Every finding on record at Signature Healthcare of Rogersville

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 1 resident (Resident #49) of 71 residents reviewed for dignity. The findings include: Review of the facility policy titled, Resident Rights, revised 8/16/2018, showed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Resident #49 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 0 indicating the resident had severe cognitive impairment. The resident required extensive assistance of one staff member for eating and had received speech therapy 5 days of the last seven days. During an observation on 9/6/2022 at 11:13 AM, showed a sign taped to the wall above Resident #49's bed .When feeding Resident .Small bites/sips .Alternate food and liquid (At least 2 sips of liquid after each bite) .Cue resident to swallow by slight pressure to cheeks, downward motion on her throat, and downward pressure of spoon .Use tongue depressor to remove food from cheeks to the tongue .No straws .Speech . The signage was visible to anyone who entered the resident's room. During interview and observation on 9/7/2022 at 2:20 PM, Licensed Practical Nurse (LPN) #1 confirmed the signage was present over Resident #49's bed and visible to anyone who entered the resident's room. She stated the sign had been placed there by the speech therapist. LPN #1 stated she was unaware if the family gave permission to hang the sign above the bed. During an interview on 9/7/2022 at 2:35 PM, the MDS Coordinator, confirmed there was no documentation the family had requested or agreed to have the sign placed above the bed. During an interview on 9/8/2022 at 9:14 AM, the Director of Nursing (DON) stated resident medical information was not to be visibly posted unless requested by the resident or family due to privacy. She confirmed the sign that had been hung above Resident #49's bed would be visible to anyone who entered the room. The DON confirmed there was no documentation the family had requested the sign to be hung above the bed.

Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 1 resident (#53) of 18 residents reviewed. The findings include: Review of the facility policy titled, Comprehensive Care Plans, last revised [DATE], showed The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .Reflect the resident's expressed wishes regarding care and treatment goals .Care plans are ongoing and revised as information about the resident and the resident's condition change .The care plan should reflect the current status of the resident and be updated with changes in the residents [resident's] status . Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's comprehensive care plan updated [DATE], stated .Honor resident?s [resident's] Advanced Directive and/or Code Status [wishes for care in the event the heart or breathing were to stop] . Record review of a Physician Orders for Scope of Treatment (POST) form dated [DATE], revealed the resident's wishes were to receive CPR [cardiopulmonary resuscitation - life-sustaining treatment] if found with no pulse or not breathing. Review of Resident #53's comprehensive care plan updated [DATE], revealed the resident's code status was .Per POST: CPR, full treatment . Review of a Physician's order dated [DATE], showed an order .Code Status: DNR [Do Not Resuscitate] . Review of a POST form dated [DATE], showed .Do Not Attempt Resuscitation (DNR / no CPR) . During an interview on [DATE] at 12:53 PM, with the Minimum Data Set (MDS) Coordinator stated care plans are updated on a quarterly and as needed basis and would be updated if the Code Status changed. MDS Coordinator confirmed Resident #53's care plan had not been revised to reflect the DNR Code Status.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store and discard an outdated nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) administration set up (nebulizer tubing and mask) for 1 resident (#59) of 7 residents reviewed for nebulizer therapy of 23 residents sampled. The findings include: Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection, revised (MONTH) 2011, revealed .Store .in plastic bag, marked with date and resident's name, between uses .Discard the administration set-up every seven (7) days . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/27/19 revealed .Resident at risk for .SOB (shortness of breath) .Observe for shortness of breath . Medical record review of the Quarterly Minimum data set ((MDS) dated [DATE] revealed Resident #59 had modified independence with decision making. Further review revealed the resident had received respiratory therapy. Medical record review of the Physician's Order Report revealed .Start Date .07/03/2019 .solution for nebulization (medication administered by nebulizer) .as needed every 6 hours for shortness of breath . Medical record review of Medications Administration History dated 8/1/19 - 8/19/19 revealed Resident #59 had received solution for nebulization on 8/18/19 at 4:16 AM. Observation of Resident #59 on 8/18/19 at 9:37 AM, in the resident's room, revealed a unstored nebulizer at the bedside with a mask dated 6/26 (6/26/19). Observation of Resident #59 on 8/19/19 at 8:40 AM, in the resident's room, revealed a unstored nebulizer at the bedside with a mask dated 6/26. Interview with Licensed Practical Nurse (LPN) #1 on 8/19/19 at 8:42 AM, in the resident's room, confirmed the date on the nebulizer mask was 6/26/19. Further interview revealed the mask was to be changed weekly. Continued interview confirmed Resident #59 had received nebulized medication with the mask on 8/18/19 at 4:16AM. Interview with the Central Supply Coordinator on 8/19/19 at 8:52 AM, in the conference room, revealed she was responsible for the weekly changing of the nebulizer administration set up and storage bag. Further interview confirmed she had not changed the administration set up and storage bag for Resident #59 weekly. Interview with the Assistant Director of Nursing (ADON) on 8/20/19 at 10:29 AM, in the ADON's office, confirmed the nebulizer administration set was to be changed on 7/3/19,7/10/19, 7/17/19, 7/24/19, 7/31/19, 8/7/19, and 8/14/19. Continued interview confirmed the facility failed to properly store and discard an outdated nebulizer administration set up for Resident #59.

