**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R6) reviewed for elopement, 2 of 3 residents (R8 and R10) who smoke, 1 of 1 resident’s (R18) who voiced suicidal ideations, and 1 of 3 residents (R13) at risk for falls. The facility’s failure to supervise a resident who was known to be an elopement risk, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 4:19 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples: R8 has no smoking assessment or care plan for smoking. R10 has no smoking assessment or care plan for smoking. R18 has no trauma assessment or care plan for suicidal ideations. R13 did not have fall interventions in place nor were fall interventions present on CNA (Certified Nursing Assistant) care cards. This is evidenced by: 1. The facility’s Policy and Procedure titled, “Wandering and Elopements” dated [DATE], documents in part: “…1. If identified as at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety…3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, and c. If the resident is not located, notify the administrator and the director of nursing services, the resident’s legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall; a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident’s legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident’s medical record. 5. When a resident requires a Wanderguard the facility will: a. Ensure a completed elopement risk assessment is in resident chart, b. Request order for Wanderguard from physician and update representative, c. Apply Wanderguard to resident ensuring the band is in a comfortable position, d. Add care plan for wandering to resident chart, e. Assess placement of Wanderguard twice daily…” R6 was admitted to the facility [DATE]. R6 has the following diagnoses: bilateral primary osteoarthritis of knee, dementia severity with other behavioral disturbance, type 2 diabetes mellitus with other diabetic kidney complication, abdominal aortic aneurysm without rupture, anxiety, major depressive disorder, OCD (obsessive compulsive disorder), emphysema, Crohn’s disease, chronic kidney disease stage 3a, and low vision (blind in L (left) eye, ocular obstruction R (right) eye). R6’s elopement assessment dated [DATE] documents the following: R6 is ambulatory, an elopement risk, has diagnosis that could contribute to elopement, history of wandering, and that an elopement care plan should be initiated. R6’s Elopement Care Plan was initiated on [DATE]. Wanderguard device was added to R6’s care plan on [DATE]. R6’s Progress Notes document the following: [DATE] 11:25 PM at approximately 1500 (3:00 PM) R6 was calm and cooperative in his room. By 1700 (5:00 PM) he became very restless, repeatedly asking staff for his car keys stating he needed to go home. He became very agitated and upset because the staff are not telling me the truth. His family tried calling him via face time on his tablet, his tablet was left at the nurses’ station. Upon his return to the nurses’ station, he was told that he missed a call from family. He stated he did not know the password to call the family back on the tablet. Writer and other staff showed R6 where his room was multiple times, but he did not believe it was his room. R6 began walking around the facility. Kitchen staff came to the nurses’ station to report R6 was found in the kitchen. Staff retrieved him and brought him back to his room. Staff offered snacks and beverages and redirected him multiple times. No medications were available to give for agitation. As of this time (2335) (11:35 PM) there are still no medications available since patient was admitted today. At approximately 1930 (7:30 PM) CNA staff took her break. She reported that while driving down the street she saw R6 walking on the side of the street. She picked him up in her car and returned him to the facility. Once CNA told writer of this, writer called … to inquire how to lock front doors to ensure that patient would not elope again. CNA called Administrator and described the above incident. Patient has been on Q (every) 15-minute checks and is now resting in bed as of 2334 (11:34 PM) [sic]. It is important to note that there was no documented set of vital signs or assessment upon R6 returning to the facility. Approximate distance that R6 ambulated was 0.4 miles. He was on the same side of the street as the facility and cemetery. [DATE] 03:07 PM Wanderguard placed to right wrist per resident high risk for elopement. Voicemail left for POA with update. It is important to note that there is no documentation of follow up monitoring after R6 eloped the facility on [DATE]. On [DATE] at 11:41 AM, Surveyor interviewed CNA R (Certified Nursing Assistant). Surveyor asked CNA R to explain what happened on [DATE] when R6 eloped from the facility. CNA R explained that she was going on break somewhere between 8:00 and 9:00 PM, I know the sun was going down. I saw R6 was walking up the street toward Kwik Trip, R6 was walking in the street. CNA R stated R6 had just been admitted to the facility on [DATE]. CNA R stated the Therapist told staff R6 was a huge elopement risk, he kept trying to leave and saying he wanted to leave the facility. CNA R stated R6 was almost by the Kwik Trip near the end of the cemetery, CNA R state she told R6 to get in the car, he just got in my car, and I brought him back in the facility. Surveyor asked CNA R what the weather was like at the time. CNA R said it was nice out, warm but not humid. Surveyor asked CNA R if R6 was dressed for the weather and if he had shoes on; CNA R replied yes, his shoes were on, and he had on appropriate clothes. Surveyor asked CNA R what happened once you returned with R6, CNA R stated they put a Wanderguard on R6, he was placed on 15-minute checks I think, I updated NHA A and reported the event to the nurse and the CNA. On [DATE] at 10:56 AM, Surveyor interviewed LPN Q (Licensed Practical Nurse). Surveyor asked LPN Q if there is an elopement, what do you need to do afterwards; LPN Q stated this is all hands on deck- look for the resident, spread staff outside, notify DON (Director of Nursing) or whomever is on call and the NHA (Nursing Home Administrator). Check Wanderguard placement or place a Wanderguard to the resident’s wrist/leg, check function of the Wanderguard, complete vital signs and assess the resident. Document what the resident was wearing, is there a change in resident baseline, document the entire episode. If the resident is not found quickly, we should call the police, notify the family/POA (Power of Attorney), MD/NP (Medical Doctor/Nurse Practitioner). Surveyor asked LPN Q if the facility does not have a Wanderguard tab what would you do? LPN Q stated report this to the NHA A and assign someone to 1:1 with resident until NOC (night shift), once resident is sleeping, we would complete frequent checks of 15-minute checks during NOC. On [DATE] at 11:54 AM, Surveyor interviewed RN P (Registered Nurse). Surveyor asked RN P if the facility has an elopement, what do you need to do after the elopement occurs. RN P stated to update the DON, take resident’s vital signs, update the family/POA, and document the event in the progress notes. On [DATE] at 12:01 PM, Surveyor interviewed RN O. Surveyor asked RN O if there is an elopement in the facility, what do you need to do after the elopement occurs. RN O said get the resident’s vital signs, a head-to-toe assessment, notify the MD and DON. On [DATE] at 9:20 AM, Surveyor interviewed MT T (Medication Technician). Surveyor asked MT T if she had received any recent training on resident elopements. MT T indicated that she had training on what to do. MT T reported that she would stop what she was doing and look for the resident. 