**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital medical record reviews, review of the facility ' s daily staffing review, interviews with facility staff, the physician, the nurse practitioner, the physician, review of the emergency squad run sheet, review of facility self-imposed action plan, review of the Enhanced Information Dissemination and Collection (EIDC) electronic reporting system, review of the facility's policies for Enteral Nutrition Therapy ,admission Assessment and Follow Up: The Role of the Nurse, and Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, the facility failed to ensure Resident #70 was free from neglect, when the facility staff failed to provide appropriate services to ensure the resident received sufficient nutrition and hydration via enteral tube feeding. Resident #70 was not assessed by a dietitian for nutritional and hydration needs, no physician orders were obtained for nutrition, and no interventions were implemented for the care and treatment of the gastrostomy tube. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes for one (#70) resident who was newly admitted to the facility on [DATE] and whose only means of nutritional intake was via gastrostomy tube (g-tube), when physician orders were not obtained for nutrition and this resident was not provided sufficient enteral nutrition and fluids for five days, from 01/05/23 to 01/10/23. Consequently, Resident #70 suffered an acute change in condition and was sent by emergency squad to the hospital. The resident was admitted to the hospital in critical care for acute hypernatremia (elevated sodium) with dehydration, acute hypoxic (low oxygen levels) respiratory failure and acute metabolic encephalopathy multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia (loss of body weight, muscle mass and weakness), and acute mucositis (inflammation of the mouth). This affected one (#70) of six residents reviewed for potential neglect. The facility identified a total of five (#07, #09, #21, #23 and #37) residents currently receiving enteral nutrition. The facility census was 64. On 02/09/23 at 3:19 P.M., Corporate Administrator #903, the facility Administrator, Director of Nursing (DON), Regional Director of Clinicals (RDC) #701, and Chief Nursing Officer (CNO) of Clinical Services #802, were notified Immediate Jeopardy began on 01/05/23 when staff failed to assess a newly admitted resident (#70) for nutrition and hydration, who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient enteral nutrition for five days, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, RD #106, and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address nutritional requirements. Resident #70 was transferred to the hospital per family request on 01/10/23. Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). The Immediate Jeopardy was removed on 02/14/23 when the facility implemented the following corrective actions: • On 01/10/23, Resident #70 was transferred out of the facility to the hospital. • On 01/12/23, a facility-wide audit was completed to ensure accuracy of residents receiving tube feed orders were documented in the residents ' medical records. • On 01/12/2023, the CNO #802 and RDC #701 reviewed the policies and procedures related to enteral nutrition and documentation. There was no revision to the policy made. • Beginning on 01/12/23, the DON began weekly audits of medical records for accuracy of diet orders and will continue until 03/09/23 and randomly after. • On 02/09/23, the consulting Nurse Practitioner (NP)#105 was made aware by the RDC #701 verbally, the Immediate Jeopardy citations and the systemic actions that were starting to be implemented. • On 02/09/23, the DON added Intake and Output orders on resident ' s medical records who receive enteral nutritional orders. • On 02/10/23, the interdisciplinary team (IDT) with Registered Dietitian (RD) #106 reviewed all residents for nutritional and hydration (at risk) status. All care plans were validated as being current and correct. • On 02/10/23, the IDT, the DON and the RD #106 reviewed all residents ' diets to validate all residents have current diet orders and are correctly listed on the medical record. • On 02/10/23, the Administrator and DON provided the agency nurse who admitted and took care of Resident#70 with a do not return to clip board agency human resource (HR) director. • On 02/10/23, a Root Cause Analysis using a Fishbone diagram was completed to review the alleged deficiency. This was completed by the CNO #802 and RDC #701 with other members of the Quality Assurance Performance Improvement (QAPI) Team. • Beginning on 02/10/23, all staff will be in-serviced on the policies and procedures related to Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. This was provided by the DON. • Beginning on 02/14/23, an agency binder for all licensed nursing placed on both units all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. • Beginning on 02/10/23, the DON will discuss and review all changes in condition of the resident with RD #106 during weekly Quality of Life meeting, that is an IDT meeting currently taking place. • Beginning on 02/10/23, the facility will discuss results of the audits during a weekly Ad-Hoc QAPI meeting for the next four (4) weeks to ensure compliance. • On 02/13/23 and 02/14/23, random staff interviews with Registered Nurse (RN) #107, Licensed Practical Nurse (LPNs) #114, #115, #116 and #117, Housekeeper #113 and State Tested Nurse Aides (STNA) #112 were completed to verify in-service on Abuse and Neglect and was able to verbalize the education. • Beginning on 02/14/23, an agency binder for all licensed nursing staff was placed on both units all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. • On 02/14/23, review of the daily