Every finding on record at Redmont Health and Rehabilitation Center

Based on record review, interview and a facility policy titled Medicare Advanced Beneficiary Notice, the facility failed to ensure Resident Identifier (RI) # 13, RI #22, and RI #125 were issued a Notice of Medicare Non-Coverage (NOMNC) (CMS ). This affected three of three Skilled Nursing Facility (SNF) Beneficiary Protection Notices reviewed. Findings Include: A review of a facility policy titled Medicare Advanced Beneficiary Notice, dated April 2021 documented: .2. If the resident's Medicare Part A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage (CMS form ) to the resident at least two calendar days before Medicare covered services end . RI # 13 was admitted to the facility on [DATE]. RI # 22 was admitted to the facility on [DATE] and readmitted on [DATE]. RI # 125 was admitted to the facility on [DATE]. On 10/27/22 at 3:57 p.m., a SNF Beneficiary Protection Notification review was conducted. There was no evidence that RI #13, RI #22 and RI #125 were issued a SNF, NOMNC (CMS ) letter which was required. On 10/27/22 at 5:00pm., an interview was conducted with EI (Employee Identifier) #1, Regional Business Office Manager. EI #1 was asked if RI #13, RI #22 and RI #125 were given a NOMNC Form CMS- . EI #1 said, no, verbal notice was given. EI #1 was asked should RI #13, RI #22, and RI #125 have been given a NOMNC (CMS ). EI #1 said, yes. EI #1 was asked why RI #13, RI #22 and RI #125 were not given a NOMNC (CMS ). EI #1 said, staff thought the verbal notice was sufficient. EI #1 was asked why residents should be given a NOMNC (CMS ). EI #1 said so if the resident wished to appeal the decision, they could do so prior to coverage ending.

Based on interview, record reviews, and review of Centers for Medicare & Medicaid Services (CMS)Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) #23's Quarterly Minimum Data Set (MDS) dated [DATE] and RI #32's Annual MDS dated [DATE] were accurately coded to reflect RI #23's, and RI #32's active/current diagnoses. This affected two of 19 sampled residents for whom MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, revealed: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. RI #23 was admitted to the facility 8/18/21 and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #23's Quarterly MDS with an Assessment Reference Date (ARD) of 9/28/22 revealed in Section I . Pneumonia and [CONDITION(S)] marked with Yes indicating current diagnoses. A review of RI #23's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/27/22 at 2:05 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse/ MDS Coordinator. EI #2 was asked if RI #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 replied, no, they were not it was marked in error. EI #2 was asked, why was the last MDS dated [DATE] marked for Pneumonia and [CONDITION(S)]. EI #2 replied, it was marked in error. EI #2 was asked, if the MDS was coded correct if RI #23 did not have current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #2 replied no it was not coded correctly. EI #2 was asked, what was the concern when an MDS was not coded correctly. EI #2 replied, it was not an accurate account of the resident's current diagnosis. EI #2 was asked, why should an MDS reflect a resident's correct medical diagnoses. EI #2 replied, it gives an accurate account for the resident. RI #32 was admitted to the facility on [DATE] and readmitted [DATE]. RI #32 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #32's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/14/22 listed an Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 10/25/22 at 4:13 PM, RI #32 stated she/he did not have pneumonia. In an interview on 10/27/22 at 2:05 PM, EI #2, RN/MDS Coordinator stated RI #32 had pneumonia May 2022. EI #2 stated pneumonia was not a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 stated RI #32's MDS was not coded accurately since it was coded for pneumonia and pneumonia was not a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, record review and review of a facility policy ADMISSION CRITERIA, the facility failed to ensure a Level II evaluation for Resident Identifier (RI) #58 was completed as indicated when the Level I screening determined a Level II was necessary. This affected Resident Identifier (RI) #58 one of two residents sampled for Pre-Admission Screening and Resident Review (PASARR). Findings Include: A review of a facility policy with a revised date of December 2016 titled ADMISSION CRITERIA revealed . Policy Interpretation and Implementation . 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent practicable. RI #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #58's PASARR revealed . Level I Screening & Results for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Condition (RC) . MAY REQUIRE A LEVEL II . 2. Does the individual have a current, suspected or history of a Major Mental Illness . 2 a. [CONDITION(S)] . A review of a form titled PASARR LEVEL II SERVICE DETERMINATION indicated this evaluation was canceled. RI #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] RI #58's PASARR in the record was reviewed. The Level I indicated may need Level II, no Level II was in the record. On 10/27/22 at 2:36 PM, an interview was conducted with Employee Identifier (EI) #3, Social Services. EI #3 was asked, what was the facility's process for identifying residents with a Level I or Level II need. EI #3 replied, review the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #3 was asked, what mental disorder or related condition did the RI #58 have prior to admission to the facility. EI #3 replied, [CONDITION(S)]. EI #3 was asked, how did the facility identify residents needing a Level II. EI #3 replied, it depended on where the resident was coming from, they review history and diagnosis. EI #3 was asked, who was responsible for ensuring the PASARR was correct. EI #3 replied, social services. EI #3 was asked, if a Level II PASARR was needed who was responsible for submitting the information. EI #3 replied, the social worker at that time. EI #3 was asked, when should RI #58's Level II had been completed. EI #3 replied, on 6/16/21 when it was discovered it had been canceled. EI #3 was asked, who was responsible for making the referral to the appropriate state designated authority when a resident was identified as having an evident or possible Mental Disorder, Intellectual Disability or related condition. EI #3 replied, the social service person. EI #3 was asked, what would the concern be in RI #58 not having a Level II completed. EI #3 replied, not knowing if there was a mental illness or Intellectual disability or a behavior, the resident could be treated wrong.

Based on Record review, interview and a facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure a care plan was developed for Resident Identifier (RI) #1 when he/she was prescribed an anticoagulation medication. This affected one of two residents sampled for the use of anticoagulation (AC) medication. Findings Include: A review of a policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 documented: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's October 2022 physicians order documented .[MEDICATION(S)] Tablet 2.5 MG . Give 1 tablet by mouth two times a day . Order date 7/20/22 Start Date 7/20/22 . A review of RI #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented in Section N . Medications Received 7 . E. Anticoagulant . A record review on 10/25/22 at 4:11 PM revealed no care plan for the use of AC Medication [MEDICATION(S)]. On 10/27/22 at 2:08PM an interview was conducted with Employee Identifier (EI) # 2, MDS Coordinator. EI #2 was asked if RI #1 was prescribed an anticoagulant and she responded yes, it was prescribed on 7/20/22. EI #2 was asked if RI #1 had a care plan in place for the use of anticoagulant medication. EI #2 stated no, it was overlooked. EI #2 further stated RI # 1 should have a care plan in place for the use of anticoagulant medication. EI #2 was asked what was the importance of developing a care plan for the use of anticoagulation medication. EI #2 replied, to ensure there was no complications with the medication.