0n [DATE] at 9:50 AM, Surveyor interviewed LPN L (Licensed Practical Nurse) asking if she had received any training regarding elopement. LPN L reported that the facility had a quiz on elopement in the last two months. The quiz covered who gets notified. Surveyor asked LPN L what she would do if she found out a resident had eloped from the building. LPN L replied she would notify management, shut down everything, lock her med cart and start looking for the resident. In halls, bed checks, elevators. If not found after 30 min call 911 or local police. On [DATE] at 11:26 AM, Surveyor interviewed ADON D (Assistant Director of Nursing). Surveyor asked ADON D would you expect every resident that is an elopement risk to have a Wanderguard put on; ADON D stated yes. ADON D stated every resident who is identified as an elopement risk has their picture in an elopement book at nurses’ station and in the employee breakroom. We place orders for function and placement checks of the Wanderguard every shift in the TAR (Treatment Administration Record). We added in the computer system to have everyone check battery life of Wanderguards. Surveyor asked ADON D what would you expect your nurses to do after an elopement. ADON D said a full assessment, update the MD (Medical Doctor), update the POA (Power of Attorney), complete an incident report, and document the event in the progress notes. Surveyor asked ADON D would you expect there to be a set of vital signs, ADON D said yes. Surveyor asked ADON D if she would you expect there to be any type of assessment, ADON D replied yes, a head-to-toe assessment. Surveyor asked ADON D if she would you expect there to be follow up documentation after an elopement, ADON D replied yes. I would expect documentation of the episode, monitoring of residents for a few days after the event, an event report and investigation to follow the elopement. Surveyor asked ADON D what would you expect staff to do if a Wanderguard is needed but there are no Wanderguard tags available, or the tags are expired. ADON D stated the resident should then be 1:1 supervision. On [DATE] at 11:42 AM, Surveyor interviewed ADON D. Surveyor asked ADON D how are the expiration dates of Wanderguards being documented. ADON D said NHA A has list of activated dates and expiration dates. On [DATE] at 2:50 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what the process would be for a late evening or weekend admission in relation to elopement process and care plan. NHA A said they would call on call nurse or manager to come in to put Wanderguard on and do the care plan. On [DATE] at 4:19 PM, Surveyor interviewed NHA A again. Surveyor asked NHA A what would you expect your nurses to do after an elopement. NHA A stated, reach out to MD, POA, myself, the DON, and complete incident report. Surveyor asked NHA A would you expect there to be a set of vital signs, NHA A said yes. Surveyor asked NHA A would you expect there to be any type of assessment, NHA A said yes. Surveyor asked NHA A would you expect there to be follow up documentation after an elopement, NHA A replied yes. Surveyor asked NHA A how the expiration dates of Wanderguards are being documented. NHA A explained that he has them set up on his calendar in his computer by serial number of devices, approximately 1 year after activation they expire so there is a week prior to this date set to remind him. Surveyor asked NHA A what you would expect staff to do if a Wanderguard is needed but there are no tags available or they are expired. NHA A stated they should reach out to me, resident will be placed on 1:1 until Wanderguard is applied. R6 was determined upon admission to be an elopement risk. The facility failed to implement interventions to ensure R6 received adequate supervision to keep R6 safe. R6 eloped from the building without staff being aware R6 left the facility. R6 was found walking down a busy street by a staff member. The facility’s failure to supervise a resident who is a known elopement risk created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement the action plan below and as evidenced by the remaining examples: Noncompliance: On [DATE] R6 was found by CNA walking down a nearby street to facility. Despite resident being assessed by admitting RN as being high risk for wandering/elopement, no measures were put into place to reduce the risk of resident leaving the facility unoccupied or without staff knowledge. Corrective Action: R6 put on 1:1 supervision immediately following incident on [DATE]. [DATE] NHA A reviewed status of Wanderguard system with staff. It was noted that potentially the current Wanderguard bands were expired and not alarming. Upon learning this, NHA A ordered new Wanderguard bands and placed staff 24/7 at exits until new bands were delivered to the facility and activated. [DATE] system was tested…and determined to be functioning. Exits still remained staff until wanderguard bands delivered to facility. [DATE] New Wanderguard bands delivered to facility. The NHA A activated bands and confirmed the function. Current residents with Wanderguards had bands replaced. The Elopement policy was reviewed and updated. Education started with staff on Elopement P/P (policy and procedure). On [DATE] education completed with remainder of staff on Elopement P/P finished up with staff. Corresponding quiz also completed by staff to determine competency of training. Facility TEL’s work order (facility system to place work orders) placed for monthly check to determine battery life of Wanderguard bands. Identification of other residents: [DATE] all residents had Elopement Risk Assessment completed to determine if any other residents at risk for elopement. All residents found to be at risk were care planned to reflect risk. Monitoring Performance: Beginning the week [DATE], NHA A or Designee to audit TELs 1x/week x 8 weeks to determine system testing for proper functioning of Wanderguard system. Beginning the week [DATE]: NHA A or Designee to monitor nursing has completed Q shift checks for Wanderguard battery lift 3x/week x 8 weeks, 2x/week x 4 weeks, 1x/week x 4 weeks. 2. The facility’s “Suicide Threats” Policy and Procedure dated [DATE], documents in part: “…1. Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. 2. The nurse supervisor/charge nurse shall immediately assess the situation and shall notify the charge nurse/supervisor and/or director of nursing services of such threats. 