schedule revealed a statement for agency staff to review the agency staff binder for the education on the facility ' s policy on abuse and neglect before the beginning of their shift. • On 02/14/23, random interviews with agency STNAs (#118, #120 and #121) revealed they had reviewed the agency binder and was able to verbalize the facility ' s education. • On 02/14/23, review of the agency binder sign in sheet revealed agency staff had been reviewing the binder and they were acknowledging the facility corrective action. Although the Immediate Jeopardy was removed on 02/14/23, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #70 revealed an admission date of 01/05/23. Admitting diagnoses for Resident #70 included: hemiplegia, hemiparesis and aphasia following a cerebral infarct (stroke) April 2022, severe protein calorie malnutrition, vascular dementia, chronic obstructive pulmonary disease, traumatic brain injury, epilepsy, hypertension, hypothyroidism, and osteoarthritis. Resident #70 had three wounds: one Stage II to the right hip and two unstageable wounds, to the left hip and left heel. Resident #70 was discharged on 01/10/23 to the hospital. Review of the hospital inpatient record dated 12/28/22 revealed Resident #70 had a diagnoses of severe protein calorie malnutrition and had received enteral nutrition for a continuous feed for 23 hours a day with 150 milliliters (ml) water flushes every 4 hours, with intake of 2100 (ml) the previous 24 hours. Review of the hospital discharge summary with a print date of 01/04/23 at 3:16 P.M., from the acute hospital revealed there was no orders for enteral feedings. Review of the admission physician orders dated 01/05/23, revealed the resident was ordered to admit to SNF (skilled nursing facility and for long-term care and skilled care) and DNRCC-A (Do Not Resuscitate Comfort Care -Arrest) code status. There were no orders to address the resident ' s nutritional status. Review of diet order changes and communication form dated 01/05/23 revealed Resident #70 was a new admit with a diet order of NPO (nothing by mouth) and did not state how Resident #70 was to receive nutrition. Review of physician orders from 01/06/23 to 01/10/23 revealed no physician orders to address the nutritional status. On 01/08/23, an order to flush enteral tube with 150 ml of water every four hours providing 900 ml per day. Review of the history and physical dated 01/07/23, revealed there was no documentation to address the g-tube or nutritional needs of the resident. This was completed by Nurse Practitioner (NP) #105. Review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #70 revealed medications administered via g-tube were documented as given per orders. Water flushes of the g-tube tube for 150 ml were documented as being completed beginning on 01/08/23 at 12:00 P.M., 4:00 P.M. and 8:00 P.M., on 01/09/23 at 12:00 A.M., 4:00 A.M., 8:00 A. M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and on 01/10/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. There was no documentation of any tube feeding being administered. Review of the speech therapy evaluation dated 01/09/23, revealed the referral was made due to feeding tube placement due to dysphagia and malnutrition. The evaluation listed the resident as NPO and with significant weight loss. Review of the progress note dated 01/09/23 at 4:55 A.M., documented this nurse was called to the resident ' s room, State Tested Nurse Aide (STNA) stated heard something from his room and found him on the floor, with his head under the bed lying on his left side. This nurse assessed resident ' s vital signs, with in normal limits for resident. Blood pressure 114/80, oxygen not on, replaced oxygen, respirations 20, temperature 97.6 degrees Fahrenheit. Oxygen levels went up to 95% after 15 minutes. Assessed for injuries, with bruise noted to left scapula of red/purple color, redness starting to form over left hip, small skin tear 0.5 by 0.5 centimeters to back of right hand, with treatment initiated. Family notified and voice mail left for nurse practitioner. Review of the medical record revealed no return call received from the nurse practitioner. Review of the neurological assessment form post fall, dated and timed from 01/09/23 at 4:55 A.M. to 01/10/23 at 11:40 A.M., revealed vitals and neurological checks were completed every fifteen minutes times four, then every 30 minutes for two hours, every one hour for four hours and then every eight hours. Neurological assessment stated the resident was alert with pupil response, equal hand grasps and moved all extremities and had an appropriate response to pain. Blood pressure ranged from 114/80 on 01/09/23 at 4:55 A.M. to 149/86 on 01/09/23 at 10:40 A.M. Heart rate ranged from 97 beats per minute on 01/09/23 at 7:10 A.M. to 117 beats per minute on 01/10/23 at 11:40 A.M. Respirations ranged from 18-20 breaths per minute and the resident remained afebrile (without temperature). Review of Resident #70's weights in the electronic health record (EHR) and paper medical record revealed there were no weights documented as being obtained by the facility. Review of the progress notes throughout the admission for Resident #70, lacked any documented evidence for nutrition or for the resident eating. Review of the progress note dated 01/10/23 at 6:07 P.M., documented the writer noted resident with increased respirations of 42 breaths a minute. Resident not responding to brother as usual, noted lethargic, pulse oximetry 90% with oxygen via nasal cannula at 3 liters, temperature 97.8 degrees Fahrenheit, and blood pressure 100/62. Writer notified on call (physician); orders were given to send resident to emergency room. Emergency 911 was called and arrived about 5:50 P.M. Resident #70 noted with elevated blood sugar