Based on observations, interviews, and review of a facility policy titled Cleaning and Disinfection of Environmental Surfaces, the facility failed to ensure: 1. Resident Identifier (RI) #54's mattress did not have a large smear of a brown substance covered by a sheet and 2. RI #34's side rail was free of a dried brown substance for two days. These observations were made on days one and two of the survey and affected two of 24 residents whose enviroment was observed. Findings include: A review of a facility policy titled Cleaning and Disinfection of Environmental Surfaces with a revised date of (MONTH) 2009 revealed, . Policy Interpretation and Implementation . 9. Housekeeping surfaces . will be cleaned on a regular basis . and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis . and when surfaces are visibly soiled. 15. potentially infectious materials will promptly be cleaned and decontaminated. 1. RI #54 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 12/10/19 at 9:11 AM, an observation was made when the surveyor entered the room to interview RI #54. RI #54 was laying on the bed. There were no sheets on the bed and the room smelled of bowel movement (BM). The surveyor observed on the mattress a large smear of a brown substance and RI #54 was laying on it. On the floor, near the sink cabinet, was linen soiled with a brown substance and a pair of pajama pants. On 12/10/19 at 9:16 AM, a Certified Nursing Assistant (CNA) entered the room. An interview was conducted with Employee Identifier (EI) #6, the CN[NAME] EI #6 was asked what was on the floor. EI #6 replied, she really did not know; it looked like a top sheet and pajamas RI #54 had on. EI #6 was asked what was on the sheet. EI #6 replied, she did not know, it did not look like BM (bowel movement/ feces). EI #6 was asked if she was caring for RI #54 that day. EI #6 replied, yes. EI #6 was asked if she put the linens and pajama pants on the floor. EI #6 replied, no she did not; he/she (resident) must have done it. The surveyor left the room so the CNA could clean up. The surveyor stood outside RI #54's room in the hallway. On 12/10/19 at 9:29 AM, the surveyor went into RI #54's room and observed the bed made. The surveyor asked EI #6 to pull back the bed covers and reveal the mattress. The covers were pulled back and the surveyor observed the brown substance was still on the mattress. EI #6 was asked what did the substance on the mattress look like to her. EI #6 replied, BM, she did not see that when she made the bed. On 12/10/19 at 12:30 PM, a second interview was conducted with EI #6. EI #6 was asked when she entered RI #54's room what was on the floor. EI #6 replied, linen. EI #6 was asked where was RI #54. EI #6 replied, in the bed. EI #6 was asked did she notice an odor in the room. EI #6 replied, yes BM. EI #6 was asked did she see BM on the mattress. EI #6 replied, no not until she was asked to identify what it was. EI #6 was asked if there was soiled linens on the floor and the resident was laying on a mattress with BM on it, was that considered a clean, homelike environment. EI #6 replied, no. 2. RI #34 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. On 12/09/19 at 5:11 PM, RI #34 was observed sleeping in bed. The surveyor observed on the inside of the left upper side rail was a dried brown substance. On 12/10/19 at 8:17 AM, RI #34 was sitting up in the bed eating breakfast. The surveyor observed the dried brown substance was on the inside of the left upper side rail. On 12/10/19 at 11:26 AM, an interview was conducted with EI #5, a housekeeper. EI #5 was asked to look at the left side rail and tell the surveyor what she saw. EI #5 stated, Probably some poop. EI #5 was asked who was responsible for cleaning the beds. EI #5 replied, housekeeping, or while providing care to a resident the side rail gets dirty, anybody could clean it off. EI #5 was asked if BM on the side rail created a risk to the resident. EI #5 replied, yes they could touch it. EI #5 was asked if there was BM on the side rail would that be considered a clean and homelike environment. EI #5 replied, no. On 12/10/19 at 11:31 AM, an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was asked to look on the left side rail and tell surveyor what she saw. EI #4 replied, BM. EI #4 was asked who was responsible for cleaning side rails. EI #4 replied, the CN[NAME] EI #4 was asked if there was risk to RI #34 with BM being on the side rail. EI #4 replied, there was a risk any time there was contamination with body fluid. On 12/10/19 at 11:41 AM, an interview was conducted with EI #3, LPN. EI #3 was asked to look on the side rail and tell the surveyor what she saw. EI #3 replied, BM. EI #3 was asked who was responsible for cleaning side rails. EI #3 replied, if she was the person who saw it she would clean it. EI #3 was asked how the BM got on the side rail. EI #3 replied, she did not know. EI #3 was asked if she knew how long the BM had been on the side rail. EI #3 replied, she did not know and that the beds were supposed to be wiped down everyday. EI #3 was asked if BM on the side rail caused a risk to RI #34. EI #3 replied, it depended on whether or not RI #34 was in the bed. EI #3 was asked what was the risk if RI #34 was in the bed. EI #3 replied, he/she could touch the BM then touch food, face, and other items. EI #3 was asked if there was BM on the side rail was that considered a clean, sanitary, homelike environment. EI #3 replied, no. On 12/12/19 at 8:16 AM, an interview was conducted with EI #1, Registered Nurse (RN), Director of Nursing (DON), and Infection Control Preventionist. EI #1 was asked who was responsible for ensuring resident side rails and mattresses were free of BM. EI #1 replied, on a daily basis the CNAs and housekeeping were supposed to wipe off side rails during daily cleaning. EI #1 was asked why should mattresses and side rails be free of BM. EI #1 replied, it was an infection control issue; it was unsanitary. EI #1 was asked how often were side rails and mattresses cleaned. EI #1 replied, a disinfectant was used with deep cleaning, but if CNAs saw something they should get housekeeping to spray it down and clean it. EI #1 was asked when should mattresses and side rails be cleaned when soiled with BM. EI #1 replied, immediately. EI #1 was asked what defined a clean, homelike environment. EI #1 replied, clutter free room, everything wiped down, and floors clean and mopped. EI #1 was asked did dried BM on a side rail left for 2 days and BM left on a mattress and covered with a sheet describe a clean homelike environment. EI #1 replied, no. EI #1 was asked what was the risk to the resident if there was BM on a side rail and mattress. EI #1 replied, there were multiple risks; it could cause an illness. EI #1 was asked when was it an acceptable practice to leave BM on a resident's side rail for 2 days and BM on the mattress covered with a sheet. EI #1 replied, never. On 12/12/19 at 8:42 AM, an interview was conducted with EI #2, the Housekeeping Supervisor. EI #2 was asked when he was called into RI #54's room on Tuesday (12/10/19) regarding the soiled mattress what substance was seen on the mattress. EI #2 replied, BM. EI #2 was asked who was responsible for cleaning side rails and mattresses. EI #2 replied, CNAs should when something becomes soiled; then housekeeping will come behind them and disinfect. EI #2 added if a CNA was caring for a resident and they see something is dirty they should clean it and notify housekeeping to disinfect. EI #2 was asked why should side rails and mattresses be clean and free of substances like BM. EI #2 replied, to keep down germs and it was in part, the job of housekeeping and CNAs. EI #2 was asked when should a side rail and mattress be cleaned when soiled with BM. EI #2 replied, immediately as soon as it was noticed. EI #2 was asked what defined a clean homelike environment. EI #2 replied, clean like your own home. EI #2 was asked if BM on a side rail and mattress covered up with a sheet was clean and homelike. EI #2 replied, no. EI #2 was asked when was it an acceptable practice to leave BM on a side rail and mattress. EI #2 replied, never.

Based on record reviews, interview, and review of a facility policy titled In-Service Training Program, Nurse Aide , the facility failed to ensure Certified Nursing Assistants received annual dementia management training. This affected two of three Certified Nursing Assistants (CNA)s, Employee Identifier (EI) #11 and #12, whose training records were reviewed. Findings Include: A review of a facility policy title In-Service Training Program, Nurse Aide revealed . Policy Statement All nurse aide personnel shall participate in regularly scheduled in-service training classes . 3. Annual in-service must : . f. Include training in dementia management and abuse prevention. On 12/12/19 the surveyor reviewed Continuing Education records for the facility CNAs. Upon review no in-service was noted for dementia management training for EI #11 and #12. On 12/12/19 at 11:19 AM, an interview was conducted with Employee Identifier (EI) # 8, Registered Nurse (RN), Supervisor, Staff Development. EI #8 was asked how many hours did EI #11, CNA, show on the in-service training record. EI #8 replied, 14 hours. EI #8 was asked if the training record included any in-service related to the topic of dementia. EI #8 replied, she did not see any. EI #8 was asked how many hours of in-service training was on EI #12's, CNA in-service training record. EI #8 replied, 12 hours. EI #8 was asked if the training record included any in-service related to the topic of dementia. EI #8 replied, this one did not. EI #8 was asked who was responsible for in-service training for CNAs and meeting the federal requirements. EI #8 replied, in (MONTH) and October, Human Resources was doing it and also the previous Administrator. In addition, she did handwashing training. EI #8 was asked what training was required. EI #8 replied, abuse, several part training for dementia, elder justice, HIPAA definitely, and patient rights. EI #8 was asked when should the training for dementia be done and how often. EI #8 replied, on hire, when working with that population and annually. EI #8 was asked what was the importance of meeting the training hour requirements to include dementia training. EI #8 replied, to know our staff could work with the specialty population adequately, properly, and safely.

Based on interviews, record review, and facility policies titled Antipsychotic Medication Use and Behavioral Assessment, Intervention, and Monitoring, the facility failed to ensure: Resident Identifier (RI) #38 did not receive [MEDICATION NAME], an anti-psychotic medication, without adequate monitoring including observation for side effects, effectiveness, and a baseline Abnormal Involuntary Movement Scale (AIMS). This affected one of five residents sampled for anti-psychotic medication usage. Findings Include: A facility policy titled Antipsychotic Medication Use, with a revised date of (MONTH) (YEAR) revealed . Policy Interpretation and Implementation . 16. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 17. Nursing staff shall monitor and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: . d. Neurologic: . extrapyramidal effects, . A facility policy titled Behavioral Assessment, Intervention, and Monitoring, with a revised date of (MONTH) (YEAR) revealed . Management . 10. When medications are prescribed for behavioral symptoms, documentation will include: . h. Monitoring for efficacy and adverse consequences; . Resident Identifier (RI) #38 was admitted on [DATE] and re-admitted on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #38's Physician order [REDACTED]. On 12/11/2019 at 10:32 AM, an interview was conducted with Employee Identifier (EI) #9, Registered Nurse (RN). EI #9 was asked, how did staff monitor for side effects of anti-psychotic medications. EI #9 replied, staff had target behaviors with a list of side effects specific to each resident in the computer. EI #9 was asked, what anti-psychotic medication was ordered for RI #38. EI #9 replied, she did not think any anti-psychotic medications were ordered for RI #38. EI #9 checked the orders in the Electronic Health Record (EHR) and replied, [MEDICATION NAME] 12.5 mg at bedtime. EI #9 was asked, when was the [MEDICATION NAME] started. EI #9 replied,11/8/2019. EI #9 was asked, what monitoring for side effects was performed for [MEDICATION NAME] for RI #38. EI #9 replied, there was none. EI #9 was asked, was there any monitoring for side effects being performed by staff. EI #9 replied, no. EI #9 was asked, why was monitoring for side effects not being performed. EI #9 replied, the order was not put in to add the side effect monitoring task on the Electronic Medication Administration Record (eMAR). EI #9 was asked, what was the potential harm to a resident when an anti-psychotic medication was administered and side effects were not appropriately monitored. EI #9 replied, with it being a new drug order she should have been looking for side effects such as [MEDICAL CONDITION] and sedation, and was not because she did not know [MEDICATION NAME] was being administered to RI #38. EI #9 was asked, were those side effects being monitored. EI #9 replied, she floated and administered medications at different medication carts. EI #9 added, since the order to monitor for side effects was not on the task list and the [MEDICATION NAME] was not administered on her shift; she did not know RI #38 was on [MEDICATION NAME] and to monitor for side effects. On 12/11/2019 at 11:15 AM, an interview was conducted with EI #10, RN, Unit Manager. EI #10 was asked, what was the potential harm to a resident who received [MEDICATION NAME] and not a task to monitor in place for side effects of the [MEDICATION NAME]. EI #10 replied, staff could not monitor for side effects if there was not a task on the eMAR. On 12/11/19 at 4:32 PM, a second interview was conducted with EI #10, RN, Unit Manager. The document titled, Physician order [REDACTED].#38 was reviewed with EI #10. EI #10 was asked, what did the order dated 12/11/2019 regarding anti-psychotic medications prompt staff to do. EI #10 replied, the task prompted staff to look for over sedation, monitor effectiveness, and monitor for the listed side effects on order. EI #10 was asked, when the order above mentioned to monitor for side effects of anti-psychotic medications was not ordered, where did nurses document the monitoring of side effects. EI #10 replied, staff could document in progress notes and 24-hr notebook. EI #10 was asked, was there any documentation that staff monitored for side effects of anti-psychotic medication of [MEDICATION NAME]. EI #10 replied, no, neither the 24-hour notebook nor progress notes contained any documentation the monitoring for [MEDICATION NAME]. EI #10 was asked, did the facility monitor Abnormal Involuntary Movement Scale (AIMS) scores. EI #10 replied, yes. EI #10 was asked, was an AIMS assessment performed and documented for RI #38. EI #10 replied, no. EI #10 was asked, were side effects and effectiveness of [MEDICATION NAME] appropriately monitored for RI #38. EI #10 replied, no. On 12/12/2019 at 8:58 AM, an interview was conducted with EI #1, RN, Director of Nursing (DON). EI #1 was asked, how did staff know to monitor for side effects and effectiveness of anti-psychotic medications. EI #1 replied, a task should appear on the eMAR to prompt staff to monitor for side effects and effectiveness. EI #1 was asked, when the task to monitor for a medication was not on eMAR and staff were not aware the resident was on a medication, how could staff monitor for side effects and effectiveness of the medication. EI #1 replied, staff could not. EI #1 was asked, what was potential harm to a resident if side effects and effectiveness of an anti-psychotic medication were not being monitored across all shifts. EI #1 replied, side effects specific to the drug could go unnoticed and possibly improperly treated. On 12/12/2019 at 10:38 AM, a second interview with EI #1, RN, DON was conducted. EI #1 was asked, when were AIMS observations completed and documented for residents with anti-psychotic medication ordered. EI #1 replied, when the medication was started and bi-annually thereafter. EI #1 was asked, was an AIMS performed for RI #38. EI #1 replied, no. EI #1 replied, what would potential harm to a resident started on an anti-psychotic medication without baseline AIMS observation. EI #1 replied, staff could miss identifying side effects of anti-psychotic medications.