3. A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident’s attending physician and responsible party and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident’s behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident’s mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident’s medical record…” R18 is a short-term resident of the facility. R18 has the following diagnoses: psychosis, psychoactive substance abuse, borderline personality disorder, conversion disorder with seizures or convulsions, abnormal involuntary movements, intellectual disabilities, and anxiety disorders. R18’s most recent MDS (Minimum Data Set) dated [DATE] did not document a BIMS (Brief Interview for Mental Status) as it is documented that R18 would not answer the questions. It is documented under “C1000. Cognitive Skills for Daily Decision Making independent”. R18 does not have a care plan for trauma or suicidal ideations. R18’s Progress Notes document the following: On [DATE] 05:30 PM Resident upset with staff member asking her if she threw cigarette butts on the ground, which she denied was her. Resident began shouting profanities down the hall. Resident went down another hall attempting to go confront another resident about the cigarette butts, staff intervened before coming near resident's room. Resident shouted in hall, I just want to die. Writer wheeled resident to room and provided therapeutic communication and active listening. Writer asked resident if she had any thoughts of killing herself, no response. Writer repeated the question, no response. Writer asked resident if she had a plan to harm herself in any way, no response. Writer repeated the question, no response. Writer called for a CNA (Certified Nursing Assistant) to come in room and sit with resident while writer stepped out to call the administrator. On [DATE] 06:15 AM Administrator placed resident on 1 on 1 care with facility RA (Resident Aide) for evening due to behavioral episode. Per NHA A (Nursing Home Administrator) the above note was supposed to be corrected to the time of 6:15 PM not AM. On [DATE] 02:38 PM Resident was upset because they couldn't go to the parade on Sunday. They started making suicide comments. Saying, I just going to cut my throat, I don't want to live anymore, I'm just done with life, and I just want a sharp object. Staff was able to redirect her thoughts to a new topic on fixing cars and going to Walmart. But once the staff was saying they are going and saying bye. Resident mentioned that they are still upset about not going to the parade and wanted to hurt themself. Staff informed CNAs and Nurse about the residents’ [sic] comments and told them to keep a close eye on her and keep her mind distracted. It is important to note that there was no update to the DON (Director of Nursing), no notification to R18’s Provider or family, and no care plan was initiated. On [DATE] at 11:35 AM, Surveyor interviewed AD Z (Activity Director). Surveyor asked AD Z what he did after R18 made the suicidal statements. AD Z said he called NHA A, ADON D (Assistant Director of Nursing), and the DON, they directed me to inform R18’s Nurse and CNAs for monitoring her. Surveyor asked AD Z if he knew what nursing staff he reported this to, AD Z stated he was unsure of what CNA or Nurse was updated. On [DATE] at 11:45 AM, Surveyor interviewed CNA R. Surveyor asked CNA R if R18 had made any suicidal comments to her. CNA R said, I heard her telling her nurse “I want to die.” Surveyor asked CNA R if she knew what happened with R18 after that; CNA R replied they put her on a 24hr watch with a service aide (1:1). On [DATE] at 12:48 PM, Surveyor interviewed RN S (Registered Nurse). Surveyor asked RN S how she became aware that R18 had made suicidal comments. RN S stated, I was aware, I got her to calm down and had her with me. Surveyor asked RN S if she knew who reported the comments to her. RN S initially said she believed it was a CNA but then later she thought it was AD Z that told her. Surveyor asked RN S what she did with the information. RN S said she called ADON D (Assistant Director of Nursing) who instructed her to send R18 to the ER (Emergency Room) for evaluation. Surveyor asked RN S what the process is if a resident makes suicidal ideations. RN S explained that safety comes first so the resident can’t be left alone, update the NHA and DON, call family if applicable, notify Provider, obtain a set of vital signs, full assessment, and care plan should be done. On [DATE] at 4:01 PM, Surveyor interviewed ADON D. Surveyor asked ADON D what are your expectations if a resident makes suicidal ideations; ADON D replied, I may need to check the policy on that, but, don’t leave them, nurse should ask about a plan and details, ensure they are safe, not leave the patient alone, call their Provider, 1:1, and follow the policy. Surveyor asked ADON D would you expect there to be nursing documentation regarding suicidal ideations, ADON D stated yes. Surveyor asked ADON D how was R18 protected on [DATE] with further suicidal ideations. ADON D said she was sent to ER. Surveyor asked ADON D how it is decided when someone comes off 1:1 for suicidal ideations. ADON D replied, there’s a protocol, follow the policy, and discuss with Provider. Surveyor asked ADON D how long R18 was on 1:1 supervision on [DATE]; ADON D stated, I’d have to look. Surveyor asked ADON D would you expect there to be a care plan in place for suicidal ideations, ADON D stated yes. Surveyor asked ADON D would there be referrals for psych services, ADON D said yes, they have a service that comes to the facility. Surveyor asked ADON D what is your expectation of “keep a close eye on her and keep her mind distracted.” ADON D said she would need to verify what that means; role in Activities engage her more . Surveyor asked ADON D if R18 was on any type of monitoring upon return from ER on [DATE], ADON D stated no, she was better then, no further comments made. On [DATE] at 4:23 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if he knew how long R18 was on 1:1 supervision on [DATE]; NHA A stated until the following day. Surveyor asked NHA A how was it determined that R18 could come off 1:1? NHA A replied that R18 hadn’t made any further comments. Surveyor asked NHA A who decided that R18 could come off 1:1; NHA A said it was an IDT (Interdisciplinary Team) discussion. Surveyor asked NHA A if he would expect there to be nursing documentation surrounding a resident making suicidal ideations, NHA A stated yes. Surveyor asked NHA A what is your expectation of “keep a close eye on her and keep her mind distracted?” NHA A said that is up for interpretation. Of note, ADON D was interviewed in place of DON B as during this survey DON B resigned. 3. R10 was admitted to the facility on [DATE]. Diagnoses include Unspecified fracture of L femur, abdominal aortic aneurysm, and repeated falls. R10's most recent Minimum Data Set (MDS) target date of [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R10 was cognitively intact. Surveyors asked for a list of smokers in the facility and R10 was among the residents on the list. R10 did not have a smoking assessment or a care plan related to smoking. On [DATE] at 11:35 AM, Surveyor interviewed ADON D (Assistant Director of Nursing) who indicated she would expect residents who smoke to have a smoking assessment done and have a care plan related to smoking. 