty shakes as a supplement. RN #223 stated in January 2024, Resident #9's guardian had begun requesting hospice services, but services were stopped due to a clerical issue with the paperwork. RN #223 could not recall when hospice stopped but stated it had been weeks (since hospice stopped) and she was told Resident #9's guardian had not contacted hospice to resume services. RN #223 stated Resident #9 would eat but because she received pureed food she refuses to eat. RN #223 stated a paper was signed by Resident #9's guardian so that she could eat comfort foods (liberalized diet) and when she was on hospice services, she could eat whatever she wanted. RN #223 stated staff were told residents could only have comfort food if they received hospice services. RN #223 stated Resident #9 did have trouble swallowing, sometimes she was fine and sometimes she would cough. RN #223 stated Resident #9 had not been receiving any type of palliative care in house while awaiting readmission to hospice services. RN #223 stated Resident #9 has always been small but has had a weight loss. RN #223 stated Resident #9 mostly just eats mighty shakes, pudding, Jell-O and some pureed fruits. Interview on 06/26/24 at 4:11 P.M. with Resident #9's guardian revealed she was not aware Resident #9 was not receiving hospice services. The guardian stated there had been challenges with weight loss but stated Resident #9 was supposed to have been taken off the pureed diet and given whatever she wanted to eat. During the interview, Resident #9's guardian revealed she was aware Resident #9 buys food from the vending machine with her monthly allowance. Interview on 06/26/24 at 4:44 P.M. with Hospice Receptionist (HR) #111 revealed Resident #9 admitted to hospice on 03/22/24 and was discharged on 03/24/24. An additional hospice evaluation was completed on 04/01/24 but she was not re-admitted at that time. No additional information was provided. Interview on 06/26/24 at 4:54 P.M. with the Hospice Administrator revealed Resident #9's paperwork had a different last name listed than her medical card, so she was discharged from services. Interview on 06/26/24 at 4:58 P.M. with the Administrator, the RDO, and the ROCS revealed Resident #9 was to receive a house shake twice daily but confirmed even with this supplement she had not regained any of the weight she lost. The ROCS stated she believed Resident #9's weight was stable, and revealed the facility does not have paperwork for a comfort food diet being in place for Resident #9. The ROCS revealed hospice was offered in house but not palliative care because she was not sure Resident #9's primary care provider would offer palliative care. The Administrator revealed the hospice company had attempted to contact Resident #9's guardian about the paperwork and confirmed apart from one attempt at a care conference on 04/09/24, no one from the facility had reached out the Resident #9's guardian regarding comfort care, palliative care, or hospice care as it pertained to the resident's ability to consume foods other than pureed foods which the resident was refusing. Interview on 06/26/24 at 6:33 P.M. with the Administrator confirmed Resident #9's care conference notes, nursing progress notes, dietary notes, care plan listed hospice, and a hospice order entered by RN #389 as noted above. Observation on 06/27/24 at 10:35 A.M. revealed Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview with staff, interview with guardian and review of the facility Wandering, Unsafe Resident policy and procedure, the facility failed to provide adequate supervision and safety interventions to prevent Resident #61 from eloping from the facility secure care unit. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on 03/24/24 between approximately 4:30 P.M. and 5:40 P.M. when Resident #61, who had a legal guardian, had a known history of eloping from skilled nursing facilities (SNFs) and who made verbal threats to elope from the facility exited the facility without staff knowledge and remained missing overnight. On 03/25/24 at 7:00 A.M. Resident #61 contacted his legal (court-appointed) guardian and notified her of his location which was noted to be approximately 50 miles away from the facility across major highways with speeds reaching up to 70 miles per hour (mph). The resident was noted to be admitted to a behavioral health crisis care center due to suicidal ideations at the time his whereabouts were identified. This affected one resident (#61) of three residents reviewed for elopement. The facility census was 86. On 03/27/24 at 1:55 P.M., the Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/24/24 between approximately 4:30 P.M. and 5:40 P.M., when Resident #61 exited the facility without staff knowledge. The resident remained missing overnight and was not located until 03/25/24 when he contacted his legal guardian to report his location. The resident's legal guardian contacted the facility and reported the resident was currently at a behavioral health crisis care center in Columbus. The Immediate Jeopardy was removed on 03/27/24 