Based on record review, interviews, and a facility policy titled Antipsychotic Medication Use, the facility failed to provide continued medical justification and indicated duration for as needed [MEDICATION NAME] for Resident Identifier (RI) #48 and RI #70. This affected two of six residents whose medical record was reviewed for as needed [MEDICAL CONDITION] medications. Findings Include: A facility policy titled Antipsychotic Medication Use, with a revised date of (MONTH) (YEAR) revealed . Policy Interpretation and Implementation . 14. The need to continue PRN (as needed) orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . . 1) RI #48 was admitted to the facility on [DATE] and re-admitted on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #48's medical record revealed a physician's orders [REDACTED]. 0.5 milligram (mg) . Frequency: every four hours- PRN . Special Instructions: one tab every fours hours per gastric tube PRN anxiety / agitation . An interview was conducted with Employee Identifier (EI) #9, Registered Nurse (RN) on 12/11/2019 at 10:45 AM. EI #9 was asked, what medication was ordered for RI #48's anxiety/ agitation. EI #9 replied, the resident was on 0.5 mg of [MEDICATION NAME] every four hours as needed for anxiety/agitation. EI #9 was asked, when was the as needed [MEDICATION NAME] ordered. EI #9 replied, 10/25/19. An interview was conducted with EI #10, RN, Unit Manager on 12/11/2019 at 4:50 PM. EI #10 was asked, was there a physician documented rationale and indicated duration for the order of [MEDICATION NAME] on 10/24/19 for RI #48. EI #10 replied, No. 2) RI #70 was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. A review of RI #70's medical record revealed a physician's orders [REDACTED]. Special Instructions: 0.5 milliliter (1 mg total) into the muscle every 6 hours as needed for [MEDICAL CONDITION], order date 8/19/2019 through Open Ended . and . [MEDICATION NAME] 0.5 mg gastric tube three times per day PRN for agitation, order date 10/11/19 through Open ended . An interview was conducted with EI #1, RN, Director of Nursing on 12/12/2019 at 8:48 AM. EI #1 was asked, was [MEDICATION NAME] a [MEDICAL CONDITION] medication. EI #1 replied, yes. EI #1 was asked, when should [MEDICATION NAME] be ordered as needed by a provider without an indicated duration or a provider documented rationale for duration greater than 14 days. EI #1 replied, never. EI #1 was asked, what was the ordered duration for the PRN [MEDICATION NAME] ordered on [DATE] for RI #48. EI #1 replied, there was not a duration. EI #1 was asked, who documented the rationale for PRN [MEDICATION NAME] use without an indicated duration which was ordered on [DATE] for RI #48. EI #1 replied, no one. On 12/12/2019 at 11:07 AM, an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was asked, what was the duration for RI #70's PRN [MEDICATION NAME]. EI #4 replied, there was not a stop date. EI #4 was asked, was there a physician documented rationale or indicated duration for the order of [MEDICATION NAME] on 10/11/2019 or 8/19/2019. EI #4 replied, no.

Based on observation and interviews, the facility failed to ensure the box that contained the controlled [MEDICATION NAME] ([MEDICATION NAME]) was permanently affixed in the medication refrigerator in the Station 2 medication room. This was observed on 12/12/19 and affected one of two medication room refrigerators observed for stored medications. Findings Include: On 12/12/19 at 10:10 AM, the surveyor observed the medication room at station 2 with Employee Identifier (EI) #7, Licensed Practical Nurse. The surveyor asked what was stored in the refrigerator. EI #7 replied, medications only. EI #7 opened the locked refrigerator; the surveyor asked if there was stock [MEDICATION NAME] in the refrigerator. EI #7 replied, yes and removed the locked box from the bottom shelf. The surveyor asked what was in the box. EI #7 replied, three vials of two (2) milliliter (mL) [MEDICATION NAME] injectable and one 30 ml bottle of liquid oral [MEDICATION NAME]. EI #7 was asked who was the medication for. EI #7 replied, the medication was stock medication. EI #7 was asked how should the locked box with the [MEDICATION NAME] in it be kept. EI #7 replied, it should be permanently secured to the refrigerator. EI #7 was asked if the box with the [MEDICATION NAME] was permanently secured to the refrigerator. EI #7 replied, no. EI #7 was asked what would the harm be in the box not being permanently secured to the refrigerator. EI #7 replied, someone could take it. On 12/12/19 at 10:40 AM, during an observation and interview with EI #1, the Director of Nursing, she was asked how should the [MEDICATION NAME] in the refrigerator be stored. EI #1 replied, in a permanently affixed box. EI #1 was asked was the [MEDICATION NAME] in the refrigerator in a permanently affixed box. EI #1 replied, it was in a box but the box was not permanently affixed. EI #1 was asked what was in the box. EI #1 replied, three [MEDICATION NAME] two mL vials and a 30 mL bottle of oral [MEDICATION NAME]. EI #1 was asked what was the harm in the [MEDICATION NAME] in the box not permanently affixed. EI #1 replied, someone could take the whole box.

