Health inspection·June 9, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and interview, the facility failed to have clear documentation of advanced directives. This affected one Resident (#56) of three residents reviewed. The facility census was 75. Residents Affected - Few Findings included: Review of Resident #56's medical record revealed an admission date of 12/28/22 with diagnoses including Parkinson's disease, dysphagia following a cerebral infarction (stroke), gastrostomy status (PEG [percutaneous endoscopic gastrostomy] tube), bipolar, anxiety disorder, and depression. Review of the Resident #56's quarterly Minimum Data Set (MDS) assessment, dated 03/16/23, revealed she was rarely/never understood and had short-term and long-term memory problems. Review of Resident #56's physician orders revealed two conflicting orders for advanced directives. Her physician order, dated 12/28/22, identified she was a full code (cardiopulmonary resuscitation would be performed) and her physician order, dated 06/02/23, identified she was a Do Not Resuscitate - Comfort Care (DNR-CC). Review of Resident #56's Ohio DNR-CC form revealed it was signed by her guardian and physician on 06/02/23. Interview on 06/09/23 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #56 had conflicting advanced directive orders in her electronic medical record of full code and Do Not Resuscitate - Comfort Care. She verified it would be confusing to know whether or not to start cardiopulmonary resuscitation with both orders. This deficiency is cited as an incidental finding to Complaint Number OH00143297. Page 1 of 4 365485 365485 06/09/2023 Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on on interview, record review, and facility policy review, the facility failed to implement dietary supplement recommendations and failed to to administer dietary supplements as ordered. This affected one Resident (#56) of three residents reviewed for dietary. The facility census was 75. Residents Affected - Few Findings included: Review of Resident #56's medical record revealed an admission date of 12/28/22 with diagnoses including Parkinson's disease, dysphagia following a cerebral infarction (stroke), gastrostomy status (PEG [percutaneous endoscopic gastrostomy] tube) , bipolar, anxiety disorder, and depression. Review of Resident #56's admission nursing assessment identified she was admitted with a weight of 142.6 pounds. Review of the Resident #56's quarterly Minimum Data Set (MDS) assessment, dated 03/16/23, revealed the resident was rarely/never understood and had short-term and long-term memory problems. The resident was totally dependent of one person to physically assist for eating. The assessment indicated the resident had a weight of 130 pounds, had no weight loss or gain, received a mechanically altered therapeutic diet. Review of Resident #56's plan of care, dated 01/10/23 revealed she had a nutritional risk related to Parkinson's disease, asthma, dysphagia, bipolar disorder, anxiety disorder, gastronomy status, PEG tube, edentulous status, poor intake, and significant weight loss and altered nutrition needs. One of the interventions included to provide enteral nutrition (nutritional support through the PEG tube) as ordered. Review of Resident #56's physician order, dated 12/28/22, identified she was to receive a regular diet, pureed texture, regular (thin) consistency. There were no orders for enteral feeding through the PEG tube. Further review of Resident #56's physician order, dated, 01/10/12 to 01/19/23 revealed she was to receive 2.0 supplement 120 milliliters (ml) two times a day. Her physician orders, dated 01/19/23 to 03/11/23, identified she was to have the 2.0 supplement 120 ml three times a day via her PEG tube. Resident #56's physician order, dated 03/11/23 to 05/18/23, identified she was to receive 2.0 supplement 120 ml four times a day via her PEG tube. Her physician order, dated 05/18/23 to current, identified she was to receive 2.0 supplement 120 ml five times a day via her PEG tube. Review of Resident #56's January 2023 medication administration record (MAR) revealed she did not receive her supplement as order on 01/10/23 (one dose missed), 01/19/23 (two doses missed), or 01/20/23 (all three doses missed). Review of her March 2023 MAR revealed she did not receive her supplement as ordered on 03/11/23 (two doses missed), 03/12/23 (all four doses missed), and on 03/13/23 (all four doses missed). Review of her May 2023 MAR revealed she did not receive her supplement as ordered on 05/18/23 (four doses missed), 05/19/23 (all five doses missed), 05/20/23 (all five doses missed), 05/21/23 (all five doses missed), 05/22/23 (all five doses missed) and 05/23/22 (four doses). Review of Resident #56's dietary progress note, dated 04/18/23, revealed she had a non-significant weight change times one week and the dietitian recommended changing her order for 2.0 Supplement 120 ml from four times a day via her PEG tube to five times a day via her PEG tube to further supplement her intake. 