4. The facility policy, Smoking Policy - Residents, revision date of [DATE], includes, in part: .7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption; c. desire to quit smoking; d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation) .10. Any smoking relating privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . R8 was admitted to the facility on [DATE] with diagnoses that include in part: acute and chronic respiratory failure with hypoxia (condition in which the body is deprived of adequate oxygen), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream), obesity, chronic osteomyelitis right ankle and foot (an infection of the bone that causes inflammation and pain), heart disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, depression, non-pressure chronic ulcer of right heel and midfoot, type 2 diabetes mellitus, and nicotine dependence. R8's most recent Minimum Data Set (MDS), target date [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R8's cognition is moderately impaired. On [DATE], Surveyors requested a list of residents who smoke. R8 was one of the residents on the list provided by the facility. On [DATE] at 12:43 PM, Surveyor reviewed R8's Electronic Health Record and was unable to find a smoking assessment and did not see smoking on R8's comprehensive care plan. On [DATE] at 3:40 PM, Surveyor requested to see smoking assessments and smoking care plans for R8 and R10. DO V (Director of Operations) told Surveyor the facility does not have smoking assessments or care plans related to smoking for those residents. On [DATE] at 8:30 AM and 9:50 AM, Surveyor observed R8 outside smoking. Throughout the course of the survey, Surveyor observed R8 smoking outside several more times. On [DATE] at 8:35 AM, Surveyor interviewed CNA W (Certified Nursing Assistant) and asked what the process is if a resident wants to smoke. CNA W indicated she would verify with the nurse that the resident could smoke and escort them to the smoking area. CNA W indicated she would make sure resident didn't have oxygen on. On [DATE] at 8:40 AM, Surveyor interviewed RN E (Registered Nurse) who indicated residents have to be assessed when they first come in to determine they can smoke safely and how much assistance they need. RN E indicated cigarettes are kept in the med cart or medication room and residents are educated to not wear oxygen while smoking. RN E indicated she was unsure if smoking goes on the resident's care plan. On [DATE] at 11:35 AM, Surveyor interviewed ADON D (Assistant Director of Nursing) who indicated she would expect staff to complete a smoking assessment and smoking care plan for a resident who smokes. 5. Facility policy titled, Falls and Fall Risk, Managing, revision date [DATE], states in part: .Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .Monitoring Subsequent Falls and Fall Risk: .2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. dizziness or weakness) has resolved .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified . R13 was admitted to the facility on [DATE] with diagnoses that include in part: encephalopathy (brain disease that alters brain function or structure), Type 1 diabetes mellitus with diabetic polyneuropathy, schizoaffective disorder, repeated falls, weakness, shock, low back pain, moderate protein calorie malnutrition, alcohol dependence in remission, nicotine dependence, hypertension, congestive heart failure, acute respiratory failure with hypoxia, acute kidney failure, and mood affective disorder. R13's most recent MDS (Minimum Data Set) dated [DATE] states that R3 has a BIMS (Brief Interview for Mental Status) score of 14 out of 15, indicating R13 is cognitively intact. R3's most recent section GG, Functional Abilities and Goals, indicates that R13 is substantial assist for toileting and partial/moderate assistance for dressing and transfers. On [DATE] around 3:00 PM, Surveyor reviewed R13's care plan. R13's Comprehensive Care Plan states, in part: Problem start date: [DATE] Category: Falls - [Resident name] is at risk for falls due to weakness, encephalopathy. Last reviewed/revised: [DATE] Goal: Short Term Goal Target date: [DATE] - Resident will be free of falls. Approach start date: [DATE] - [Resident name] will have fall mats at bedside. *Of note, this approach does not specify when the mats should be at bedside. Approach start date: [DATE] - Implement exercise program that targets strength, gait and balance. Approach start date: [DATE] - Increase staff supervision with intensity based on resident need. Bed in lowest position. Approach start date: [DATE] - Provide individualized toileting interventions based on needs/patterns. *Of note, throughout the survey, Surveyor did not observe a fall mat in R13's room. On [DATE] at 3:30 PM, Surveyor interviewed LPN Q (Licensed Practical Nurse) and asked her what R13's current fall interventions were. LPN Q stated they would be on the Kardex on R13's door. LPN Q indicated R13 had grippy socks and floor mats. At 3:43pm, LPN Q came up to Surveyor and stated the CNA (Certified Nursing Assistant) told her R13 doesn't use the mat anymore, doesn't know when she stopped using it. LPN Q indicated she put the mat down a laundry chute to be cleaned that day. On [DATE] at 3:35 PM, Surveyor interviewed CNA X (Certified Nursing Assistant) and asked about fall interventions for R13. CNA X stated R13 uses grippy socks, making sure call light is in place and within reach, 2 hour toileting schedule, and indicated R13 doesn't use the mat anymore and doesn't remember how long it's been since R13 stopped using the fall mat. On [DATE] at 9:10 AM, CNA X and Surveyor observed the Kardex in R13's room together and noted there were no fall interventions on this Kardex which was dated [DATE]. The only interventions on the Kardex in R13's room were Activities of Daily Living, Functional Status information. CNA X stated the fall interventions should be on there. In a follow up interview on [DATE] at 9:45 AM, CNA X indicated fall interventions are in the care plan and Kardex, she would check the Kardex first, and stated the date last updated should be on both. On [DATE] ar

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who receives assisted nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R14) reviewed for nutrition and hydration.R14 has diagnoses including severe protein malnutrition, severe weight loss, and adult failure to thrive (FTT). R14 was admitted to the facility on [DATE]. R14's discharge physician orders included an order indicating NPO (Nothing by Mouth). R14 was to receive enteral feedings. (An enteral feeding, also known as tube feeding, is a method of providing nutrition directly into the gastrointestinal (GI) tract when a person cannot consume enough food or fluids orally.) R14's enteral feeding orders were not transcribed into the MAR (Medication Administration Record) resulting in R14 not receiving his enteral feeding from 6/27/25 until the staff recognized the transcription error on 6/30/25. On 7/1/25, R14 weighed 113 lbs. 7 oz. This is approximately a 12 lb. weight loss from the hospital weight of 125 lbs. 7.1 oz. recorded on 6/25/25. This is approximately a 9.6% severe weight loss in 6 days.The facility's failure to ensure R14 received nutrition and hydration to maintain acceptable parameters of nutritional status, failure to recognize R14's enteral feeding orders were not transcribed into the MAR, and failure to ensure R14 received his enteral feeding and water flushes as ordered created a finding of immediate jeopardy that began on 6/27/25. Surveyor notified NHA A (Nursing Home Administrator) of the of the immediate jeopardy on 7/2/25 at 1:10 PM. The immediate jeopardy was removed on 7/3/25, however, the deficient practice continues at a severity/scope of D (potential for no more than minimal harm/isolated) as the facility continues to implement its action plan.This is evidenced by:The facility's policy titled Reconciliation of Medications on admission revised July 2017, states in part; the purpose of this procedure is to ensure medication safety accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. General Guidelines: Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medication by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages, routes, during the admission/transfer process. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition and not interact in a negative way with other medications/supplements on the list. Medication reconciliation helps to ensure that the medications, routes, and dosages have been accurately communicated to the attending physician and care team. https://www.todaysgeriatricmedicine.com/archive/110310p8.shtml> states in part: FTT (Failure to Thrive) in older adults has been described as a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels. It may result from issues such as chronic disease and functional decline, physical and emotional deprivation, poor appetite, poor diet, or medical problems. All of these combined can easily lead to inadequate food intake, malnutrition, unintended weight loss, weakness, functional decline, and other complicating factors such as falls, impaired immune response, and poor wound healing. FTT affects 5% to 35% of community-dwelling older adults and 25% to 40% of nursing home residents. Its prevalence appears to increase with age. Studies indicate that it is associated with decreased immunity and increased rates of infection, incidence of hip fractures, pressure ulcers, surgical mortality, mortality rates, and medical costs. FTT is not a normal consequence of aging or chronic disease, and caution should be used in applying the geriatric FTT label. It should not be treated as a diagnosis or a disease or equated with frailty, and it should not signal the withdrawal of efforts to find and treat underlying causes. Instead, it should be viewed as an unexpected and significant change in normal health status, a decline in vigor, weight, and function that can affect even the healthiest of older adults. For older patients exhibiting an unintended reduction of food intake, unintended weight loss, decline in the ability to provide self-care, a decline in cognitive function, and a general decline in interest in daily life, the term failure to thrive should trigger a thorough evaluation to determine possible reversible underlying causes. https://my.clevelandclinic.org/health/diseases/22987-malnutrition> states in part: one of the most common symptoms of FTT (failure to thrive) is unintended weight loss that can result in undernutrition or protein energy malnutrition if left untreated. Depression is common in FTT, and it may be either a cause or a result of the syndrome. Depression can be a major cause of unintended weight loss, and if left untreated, it is associated with increased morbidity and mortality in FTT patients. Malnutrition happens when the nutrients it (your body) gets don't meet these needs. Undernutrition is what most people think of when they think of malnutrition. Macronutrient undernutrition also called protein-energy undernutrition, this is a deficiency of macronutrients: proteins, carbohydrates and fats. Macronutrients are the main building blocks of your diet, the nutrients that your body relies on to produce energy to maintain itself. Without them - or even just one of them - your body soon begins to fall apart, breaking down tissues and shutting down nonessential functions to conserve its low energy.Macronutrient undernutrition (protein-energy undernutrition) deprives your body of energy to sustain itself. To compensate, it begins breaking down its own tissues and shutting down its functions. This begins with its body fat stores and then proceeds to muscle, skin, hair and nails. People with protein-energy undernutrition are often visibly emaciated. Undernutrition is usually caused by not eating enough nutrients. It can also be caused by certain medical conditions that prevent your body from absorbing nutrients.R14 was admitted to the facility on [DATE] with severe protein malnutrition (severe protein-calorie malnutrition (PCM), decreased appetite, and functional decline), autism, psychosis, bipolar disorder, drug induced parkinsonism, aphasia (loss of language), and acute pyelonephritis (kidney infection).R14's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/1/25 indicates R14 has a BIMS (Brief Interview of Mental Status) score of 99 indicating R14 was unable to complete the assessment. Section K of the MDS indicates R14 is on a physician prescribed weight gain regimen and R14 is not on a weight loss regimen. R14's Care Plan dated 6/30/25 Nutritional Status states: Resident requires a feeding tube to meet their nutrition, and hydration needs and to support overall metabolic demands. Resident is malnourished at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands. Goal: Resident to maintain their weight, labs to remain within acceptable ranges, and to remain free of s/s (signs and symptoms) of GI (Gastrointestinal) intolerance of fluid imbalance. Approach: Administer tube feeding as ordered by physician. Provide free water flushes as ordered. Keep head of bed elevated 30 degrees during tube feeding administration. Check proper placement of tube feeding. Check and residuals per physician orders. Hold and resume enteral feeds as ordered. Assess any complications of aspiration, tube dysfunction, or GI intolerance. R14's hospital Discharge summary dated [DATE] states in part; [R14] has bipolar disorder complicated by (c/b) medication-induced Parkinsonism with tardive dyskinesia, who presented for decreased intake now with severe protein malnutrition, bipolar disorder, and acute food refusal by mouth. Ultimately place of a PEG (feeding tube) for nutrition. Issue: Dysphagia (difficulty swallowing) with high aspiration risk. Nutrition via G-tube (Feeding tube). Details of Hospital Stay: Psychosis (Psychosis is a mental state where a person's thoughts, perceptions, and behaviors are significantly altered, and they may lose touch with reality), Psychosis c/b medication-induced Parkinsonism and TD, Autism spectrum disorder, Hx (history of) schizoaffective with bipolar features or bipolar disorder 1, Metabolic encephalopathy, severe protein calorie malnutrition, dysphagia, multiple episodes of aspiration (food/fluid into lungs). Prior to admission noted 43-pound weight loss in 4 months (from September to January). Patient (pt) has been perseverating on food since moving to assisted living facility in February 2025. A Dobhoff (feeding tube through nose) was placed and later a G-tube (feeding tube through stomach) given life-prolonging goals of care. Was evaluated by swallow therapy multiple times and with concerns for ongoing aspiration with the brief assessment able to be completed. Experienced multiple instances of likely aspiration events including one requiring intubation and other resulting in sepsis after attempting further swallow evaluation/therapy. Ultimately determine in discussion with guardian to maintain NPO (nothing by mouth) indefinitely with ongoing nutrition via G-tube given high risk of aspiration and goal of life-prolonging care. Final nutrition plan was tube feeding of 6 cartons of Jevity 1.5 (liquid protein supplement) over 