Based on review of facility policy, medical record review, review of a facility grievance document, and interview, the facility failed to report an allegation of sexual abuse to the State Survey Agency for 1 resident (#1) of 3 residents reviewed for Abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, undated, revealed .Reporting Guidelines: Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 13 (cognitively intact). Continued review revealed the resident required limited assistance with transfers and toilet use with 1 person assist. Further review revealed the resident was occasionally incontinent of urine. Review of a facility grievance document dated 3/25/19 revealed Resident #1 reported to the Director of Nursing (DON) .a man took her to the bathroom while wiping her, he stuck his fingers 'back there' .Plan .female care givers only for personal care . Interview with the Administrator on 5/8/19 at 9:30 AM, in the conference room, revealed she was unaware of the allegation of abuse reported by Resident #1 until a representative from Adult Protective Services (APS) advised them on 5/3/19. Continued interview confirmed she was advised by the corporate offices there was no need to report the allegation to the State survey agency. In summary, Resident #1 reported an allegation of sexual abuse on 3/25/19 and APS informed the facility of the allegation on 5/3/19. As of 5/8/19 the facility had failed to report the incident to the State Survey Agency.

Based on review of facility policy, medical record review, review of a facility grievance report, and interview, the facility failed to investigation an allegation of Abuse for 1 resident (#1) of 3 residents reviewed for Abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, undated, revealed .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish .conducting a reasonable investigation: date and time of incident; the nature and circumstances of the incident; the location of the incident; a description of any injury; the condition of any injured person; the disposition of the injured person; names of witnesses and their accounts of the incident; time and date of notification of the resident's physician and family .in cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or entire Facility, as appropriate; shall conduct an appropriate physical assessments of residents who are not capable of being interviewed . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 13 (cognitively intact). Continued review revealed the resident required limited assistance with transfers and toilet use with 1 person assist. Further review revealed the resident was occasionally incontinent of urine. Review of a facility Grievance document dated 3/25/19 revealed Resident #1 reported to the Director of Nursing (DON) .a man took her to the bathroom while wiping her, he stuck his fingers 'back there' .Plan .female care givers only for personal care . Interview with the DON on 5/8/19 at 12:00 PM, in the conference room, revealed .was told she (Resident #1) wanted to talk to me around noon .She told me a man (Certified Nursing Assistant (CNA) #1) took her to the shower room and while he was wiping me he stuck his fingers back there .she could not tell me who or when .felt like the concern was a man giving care so implemented females only to provide care . Continued interview confirmed the facility was again notified of the allegation by an outside agency on 5/3/19. Further interview confirmed the facility did not begin their investigation until 5/3/19 (40 days after Resident #1 reported the incident). Telephone interview with Resident #1 on 5/9/19 at 1:40 PM revealed .told that woman in charge (DON) that (CNA#1) took my clothes off in the shower .put his fingers in my private areas and jerked .I talked with (outside agency) and told her the same thing I told (DON) .he didn't take care of me after that and I was glad . In summary, Resident #1 reported an allegation of abuse to the DON on 3/25/19. The DON assumed Resident #1 was uncomfortable with personal care provided by a male and did not investigate the allegation per facility policy until reported to the facility by an outside agency on 5/3/19.