Based on record review, interview, hospital records and review of a facility document titled, Admission Assessment and Follow Up: Role of the Nurse, the facility failed to ensure: 1) Resident Identifier (RI) #1 received the IV (Intravenous) antibiotic that was ordered, at the time the resident was admitted to the facility, to run continuously 24 hours. This affected one of one resident sampled for IV antibiotic. 2) RI #2 received pain medication when the resident requested it. This affected one of three sampled residents for pain medications. Findings include: 1) A review of a facility document titled, Admission Assessment and Follow Up: Role of the Nurse, revised date (MONTH) 2012, revealed steps in the procedure. One of the steps included: . 11. Reconcile the list of medications from the medication history, admitting orders, . and the discharge summary from the previous institution, according to established procedures. RI #1 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. The resident was transferred to the facility from a local hospital. At the time of RI #1's admission to the facility, medications included [MEDICATION NAME], aspirin, celecoxib, cephaexin, [MEDICATION NAME], [MEDICATION NAME], pantoprazole. [MEDICATION NAME] and [MEDICATION NAME]. Review of the hospital discharge summary revealed the document was loaded into a hospital system on 6/21/19 at 7:15 AM. According to an interview with a hospital social worker, this system allowed the nursing facility access to the documents. The summary did indicate the [MEDICATION NAME] antibiotic was switched to Dapto. On 8/14/19 at 2:57 p.m., an interview was conducted with Employee Identifier (EI) #5, Registered Nurse/Unit Manager. EI #5 was asked if she remembered RI #1. She said she did and was then asked what she remembered about the resident. EI #5 said she had come to the facility on Saturday and Sunday to help cover the IVs. She came to do RI #1's and another resident's IV. She said on Saturday she and two other nurses looked through the orders and did not see orders for IV and did not know if maybe the resident was then on PO (by mouth) antibiotic. When she looked again on Sunday, another nurse had said the IV antibiotic was in the refrigerator. EI #5 said the pharmacy would not send any medications without an order so she called the pharmacy. She asked them to send the order for the medication. EI #5 said they faxed over the order and she put it in the system (6/23/19). EI #5 said RI #1 never received the medication because the resident went out to the hospital. She said she called the facility physician and told him the resident had been there since Friday, IV was continuous and the resident had not received it and the doctor gave the order to send the resident back to the hospital. EI #5 said she explained to the doctor they just found the order on Sunday. EI #5 said she also told the Administrator. When asked how she knew she was getting this resident that required continuous IV infusion, EI #5 said EI #4, Interim Director of Nursing said they would get a new patient with an IV. EI #5 was asked how EI #4 knew about the IV. EI #5 said EI #4 was the Interim DON and she had to approve admissions. EI #5 was asked if she saw the order. She said it came from the pharmacy and she saw the med in the refrigerator, with the IV supplies, on Sunday. She said she did not know how the pharmacy got the order. When asked where the order for the [MEDICATION NAME] infusion came from and who sent it to the pharmacy, EI #5 said it had to come from the facility, the hospital does not send it to the pharmacy. EI #5 also reported that she and another nurse (EI #7, Licensed Practical Nurse) helped her looked for the IV order on both days. After the interview EI# 5, provided the surveyor with the copy of the hospital post discharge orders that the facility had faxed to the pharmacy on 6/21/19 at 3:20 pm. The order included [MEDICATION NAME] (dose) 12 grams (route) IV. The order further revealed the IV antibiotic was continuous and end on 7/24/19. On 8/14/19 at 3:37 p.m., EI #7 was interviewed. She was asked what she remembered about RI #1. She said she remembered looking for the resident's chart, looking for an order for [REDACTED].#5 were looking for the chart to find the orders. She said they looked on Saturday but did not find it until Sunday. She said the orders just showed up. She said she did not know what EI #5 did with the orders, she was just helping her look for the order. A review of the facility's Physician order [REDACTED]. A review of the hospital History and Physical for RI #1, after the resident was discharged back to the hospital on [DATE] from the facility, was conducted. The document revealed for History of Present Illness, per EMS (Emergency Medical Services), nursing home that patient was discharged to did not have 24-hour nursing and thus was unable to give (resident) antibiotics. (Resident) states that (he/she) has not had . antibiotics in 2 days since arriving to the nursing home. Resident had denied any issues/ changes to the EMS staff. 2) RI #2 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #2's medications included [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams 1 tablet every four hours as needed. RI #2's pain medication also included Tylenol every six hours and [MEDICATION NAME] twice a day. A review of RI #2's Minimum Data Set (MDS) assessment, (ARD) assessment reference date 7/19/19, revealed the resident was cognitively intact with no issues with short or long term memory. RI #2's care plans also reflected the resident exhibiting pain related to [MEDICAL CONDITION]. On 08/16/2019 at 1:00 p.m., RI #2 was interviewed regarding not receiving pain medications as requested. RI #2 said he could not be 100% sure, but on (MONTH) 10 th, he/she probably took one or two pills for pain. RI #2 reported that on (MONTH) 10 th, he asked his/her nurse, LPN EI #10, about the pain pill. RI #2 said the nurse told him/her it was in the residents cup of medicine and that it had already dissolved. RI #2 did say he/she takes medication in applesauce sometimes, but said he/she knew what a dissolved pill would taste like. A review of the Controlled Substances Proof Of Use form and the Medication Administration History forms for (MONTH) 2019, was conducted. According to the Controlled Substances Proof Of Use form the pain medication [MEDICATION NAME]-Acetamin 7.5-325 was indicated to have been removed from the pack at 9:15 am, 4:30 p.m. and 8:45 p.m. on 8/10/19. According to the Medication Administration History form, the [MEDICATION NAME]-Acetamin was signed by nurses to have been given to the resident at 9:15 am. There was no other documentation to show the resident had been given the other two pills that had been signed out at 4:30 pm and 8:45 pm. This citation was written as a result of the investigations of complaint/report #AL 421 and AL 403.

Based on interviews, medical record review, and a review of the facility's policy titled,Admission Criteria, the Administrator's Job Description, the Director of Nursing's Job Description, the hospital's Post-Discharge Orders Documentation for RI #1, the hospital's messaging system for communicating from the hospital to the facility, and the facility's Resident Progress Notes, the facility failed to ensure administrative staff did not admit Resident Identifier (RI) #1, with a physician's orders [REDACTED]. The resident was ultimately sent back to the hospital, two days after being admitted to the facility, due to the resident not receiving the IV antibiotic as ordered. This affected one of one residents sampled for IV therapy. Findings Include: A review of the facility's policy titled, Administrative Criteria, with a revised date of (MONTH) (YEAR), revealed: Policy Statement Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives to our admission criteria policy are to: . b. Admit residents who can be cared for adequately by the facility. 10. The acceptance of residents with certain conditions or needs may require authorization or approval by the Medical Director, Director of Nursing Services, and/or Administrator. A review of the facility's Job Description for the Administrator, with an Effective Date 01/01/2018, revealed: . SUMMARY Responsibility for the overall management of the facility. Plans, develops, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Ensures the quality and appropriateness of resident / patient care needs meets or exceeds company and regulatory standards. A review of the facility's Job Description for the Director of Nursing (DON), with and effective date of 01/01/2018, revealed: . SUMMARY Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents. Ensures quality care that is consistent with company and regulatory standards. ESSENTIAL DUTIES AND RESPONSIBILITIES . * Ensures nursing staff is providing quality and appropriate resident / patient care that meets or exceeds company and regulatory standards. A review of the hospital's messaging system to the facility revealed: .Continuous frequency means you hook it up once, but the antibiotic runs continuous for a 24 hour period. A review of the document loaded into the hospital messaging system on 6/21/19 at 07:15 a.m. titled, Extended Care Facility Transfer, page 2, revealed: Additional ID (Infectious Disease) orders: THIS PATIENT IS ON IV ANTIBIOTICS. PLEASE REFER TO THE SEPARATE D[NAME]UMENT TITLED POST DISCHARGE ORDERS FOR SPECIFICS ON THE ANTIBIOTIC AND LAB ORDERS. A Review of the POS [REDACTED] . IV antibiotics to end 7/24 . continuous infusion will run until out change once a day . [MEDICATION NAME]: Dose: 12 gm (grams) Route: IV . This is the order that was faxed from the facility to the pharmacy on 6/21/19 at 3:20 pm. This order was then faxed back to the facility on [DATE] at 3:27 pm for the clarification that this was the order received by the pharmacy. EI #5 had requested this fax from the pharmacy. A review of the facility's document titled, Resident Progress Notes: . 06//23/2019 at 10:54 a.m. revealed: This writer called (pharmacy) to verify IV ABT (antibiotic) medication orders. Orders were faxed to writer from pharmacy. Dr. (doctor's name) was notified of resident not receiving his/her [MEDICATION NAME] IV 12 gm since admission on Friday. MD (Medical Doctor) was informed that dose is continues (continuous) and the facility is unable to provide continues (continuous)IV therapy for six weeks. A new order was given to transfer resident back to (hospital name). RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 8/13/19 at 1:03 p.m., an interview was conducted with the hospital social worker that RI #1 was discharged from on 6/21/19. The social worker reported the resident was not able to return home after the hospitalization because RI #1 required IV antibiotic. She said the hospital's Infectious Disease put in the post discharge orders saying the resident needed IV antibiotic with [MEDICATION NAME] which needed to be infused continuously for 24 hours. The social worker reported she reached out with two facilities willing to accept the resident with [MEDICATION NAME]. She said the hospital's messaging system was uploaded with the post discharge orders for IV antibiotic loaded from the chart to the facilities for [MEDICATION NAME] 12 grams 6/18-7/24. The order was sent out electronically through their message system. The social worker said the message was sent to the previous Director of Nursing of the facility, at the time the resident was discharged from the hospital. The social worker said the DON asked about the IV frequency, did that mean once a day. The DON was told the antibiotic ran for a 24 hour period. She said the DON asked her to call Employee Identifier (EI) #3, the Director of Marketing of the facility. The social worker reported EI #3 confirmed the facility could take the resident. The plan was to discharge the resident on 6/21/19. The resident was discharged from the hospital and accepted by the facility. The DON at the time did notify the social worker later to see if the antibiotic could be changed to something else that was not continuous. The social worker told her this was the only option. The facility accepted the resident for the continuous infusion. On 8/15/19 at 9:32 a.m., EI #3, the Marketing Director of the facility at the time RI #1 was admitted to the facility, was interviewed. When asked if she remembered RI #1 she said she did and they received a referral from the hospital and she remembered talking to the Interim DON, EI #4. EI #3 said EI #1, the Administrator approved the referral, he said they had the RN (Registered Nurse) coverage. EI #3 said she then completed the admission. She said she checked all the boxes saying they could manage the the medication before the resident was admitted to the facility. She said the resident was sent out over the weekend saying they were not able to manage it. The Administrator and DON said it was a 24 hour infusion and they had the RN coverage. EI #3 said she initially went to the DON, then they went to the Administrator for clarification. She said the Administrator and DON approved the admission. RI #3 said the DON was following the instructions of the Administrator. On 8/15/19 at 10:23 p.m., EI #1, the Administrator was interviewed. He was asked who approved admissions to the facility. He reported it went through an approval process. He said the DON clinically reviewed the referral and the business office reviewed the financial info; once that info was compiled, a decision was made. EI #1 was asked if he had input into this. He said if the referral was denied, he got involved. He said he reviewed all denials. EI #1 was asked who approved RI #1 to be admitted to the facility. He said he did not remember exactly. EI #1 said it had to be financially approved, meaning the resident had some payor source, and a clinical approval, meaning they could meet the resident's needs. When asked if he had anything to do with the resident's admission, EI #1 said he did not recall having anything to do with it. He said he got a call on Sunday from EI #5, the day the resident was discharged , stating the resident had orders for continuous IV antibiotic, she had spoken to the doctor and she was making the Administrator aware. EI #1 was asked did he have the RN staff to accommodate a 24 hour IV infusion. He said he would have to check on staffing. He said sometimes the DON or Unit Manager comes in and does infusions. EI #1 was asked would he have RN staff to do a continuous 24 hour infusion. EI #1 replied, no, but if it was every 24 hours, they could have accommodated that. EI #1 was asked was the resident was admitted if the Administrator did not have the ability to do continuous IV's. EI #1 said he did not have a response to that. EI #1 was asked did EI #4 and EI #3 come and discuss RI #1 and the infusions prior to the admission. He said he did not recall, typically with admissions once they are coming, he is aware of every admission that admits to the facility. EI #1 was asked was an investigation done as to why a resident arrived at that facility for an IV infusion and did not receive it. EI #1 said he did not recall. EI #1 was asked did he refuse to accept the resident back after being returned to the hospital. EI #1 said he did not recall that; in a situation like that where a resident requires continuous antibiotic, he would approve that denial if they did not have appropriate RN coverage. This citation was written as a result of the investigation of complaint/report #AL 421.