4 bolus feedings per day with free water flushes before and after each feeding for additional hydration. Physical exam at discharge: Weight: 125 lbs. 7.1 oz. (6/25/25 6:00 AM). No apparent distress, fidgeting, mumbling, thin chronically ill appearing. Diet Orders: No solids; no liquids; strict NPO. Being discharged on tube feeding to meet nutrition needs. Tube feed route: Gastrostomy; tube feeding frequency: Bolus; feeding plan: 6 cartons over 4 feeding per day. Give 1.5 cartons (355 ml (milliliters) at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM via a gravity drip over greater than 30 minutes. Flush with 135 ml tap water before and after each bolus feeding (total 8 times per day). Formula: Jevity 1.5 Cal, unflavored. Progress noted dated 6/27/25 7:31 PM: readmitted to the facility from [hospital] this afternoon by ambulance and stretcher. Full code with temporary guardianship. He has a PMH (past medical history) of bipolar I disorder c/b medication-induced Parkinsonism with tardive dyskinesia. He admitted to UW 5/3/25 from his ALF (Assisted Living Facility) due to severe malnutrition and escalating behaviors. After multiple episodes of aspirating resulting in complications, a g-tube was placed for nutrition, and he will remain NPO indefinitely. On 6/20/25 blood cultures were positive for MSSA (Methicillin-Susceptible Staphylococcus aureus) bacteremia. It refers to a bloodstream infection caused by the bacteria Staphylococcus aureus). Single lumen PICC (peripherally inserted central catheter- line inserted in skin to deliver long-term antibiotics) placed in RUE (right upper extremity) for prolonged IV abx (antibiotic) therapy until 7/20/25.R14's June 2024 physician orders state in part:Enteral feeding: Formula: Jevity 1.5 Cal, Unflavored. Start date 6/27/25. (Of note this order is incomplete.)Enteral feeding: Tube site care: Twice a day 8:00 AM and 4:00 PM. Start date 6/27/25.Enteral feeding: Change irrigation set every day. 8:00 AM. Start date 6/27/25.Enteral feeding: Elevate HOB (head of bed) 30 degrees. Continuous. Start date 6/27/25. Discontinued: 6/30/25Enteral feeding: Elevate HOB 45 degrees or greater. Continuous. Start date 6/30/25.Jevity 1.5 Cal (lactose-reduced food with fiber liquid; 0.06 gram-1.5 kcal (kilocalorie/ml); amount to administer: 1.5 cartons (355 ml); oral four times a day. Special instructions: give 1.5 cartons (355ml) at 8:00, 12:00, 1600 (4:00 PM), 2000 (8:00 PM) via gravity drip over greater 30 minutes. Flush with 135 ml tap water before and after each bolus feeding. Start date: 6/30/25.(Of note R14's complete tube feeding order was not entered into the physician orders until 6/30/25.)R14's June MAR (Medication Administration Record) indicates an order for Jevity 1.5 Cal (lactose-reduced food with fiber liquid; 0.06 gram-1.5 kcal (kilocalorie/ml); amount to administer: 1.5 cartons (355 ml); oral four times a day. Special instructions: give 1.5 cartons (355ml) at 8:00, 12:00, 1600 (4:00 PM), 2000 (8:00 PM) via gravity drip over greater 30 minutes. Flush with 135 ml tap water before and after each bolus feeding. Start Date: 6/30/25. The June MAR indicates the first feeding was administered on 6/30/25 at 4:00 PM by RN J.(It should be noted R14's first tube feeding was not signed out until 4:00 PM on 6/30/25.)On 7/1/25 at 3:00 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) regarding entering admission orders. Surveyor asked ADON D how long she has worked at the facility. ADON D stated she started in January 2025; she stated that new admissions orders are entered by her and medical records. ADON D stated she and another nurse will verify the orders that medical records enter. ADON D stated there are always two nurses who verify the orders. ADON D stated if there are treatment orders or more nursing orders she enters these orders into the medical record and has a second nurse verify the orders. Surveyor asked ADON D if she completed the admission orders for R14? ADON D stated she did and stated, that was my error. ADON D explained she thought she must have had R14 and R20's profile up on her computer and she accidentally added R14's tube feeding orders into R20's chart. Surveyor asked ADON D if she had another nurse verify R14's orders and ADON D stated, I asked RN P to verify the orders. Surveyor asked if there is anywhere in the EMR (electronic medical record) to show two nurses verified the orders and ADON D stated there is not. Surveyor asked ADON D when she was notified there was an error. ADON D stated RN J called her on Saturday and she was not on call and stated there were orders for tube feeding in R20's MAR and R20 does not have a tube feeding. Surveyor asked ADON D did RN J state you were the one to enter these orders; ADON D stated I do not recall, she just stated R20 has this order in his MAR, but he does not have a G-tube. Surveyor asked ADON D what she instructed RN J to do. ADON D stated I told her to discontinue them. Surveyor asked at any point when RN J mentioned that R20 had tube feeding orders in his chart, but no tube feeding did it occur to you to check R14 who was a new admission with a tube feeding order? ADON D stated it did not. Surveyor asked ADON D when did the facility realize R14 did not have orders in his MAR to provide tube feedings. ADON D stated on Monday afternoon, 6/30/25, I was reviewing R14's record and realized he did not have tube feeding orders. ADON D stated she immediately entered the orders from admission, called NP G (Nurse Practitioner) and let the nurse working with R14 know to administer the tube feeding. Surveyor asked ADON D is it your understanding R14 did not receive a feeding from admission on Friday until the PM shift on Monday? ADON D stated yes, that is my understanding. Surveyor asked ADON D if new orders were received and ADON D stated NP G ordered an immediate blood glucose check and labs are ordered for 7/3/25. ADON D stated, I did complete an immediate assessment of R14 and R14's blood glucose was within normal limits. R14's tube feeding was immediately started. Surveyor asked ADON D to check R14's progress notes for 6/30/24; Surveyor asked if ADON D documented the assessment findings for R14. ADON D stated she did not write a progress note. Surveyor asked ADON D if she spoke with the nurses who worked with R14 over the weekend to find the root cause of why no one recognized R14 was not receiving his tube feeding. ADON D stated she spoke with LPN L. ADON D stated I am not sure why nurses did not recognize R14 was not receiving his tube feedings, I do not know why no one questioned it. ADON D stated when I realized R14 did not have orders for his tube feedings I asked LPN L if she had provided tube feeding for R14 and she said she did not have orders to administer a tube feeding. ADON D stated it is disheartening that no one checked further into why R14 was not receiving his tube feedings. ADON D stated, I take full responsibility for making the error. Surveyor asked ADON D if anyone contacted R14's guardian; ADON D stated she left a message on Monday for the guardian but has not heard back. Surveyor asked ADON D what the facility's response was regarding the tube feeding error. ADON D stated we complete a medication error report, report to the provider, complete an assessment, vital signs, and in this case completed a blood sugar. Surveyor asked if