Health inspection·July 10, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to administer enteral feeding (tube feeding) as ordered. This affected one (#137) out of the three residents reviewed for enteral feedings. The facility census was 140. Residents Affected - Few Findings include: Review of the medical record for Resident #137 revealed an admission date of 03/09/22 with medical diagnoses of dementia, chronic kidney disease stage III, hypertensive heart disease, dysphagia. Review of the medical record for Resident #137 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #137 had severe cognitive impairment and required substantial staff assistance for eating, dressing bed mobility and transfers. Review of the MDS revealed Resident #137 received 51% or more proportion of total calories through parenteral or tube feeding. Review of the medical record for Resident #137 revealed a physician order dated 01/28/24 for enteral feed order as needed for tube patency, check for residual prior to each intermittent feeding: if greater than or equal to 100 cubic centimeters (CC), hold tube feeding and check residual again in two hours and notify physician and/or nurse practitioner when appropriate. Review of the medical record revealed an order dated 04/09/24 for nothing by mouth (NPO) status and an order dated 06/23/24 for Jevity 1.5, 55 milliliter (ml) per hour for 22 hours via pump, on at 10 P.M., off when total volume of 1,210 ml infused. Review of the medical record for Resident #137 revealed a nurse progress note dated 07/10/24 at 11:58 A.M. which stated the tube feeding was placed on temporary hold at approximately 10:15 A.M. due to approximately 50 ml of residual volume. The note stated Resident #137 did not have any discomfort, abdomen was soft and round, placement checked, no distension noted, and not signs of distress noted. The note stated the nurse practitioner was notified, ordered to follow up within two hours and notified to continue the tube feeding. Observation on 07/10/24 at 8:40 A.M. of Resident #137 revealed tube feeding was being administered via pump at 55 ml per hour. Observation on 07/10/28 at 11:40 A.M. of Resident #137 revealed the tube feeding pump was turned off and Resident #137 was not receiving any tube feeding. Interview on 07/10/24 at 11:45 A.M. with Licensed Practical Nurse (LPN) #217 stated she had checked Resident #137's tube feeding residual at 10:15 A.M. and it was between 50-60 ml so she turned off the tube feeding for a little while. LPN #217 stated Resident #137 was not in any distress or showing any signs or symptoms of aspiration. LPN #217 stated the amount of tube feeding that had been (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365722 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)