Based on medical record review and interview, the facility failed to provide pharmaceutical services to meet the needs of 1 resident (#66) of 38 residents reviewed. The findings include: Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nurses (DON) on 8/15/18 at 10:30 AM, in the conference room, revealed the verbal order was sent to the pharmacy, and entered into the computer system. Review of the Medication Administration Record [REDACTED]. The resident received 50 mg daily from 2/1/18 to 2/15/18. Medical record review of the pharmacy medication reorder form dated 2/16/18 revealed [MEDICATION NAME] 50 mg tablet was reordered. Medical record review of the pharmacy's Change Report (provided to the DON from the pharmacy) dated 2/15/18 revealed a pharmacy technician at the pharmacy changed the [MEDICATION NAME] 50 mg to [MEDICATION NAME] 100 mg every day. Interview with the Pharmacist on 8/15/18 at 10:25 AM, via telephone, revealed a new technician (who is no longer employed with the pharmacy) changed the order to 100 mg [MEDICATION NAME], filled the 100 mg [MEDICATION NAME] order, and sent it to the facility. At the time of the change the MAR indicated [REDACTED]. Further interview confirmed the pharmacy did not dispense the correct dosage of the [MEDICATION NAME] to the facility. Interview with the DON on 8/15/18 at 8:00 AM, in the conference room, confirmed the resident received 4 days (2/17, 2/18, 2/19 and 2/20/2018) of 100 mg of [MEDICATION NAME] and not the 50 mg which was ordered and the pharmacy had not dispensed the correct dose.

Based on observation and interview, the facility failed to discard expired medical supplies in 1 of 2 medication storage rooms. The findings include: Observation with Registered Nurse (RN) #1 on [DATE] at 9:25 AM, in the North Medication Storage Room, revealed in the left drawer (under the countertop), two 3-way 24 f (French) 30 cc (cubic centimeters) urinary catheters with an expiration date of 2002; one 2-way 20 f, 5cc urinary catheter with an expiration date of 2004; and one 2-way 22 f, 30cc urinary catheter with an expiration date of ,[DATE]. Observation and interview with RN #1 on [DATE] at 9:28 AM, at the North Nurse's station confirmed the urinary catheters were expired and available for resident use.

Based on review of facility policy, review of 2013 Food Code, observations, and interviews, the facility failed to follow appropriate glove use and handwashing to prepare, distribute and serve food in accordance with professional standards for food service in one of one kitchen and two of three dining rooms, having the potential to affect any resident consuming food prepared in the kitchen and served in the dining rooms. The findings included: Review of the facility policy Serving Resident Food-Resource dated 6/1/15, revealed, .Employees must wash their hands before serving food to residents .If there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash their hands .When cutting up food, buttering bread etc., utilize a barrier to prevent touching the bread/food with bare hands . Review of the 2013 Food Code from the U.S Department of Health and Human Services, page 65 and 73, revealed, .Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves .If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled . Observation on 6/12/17 at 11:27 AM, revealed Volunteer #1 was observed with gloves on during meal service in the main dining room. The volunteer opened a package of crackers for a resident and crushed the crackers with her gloved hand. She placed the crackers into a resident's soup. She touched the handles on the dietary carts and a family's shoulder with the gloved hands. At 11:30 AM, with the same gloved hands, she touched meal tickets and proceeded to deliver a plate of food to a resident. At 11:32 AM, Volunteer #1 handled another plate and delivered it to a resident. She touched a resident's back and glass of fluids. At 11:37 AM, she handled another plate and touched another resident's shoulder. All tasks were completed with the same pair of gloves and no hand washing or glove changes were observed. Observation of a second dining room area on 6/13/17 at 6:13 PM, revealed Certified Nurse Aide (CNA) #2 served a tray to a resident. She touched the hamburger bun with her bare left hand, touched the tomato, onion and lettuce with her bare hands, and was observed cutting up the lettuce with her bare left hand. She placed the lettuce onto the hamburger and moved the tomato and onion with her bare hand. Another staff member noted the observations and the tray was taken away. Interview with CNA #2 on 6/13/17 at 6:22 PM, in the dining room, revealed she always washed her hands before touching the resident's food and it had been a while since she had been trained on meal service. Observation of the kitchen on 6/13/17 at 10:51 AM, revealed Cook #1 dropped a thermometer on the ground in front of the steam table. Cook #1 picked up the thermometer with her gloved hand and placed it into the three complartment sink. Without changing her gloves or washing hands, she continued to stir the pork. She took the temperature of the pork with another thermometer. She documented the temperature of the pork on the food temperature log. She placed another thermometer into the blackeyed peas and a third thermometer into the greens. She reached into her pocket and retrieved sanitizer packets and sanitized the thermometers. She proceeded to check the temperature of the pureed texture and the mechanical meat. All the tasks were completed with the same pair of gloves and no hand washing or glove changes were observed. Observation of the kitchen on 6/14/17 at 4:05 PM, revealed Cook #2 was observed during the pureed texture process. She washed the dirty blender container, lid, and blade in the three-pan sink. After she finished with the sanitizer sink, she went to the fryer and placed the French fries into the fryer. She checked the steamer and touched the handles of the doors on the oven. She grabbed the clean blender container, lid, and blade and placed the components near the blender base. She placed the oven mitts on top of her wet gloved hands. She grabbed a pan of meat and the French fries out of the oil to check. At 4:06 PM, she placed the meat patties in the blender and blended to a mechanical meat texture. She got a metal pan, placed a plastic liner into the pan, and then poured the mechanical meat into the pan. At 4:09 PM, she placed the rest of the meat into the blender. During all the tasks, Cook #2 wore the same pair of gloves and no hand washing or glove changes were observed. Interview with the Certified Dietary Manager (CDM) on 6/14/17 at 11:23 AM, in her office, confirmed education was needed.