Based on record record, interviews and the facility policy titled, Administering Medication, the facility failed to ensure staff consistently documented on the Medication Administration Record (MAR) the provisions of medications to Resident Identifier (RI) #2. This affected one of one resident whose MAR was reviewed. Findings include: A review of a facility policy titled, Administering Medication with a revised date of (MONTH) 2012, revealed the policy statement and interpretation and implementation. The interpretation and implementation included, . 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication . 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; . f. Any results achieved and when those results were observed; g. The signature and title of the person administering the drug. RI #2 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #2's medications included [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] milligrams 1 tablet every four hours as needed. RI #2's pain medication also included Tylenol every six hours and [MEDICATION NAME] twice a day. A review of the Controlled Substances Proof Of Use form and the Medication Administration History form for (MONTH) 2019 was conducted. For (MONTH) 10 th, according to the Controlled Substances Proof Of Use form the pain medication [MEDICATION NAME] 7XXX,[DATE] was indicated to have been removed from the pack at 9:15 a.m., 4:30 p.m. and 8:45 p.m. on [DATE]. According to the Medication Administration History form, the [MEDICATION NAME]- was signed by nurses to have been given to the resident at 9:15 a.m. There was no other documentation to show the resident had been given the other two pills that had been signed out at 4:30 p.m. and 8:45 p.m. The 9:15 a.m. and 4:30 p.m. dosages were signed out on the Controlled Substances form by Employee Identifier (EI) #8. EI #8 only signed on the Administration History for the 9:15 am as given. The 8:45 pm was signed on the Controlled Substances form by EI #10. EI #10 did not sign on the Administration History form as being given to the resident. On (MONTH) 11th, there were three sign outs for the [MEDICATION NAME] at 8:44 a.m., 2:45 p.m. and (unclear) p.m The 8:44 a.m. and the 2:45 p.m. were signed out by EI #8. The last sign out was documented by EI #10. The only initial on the MAR was at 8:44 a.m On [DATE] at 1:30 pm, EI #8 was interviewed. She was asked what her process was for medication administration. EI #8 replied, pull up the Electronic-Medication Administration Record, identify the medication, medication orders and card in cart and make sure the card matches the order date and not expired. She further reported identify the resident, pull cup, pop pill in cup, administer the medication and mark as given on the E-MAR. EI #8 was asked if the medication was narcotic was there anything different in the process. EI #8 replied that she would ask the pain level, location of pain, type of pain and after thirty minutes or an hour she would check for effectiveness. EI #8 was shown the Controlled Substances Proof Of Use form and a copy of RI #2's Medication Administration record. On (MONTH) 10 th and 11th EI #8 had charted on the Controlled Substance form two doses of the pain medication for the resident but only one was charted on the E-MAR. EI #8 was asked why the other dose of medication was not charted. EI #8 reported it was an oversight and it was not intentional. EI #8 was asked what the concern would be with medication not being charted on the E-MAR. She stated it is confusion, staff think the resident can have it and staff go to sign it out and they (resident) have already had one. This citation was written as the result of the investigation of complaint/report #AL 403.

Based on observations, interviews and review of the (YEAR) U.S. (United States) Public Health Service Food Code, the facility failed to ensure: (1) a container of sliced dill pickles, mayonnaise, dill relish pickles, mustard, jelly and barbeque sauce in the walk-in-cooler contained a use by date; this was observed on 10/29/18, during the initial tour of the kitchen; (2) dented cans in the dry storage were not stored with the other canned food items; this was observed on 10/29/18, during the initial tour of the kitchen; and (3) dust was not on the fan on the back of the oven and on the pipes and sprinkler heads over the serving area; this was observed on two of four days of the survey. These deficient practices had the potential to affect all 90 residents receiving meals from the kitchen. According to the facility's RESIDENT CENSUS AND CONDITION OF RESIDENTS form, the census was 108. Findings Include: (1) A review of the (YEAR) U.S. Public Health Service Food Code revealed: . 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES . On 10/29/18 at 5:20 p.m., the surveyor observed food items in the walk-in-cooler. There was a one gallon container of sliced dill pickles with an open date of 10/9 (2018), a one gallon container of mayonnaise with an open date of 10/28 (2018), a container of dill pickle relish with an open date of 10/28 (2018), a six lb (pound) container of yellow mustard with an open date of 10/18 (2018), and a four lb jar of jelly with an open date of 10/27 (2018) and a one gallon container of barbeque sauce with an open date of 10/23 (2018). None of the food items had a use by date on the container. On 11/01/18 at 9:16 a.m., the surveyor conducted an interview with Employee Identifier (EI) #5, the Dietary Manager (DM). The surveyor asked EI #5 if there was no use by date on the food item, how would staff know when not to use the items. EI #5 said by the open date on the item. On 11/01/18 at 1:16 p.m., the surveyor conducted a telephone interview with EI #6, the Dietitian. The surveyor asked EI #6, what did she expect the dietary staff to do after opening any food item. EI #6 replied, make sure it was closed and dated. The surveyor asked EI #6, dated with what. EI #6 replied when it was opened and when it needed to be used by. (2) On 10/29/18 at 5:32 p.m., the surveyor observed the dry storage food area. Observed were eight, six pound 10 ounce cans of sliced peaches and three six pound cans of cheddar cheese sauce. Two of the eight cans of sliced peaches had dents on the side of the cans and one of the three cans of cheddar cheese sauce had a dent on the side of the top rim. On 11/01/18 at 9:24 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 where should the cans with dents be stored. EI #5 said on the shelf that was labeled dented cans. The surveyor asked EI #5 why should the dented cans not be stored with the other canned food items. EI #5 said the risk of [DIAGNOSES REDACTED], especially with high protein canned food items. (3) A review of the (YEAR) U.S. Public Health Service Food Code revealed: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 . Nonfood-Contact Surfaces . (C) NonFOOD-CONTACT SURFACES . shall be kept free of an accumulation of dust . On 10/31/18 at 10:50 a.m., the surveyor observed dust like particles on the back of the oven fan. There were plate lid covers on top of the lid rack beneath the fan. On 11/01/18 at 9:33 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 what did it look like was on the back of the oven fan. EI #5 replied, that was dust. The surveyor asked EI #5 what was there a potential for if the dust came loose. EI #5 said cross contamination; dust getting on the lid dome and then getting on residents' plate. On 10/31/18 at 11:03 a.m., the surveyor observed dust like particles on the sprinkler heads and the pipes above the serving line. There were plates (inside of plate facing up) beneath the area at this time. On 11/01/18 at 9:35 a.m., the surveyor asked EI #5 what did it look like was on the sprinkler heads and on the pipes above the serving line. EI #5 said dust. The surveyor asked EI #5 what was there a potential for if the dust came loose. EI #5 said cross contamination. EI #5 said the dust could get on the plates and on the residents' tray.

Based on observations, interviews and a facility policy titled, Quality of Life-Dignity, the facility failed to ensure staff did not conduct a social conversation with another staff while feeding RI (Resident Identifier) #96 during the lunch meal on 10/31/18. This deficient practice affected RI#96, one of nine residents who required assistance with meals. Findings Include: A review of a facility policy titled, Quality of Life-Dignity with a revised date of (MONTH) 2009 documented: . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . RI #96 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 10/31/18 at 1:12 p.m., the surveyor observed EI (Employee Identifier) #2, a LPN (Licensed Practical Nurse), feeding RI #96 during the lunch meal on 10/31/18. EI #2 and EI #3, a Registered Nurse, were engaged in a social conversation while EI #2 was feeding RI #96. On 11/01/18 at 2:08 p.m., an interview was conducted with EI #2, LPN. EI #2 was asked who was she feeding on 10/31/18, during the lunch meal. EI #2 said RI #96. EI #2 was asked if she was talking/interacting with another staff while feeding RI #96. EI #2 said, Yes I was. EI #2 was asked who was the other staff she was talking to. EI #2 said, (Name) EI #3. EI #2 was asked what was she discussing with EI #3 while feeding RI #96. EI # 2 said, She quoted a bible scripture and we were discussing it. EI #2 was asked what was it considered when talking to another staff while feeding a resident or providing assistance/care to a resident. EI #2 said, I don't know. EI #2 was asked could it be considered a dignity issue. EI #2 said, It could be considered a dignity issue. On 11/01/18 at 2:26 p.m., an interview was conducted with EI #3. EI #3 was asked on 10/31/18, during the lunch meal, what was she and EI #2 discussing while EI #2 was feeding RI #96. EI #3 said something in reference to church, a scripture or the quote of the day. EI #3 was asked if EI #96 was included in the conversation. EI #3 said, No. EI #3 was asked what was it considered when staff was assisting a resident with meals and not interacting or talking to residents. EI #3 said not interacting with the resident and she said she did not interact or talk to resident while EI #2 was feeding him/her. EI #3 was asked should EI #2 have been interacting with RI #96 rather than talking to her. EI #3 said, Yes, she should have been interacting with RI #96.