when the facility implemented the following corrective actions: • On 03/24/24 at 5:45 P.M., State Tested Nursing Assistant (STNA) #171 activated the facility's code [NAME] (missing resident). • On 03/24/24 at 5:58 P.M., Registered Nurse (RN) #172 notified the Administrator in Training (AIT), the resident's legal guardian and the Medical Director (MD). • On 03/24/24 at 6:02 P.M., the facility notified the local law enforcement Resident #61 was missing from the facility's secure care unit. Staff began to search the facility grounds working out to the county roads, corn fields and woods. • On 03/24/24 at 6:30 P.M., local law enforcement arrived at the facility and obtained a description of the resident. • On 03/24/24 at 8:00 P.M., Regional Administrator (RA) #191, DON, Unit Managers (UM) #180 and #176 undated elopement assessments for all residents based on their elopement review and Brief Interview for Mental Status (BIMS). • On 03/24/24 at 12:00 A.M., Regional Director of Clinical Services (RDCS) #195, AIT and DON completed education to all staff regarding the facility elopement policy and procedure. • On 03/25/24 at 7:45 A.M., UM #180 received an email from Resident #61's guardian alerting the facility Resident #61 was found and was safe at a behavioral health crisis care center. • On 03/25/24 at 12:00 P.M., Regional Maintenance Director (RMD) #194 changed the door security system codes to all doors. RA #191, AIT, educated all department heads, Dietary Manager (DM) #145, Human Resources (HR) #190, Admissions Coordinator (AC) #107, UM #176 and #180, Minimum Data Set Coordinator (MDSC) #119, Activities Director (AD)/Business Office Manager (BOM) #119, Social Services Designee (SSD) #169 and Marketing Director #189 regarding door code changes and assuring the code is covered when entering the code into the door security system when exiting the facility. All department managers would then educate their respective departments. • On 03/25/24 at 12:30 P.M., the AIT and DON spoke with Resident #61's guardian who revealed the resident was currently at a behavioral health crisis center and planned to be transferred to a different behavioral health setting housed in the same building due to Resident #61 exhibiting suicidal ideations. The guardian would follow up with facility when more information was available. • On 03/25/24 at 12:45 P.M., RA #191 called the behavioral health crisis center to obtain an update on Resident #61; however, the center would not release any information to the facility due to court appointed guardian in place. • On 03/25/24, RMD #194 installed cameras above all exit doors on the secure care unit. • On 03/25/24 at 3:00 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held with RA #191, Regional Director of Clinical Services (RDCS) #197, DON, UM #176, #180, AIT and Medical Director (MD) to discuss Resident #61's eloping from the facility, changing security system codes to the doors, BIMS and elopement review on all residents, how Resident #61 was able to elope from the facility, education to complete with staff, audits for facility and root cause analysis. • On 03/25/24 at 3:15 P.M., AIT/designee began to audit for safe entry and exit of doors. The audits would continue five times per week for four weeks. • On 03/27/24 at 3:00 P.M., RA #191, RDCS, #197, educated the following department heads Dietary Manager (DM) #145, Human Resources (HR) #190, Admissions Coordinator (AC) #107, UM #176 and #180, Minimum Data Set Coordinator (MDSC) #119, Activities Director (AD)/Business Office Manager (BOM) #119, Social Services Designee (SSD) #169 and Marketing Director #189 regarding what to do if they hear a resident state they want to leave the facility. The staff would notify the nurse on duty so that the nurse may review resident cognition status (BIMS score) to identify if resident had a BIMS score of 12 or below and/or if the resident had a legal guardian. If the BIMS was noted to be 12 or below and/or the resident had a guardian, the resident would have increased safety measures implemented such as 15-minute checks, 30-minute checks, 1 on 1 supervision, psych eval, etc. The DON/Admin, Guardian and MD would be notified of resident statements and of plan to increase resident safety. • On 03/27/24 at 3:55 P.M., one resident (#58) was identified and placed on every 15-minute checks. The Medication Administration Record (MAR) and care plan was updated. • The facility implemented a plan beginning 03/28/24 for the DON/designee to begin audits for residents who have stated that they want to leave to ensure that interventions had been put into place to increase resident safety. This would be completed five days per week for four weeks then weekly for eight weeks. The results of the audits would be reviewed in QAPI for further need of monitoring or enhancement. Although the Immediate Jeopardy was removed on 03/27/24, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #61 revealed an initial admission date of 03/08/24 with admitting diagnoses including traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, nontraumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), diabetes mellitus, bipolar disorder, cerebral infarction, gastro-esophageal reflux disease (GERD), major depressive disorder, post-traumatic stress disorder, hypertension, seizures, anxiety disorder, atrial fibrillation, anterior displaced fracture of sternal end of clavicle, conversion disorder with motor symptom of deficit, mood disorder, fracture of second thoracic vertebra, multiple fractures of ribs, right side, psychoactive substance abuse, cocaine dependence in remission, nicotine dependence in remission, history of traumatic brain injury (TBI) and alcohol dependence. Record review revealed Resident #61 had a legal (court-appointed) guardian effective 01/24/22 due to incompetency. Review of Resident #61's acute care hospital Discharge summary dated [DATE] revealed the resident was admitted to the hospital on [DATE] following a motor vehicle accident versus pedestrian after the resident had walked away from another skilled nursing facility (SNF) and was living homeless in downtown Columbus. The resident was admitted with diagnoses of subdural hematoma over right frontal and right temporal convexities, right temporal intraparenchymal hemorrhage, right thoracic one transverse process fracture and non-displaced right sphenoid fracture. Review of the physician's orders revealed an order dated 03/08/24 to admit to secure unit. Review of the resident's elopement assessment dated [DATE] (admission) revealed a score of 16 indicating the resident was at high risk for elopement. Review of the resident's physician medication orders revealed the resident had orders dated 03/08/24 Lipitor 40 milligrams (mg) by mouth daily at bedtime, Flector external patch 1.3% with special instructions to apply one patch to the left shoulder topically twice daily for pain, Depakote 500 mg by mouth daily for bipolar disorder, Dulera inhalation 200-5 micrograms (mcg) with the special instructions to inhale two puffs orally twice daily for COPD, Folic Acid 1 mg by mouth daily, Lidocaine external patch 4% with the special instructions to apply to skin topically daily and remove in 12 hours, Miralax 17 grams one scoop by mouth twice daily for constipation, Protonix 40 mg by mouth daily for GERD, Oxycodone 5 mg by mouth every six hours as needed for pain, Senna S 8.6-50 mg by mouth twice daily for constipation, Seroquel 50 mg by mouth daily at bedtime for bipolar disorder, Zoloft 150 mg by mouth daily for major depressive disorder, Sodium Chloride 1000 mg by mouth three times a day, Thiamine 100 mg by mouth daily and Metoprolol 50 mg by mouth daily for hypertension. Review of a plan of care dated 03/11/24 revealed Resident #61 resided on a secured unit related to history of elopement at other facilities. Interventions included encourage to attend activities of interest on the unit as needed, monitor for changes that may reduce the need for secure unit, monitor for exit seeking behavior and document when exit seeking occurs, promote consistent routine and caregivers, provide activities of interest, provide education to family and/or guardian about risks/benefits of secured unit as needed, secure unit orders per physician and supervision is required for attendance to off unit activities. Review of a plan of care dated 03/11/24 revealed Resident #61 was an elopement risk/wanderer related to history of attempts to leave other facilities unattended and impaired safety. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, divert as needed and intervene as appropriate, monitor for fatigue and weight loss, provide activities of interest to deter wandering, and take the resident for a walk inside the building. Review of a Social Service (SS) progress note dated 03/11/24 at 5:06 P.M. revealed a care conference was held with the resident and guardian. The Interdisciplinary Team (IDT) discussed the resident refusing medications. The entry also documented the resident did not want to be at the facility and saying he was going back to Columbus wherever he wants. The guardian verified the resident was admitted for long term care placement at the facility. Review of the electronic Medication Administration Record (eMAR) dated 03/13/24 at 1:41 P.M. revealed Resident #61 had refused all morning medications and breakfast. The resident also stated, I want out of this place, I would rather be on the streets. The nurse educated the resident on the importance of taking medication as ordered. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior section of the MDS assessment revealed the resident rejected care. The assessment indicated the resident required supervision with transfers and ambulation and received scheduled and as needed pain medication. The resident denied pain at the time of the interview for the assessment. Review of the progress note dated 03/20/24 at 5:36 P.M. revealed the resident had constantly called his guardian after returning from an appointment. The resident stated he was leaving tomorrow regardless of what his guardian said. The resident's guardian was informed of the resident's behavior. However, record review revealed no new safety or individualized interventions were implemented at this time to address the resident's desire to leave the facility. Review of a progress note dated 03/24/24 at 6:00 P.M. and authored by the DON revealed she was notified at 6:00 P.M. Resident #61 was not in the facility. A facility wide and facility grounds search was conducted without finding the resident. The Administrator in Training (AIT), DON, guardian and local law enforcement were notified the resident was missing. There were no additional nursing progress notes completed for Resident #61 to document when or where the resident was located, the circumstances of the resident being missing from the facility and/or the resident's condition/status when found. Record review revealed the incident of elopement involving Resident #61 was not reported to the State agency as a facility self-reported incident (SRI) as a potential incident of neglect. On 03/27/24 at 8:15 A.M., interview with the Administrator in Training (AIT) and DON revealed on 03/24/24 Resident #61 eloped from the facility secure care unit between the hours of 4:30 P.M. and 5:40 P.M. The DON revealed she felt the resident knew the secure system code on the door to the courtyard and he put it in and left the facility. The AIT said she felt when Resident #61 went out to smoke, he saw a staff member punch the code into the secure system on the door and was able to remember the code (which allowed him to leave without staff knowledge). During the interview, the AIT verified not permitting the residents residing on the secure care unit to visualize the code was a component of keeping the residents safe. The AIT stated, right' when asked if it was neglectful to not keep the code covered when staff punched the code into the secure system on the door. The AIT revealed she was told a self-reported incident (SRI) was not required because the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 (out of 15). However, the AIT indicated the facility had initiated corrective actions following the incident of elopement involving Resident #61. On 03/27/24 at 9:44 A.M., an interview with Unit Manger (UM) #180 revealed Resident #61's guardian was made aware of he was threatening to leave on 03/23/24. UM #180 revealed she received a phone call on 03/24/24 alerting her Resident #61 was missing from the facility. UM #180 revealed she instructed the staff to call the AIT, DON and the police to file a missing persons report. UM #180 revealed she felt Resident #61 obtained the code to the door secure system watching a staff member enter the code on the keypad. UM #180 revealed the E hallway was the only hallway on the second floor with an exit door to the outside of the facility. UM #180 revealed the door opened into a fenced in courtyard however, the gate used the same code for the secure system keypad and after entering the code, the resident likely was able to walk down the sidewalk. On 03/27/24 at 11:17 A.M., an interview with the Administrator revealed he was notified of Resident #61's elopement on 03/27/24 between 6:03 P.M. to 6:08 P.M. The Administrator said the AIT called him and said the resident eloped from the secure care unit at the facility. The Administrator revealed he assumed based on the resident's cognition he observed a staff member enter the code on the secure system when taking the residents out to smoke. The Administrator revealed the resident's court appointed guardian felt the resident was not safe to reside off the secure care unit. The Administrator revealed the guardian alerted the facility on 03/25/24 the resident called her and reported he was at a psychiatric facility that he had hitchhiked to the Columbus area. On 03/28/24 at 8:52 A.M., during an interview with Registered Nurse (RN) #172, the RN indicated the facility elevator doors were not working properly and were opening randomly allowing residents to potentially enter the elevators and leave the secure care unit. RN #172 revealed staff were supposed to be doing every 15-minute checks on all residents on the secure care unit (due to the elevators not working). RN #172 revealed State Tested Nursing Assistant (STNA) #171 delivered Resident #61's dinner meal at approximately 4:30 P.M. however, STNA #171 failed to visually ensure Resident #61 was in his room and/or bathroom when the meal tray was delivered. RN #172 revealed when STNA #171 returned to remove the meal tray, the resident was not observed in his room and the meal remained untouched. RN #172 revealed STNA #171 searched Resident #61's room and was unable to locate him. STNA #171 then notified RN #172 Resident #61 was missing. RN #172 revealed a facility wide and ground search was conducted; however, Resident #61 was not found. RN #172 revealed she notified the AIT and the DON of Resident #61's elopement. RN #172 revealed she was instructed to call 911 and report Resident #61 as a missing person. RN #172 revealed Resident #61 vocalized he was leaving the facility daily. On 03/28/24 at 9:05 A.M., an interview