education had been provided to the nurses. ADON D stated she would be providing education. ADON D stated she will be changing the process for completing admission orders to have two nurses looking at the new admission orders at the same time and verifying the orders together. Surveyor reviewed R20's General Orders which indicate Order Description: Tube Feed via G-tube. Frequency: Bolus. Formula: Jevity 1.5 Cal, Unflavored. Feeding Plan: Give 1.5 cartons (355ml) at 8:00, 12:00, 1600 and 2000 via gravity drip over 30 minutes. Flush with 135 ml tap water before and after each bolus feeding 8x's/day. Start Date: 6/27/25.This order was entered into R20's medical record by ADON D. Of note, R20 does not have a G-tube, and these orders were entered into R20's record in error. The orders entered in R20's chart should have been entered into R14's chart.R14's June MAR indicates an order for daily weights times 3 days. Start Date: 6/28/25. End Date: 6/30/25. The Information Key on the June MAR states in part: Initial parenthesized= Not Administered, see reasons. On 6/28/25 and 6/29/25, R14's MAR has the initials of LPN L with parentheses indicating the weight was not completed; there is no reason documented in R14's medical record. On 6/30/25, the MAR has RN P's initials with parentheses indicating the weight was not completed. There is no reason in R14's record indicating why the weight was not completed.R14's g-tube TAR (Treatment Administration Record) states in part; G-tube: Verify placement of G-tube. Flush with 30 ml of tap water before and after each medication administration. Start Date: 7/2/25. Discontinue Date: 7/2/25. R14's CAA (Care Area Assessment) for Nutritional Status dated 7/1/25 states in part, recent hospitalization for psychosis, acute refusal of food PO (by mouth). Multiple aspiration and hx (history) dysphagia (difficulty swallowing). Noted to have a -43# wt. (weight) loss between [DATE]-[DATE] (significant wt. loss) and presenting w/severe PCM (protein calorie malnutrition). Has dentures but does not wear/no longer fit d/t (due to) wt. loss. Confirmed TF (tube feeding) order w/nsg (nursing) prior to admitting . Ht: (height) 72in. Wt: (weight) 140.0# (6/28). BMI: 19.0 kg/m2 (normal). Wt hx 125# acute 6/27 (At hospital); [DATE] wts. 161-168#. -43#/25.6% significant wt. loss from [DATE]-[DATE]; -28#/16.7% significant wt. loss x10 mons; +15#/12% significant wt. gain x1 week (hospital D/C (discharge) to present; question accuracy d/t differing scales?). It should be noted the 140 lbs. weight recorded in R14's record for 6/28/25 is inaccurate. R14 was not weighed at the facility until 7/1/25 when Surveyor requested a weight for R14. On 7/1/25, R14's weight was recorded at 113 lbs. 7 oz. Progress notes dated 6/30/25 2:36 PM state in part; Patient seen today for initial evaluation of a stage II pressure injury to his coccyx. Pressure injury was present at time of admission on [DATE].Patient is on a strict NPO diet and has G-Tube in place. Receives Jevity 1.5- 1.5 cartons (355 mL) four times daily with 135 mL water flush after each feeding. Has PICC line to right AC (antecubital/bend in arm at elbow) which is currently infusing ABX, Cefazolin 2g/100 mL. All medications are administered via G-Tube. Progress notes dated 7/1/25 12:16 AM: NP G (Nurse Practitioner) contacted by phone for missed tube feeds over the weekend. N/O (new order) Check blood glucose 1x on 6/30/25, cmp & cbc (complete metabolic panel and complete blood count) lab order placed for 7/3/25.On 7/2/25 at 3:30 PM, Surveyor interviewed NP G regarding R14. NP G stated she was contacted on 6/30/25 at 3:02 PM by ADON D who stated she had not entered R14's tube feeding order into correct chart and R14 had not received his tube feeding. NP G stated ADON D explained day shift nurses thought the resident was receiving his tube feeding on NOC (night) shift and NOC shift thought he was receiving on day shift, and no one realized R14 was not receiving his feeding. NP G stated she ordered labs and had the staff check an immediate blood sugar which was normal.On 7/1/25 at 4:00 PM Surveyor interviewed LPN L (Licensed Practical Nurse) regarding R14. Surveyor asked LPN L if she was familiar with and had worked with R14. LPN L indicated she was not at the facility on the day of R14's admission but has worked with him since. Surveyor asked LPN L about R14's tube feeding. LPN L stated when she worked with R14 what showed up on the MAR was to do tube site care. LPN L stated, I was aware he has a tube feeding, I saw the pole for the tube feeding, and tube feeding supplies in his room; I knew R14 was to receive nutrition by a g-tube. LPN L stated R14 did not have scheduled tube feedings on her shift, so she assumed they were not scheduled on her shift. LPN L stated on Monday 6/30/25, at the end of her shift, ADON D told her she (ADON D) messed up, she said she entered R14's tube feeding orders into the medical record of another resident who resides on the north wing (R20). LPN L indicated she doesn't work the north wing, so she doesn't know the resident but heard the orders were placed on R20's MAR. LPN L indicated she was told this at 3:00 PM yesterday (6/30/25). LPN L stated R14 did not receive any of his tube feedings from the date of admission which was Friday 6/27/25 until Monday 6/30/25 on the PM shift. LPN L stated she sent a text message to NHA A (Nursing Home Administrator) regarding the incident. LPN L stated she called NP G and reported R14 had not received tube feeding since admission. LPN L stated NP G called back around 5:00 pm on 6/30/25. LPN L stated we put the tube feeding orders in yesterday 6/30/25 for 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN L indicated she told the oncoming nurse the next tube feeding was due at 4:00 PM and it's 3:00 PM, you should give it to him now. LPN L stated R14 received his first tube feeding since admission at 3:00 PM on 6/30/25. Surveyor asked LPN L the process for entering new orders into the medical record. LPN L stated she does not do admissions as she is an LPN. LPN L stated new orders are placed in Matrix (the facility's electronic health record) under orders and staff can select nursing role, treatment, medication etc. This information is placed in order entry and based off the information a resident is being admitted with from hospital or home. Staff should collaborate with whomever they receive report from and verify orders are entered into the system correctly. Surveyor asked LPN L about flushing R14's feeding tube. LPN L stated she did not have orders to flush R14's tube on her shift, which isn't uncommon as not every resident has flush orders for each shift. LPN L stated she assumed R14 was receiving flushes on other shifts. Surveyor asked LPN L if she checked R14's tube feeding site. LPN L stated yes, it's on his left upper abdomen and the tube site has always been healthy pink tissue. LPN L stated R14 was cooperative with care and able to state random things that made sense. LPN L stated he would state he wanted to stand up and he was always cooperative with g-tube site care. Surveyor asked LPN L about R14's weight. Surveyor stated it looks as if you recorded R14's weight as 140 lbs., was that accurate? LPN L stated there is a note that is taped on the computer at the nursing station that states NOC shift must complete weight sheet for day shift