of 432. Resident #70 transferred out of facility at 6:07 P.M. Family at bedside aware of it all. Writer called hospital to give report. Review of the complete medical record from admission to discharge revealed no evidence of the physician being contacted for physician orders to address the nutritional need. There was no assessments and treatment plan to address Resident #70 ' s nutritional needs addressed by the Registered Dietitian #106. Review of the emergency squad run sheet dated 01/10/23, reveals no documentation of the resident having any enteral tube feeding being administered. The report documented the chief complaint was for respiratory distress lasting for three days. The level of distress was listed as severe acute respiratory distress. The injury listed was from a fall from the bed at the nursing home on [DATE]. Review of the hospital record dated 01/10/23 revealed Resident #70 arrived at the emergency department at 6:23 P.M., upon arrival the resident had tachycardia (elevated heart rate) was hyperglycemic (elevated blood sugar) and hypoxic (low oxygen levels) with oxygen saturation in the 80 ' s. Review of the emergency department laboratory test results dated 01/10/23, revealed a blood sugar of 294 (normal range 70 to 99), blood urea nitrogen was elevated at 95 (normal range 8 to 23), creatinine level was 1.19 (normal range 0.7 to 1.2) and the ammonia level was 75 (normal range 11 to 32). Review of the emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level) Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). Review of the daily staffing for nurses assigned to care for Resident #70 revealed: on 01/05/23 and 01/06/23, for the 6:45 A.M. to 7:15 P.M. shift and the 6:45 P.M. to 7:15 A.M. shift, revealed agency nurses were assigned; on 01/07/23 and 01/08/23, for the 6:45 A.M. to 7:15 P.M. shift, Registered Nurse (RN) #107 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/09/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #109 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/10/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #110 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned to the care. Review of the facility ' s self- imposed action plan dated 01/12/23, revealed under the area of identified practice there was no area of concern listed. The next category was addressing how corrective action will be accomplished for the residents found to be affected by the identified practice: What did you do for the Resident affected? Resident #70 was transferred to the emergency department on 01/10/23. Review of the Enhanced Information Dissemination and Collection (EIDC) electronic reporting system for the potential neglect being reported to the state agency revealed there was no incidents of potential neglect reported by the facility from January 2023 to February 13, 2023. Interview on 02/07/23 at 7:30 A.M., with LPN #110 verified she had cared for Resident #70. LPN #110 was unable to state if the resident had a feeding tube and was unsure about tube feeding. Interview on 02/07/23 at 10:17 A.M., with the Registered Dietitian (RD) #106 revealed RD #106 did not receive a call when Resident #70 was admitted to the facility and had not seen the resident. RD #106 verified she had not completed a nutritional assessment and did not order tube feeding. When asked about the process for a new admission with a feeding tube, RD #106 stated I am to be notified to ensure a timely assessment and recommendations for those residents at high nutritional risk are made. RD #106 stated I am clueless on what happened and again stated she had not seen the resident. Interview on 02/07/23 at 11:42 A.M., with the Director of Nursing (DON) verified Resident #70 did not have enteral feeding ordered, verified documentation did not exist for any type of feeding in the medical record for Resident #70 and further verified no proof existed for enteral feeding was provided. Interview on 02/07/23 at 3:19 P.M., with LPN #109 verified Resident #70 was transferred to the hospital per family request on 01/10/23. LPN #109 had only provided care to the resident on 01/10/23 and remembered providing water flushes through the g- tube, however, was unable to verify Resident #70 received tube feedings. Interview on 02/08/23 at approximately 10:20 A.M., with Resident #70's NP #105, revealed NP #105 stated she was unfamiliar with the resident and had only seen the resident once after the fall on 01/09/23. NP #105 verified no feeding was ordered for Resident #70 and further verified the history and physical review completed by herself on 01/07/23, did not address the diet or nutritional status of Resident #70. Interview on 02/08/23 at approximately 11:00 A.M., with Registered Nurse (RN) #107 verified Resident #70 had a g-tube; however, RN #107 could not recall if the resident received an enteral feeding and stated, I will have to check the orders. Review of the physician orders by RN #107 verified no enteral feeding formula had been ordered for Resident #70. Interview on 02/08/23 at 4:05 P.M., with RN #108 verified she completed the nutritional section of the admission assessment. RN #108 stated she does not remember if Resident #70 had tube feeding. Interview on 02/08/23 at 5:00 P.M., with the Administrator, the DON, and the RDC #701, verified the electronic medical record for Resident #70 contained no orders for enteral tube feeding and further verified the medical record provided no evidence Resident #70 received feeding while at the facility from 01/05/23 to 01/10/23. Interview on 02/13/23 at 2:32 P.M., with Physician #01 revealed he was unfamiliar with Resident #70 and had only seen him once. Physician #01 stated he knew the resident had a feeding tube. Physician #01 verified the resident did not have an enteral tube feeding