Based on interview and a document review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, the facility failed to ensure RI ( Resident Identifier) #63 and RI #84 were issued a Medicare Coverage/Liability Notice. This deficient practice affected two out of three SNF Beneficiary Protection Notices reviewed. Findings Include: RI #63 was admitted to the facility on [DATE]. RI #84 was admitted to the facility on [DATE]. On 11/01/18 at 4:36 p.m., a SNF Beneficiary Protection Notification review was conducted. There was no evidence that RI #63 and RI #84 were issued a SNF, ABN(Advance Beneficiary Notice of Non-Coverage) letter which was required. On 11/01/18 at 4.59 p.m., an interview was conducted with EI (Employee Identifier) #1, Regional Business Office Consultant. EI #1 was asked if RI #63 and RI #84 were given a SNF-ABN letter. EI #1 said, No. EI #1 was asked should RI #63 and RI #84 have been given a SNF-ABN letter. EI #1 said, Yes. EI #1 was asked why were RI #63 and RI #84 not given a SNF-ABN letter. EI #1 said, I don't know,they could have been done, but got lost

Based on observations, record review and interview, the facility failed to ensure: (1) the right arm rest on Resident Identifier (RI) #35's wheelchair (W/C) was not torn; (2) the arm of RI #66's recliner chair was not torn/ripped; and (3) the right arm rest on RI #78's Geri chair was not torn/ripped. These deficient practices affected RI #'s 35, 66 and 78, three of 34 sampled residents who used a recliner chair, W/C or Geri chair. Findings Include: 1) RI #35 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #35's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/22/18, revealed RI #35 used a W/C for mobility. On 10/30/18 at 7:45 a.m., the surveyor observed RI #35 sitting in a W/C. The left arm rest of the W/C was torn. On 10/31/18 at 7:30 a.m., the surveyor again observed RI #35 sitting in the W/C. The left arm rest on the wheelchair remained torn. On 10/31/18 at 12:27 p.m., RI #35 was again observed sitting in the WC with the left arm rest torn. On 11/01/18 at 7:30 a.m., RI #35 was observed for a third day, sitting in the W/C with the left arm rest torn. On 11/01/18 at 3:42 p.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Maintenance Director. The surveyor asked EI #4 who was responsible for ensuring the residents equipment, such as the W/C's (Geri-chairs), are kept in good condition. EI #4 replied his department. The surveyor asked EI #4 should the arm rest on a resident's W/C be torn. EI #4 said no ma'am. When asked how the arm rest should look, EI #4 said if it was solid plastic it should not have any cracks in it and if it was leather it should not be torn. On 11/01/18 at 4:00 p.m., the surveyor asked EI #4 to describe the left arm rest on RI #35's W/C. EI # 4 replied it was badly torn. 2) RI # 66 was readmitted to the facility on [DATE]. On 10/30/18 at 10:26 a.m., the surveyor observed RI #66 sitting in hallway in a recliner. The recliner had jagged, torn edges on the arm of it. On 11/01/18 at 3:53 p.m., the surveyor asked EI #4 to describe the arm of RI #66's recliner chair. EI #4 described the arm of the chair as being ripped. When asked should the arm of the chair be ripped, EI #4 said no. EI #4 said the arm of the chair could be replaced. 3) RI #78 was admitted to the facility on [DATE]. On 10/30/18 at 10:36 a.m., the surveyor observed RI #78 sitting in a Geri chair with black tape on the edges of the arm rest, exposing the cushion. On 11/01/18 at 3:56 p.m., the surveyor observed RI #78 sitting in a Geri chair. The surveyor asked EI #4 to describe the end of the right arm rest. EI #4 said it was torn, ripped and need to be replaced.

Based on observations, interviews, review of the (YEAR)-2019 Fall and Winter Menus and a facility policy titled, MENUS, the facility failed to ensure RI (Resident Identifier) # 19, #34 and #66 received their dessert during the lunch meal on 10/31/18 and RI #13 and RI #22 received their dessert during the dinner meal on 10/31/18. This deficient practice affected five of nine residents observed for meals. Findings Include: A review of an undated facility policy titled, MENUS revealed: POLICY .Menus are implemented by the Dietary Manager .Well planned menus aid in meeting the nutritional and psychosocial needs of the residents . A review of a document titled, .2018-2019 Fall and Winter Menus dated 10/3/18, revealed the dessert for the lunch meal for 10/31/18 was Oatmeal Raisin Cookie and the dessert for evening meal was Fruit Crisp. RI #19 was re-admitted to the facility on [DATE] and was on a Regular Mechanical Soft Diet. RI #34 was admitted to the facility on [DATE] and was on a Regular Diet. RI #66 was re-admitted to the facility on [DATE] and was on a Regular Mechanical Soft Diet. At 1:12 p.m. on 10/31/18, the Surveyor observed dining in the DR(Dining Room)/Activity Room. RI #19, RI #34 and RI #66 did not receive a dessert on their trays. On 11/01/18 at 2:01 p. m., an interview was conducted with EI (Employee Identifier)# 7, LPN (Licensed Practical Nurse). EI #7 was asked what resident she fed on 10/31/18, during the lunch meal. EI #7 said RI #66. EI #7 was asked if RI #6 had a dessert on his/her tray. EI #7 said, No (she/he) did not. On 11/01/18 at 2:42 p.m., an interview was conducted with EI #8, CNA (Certified Nursing Assistant). EI #8 was asked what resident she fed on 10/31/18, during the lunch meal. EI #8 said RI #19. EI #8 was asked if RI #19 had a dessert on his/her tray. EI #8 said, No (he/she) did not. On 11/01/18 at 3:05 p.m., an interview was conducted with EI #9, CNA. EI #9 was asked what resident she was feeding on 10/31/18, during the lunch meal on 10/31/18. EI #9 said RI #34. EI #9 was asked if RI #34 received a dessert with his/her lunch meal. EI #9 said, No (she/he) did not. RI #13 was re-admitted to the facility on [DATE] and was on a Consistent Carbohydrate Diet. RI #22 was re-admitted to the facility on [DATE] and was on a Consistent Carbohydrate Diet. On 10/31/18 at 6:24 p.m., the Surveyor observed RI #22 eating dinner in her/his room and RI #22 did not have a dessert on his/her tray. On 10/31/18 at 6:27 p.m., the Surveyor observed RI #13 eating dinner in his/her room and he/she was not served a dessert. The Surveyor asked RI #13 if he/she requested not to have a dessert. RI #13 said, No. On 11/01/18 at 3:10 p.m., an interview was conducted with EI #5, Dietary Manager. EI #5 was asked if she was aware that three residents did not receive a dessert with the lunch meal and two residents did not receive a dessert with the evening meal on 10/31/18. EI #5 said she was not made aware of residents not receiving dessert. EI #5 was asked, with the planned menu, were residents supposed to get a dessert. EI #5 said yes they were. EI #5 was asked why were the five residents not served a dessert. EI #5 said, Just human error.

Based on observations and interviews, the facility failed to ensure the door to the dumpster was not left opened. This was observed on 10/29/18, during the initial tour of the kitchen. This deficient practice had the potential to affect all 108 residents residing in the facility. Findings Include: On 10/29/18 at 5:38 p.m., the surveyor observed the dumpster. The side door on the dumpster was open and three trash bags and a cardboard box with yellow looking gowns on the inside of it was observed. On 11/01/18 at 9:30 a.m., the surveyor conducted an interview with Employee Identifier (EI) #5, Dietary Manager. The surveyor asked EI #5 how should the door on the dumpsters be kept. EI #5 said closed. When asked what was there a potential for when left opened, EI #5 replied pests and rodents could get in the dumpster.

Based on observation, interviews, and review of Resident Identifier (RI) #1's medical record, the facility failed to allow RI #1 his/her right to smoke during the 3:00 PM to 11:00 PM shift on 04/05/2018. This deficient practice affected RI #1, one of three sampled residents. Findings include: On 04/11/2018, the Alabama State Survey Agency received an anonymous complaint which alleged staff did not allow RI #1 to smoke on 04/05/2018. RI #1 was admitted to the facility on [DATE]. RI #1's Annual Minimum Data Set (MDS) with an assessment reference date of 01/15/2018, indicated RI #1 was severely impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) of 2. On 04/11/2018 at 8:30 PM, an interview was conducted with Employee Identifier (EI) #1, a 3:00 PM to 11:00 PM shift Certified Nursing Assistant (CNA). EI #1 was asked to explain what had occurred with RI #1 on the evening of 04/05/2018. EI #1 reported the resident was agitated and upset because the resident wanted to smoke. EI #1 reported the resident could not smoke until the nurse came back to the unit because the cigarettes were locked in the medication cart. EI #1 reported RI #1 kept going to the locked unit's double doors kicking at the doors wanting to smoke. EI #1 reported RI #1 started kicking on the doors around 3:00 pm and continued into the evening. EI #1 said the resident never went to smoke that evening. On 04/12/2018 at 2:18 PM, an interview was conducted with EI #3, the Registered Nurse (RN) Unit Manager. EI #3 reported that on 04/05/2018 she had bought RI #1 cigarettes that morning. She reported she gave the resident a cigarette between 11:00 AM and 12:00 PM that day. She also reported that she explained to the resident that in order for the cigarettes to last for a few days, he/she could smoke three to four times a day and the resident had agreed. EI #3 explained that RI #1 had, until that week, been on a nicotine patch; however the resident had expressed a desire to smoke again. During a telephone interview on 04/12/2018 at 7:36 PM, EI #7, a Licensed Practical Nurse (LPN) who worked in the facility during the 3:00 PM to 11:00 PM shift on 04/05/2018, stated she was told by one of the CNAs that EI #3, the RN Unit Manager, had told them (CNAs) that RI #1 could smoke if the resident ate all his/her dinner and did not act out. EI #7 stated there should be no stipulations on when a resident could smoke. In a telephone interview on 04/13/2018 at 9:06 AM, EI #6, a Certified Nursing Assistant who worked in the facility during the 3:00 PM to 11:00 PM shift on 04/05/2018, was asked did RI #1 smoke on 04/05/2018. EI #6 replied, not during the 3:00 PM to 11:00 PM shift. When asked why not, EI #6 said because RI #1 had swung at a staff member. EI #6 explained there was a stipulation that if RI #1 did not act up and ate all his/her food, the resident could have a cigarette. EI #6 stated when RI #1 saw the others residents smoking, then he/she wanted to smoke too. When asked who gave the instructions on when RI #1 could smoke, EI #6 said EI #3, the RN/Unit Manager. On 04/13/2018 beginning at 9:50 AM, a video of the incident that occurred on the evening of 04/05/2018 was reviewed. The video revealed RI #1 never went off the unit to smoke during the 3:00 PM to 11:00 PM shift. In an interview on 04/13/2018 at 12:00 PM, EI #3, the RN Unit Manager was asked if she had told the staff that RI #1 could only smoke if the resident ate all his/her food and did not act up. EI #3 replied, she did not. When asked why the staff said she did, EI #3 stated she did not know. This deficiency was cited as a result of the investigation of complaint/report number AL 651.