Based on policy review, medical record review, observations, and interviews, the facility failed to ensure accurate assessment of intake and consistent implementation of interventions, including offering dietary substitutes and foods to meet a resident's preferences, and failed to monitor weight changes to maintain acceptable parameters of nutritional status and prevent weight loss for 1 (#158) of 3 residents reviewed for nutrition. The findings included: Review of the undated Weight Monitoring Policy revealed, .Parameters for evaluating significant weight loss: 5% weight loss/gain in 1 month, 7.5% weight loss/gain in 3 months, 10% weight loss/gain in 6 months, any unintentional weight change. The weight change will be compared to the resident's usual weight as well as the resident's current diagnosis. If a significant weight change is identified, the nurse will complete the SBAR (situation, background, assessment, recommendation) and the physician and responsible party will be notified. Medical record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nutrition Risk Review Assessment signed by the Registered Dietitian (RD) on 1/23/17, revealed Resident #158's height as 66 inches, weight was 123.7 pounds, and body mass index (BMI) was 20.2 (normal range is 18.5-24.9). The usual body weight (UBW) was blank. The RD recommendations included Vitamin C fortified beverage twice per day, fortified foods, multivitamin with minerals, weekly weights, and to discuss the resident in clinical risk meeting. Medical record review of the Clinical Progress Nutritional Notes dated 1/23/17, revealed Resident #158's Oral (PO) intake less than needs, dysphagia and decline in self-feeding. RD to monitor weights and intakes. Medical record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had long and short term memory problems, had moderately impaired cognition, was not marked for weight loss, and required extensive assistance of one staff member for eating. Medical record review of the admission care plan revealed Resident #158 was at nutritional risk andwas at risk for weight loss related to recent illness, new environment, and dysphagia, and goals included resident's weight would not be more than 5% above or below current weight (123.7 pounds) through next review. Medical record review of the Weight Report revealed the following weights: 1/19/17: Weight was 123.7 pounds 2/15/17: Weight was 117.9 pounds (4.7% weight loss) 4/19/17: Weight was 113 pounds (12% weight loss in 3 months) 5/16/17: Weight was 114.8 pounds; and 6/13/17: 107.8 pounds, reflecting a total of 12.8% weight loss in 5 months since admission Medical record review of the quarterly MDS dated [DATE] revealed Resident #158 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition, had a weight of 113 pounds indicating a 10-pound weight loss or 12% since admission, and was total dependence on staff for eating. Medical record review of a Nurse Practitioner (NP) assessment dated [DATE], revealed the Resident #158's weight was 113.2 pounds and, The patient denied decreased appetite, loss of weight, fever and malaise .No [MEDICAL CONDITION] .Resident receives diet of pureed food with nectar thick liquids. Continue current diet and monitor .Poor prognosis, anticipate less than 6-month survival. Medical record review of the care plan dated 4/27/17 revealed interventions to offer meal substitutes if 50% or less of a meal was consumed and to monitor and report any significant weight changes to the physician. Observation of Resident #158 on 6/13/17 at 3:39 PM, in his room, revealed he was in bed sleeping, thickened liquids were noted on a bedside table, and the resident had thin, fragile facial features. Interview with the RD on 6/13/17 at 5:02 PM, in the chapel, revealed she did not have a usual body weight for the resident. Further interview revealed she thought the resident was probably taking the supplement she ordered because staff would have told her if he wasn't. The RD did not consider him high risk because he was eating more than 50% and he was receiving supplements. Interview with Family Member #1 on 6/13/17 at 5:43 PM, revealed the family member did not believe Resident #158 had a poor appetite because he ate great with some of his meals, it was only some meals he would only eat bites. It depended on the foods. Family Member #1 stated some foods made the resident gag, then he didn't want to eat, and mashed potatoes was one of those foods Resident #158 did not like to eat. The family member stated the family would try to thin out the mashed potatoes so the resident could eat it better. Further interview revealed when Resident #158 first came into the facility, he weighed in the 120's, now he was 108 pounds, with his usual body weight at 120-135 pounds. Observation of Resident #158 on 6/13/17 at 6:33 PM, in his room, revealed a staff member was feeding him his supper meal with mashed potatoes, pureed beef, milk, pureed fruit, and a glass full of what appeared to be a supplement. The staff member asked the resident if he wanted some mashed potatoes and he said no. The staff member asked if he was full and he said yes. The resident appeared to have taken a few bites, drank some of the milk, and consumed none of the supplement. Observation revealed the resident was not offered any food substitutes for the meal not consumed. Review of the Meal Intake Record for the meal observed on 06/13/17 at 6:33 PM, revealed staff documented the intake as 75%, however, he only ate a few bites. Observation on 6/14/17 at 8:17 AM, in the resident's room, revealed the resident was lying in bed and was fed breakfast by staff. The resident had some bites of eggs, some bites of pureed meat, drank two containers of juice and a cup of coffee. Observation revealed no food substitutes were offered to the resident during observation. Interview with the Assistant Director of Nurses (ADON) on 6/14/17 at 9:30 AM, in the nursing station, revealed the ADON placed the weights into the computer and weight losses would trigger at 1, 3 and 6 months. Weight loss would only trigger from the weights taken at the beginning of the month, therefore, weights taken throughout the month would get missed. Further interview revealed the resident's weight had leveled out. Interview with the Certified Dietary Manager (CDM) on 6/14/17 at 11:23 AM, in her office, revealed the facility had a care plan meeting with the family last month for food preferences and the resident was on a fortified food program that included shakes, oats, whole milk and mashed potatoes at lunch and dinner. The CDM was aware the resident preferred fruits in place of desserts, but was unaware of mashed potatoes being problematic for the resident. Further interview revealed the staff had been taught how to measure correctly. I've talked to them about it. Further interview confirmed Resident #158 was not showing up on the insidious (progressive weight loss over time) list and she could not remember if this resident had been discussed in the nutrition at risk (NAR) meeting.