order in the record. Interview on 02/13/23 at 3:00 P.M., with the Administrator and the RDC #701 revealed their concern related to the care of residents due to the number of agency staff used by the facility, both nurses and aides. The Administrator stated their hands are tied due to the facility staff being a union as they cannot get staff hired based on the wage offered. The RDC #701 stated the agency staff just do not care and are not vested in the facility, and added it is hard to get consistent care. Review of the policy and procedure titled, Enteral Nutrition Therapy dated April 2018 and revised March 2022, revealed the purpose of the policy was to provide liquid nourishment through a tube inserted into the stomach and to provide hydration through a tube inserted into the stomach. Review of the policy titled, admission Assessment and Follow Up: The Role of the Nurse, dated April 2018, revealed the policy indicated the nurse is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The nurse is required to reconcile the list of medications from the medication history, admitting orders, the previous medication administration record (if available), and the discharge summary from the previous institution, contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings and notify other disciplines and departments of the resident ' s admission. The nurse is also responsible to for reporting immediate needs of the resident to the supervisor and the attending physician. Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, indicated residents have the right to be free from neglect and further revealed neglect is the failure of the facility, its employees or facility services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency demonstrates non-compliance related to the allegations in Master Complaint OH00139917, and Complaint Numbers OH00139754 and OH00139691.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital medical records review, review of the facility's daily staffing, interviews with facility staff, the physician, the nurse practitioner, and the fire captain, review of the emergency squad run sheet, review of the facility's policies for Enteral Nutrition Therapy, admission Assessment and Follow Up: The Role of the Nurse, Weight Policy, Care Plan Policy, Dietary Communication Pathway and review of the job description of the Registered Dietitian, the facility failed to assess a newly admitted resident for nutrition and hydration who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, Registered Dietitian (RD) #106 and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address the resident's nutritional requirements. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes for one (#70) resident who was newly admitted to the facility on [DATE] and whose only means of nutritional and hydration intake was via gastrostomy tube (g-tube), when physician orders were not obtained for enteral nutrition needs, no assessment was completed for nutritional requirements and no documented evidence of this resident being provided sufficient enteral nutrition for five days, from 01/05/23 to 01/10/23. Consequently, Resident #70 suffered an acute change in condition and was sent by emergency squad to the hospital. The resident was admitted to the hospital in critical care for acute hypernatremia (elevated sodium) with dehydration, acute hypoxic (low oxygen levels) respiratory failure and acute metabolic encephalopathy multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia (loss of body weight, muscle mass and weakness), and acute mucositis (inflammation of the mouth). This affected one (#70) of six residents reviewed for nutrition and hydration needs. Additionally, the facility failed to ensure two (#21 and #23) of six residents reviewed were receiving the care and treatment to meet their hydration and nutritional needs that placed the residents at risk for potential for more than minimal harm that is not Immediate Jeopardy. The facility identified a total of five (#07, #09, #21, #23 and #37) residents currently receiving enteral nutrition. The facility census was 64. On 02/09/23 at 3:19 P.M., Corporate Administrator #903, the facility Administrator, Director of Nursing (DON), Regional Director of Clinicals (RDC) #701, and Chief Nursing Officer (CNO) of Clinical Services #802, were notified Immediate Jeopardy began on 01/05/23 when staff failed to assess a newly admitted resident (#70) for nutrition and hydration, who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient enteral nutrition for five days, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, RD #106, and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address nutritional requirements. Resident #70 was transferred to the hospital per family request on 01/10/23. Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). The Immediate Jeopardy was removed on 02/14/22 when the facility implemented the following corrective actions: • On 01/10/23, Resident #70 was transferred out of the facility to the hospital. • On 01/12/23, a facility-wide audit was completed to ensure accuracy of residents receiving tube feed orders were documented in the residents ' medical records. • On 01/12/23, CNO #802 of Clinical Services and RDC #701 reviewed the policies and procedures related to enteral nutrition and documentation. There were no revisions made to the policy and procedures. • Beginning on 01/12/23, the DON began weekly audits of medical record of physician orders for diet orders and will continue until 03/09/23 and randomly after. • On 02/09/23, the consulting Nurse Practitioner (NP) #105 was made aware by RDC #701 verbally, of the Immediate Jeopardy citations and the systemic actions that were starting to be implemented. • On 02/09/23, the DON added Intake