Based on observation, interviews, review of Resident Identifier (RI) #1's medical record and the facility's policy titled Behavior Management Policy & Procedure, the facility failed to ensure staff did not contribute to the reported progressive escalation of RI #1's aggressive behaviors that resulted in the resident being sent to the local geri-psych unit. This deficient practice affected RI #1, one of three sampled residents reviewed for behaviors. Findings include: On 04/11/2018, the Alabama State Survey Agency received an anonymous complaint which alleged, RI #1 became agitated when the resident asked the staff to smoke and was told, that if he/she ate all his/her food and didn't act up, he/she could go smoke. The facility's undated policy titled, Behavior Management Policy & Procedure, documented: Policy Statement: It is the policy of this facility to enable residents to function at the highest level without infringing on the rights of others and to utilize non-drug therapy interventions to meet the needs of residents with psychotic and/or behaviors that cause harm or impairment in functional capacity. Purpose: To provide staff with a tool to assist them in altering and/or reducing behavioral symptoms . RI #1 was admitted to the facility on [DATE]. RI #1 had a medical history to include: Behavioral and Emotional Disorders. RI #1's Annual Minimum Data Set (MDS) with an assessment reference date of 01/15/2018, indicated RI #1 had other behavioral symptoms not directed toward others (for example, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) one to three days during this assessment period. On 04/11/2018 at 8:30 PM, an interview was conducted with Employee Identifier (EI) #1, a 3:00 PM to 11:00 PM shift Certified Nursing Assistant (CNA). EI #1 was asked to explain what had occurred with RI #1 on the evening of 04/05/2018. EI #1 reported the resident was agitated and upset because the resident wanted to smoke. EI #1 reported the resident could not smoke until the nurse came back to the unit because the cigarettes were locked in the medication cart. EI #1 reported RI #1 kept going to the locked unit's double doors kicking at the doors wanting to smoke. EI #1 reported RI #1 started kicking on the doors around 3:00 PM and continued into the evening. EI #1 said the resident never went to smoke that evening. On 04/11/2018 at 8:40 PM, an interview was conducted with EI #2, a CNA who also worked the 3:00 PM to 11:00 PM shift on 04/05/2018. EI #2 was asked to explain what she heard and saw on that evening with RI #1. EI #2 reported the resident was banging on the door with his/her feet and she asked the resident why he/she was banging on the door and to stop. EI #2 explained that RI #1 got agitated if he/she wanted something and did not get it. EI #2 was asked could the incident have been avoided. She replied it could have. In a telephone interview on 04/12/2018 at 3:15 PM, EI #4, a License Practical Nurse (LPN) was asked to explain what she knew of the incident that had occurred on 04/05/2018 with RI #1. EI #4 reported the resident was already upset when she went to the locked unit after arriving on duty. EI #4 explained it was reported to her that RI #1 had been kicking on the door all day. According to EI #4, EI #1 (CNA) was told by EI #3 (Registered Nurse (RN) Unit Manager) that the resident could not have a cigarette until the resident ate and if he/she did not act out. During a telephone interview on 04/12/2018 at 7:36 PM, EI #7, a LPN who worked in the facility during the 3:00 PM to 11:00 PM shift on 04/05/2018 stated she was told by one of the CNAs that EI #3, the RN Unit Manager, had told them (CNAs) that RI #1 could smoke if the resident ate all his/her dinner and didn't act out. EI #7 stated there should be no stipulations on when a resident could smoke. According to EI #7, later in the evening RI #1 swung at EI #1, so she called the Director of Nursing (DON) and told her what was going on. EI #7 stated when the physician was called, he gave an order to send the resident out as a direct admit to the geri-psych unit. EI #7 stated before transport had arrived to take the resident to the hospital, the resident had calmed down. EI #7 stated she communicated to the DON that the resident had calmed down. According to the EI #7, the DON told her all RI #1 wanted to do was to smoke. EI #7 stated she felt the incident could have been avoided had the staff not placed stipulations on when RI #1 could and could not smoke. In a telephone interview on 04/13/2018 at 9:06 AM, EI #6, a CNA who worked in the facility during the 3:00 PM to 11:00 PM shift on 04/05/2018, was asked did RI #1 smoke on 04/05/2018. EI #6 replied, not during the 3:00 PM to 11:00 PM shift. When asked why not, EI #6 said because RI #1 had swung at a staff member. EI #6 explained there was a stipulation that if RI #1 did not act up and ate all his/her food, the resident could have a cigarette. EI #6 stated when RI #1 saw the others residents smoking, then he/she wanted to smoke too. When asked who gave the instructions on when RI #1 could smoke, EI #6 said EI #3, the RN/Unit Manager. On 04/13/2018 beginning at 9:50 AM, a video of the incident that occurred during the evening of 04/05/2018 was reviewed. RI #1 was observed walking on the locked unit. The resident showed no signs of being agitated or upset. Approximately three to four times, the 3:00 PM to 11:00 PM staff were observed going through the unit and outside to where the staff smoke area was located. During the viewing of the video, one time RI #1 appeared visibly upset. The resident was observed to enter another resident's room that EI #1 (CNA) had just gone into a minute earlier. RI #1 looked into another resident's room and bolted in, almost running back out a few seconds later. The CNA, EI #1, followed behind RI #1. EI #1 and RI #1 was then seen coming off the unit toward the nurses' station. This was the time EI #1 had reported to the other staff that RI #1 had hit her on the shoulder. RI #1 was then taken and placed in a chair at the nurses' station. RI #1 was later returned to the unit, until transfer to the local hospital. The video revealed RI #1 never went off the unit to smoke during the 3:00 PM to 11:00 PM shift. In an interview on 04/13/2018 at 12:00 PM, EI #3, the RN Unit Manager was asked if she had told the staff that RI #1 could only smoke if the resident ate all his/her food and did not act up. EI #3 replied, she did not. When asked why the staff said she did, EI #3 stated she did not know. According to the local hospital's History and Physical, RI #1 was beating on the door of the dementia unit wanting to go smoke. When the staff attempted to redirect the resident, he/she became combative and began to strike at the staff on redirection. This deficiency was cited as a result of the investigation of complaint/report number AL 651.