365485 Page 2 of 4 365485 06/09/2023 Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #56's dietary progress note, dated 05/18/23, revealed she had a significant weight change of an 8.1% loss in one week and again recommended changing her order for 2.0 Supplement 120 ml from four times a day via her PEG tube to five times a day via her PEG tube to further supplement her intake. Review of Resident #56's dietary progress note, dated 05/25/23, revealed had a recent significant weight loss was noted and indicated that Resident #56 may not have been receiving her ordered enteral nutrition support. Review of Resident #56's dietary progress note, dated 06/01/23, revealed she had a recent significant weight loss noted and indicated that SR #56 may not have been receiving her ordered enteral nutrition support. Review of the Nutrition Therapy Recommendation, dated 04/18/23, revealed Dietitian #198 recommended Resident #56 receive 2.0 supplement 120 ml five times a day via her PEG tube. Telephone interview on 06/09/23 at 11:14 A.M. with Dietitian #198 revealed he thought Resident #56 was not receiving her 2.0 supplement because it should have been providing all of her nutritional needs. He reported he discovered this on 05/25/23 and informed nursing of his concerns. Telephone interview on 06/09/23 at 11:35 A.M. with Dietitian #198 revealed Resident #56's weight had been relatively stable. He reported that on 04/18/23 he had recommended her 2.0 supplement be increased to five times per day. However, this recommendation was not implemented. He reported he evaluated her on 05/18/23 and made the same recommendation to increase the 2.0 supplement to five times per day and her weight did trend upward. Dietitian #198 reported the process for dietary recommendations was he would put them into the electronic health record (Point Click Care) and send a form to the Director of Nursing (DON) and Registered Nurse (RN) # 116. Interview on 06/09/23 at 11:41 A.M. with the RN #116 revealed she was aware of Resident #56 having a weight loss, but that the resident had been having a steady decline in all aspects of life and that is why the family has decided to have hospice services provide end of life care. Interview on 06/09/23 at 11:45 A.M. with the Director of Nursing (DON) revealed the dietitian emailed his recommendations to her after he sees the residents in the facility and the dietitian puts the recommended order in the electronic health record. Interview on 06/09/23 at 12:06 P.M. with the DON revealed the dietitian did email his recommendation to her on 04/18/23 for Resident #56 to have her order for 2.0 supplement 120 ml four times a day via her PEG tube increased to five times daily via her PEG tube to further supplement her intake. The DON reported the email was unopened and for some reason she did not open the email. She reported the recommendation for Resident #56 was not implemented. She reported the dietitian did not put the order in the electronic health record for the recommendation. Review of the emailed documentation titled, Nutrition Therapy Recommendations, dated 04/18/23, at the time of the interview confirmed the recommendation for Resident #56's 2.0 supplement 120 ml to be increased from four times a day to five times a day. Interview on 06/09/23 at 12:10 P.M. with the DON verified there were boxes without documentation of administration of her dietary supplement on Resident #56's January, March, and May 2023 MARs. She was unable to explain why there was no documentation of the supplement administration. 365485 Page 3 of 4 365485 06/09/2023 Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone interview on 06/09/23 at 12:27 P.M. with Dietitian #198 revealed the email with the Nutrition Therapy Recommendations form is the main communication for needed dietary changes for residents. He reported he only recently started putting orders into the electronic health record pending approval to assist the nursing staff. Interview on 06/09/23 at 3:18 P.M. with the DON verified if she would have opened her email and seen the recommendation from Dietitian #198 and not seen a corresponding order, she would have reached out to him to verify what was needed for Resident #56. Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2022, revealed the physician will authorize and the staff will implement appropriate general or cause-specific interventions, as indicated, with careful consideration of the following: supplementation Strategies to increase a resident's intake of nutrients and calories may include fortification of foods, increasing portions sized at mealtimes, and providing between-meal snacks and/or supplementation. This deficiency represents non-compliance investigated under Complaint Number OH00143297. 365485 Page 4 of 4