with Licensed Practical Nurse (LPN) #100 revealed she reported to duty on the secure care unit the morning of 03/24/24 and the elevators were barricaded with the medication carts. LPN #100 revealed for approximately two months the elevator doors were randomly opening so the staff were supposed to be doing every 15-minute checks and keep a staff member in the lounge to watch the elevator doors. LPN #100 revealed on 03/23/24 Resident #61 had removed the window frame in his room trying to escape the secured care unit. LPN #100 revealed Resident #61 was moved from the F hallway to the D hallway (as a result of this incident). LPN #100 revealed she had last seen Resident #61 at 4:00 P.M. when she tried to administer his scheduled medication to him. She revealed at 5:40 P.M. she was made aware by RN #172 Resident #61 was missing. LPN #100 revealed she assisted with the facility search and gave the local law enforcement a statement. LPN #100 revealed she felt Resident #61 obtained the code to the secure system on the exit door and walked away from the facility. LPN #100 revealed Resident #61 threatened to leave the facility daily. On 03/28/24 at 9:27 A.M., an interview with STNA #171 verified she delivered Resident #61 his meal tray on 03/24/24 at approximately 4:30 P.M. STNA #171 revealed she did not see the resident at that time and verified she had not visually ensured Resident #61 was in his room when she delivered his dinner meal. STNA #171 revealed she went to Resident #61's room to pick his meal tray up, the meal was untouched, and Resident #61 was not in his room. STNA #171 revealed she search his room, closet, bathroom and under his bed. STNA #171 revealed she asked STNA #118 if she had seen Resident #61; however, the STNA stated she had not. STNA #171 revealed she reported to RN #172 she was unable to locate Resident #61 and thought he was missing. STNA #171 revealed she then assisted with the facility wide and grounds search for Resident #61 but was unable to locate him. STNA #171 revealed she did give a written statement to local law enforcement. STNA #171 revealed Resident #61 previously was on the F hallway but Resident #61 removed his entire window trying to leave the facility on 03/23/24. STNA #171 revealed he was then moved to the D hallway. On 03/28/24 at 9:38 A.M., interview with STNA #118 revealed Resident #61 was discovered missing on 03/24/24 at dinner time between 4:30 P.M. and 5:30 P.M. STNA #118 revealed she assisted with the facility wide search and grounds search but was unable to locate Resident #61. STNA #118 revealed she had not visually observed Resident #61 since 3:30 P.M. when she assisted with smoke break (Resident #61 did participate in the smoke break). STNA #118 revealed Resident #61 attended smoke breaks in the courtyard of the secure care unit. STNA #118 revealed Resident #61 voiced he was leaving the facility on a daily basis. On 03/28/24 at 9:47 A.M., an interview with Resident #61's legal guardian revealed she was notified on 03/24/24 at 6:00 P.M. the resident was missing from the secured care unit of the facility. The guardian revealed the resident stated he walked out the back door and hitchhiked to Columbus. The guardian revealed Resident #61 called her the morning of 03/25/24 and informed her he was at a behavioral health crisis center in Columbus. She revealed Resident #61 had severe alcohol damage and a history of a traumatic brain injury (TBI) which affected the resident by him being impulsive and not making good decisions. The guardian revealed Resident #61 walked away from the last SNF he resided at (in December 2023) and was homeless in downtown Columbus where he was stuck (as a pedestrian) by a motor vehicle requiring hospitalization. The resident was admitted to this facility following the hospitalization for treatment of the injuries he sustained after being struck by a motor vehicle. Based on the time period the resident was noted to be missing from the facility, the resident did not receive any scheduled medications after he left the faciity on [DATE] at 3:30 P.M. Attempts to reach the resident's primary care physician during the investigation were unsuccessful. An attempt to obtain the police report associated with this incident was also requested during the investigation, but not provided. Review of the facility Root Cause Analysis, not dated revealed the resident expressed want to leave the facility several times and the facility failed to put proper interventions in place to stop the resident from leaving the facility. The resident exited the facility without the staff's knowledge of the event due to staff not properly hiding the code to the secure system when exiting the door. Review of the facility policy, Wandering, Unsafe Resident, last revised 10/13/20 revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement or other risk due to judgement or cognition. The staff would identify residents who were at risk for harm because of unsafe wandering, including elopement. This deficiency represents non-compliance investigated under Complaint Number OH00152379.