Based on interviews, record review, and review of a facility policy titled "Weight/Hydration Management", the facility failed to ensure Resident Identifier (RI) #1 received adequate fluids to maintain her hydration status. RI #1's Medical Nutritional Therapy Review dated 05/08/12, under "Nutrient Needs", indicated the resident needed 1,538 cc's (cubic centimeters) fluid daily. According to RI #1's "Fluid Intake Detail Report" (amounts received for breakfast, lunch, dinner, bed time and additional fluids), the facility failed to provide the required fluid need for seven consecutive days, September 24 - 26, 2013. During this seven day period, a total of 1,175 cc's of fluid was provided to RI #1. This intake was less than the daily required need to maintain RI #1's hydration status. On 10/30/13, RI #1 was sent to a local emergency room and admitted to the hospital with [REDACTED]." According to ER records, RI #1 had a poor intake by mouth for greater than 5 days. This affected RI #1, one of six residents sampled for hydration. Findings Included: RI #1 was originally admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. A facility policy titled "Weight/Hydration Management" dated February 2010, documented: "Overview Resident's nutritional status will be monitored on a regular basis ... Nutritional status, including weight, is influenced by calories, protein, and fluid. The Federal Regulations (F - Tag 327) also indicate that residents are provided with sufficient fluid intake to maintain proper hydration and health. Clarification ... Sufficient fluid: The amount of fluid needed to prevent dehydration (output of fluids far exceeds fluids intake) and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates ..." A review of RI #1's medical record revealed an Annual Minimum Data Set (MDS) assessment, with an ARD (Assessment Reference Date) of 09/10/13. In Section C0500 - Cognitive Patterns, RI #1 was assessed to have a Brief Interview Mental (BIMS) score of 7, indicating moderately impaired cognition for daily decision making. In Section G - Functional Status, RI #1 was assessed to need extensive assistance with bed mobility, transfers, dressing and eating. A physician's orders [REDACTED]." A review of RI #1's care plan titled "Care Plan - Fluid Deficit" dated 9/2013, documented the following goal: "... RI #1 will have adequate hydration levels ... adequate urinary output ..." The approaches included "Place fluids at bedside in resident's reach, provide 6-8 ounces of fluids at each medication pass as tolerated ... " RI #1's Medical Nutritional Therapy Review dated 05/08/12, under "Nutrient Needs", indicated the resident needed 1,538 cc's (cubic centimeters) fluid daily based on RI #1's weight of 135.3 pounds. RI #1's "Dietary Progress Notes" dated 9/11/2013 (no time) documented: "Resident continues & (and) receives assistance @ (at) meals - Receives change of diet - thicken liquids to nectar consistency - due to swallowing problems - appetite noted to be good - usually 50% or more - Wt (weight) this month 108.7 # (pounds) - will follow CP (care plan) as needed - same plan." RI #1's Nurses Notes (NN) dated 9/23/13 at 2:25 p.m., documented the following: "Writer informed resident did not void this tour. Consumed 120 cc (cubic centimeter) of water, coffee and juice ... Dr. (name of Medical Director), Employee Identifier (EI) #3 paged, awaiting his return phone call. Assessment done, bladder not distended & abdomen soft. On coming nurse aware, care & observation continues." This NN was written by EI #14. A form titled "24 Hour Report/Change Of Condition" dated 9/23/13, on the 7-3 (shift) documented: "Remarks (Day) 2:25 P (P.M.) resident (RI #1) had not voided Consumed 260 cc (EI #3) paged waiting return call. Remarks (Evening) receive 240 cc fluid, void x 1. 99/57 (Blood Pressure), 60 (heart rate), 18 (resp), 97.2 (Temperature degrees Fahrenheit) ..." NN for RI #1 dated 9/23/13 at 2229 (10:29 p.m.), documented: "... Resident received a total of 240 cc liquid this shift. Resident void x's (times) 1 this shift ..." NN for RI #1 dated 9/24/13 (no time), documented: "Resident given free h20 (water) per shift ... Continue observations." An "Early Warning Tool, Stop and Watch" form for RI #1 dated 9/26/13 at 6:00 a.m., documented: "Seems different than usual. Talks or communicates less than usual." NN for RI #1 dated 9/30/13 at 1627 (4:27 p.m.), documented: "Resident transferred to (name of local hospital) ..." NN for RI #1 dated 9/30/13 at 2030 (8:30 p.m.), documented: "Report received from nurse ... states resident is being admitted to hosp (hospital) with diagnosis (diagnoses) of AMS (Altered Mental Status) and [MEDICAL CONDITION] (elevated Sodium level)." A review of the hospital emergency room (ER) records dated 9/30/13 at 2050 (8:50 p.m.), revealed RI #1 was admitted to the hospital with [REDACTED]. RI #1's condition was listed as "Guarded." RI #1 was started on IV (Intravenous Fluids) NS (Normal Saline) at 125 ml (milliliters)/hr (hour). The ER department assessed RI #1 to have a "Poor intake by mouth for > (greater than) 5 days." A review of RI #1's labs values, from the local hospital, revealed the following: "... BUN (Blood Urea Nitrogen) 126 H normal range (7-17) MG/DL (Milligrams/Deciliter) ... Sodium (x) *H normal range (137-145) MMOL/L (MiliMole/Liter) ..." A review of RI #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 24, 2013 - [DATE]. However, the documentation (MAR) failed to indicate the number of times the 120 cc's of fluid was offered. Further review of RI #1's medical record revealed the only additional fluid offered to RI #1 was 118 cc's on September 29, 2013. On 11/15/13 at 3:00 p.m., the surveyor and the Administrator, EI #6, reviewed RI #1's "Fluid Intake Detail Report." A review of this report from [DATE] - Sept. 30, 2013, revealed RI #1 received a total of 1,175 cc's of fluids during this seven day time period. On [DATE] and 30, 2013, there was no evidence RI #1 received any fluids from her 3 meal trays. Also, during this seven day period, a total of only 1,175 cc's was provided to RI #1. This intake was less than the daily required fluid needed for RI #1 to maintain her hydration status, according to the recent assessed required fluids needs for RI #1. The Fluid Intake Detail Report revealed: "Sept. 24, 2013 Sept. 25, 2013 Breakfast 120 cc's Breakfast 0 Lunch 0 Lunch 0 Dinner 100 cc's Dinner 240 cc's Hour of Sleep (HS) 0 Hour of Sleep 0 Additional Fluids 0 Additional Fluids 0 Sept. 26, 2013 Sept. 27, 2013 Breakfast 0 Breakfast 0 Lunch 0 Lunch 0 Dinner 237 cc's Dinner 120 cc's Hour of Sleep 0 Hour of Sleep 0 Additional Fluids 0 Additional Fluids 0 Sept. 28, 2013 Sept. 29, 2013 Breakfast 0 Breakfast 0 Lunch 0 Lunch 0 Dinner 240 cc's Dinner 0 Hour of Sleep 0 Hour of Sleep 0 Additional Fluids 0 Additional Fluids 118 cc's Sept. 30, 2013 Breakfast 0 Lunch 0 Dinner 0 Hour of Sleep 0 Additional Fluids 0" On 11/15/13 at 3:49 p.m., the surveyor conducted an interview with the facility's Licensed Dietitian, EI #1. The surveyor asked EI #1 who was responsible for assessing the residents for their fluid needs. EI #1 said the facility's consultant RD (Registered Dietitian's) name. The surveyor asked EI #1 what was RI #1's assessed fluid needs on the Annual MDS dated [DATE]. EI #1 said, 9/11/13 was her last note on RI #1. The surveyor asked EI #1, with a weight of 108.7 pounds, what would have been RI #1's assessed fluids needs. EI #1 said, based on 108.7 pounds, RI #1's fluid needs would be approximately 1,235 cc's to 1, 482 cc's. The surveyor asked EI #1, when was RI #1's fluid needs calculated. EI #1 said she calculated the fluid needs yesterday (11/14/13). The surveyor asked EI #1 if there was any reason RI #1's fluid needs were not assessed when the Annual MDS was completed (9/10/13). EI #1 said she did not know. EI #1 said the RD is responsible for that. The surveyor asked EI #1, what does she expect the nurses to do when a resident has poor intake. EI #1 said offer them a different variety of fluids, jello, water, juice, milk and sodas. The surveyor asked EI #1 if these items were offered to RI #1. EI #1 said she did not know. The surveyor asked EI #1, according to "Fluid Intake Detail Report" if RI #1 received adequate water for her assessed fluid needs. EI #1 said according to the Intake Sheets, RI #1 did not. The surveyor asked EI #1 if RI #1 could become dehydrated. EI #1 said, possibly. A review of RI #1's Dietary Progress Notes dated 9/11/13, revealed the facility failed to calculate RI #1's weight of 108.7 lbs. to determine her fluid needs. EI #1 recalculated RI #1's fluid needs on 11/14/2013. The Dietary Progress Note revealed: "Reviewed residents' needs for fluids - wt reported on 9/7 (2013) at 108.7 lb fluid needs as noted approx (approximately) 1235.2 - 1482 cc's fluids - Resident received approx 1320 on nectar thicken liquids." This review was done after the resident had been discharged from the facility (10/30/2013). On 11/15/13 at 6:30 p.m., the surveyor conducted an interview with one of the LPN's (Licensed Practical Nurse), EI #10, who was assigned to RI #1. The surveyor asked EI #10 who was responsible for monitoring RI #1's fluid intake during her shift (3-11). EI #10 said she was responsible. The surveyor asked EI #10 if RI #1 had a poor intake by mouth what was she suppose to do. EI #10 said mark it down, and chart it. EI #10 said she knew RI #1 was sick. The surveyor asked EI #10 if she documented anything in the nurses notes on 9/27/13 about EI #1 being sick. EI #1 said no. The surveyor asked EI #10 how would she know how much fluids RI #1 took by mouth during her shift. EI #10 said the CNA's (Certified Nursing Assistants) would tell her. The surveyor asked EI #10, if RI #1 had poor intake what was she suppose to do. EI #10 said, normally she does not call the doctor unless there was something significantly going on with RI #1. The surveyor asked EI #10 if a supplement was offered to RI #1. EI #10 said she did not remember if she gave RI #1 a house shake. EI #1 said if she signed the MAR indicated [REDACTED]'s of fluid. On 11/15/13 at 7:45 p.m., the surveyor conducted a phone interview with the Medical Director, EI #3. The surveyor asked EI #3 if he had received a call from the facility staff, saying RI #1 had declined in her overall health and had poor PO intake (of fluids). EI #3 answered he did not recall. The surveyor asked EI #3 what would he expect the nurses to do if a resident had poor intake and AMS (Altered Mental Status) from [DATE] - [DATE]. EI #3 said, he would expect the nurses to call him to get orders for labs, CBC (complete blood count) and encourage PO fluids to the resident. The surveyor asked EI #3 should the staff/nurses have called him about RI #1's poor intake. EI #3 said, yes they should have. On 11/15/13 at 8:10 p.m., the surveyor conducted an interview with EI #12, the facility's DON (Director of Nursing). The surveyor asked EI #12, when the CNA's see that a resident is taking in less fluids than normal, what are they expected to do. EI #12 stated, to notify the nurse of the change in the decrease of fluid intake. The surveyor asked EI #12 was she aware that RI #1 began to have a decrease in her fluid intake from September 24-30, 2013. EI #12 replied, not in her fluid intake, but in the decrease of her meal intake. The surveyor asked EI #12, what are the nurses expected to do when the CNA's report to them or they realize a resident has a decreased fluid intake. EI #12 said, to assess the resident. The surveyor asked EI #12, would she expect the nurse to notify her or the medical doctor. EI #12 stated, "Yes, if there is a true decline." On 11/15/13 at 8:15 p.m., the surveyor conducted an interview with EI #14, the LPN assigned to care for RI #1 during the day shift on 7 - 3 on 9/23/13. The surveyor asked EI #14 how much fluid she gave RI #1 during her shift. EI #14 said she gave RI #1 120 cc's of coffee. EI #14 said RI #1 started getting bad (shaking) that morning and didn't drink all of the coffee. The surveyor asked EI #14 what is the policy/procedure for residents refusing to eat/drink. EI #14 replied she paged EI #3 on the 23 rd at 2:25 p.m. because a CNA whose name she couldn't remember told her RI #1 hadn't had any output (voided) that shift. The surveyor asked EI #14 why she called EI #3 when RI #1 did not have an output. EI #14 stated, "That's not normal." The surveyor asked EI #14 what were the signs and symptoms of dehydration. EI #14 replied, decreased out put, increase Sodium. The surveyor asked EI #14 what was a side effect of dehydration. EI #14 stated, "Kidneys can shut down." This deficiency was written as a result of the investigation of complaint/report #AL 002.