and Output orders on resident's medical records who receive enteral nutritional orders. • On 02/10/23, the interdisciplinary team (IDT) with the Registered Dietitian (RD) #106 reviewed all residents for nutritional and hydration (at risk) status. All care plans were validated as being current and correct. • On 02/10/23, the IDT, the DON and the RD #106 reviewed all residents ' diets to validate all residents have current diet orders and are correctly listed on the medical record. • On 02/10/23, the Administrator and DON provided the agency nurse who admitted and took care of Resident#70 with a do not return to the clip board agency human resource (HR) director. • On 02/10/23, a Root Cause Analysis using a Fishbone diagram was completed to review the alleged deficiency. This was completed by CNO #802 of Clinical Services and RDC #701 with other members of the Quality Assurance Performance Improvement (QAPI) Team. • Beginning on 02/10/23, all licensed nursing staff will be in-serviced on the policies and procedures related to enteral nutrition and documentation. In addition, the policies for notice for change in condition to the physician and implementing admission orders upon admit was also addressed. This was provided by the DON. • Beginning on 02/10/23, the DON will discuss and review all changes in condition of residents with the RD #106 during weekly Quality of Life meeting, that is an IDT meeting currently taking place. • Beginning on 02/10/23, the facility will discuss results of the audits during a weekly Ad-Hoc QAPI meeting for the next four (4) weeks to ensure compliance. • On 02/13/23 and 02/14/23, random staff interviews with Registered Nurse (RN) #107, Licensed Practical Nurses (LPNs) #114, #115, #116 and #117, and State Tested Nurse Aide (STNA) #112 were completed to verify in-service on enteral nutrition, documentation and change in condition had been completed and staff were able to verbalize the education. • On 02/14/23, review of in-service records revealed all facility staff had received education on the on enteral nutrition, documentation and change in condition. • Beginning on 02/14/23, an agency binder for all licensed nursing staff was placed on both units with phone numbers to call for admission orders and change in condition and all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. • On 02/14/23, review of the daily schedule revealed a statement for the agency staff to review the agency education binder on the enteral nutrition and documentation, and change in condition. • On 02/14/23, random interviews with agency STNAs (#118, #120 and #121) revealed they had reviewed the agency binder and they were able to verbalize the facility's education. • On 02/14/23, review of the agency binder sign in sheet revealed agency staff had been reviewing the binder and acknowledging the facility corrective action. Although the Immediate Jeopardy was removed on 02/14/22, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #70 revealed an admission date of 01/05/23. Admitting diagnoses for Resident #70 included hemiplegia, hemiparesis and aphasia following a cerebral infarct (stroke) April 2022, severe protein calorie malnutrition, vascular dementia, chronic obstructive pulmonary disease, traumatic brain injury, epilepsy, hypertension, hypothyroidism, and osteoarthritis. Resident #70 had three wounds: one Stage II to the right hip and two unstageable wounds to the left hip and left heel. Resident #70 was discharged on 01/10/23 to the hospital. Review of the hospital inpatient record dated 12/28/22 revealed Resident #70 had a diagnoses of severe protein calorie malnutrition and had received enteral nutrition for a continuous feed for 23 hours a day with 150 milliliters (ml) water flushes every 4 hours, with intake of 2100 (ml) the previous 24 hours. Review of the hospital discharge summary with a print date of 01/04/23 at 3:16 P.M., from the acute hospital, revealed under the area Nursing/Mobility and Activities of Daily Living revealed a subcategory of feeding: medication delivery g-tube. Under the area of Nutrition Therapy revealed a subcategory of Current Nutrition Therapy: oral diet: general; subcategory of Routes of Feeding: g-tube and subcategory of Liquids: no restrictions. The last weight documented as obtained on 01/02/23, was 116 pounds 13.5 ounces (53 kilograms), with a height of five foot ten inches and a body mass index of 16.77. Resident #70's prognosis at discharge was listed as fair; condition at discharge was listed as stable and rehabilitation potential as fair. Review of the admission physician orders dated 01/05/23, revealed the resident was ordered to admit to SNF (skilled nursing facility and for long-term care and skilled care), DNRCC-A (Do Not Resuscitate Comfort Care -Arrest) code status, verbal order for I approve the plan of care and discharge, may crush meds (medications) as appropriate, may crush meds or open capsules and mix with food if not contraindicated, may have annual flu vaccine, may substitute generics unless otherwise indicated, may use OTC (over the counter) meds from house supply, may use liberal medication administration times, Tiotropium Bromide Monohydrate capsule 18 micrograms (mcg), one inhalant each morning and at bedtime, pain evaluation every shift for monitoring of patient's pain level, POC (point of care) testing PRN (as needed) per regulation until further notice, physical therapy two to five times a week and prescriber written order for overall plan of care approved. There were no orders to address the nutritional status. Review of diet order changes and communication form dated 01/05/23 revealed Resident #70 was a new admit with a diet order of NPO (nothing by mouth). Review of the admission assessment dated [DATE], and started 01/06/23, revealed the