to fill out, then the CNA (Certified Nursing Assistant) fills it out and hands it to the nurse when completed. LPN L stated staff would mark the weight down. Surveyor asked was R14's weight obtained? LPN L stated if a weight is not obtained staff can mark as last previous weight known, refused, or unable to obtain. LPN L stated R14's weight was recorded as the last previous weight known. LPN L stated if a weight appeared incorrect staff would try to reweigh the resident the next day. Surveyor asked LPN L how often a new resident is weighed. LPN L stated daily for the first 3 days. On 7/2/25 at 8:37 AM, Surveyor interviewed RN J (Registered Nurse) and asked if she worked with R14. RN J stated either Saturday or Sunday she was asked by the LPN to come over and hang R14's IV antibiotics. RN J stated, I was not on R14's hall but did assist to hang his antibiotic one day. Surveyor asked RN J if she worked with R20 over the weekend. RN J stated yes. Surveyor asked if anything unusual occurred with R20. RN J asked are you referring to the tube feeding orders? RN J stated she noticed on Saturday that R20 had an order for Jevity to be administered via feeding tube. RN J stated R20 does not have a feeding tube. RN J stated she called ADON D and told her, ADON D entered an order for R20 to have a tube feeding but R20 does not have a g-tube, and she was calling to clarify. RN J stated ADON D stated she was at a concert and not on call. RN J stated she then texted ADON D and stated an order was put in R20's chart for a tube feeding, did you put in the wrong chart but did not hear back from ADON D until Sunday. On Sunday, ADON D told RN J she meant to put the order in another resident's chart and to go ahead and discontinue the order for R20. Surveyor asked did ADON D state who the tube feeding order belonged to and RN J stated she did not, only that it was meant to go into another resident's chart. Surveyor asked RN J if she could clarify the admission order process and how orders get into the electronic health record. RN J stated up until a few weeks ago the facility had an admissions nurse, now ADON D or medical records enters the orders. RN J stated the orders are entered from the hospital discharge summary and then the nurse can verify the orders. RN J stated, I can enter a new order, but I do not enter admission orders. Surveyor asked RN J how you verify the orders. She said if we have questions, we can look at the discharge summary and compare to the orders entered into the resident record. Surveyor asked, are you asked to verify orders? RN J stated I have not been asked to do that. On 7/1/25 at 4:14 PM, Surveyor interviewed CNA K (Certified Nursing Assistant) regarding R14. CNA K stated she worked day shift on Friday 6/27/25 and R14 was admitted to the facility at the end of her shift. CNA K stated she worked a double shift on Saturday and noticed R14 had a feeding tube, R14 was not receiving a feeding on her shift. CNA K stated it was reported to her R14 had not voided (excreted urine) on the night shift. CNA K stated R14 did not void on day shift on Saturday either. CNA K stated she noted R14 was very agitated and R14 was mumbling about food. CNA K stated she told R14 he could not have food by mouth, but the nurses would give him his feeding. CNA K stated on Saturday PM she had rearranged R14's room so staff could see him better from the hall when he was in bed or up in the recliner. CNA K stated, I moved his feeding pole close to the doorway so I could move his bed and recliner. CNA K stated on Monday when she returned to work, she noticed the tube feeding pole to be in the same spot she put it on Saturday. CNA K stated later that day when the tube feeding pole still had not moved, I asked the floor nurse, LPN L, when R14 receives his tube feeding and LPN L shared there had been a mistake and R14 had not received his tube feeding all weekend. CNA K stated, I could not believe R14 had not received any feedings from admission until Monday afternoon. Surveyor asked CNA K if she had weighed R14; CNA K stated she had not weighed R14. CNA K stated usually there is a list for the residents that need a weight, and she did not see R14 on the list.R14's Vital Report indicates R14 did not void on the NOC (night) shift of 6/28/25.On 7/1/25 at 12:50 PM, Surveyor interviewed RN E (Registered Nurse) regarding R14. Surveyor asked RN E if she could share any information regarding R14 and his tube feeding. RN E stated she understood R14's orders were not entered in R14's record upon admission and R14 did not receive his feeding from time of admission on Friday afternoon until late in the afternoon on Monday. RN E stated there were orders to flush R14's tube and to provide site care; I cannot understand how a nurse would not question or research why the resident was not receiving a tube feeding on their shift, this should have never happened. R14 is really deteriorating, he is very thin and frail. Surveyor asked RN E if resident had been weighed. RN E looked in the medical record and stated it does not appear there is a weight - I can weigh him today for you. On 7/1/25 at 2:05 PM, Surveyor interviewed R14's Guardian, Guardian F. Surveyor asked Guardian F if she was notified R14 had not received tube feedings. Guardian F stated she was not notified R14 had not received tube feedings. Guardian F stated how did this happen, my goodness he just had the tube feeding permanently placed due to him not eating. I'm just sick this has happened to him. Guardian F stated she has been newly appointed as R14's guardian; however, she is aware of his very poor nutritional status and need for feedings via a g-tube. R14 stated she would be contacting the facility to find out how this occurred.On 7/1/25 at 2:30 PM, RN E called Surveyor and reported R14's weight today was 113 lbs. 7 oz. Of note, this is approximately a 12 lb. weight loss from the hospital weight of 125 lbs. 7.1 oz. recorded on 6/25/25. This is approximately a 9.6% severe weight loss in 6 days.On 7/2/25 at 8:25 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H if she worked over the weekend with R14. LPN H stated she did work with R14. Surveyor asked LPN H if she gave R14 a tube feeding during her night shift/s. LPN H stated she did not as R14 did not have an order to receive a tube feeding, only an order to give medications and provide water flushes before and after medications.On 7/2/25 at 8:57 AM, Surveyor interviewed RN I. Surveyor asked RN I if she had worked with R14 over the weekend. RN I stated she worked Saturday night shift. Surveyor asked RN I if she had provided R14 with a tube feeding. RN I stated she had not as RN I did not have an order for tube feeding on her shift. On 7/1/25 at 12:30 PM, Surveyor observed R14 sitting up in his recliner in his room. R14 was very cachectic appearing (a condition characterized by severe weight loss and muscle wasting), very thin, frail, and restless. R14 was mumbling words but speech was unintelligible and R14 was unable to converse with Surveyor. R14's feeding was hanging and administering via gravity. R14 had a box of Jevity complete balance nutrition with fiber 1.5 cal. 355 calories/8oz. at bedside. R14 was admitted with orders to receive nothing by mouth and all enteral nutrition and water flushes to be administered via G-tube. R14's enteral feeding orders were en[TRUNCATED