nutrition section listed the resident as NPO or un supplemented clear liquid (without enteral total parental nutrition support) for greater than forty-eight hours. Further review of the medical record revealed there was no evidence of a nutrition assessment, or the resident being evaluated by the dietitian. Review of the care plan initiated on 01/05/23, revealed no interventions to address the type or method of enteral nutrition provided. The facility revised the resident's care plan on 01/10/23 (date of discharge) to include encouraged good nutrition and hydration to promote healthy skin due to Resident #70 identified with the potential and actual skin impairments and due to the risk for pain staff were to monitor, record and report to the nurse loss of appetite, refusal to eat and weight loss. Review of additional physician orders dated 01/06/23, revealed Resident #70 was ordered occupational therapy two to five times a week for 30 days. There were no orders to address the nutritional status. Review of physician orders dated 01/07/23, revealed the resident was ordered oxygen at two liters minute to keep oxygen saturation above 90 percent, Aspirin 81 milligrams (mg) once daily administered per gastrostomy tube (g-tube), Carbidopa-Levodopa 25-100 mg tablet twice a day administered per g-tube, Clopidogrel Bisulfate 75 mg twice daily administered per g-tube, Ferrous Sulfate Liquid 5.4 milliliters (ml) via g-tube once a day, Pantoprazole Sodium, delayed release 40 mg once daily via g-tube, Quetiapine Fumarate 25 mg once daily via g-tube, Lacosamide Solution (10 mg per ml) with 20 ml administered per g-tube once daily. There were no orders to address the nutritional status for Resident #70. Review of the history and physical dated 01/07/23, revealed Resident #70 was admitted from the hospital after being found down and suffering a laceration to the left side of head and was diagnosed with a heart attack. Past medical history of chronic obstructive pulmonary disease, dementia, cardiovascular accident, falls, hypothyroid, hyperlipidemia, osteoarthritis seizure disorder and trans ischemic attack, and a developmental delay related to traumatic brain injury. Surgical history revealed a right carotid stent and a left aneurysm clipping. Social history stated resident was single, had a history of smoking, alcohol, and marijuana use. Advance directive was reviewed and indicated, do not resuscitate, if arrest. Allergies to codeine and Keppra. There was no documentation to address the g-tube or nutritional needs of the resident. This was completed by Nurse Practitioner (NP) #105. Additional review of physician orders dated 01/08/23, included Midodrine Hydrochloride 5 mg, three times a day administered via g-tube and an order to flush enteral tube with 150 ml of water every four hours. There were no orders to address the nutritional status. Review of physician orders dated 01/09/23, included a diet order for nothing by mouth (NPO), speech therapy evaluation and treatment one to three times a week for thirty days. Review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #70 revealed medications administered via g-tube were documented as given per orders. Water flushes of the g-tube tube for 150 ml were documented as being completed beginning on 01/08/23 at 12:00 P.M., 4:00 P.M. and 8:00 P.M., on 01/09/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and on 01/10/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. There was no documentation of any tube feeding being administered. Review of the speech therapy evaluation dated 01/09/23, revealed the referral was made due to feeding tube placement due to dysphagia and malnutrition. The evaluation listed the resident as NPO and with significant weight loss. Review of the progress note dated 01/09/23 at 4:55 A.M., documented this nurse was called to the resident's room, State Tested Nurse Aide (STNA) stated heard something from his room and found him on the floor, with his head under the bed lying on his left side. This nurse assessed resident's vital signs, with in normal limits for resident. Blood pressure 114/80, oxygen not on, replaced oxygen, respirations 20, temperature 97.6 degrees Fahrenheit. Oxygen levels went up to 95% after 15 minutes. Assessed for injuries, with bruise noted to left scapula of red/purple color, redness starting to form over left hip, small skin tear 0.5 by 0.5 centimeters to back of right hand, with treatment initiated. Family notified and voice mail left for nurse practitioner. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had total dependence for feeding and had a feeding tube. Review of Resident #70's weights in the electronic health record (EHR) and paper medical record revealed there were no weights documented as being obtained by the facility. Review of the progress notes throughout the admission for Resident #70, lacked any documented evidence for nutrition or for the resident eating. Review of the progress note dated 01/10/23 at 6:07 P.M., documented the writer noted resident with increased respirations of 42 breaths a minute. Resident not responding to brother as usual, noted lethargic, pulse oximetry 90% with oxygen via nasal cannula at 3 liters, temperature 97.8 degrees Fahrenheit, and blood pressure 100/62. Writer notified on call (physician); orders were given to send resident to emergency room. Emergency 911 was called and arrived about 5:50 P.M. Resident #70 noted with elevated blood sugar of 432. Resident #70 transferred out of facility at 6:07 P.M. Family at bedside aware of it all. Writer called hospital to give report. Review of the emergency squad run sheet dated 01/10/23, reveals no documentation of the resident having any enteral tube feeding being administered. The report documented the chief complaint was for respiratory distress lasting for three days. The level of distress was listed as severe acute respiratory distress. The injury listed was from a fall from the bed at the nursing home on [DATE]. Review of the hospital record dated 01/10/23 revealed Resident #70 arrived at the emergency department at 6:23 P.M. Upon arrival, the resident had tachycardia (elevated heart rate) was hyperglycemic (elevated blood sugar) and hypoxic (low oxygen levels) with oxygen saturation in the 80's. Review of the emergency department laboratory test results dated 01/10/23, revealed a blood sugar of 294 (normal range 70 to 99), blood urea nitrogen was elevated at 95 (normal range 8 to 23), creatinine level was 1.19 (normal range 0.7 to 1.2) and the ammonia level was 75 (normal range 11 to 32). Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). Review of the daily staffing for nurses assigned to care for Resident #70 revealed on 01/05/23 and 01/06/23, for the 6:45 A.M. to 7:15 P.M. shift and the 6:45 P.M. to 7:15 A.M. shift, revealed agency nurses were assigned; on 01/07/23 and 01/08/23, for the 6:45 A.M. to 7:15 P.M. shift, Registered Nurse (RN) #107 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/09/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #109 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/10/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #110 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned to the care. Interview on 02/07/23 at 7:30 A.M. with LPN #110 verified she had cared for Resident #70. LPN #110 was unable to state if the resident had a feeding tube and was unsure about tube feeding. Interview on 02/07/23 at 10:17 A.M. with Registered Dietitian (RD) #106 revealed RD #106 did not receive a call when Resident #70 was admitted to the facility and had not seen the resident. RD #106 verified she had not completed a nutritional assessment and did not order a tube feeding. When asked about the process for a new admission with a feeding tube, RD #106 stated I am to be notified to ensure a timely assessment and recommendations for those residents at high nutritional risk are made. RD #106 stated I am clueless on what happened and again stated she had not seen the resident. Interview on 02/07/23 at 11:42 A.M., with the DON verified Resident #70 did not have enteral feeding ordered, verified documentation did not exist for any type of feeding in the medical record for Resident #70, and further verified no proof existed for enteral feeding was provided. Interview on 02/07/23 at 3:19 P.M., with LPN #109 verified Resident #70 was transferred to the hospital per family request on 01/10/23. LPN #109 had only provided care to the resident on 01/10/23 and remembered providing water flushes through the g- tube; however, was unable to verify Resident #70 received tube feedings. Interview on 02/08/23 at approximately 10:20 A.M., with Resident #70's NP #105, revealed NP #105 stated she was unfamiliar with the resident and had only seen the resident once after the fall on 01/09/23. NP #105 verified no feeding was ordered for Resident #70 and further verified the history and physical review completed by herself on 01/07/23, did not address the diet or nutritional status of Resident #70. Interview on 02/08/23 at approximately 11:00 A.M., with RN #107 verified Resident #70 had a g-tube; however, RN #107 could not recall if the resident received an enteral feeding and stated, I will have to check the orders. Review of the physician orders by RN #107 verified no enteral feeding formula had been ordered for Resident #70. Interview on 02/08/23 at 4:05 P.M., with RN #108 verified she completed the nutritional section of the admission assessment. RN #108 stated she does not remember if Resident #70 had a tube feeding. Interview on 02/08/23 at 5:00 P.M., with the Administrator, the DON, and RDC #701, verified the electronic medical record for Resident #70 contained no orders for enteral tube feeding and further verified the medical record provided no evidence Resident #70 received feeding while at the facility from 01/05/23 to 01/10/23. Interview on 02/13/23 at 11:47 A.M., with Fire Captain #111 revealed the run sheet for 01/10/23 for Resident #70 contained no information regarding the resident having a tube feeding and would be on there if the resident had one. Interview on 02/13/23 at 2:32 P.M., with Physician #01 revealed he was unfamiliar with Resident #70 and had only seen him once. Physician #01 stated he knew the resident had a feeding tube. Physician #01 verified the resident did not have an enteral tube feeding order in the record. Interview on 02/13/23 at 3:00 P.M., with the Administrator and RDC #701, revealed their concern related to the care of residents due to the number of agency staff used by the facility, both nurses and aides. The Administrator stated their hands are tied due to the facility staff being a union as they cannot get staff hired based on the wage offered. RDC #701 stated the agency staff just do not care and are not vested in the facility, and added it is hard to get consistent care. 2) Review of the medical record for Resident #21 revealed an admission date of 12/30/22 with diagnoses including pericardial effusion, type II diabetes mellitus, severe protein-calorie malnutrition, acute respiratory failure, emphysema, hypertension, atrial fibrillation, and epilepsy. Review of the hospital continuation of care instructions printed on 12/30/22 at 3:39 P.M. revealed Resident #21 had a gastrostomy tube, was to have nothing by mouth, and received tube feedings at 45 ml per hour continuously for 20 hours and received a water flush of 200 ml every six hours. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #21 had moderate cognitive impairment, required total dependence for eating and had a gastrostomy tube and received more than 51% of total calories through the feeding tube with an average fluid intake of 501 milliliters (ml) or more per day via the feeding tube. Review of the admission physician orders written on 12/31/22 revealed a nothing by mouth diet, tube feeding administered via pump at 45 ml per hour 24 hours a day. Review of the nutrition assessment completed on 01/02/23, revealed Resident #21 was severely underweight and it was recommended for the tube feeding to be increased to 75 ml per hour at 10 ml increments as tolerated and 100 ml water flushes to be administered every four hours. Review of the physician orders dated 01/02/23 revealed Resident #21 was not to receive anything by mouth, tube feeding at 45 ml per hour and advanced by 10 ml per hour as tolerated to a goal rate of 75 ml per hour, six times a day flush the feeding tube with 100 ml water. Review of the medication administration record for January 2023 revealed the first bolus of water was received by Resident #21 via the feeding tube at 5:00 P.M. on 01/02/23. Interview on 02/14/23 at 11:25 A.M. with the DON verified the recommended continuation of care order for water flushes were not followed and the DON further verified Resident #21 admitted to the facility on [DATE] and had not received the recommended water flushes per feeding tube until 01/02/23. 3) Review of the medical record for Resident #23 revealed an admission date of 01/13/23 with diagnoses including nontraumatic intracerebral hemorrhage, dysphagia, acute respiratory failure, moderate protein-calorie malnutrition, seizures, hypertension, bipolar disorder, pulmonary hypertension, substance abuse, alcohol dependence, heart failure, Vitamin D deficiency, and depression. Review of the comprehensive MDS assessment dated [DATE], revealed resident had a feeding tube and received 51% or more of total calories from enteral nutrition and 501 ml or more of fluid intake per day via the feeding tube. Review of the current physician orders for February 2023 revealed Resident #23 had an order written on 02/09/23 for enteral tube nutrition at 90 ml hour for twenty hours a day from 1:00 P.M. to 9:00 A.M. per pump and record every shift the amount of enteral intake. An order dated 02/11/23 revealed the enteral feeding tube to be flushed with 65 ml of water every hour while the continuous enteral nutrition formula was running for twenty hours. Observation on 02/13/23 at 7:49 A.M. of the feeding pump for Resident #23 revealed enteral nutrition infusing at 90 ml per hour with 65 ml of water programmed to be infused every zero hours. The water flush bag was dated 02/12/23 and timed 5:50 A.M. and contained approximately 400 ml. Review of the intake for the 65 ml an hour water flush, every hour for 20 hours while the tube feeding was running, revealed an intake on 02/12/23 from 7:00 A.M. to 7:00 P.M. of 130 ml and from 7:00 P.M. to 7:00 A.M. of zero ml. Observation on 02/13/23 at 9:59 A.M. of the feeding pump for Resident #23 revealed the enteral feeding infusing at 90 ml per hour with the total volume infused at 347 ml and the water flush programmed at 65 ml every zero hours with zero volume infused. The water flush bag was observed with approximately 400 ml of fluid and was dated 02/12/23 timed 5:50 A.M. Interview on 02/13/23 at 9:59 A.M. with the DON revealed the water flush was programmed incorrectly for Resident #23 on the pump and verified the total volume for the water infused read zero. The DON further verified Resident #23 had not received water flushes as ordered for an unknown amount of time. Review of the policy and procedure titled Enteral Nutrition Therapy dated April 2018 and revised March 2022, revealed the purpose of the policy was to provide liquid nourishment through a tube inserted into the stomach and to provide hydration through a tube inserted into the stomach. Review of the policy titled, admission Assessment and Follow Up: The Role of the Nurse, dated April 2018, revealed the policy indicated the nurse is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The nurse is required to reconcile the list of medications from the medication history, admitting orders, the previous medication administration record (if available), and the discharge summary from the previous institution, contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings and notify other disciplines and departments of the resident's admission. The nurse is also responsible to for reporting immediate needs of the resident to the supervisor and the attending physician. Review of the policy titled, Weight Policy, revised May 2021, revealed weights will be obtained within 72 hours of admission then weekly for four weeks. If a resident experiences a significant change in weight, nursing staff will complete a re-weigh within four days. In addition, this policy denoted if a significant weight change is verified, the resident may be weighed on a weekly basis until the weight is stabilized. Review of the policy titled, Care Plan Policy, dated October 2022, revealed a baseline care plan to identify key areas such as diagnoses, medications, care needs, treatments, risks, and other areas of immediate concern will be developed with input from the resident and/or the identified resident representative and implemented within 48 hours of admission. Review of the policy titled Dietary Communication Pathway, dated February 2021 revealed in a healthcare setting such as long-term care, it is very important for the clinical team to have a clear means of communication with the Registered Dietitian. The attending can address any nutritional concerns until the registered dietitian can be present to access. Review of the undated job description for the Registered Dietitian (RD) stated the RD is responsible for the cli[TRUNCATED]