Based on observation and interview, the facility failed to maintain comfortable temperatures for two residents (#114, #116) of ten residents interviewed during stage 1 of the survey. The findings included: Observation on 7/6/16 at 10:37 AM in a shared resident room, revealed Resident #114 and Resident #116 awake in bed with covers pulled up. Continued observation revealed the residents individual heating/air unit was in the off position. Interview on 7/6/16 at 10:41 AM revealed Resident #114 and #116 both stated we get cold at night. Continued interview revealed both residents stated they have told staff. Observation and interview with the Plant Operations Director on 7/7/16 at 8:34 AM in Resident #114 and #116's room revealed the resident's heating/air unit was on the fan only position. Continued observation and measure of the air temperature with the Plant Operations Director revealed the room temperature to be 69 degrees. Interview with Resident #114 and #116, at the time of the observation revealed both residents stated they were cold. Interview with the Administrator on 7/7/16 at 9:04 AM, in the Administrators office confirmed Resident #114 and #116's room temperature was not maintained at a comfortable level.

Based on observation and interview, the facility failed to ensure the Nurse Staffing data posted was correct. The findings included: Observation during the initial tour on 7/5/16 at 10:30 AM, inside the main entrance revealed the Nurse Staffing posted listed 8 Registered Nurses (RNs) working on the day shift. Further observation revealed 5 RNs were working direct care. Interview with the Director of Nursing (DON) on 7/7/16 at 9:40 AM, in the DON's office confirmed there were only 5 RNs working direct care and the Nurse Staffing posted was incorrect.

Based on medical record review and interview, the facility failed to ensure a discharge summary was completed for an anticipated discharge for five residents (#46, #75, #170, #39, #168) of thirty admission sample records reviewed. The findings included: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated December 31, 2013, revealed resident was dicharged home. Continued medical record review revealed no documentation a Discharge Summary had been completed. Resident #75 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's telephone order dated January 24, 2014, revealed "...may d/c (discharge) home on January 27, 2014..." Continued record review revealed no documetnation a Discharge Summary had been completed. Resident #170 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated November 1, 2013, revealed "...Resident Ambulating about facility...excitement about going home today..." Continued record review revealed no documentation a Discharge Summary had been completed. Interview with the Medical Records Director on March 25, 2014, at 11:38 a.m., in the facility conference room confirmed the facility had failed to complete a Discharge Summary for residents #46, #75, and #170. Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing notes dated March 19, 2014, revealed the resident was discharged home with home health services. Medical record review revealed no documentation a Discharge Summary had been completed. Resident #168 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing notes dated November 16, 2013, revealed the resident was discharged home. Medical record review revealed no documentation a Discharge Summary had been completed. Interview with the Medical Records Director on March 24, 2014, at 11:50 a.m., in the conference room, confirmed a Discharge Summary had not been completed for residents #39 and #168.

Based on medical record review, observation, and interview, the facility failed to revise the care plan for one resident (#179) of thirty-six residents reviewed. The findings included: Resident #179 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner's order dated February 28, 2014, revealed "[MEDICATION NAME] (antidepressant) 25 mg (milligrams)...x (times) 1 week then increase to 50 mg...q (every) HS (hour of sleep)...Depression/Anxiety...Psych Recommendation..." Medical record review of the Comprehensive Care Plan dated February 25, 2014, revealed no documentation to address the addition of the antidepressant medication. Observation on March 24, 2014, at 12:57 p.m., revealed the resident lying on the bed with the head of the bed in the raised position, eating lunch. Interview with the Director of Nursing on March 25, 2014, at 1:45 p.m., in the conference room confirmed the care plan was not revised to address the use of the antidepressant medication.

Based on medical record review, observation, and interview, the facility failed to timely follow a psychiatric recommendation for one resident (#179) of thirty-six residents reviewed. The findings included: Resident #179 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric note dated February 19, 2014, revealed a recommendation for [MEDICATION NAME] (antidepressant) 25 mg (milligrams) every hour of sleep for one week, then increase the dosage to 50 mg every hour of sleep for anxiety and depression. Medical record review of a Nurse Practitioner's order dated February 28, 2014, revealed "[MEDICATION NAME] 25 mg...x (times) 1 week then increase to 50 mg...q (every) HS (hour of sleep)...Depression/Anxiety...Psych Recommendation..." Observation on March 24, 2014, at 12:57 p.m., revealed the resident lying in bed with the head of the bed in the raised position, eating lunch. Interview with Nurse Practitioner #1 on March 25, 2014, at 1:55 p.m., at the South nursing station confirmed the facility had failed to follow the psychiatric recommendation for the antidepressant medication resulting in a delay (nine days) in starting the medication.

Based on medical record review, observation, and interview, the facility failed to provide thickened liquids as part of a therapeutic diet for thickened liquids for one (#52) of three residents reviewed. The findings included: Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Speech Therapy assessment dated [DATE], revealed "... pt (patient) upgraded to begin PO (by mouth) supervised feedings one time per day of puree texture and nectar thick liquids. Caregivers trained...to safety consume food/liquid without any significant s/s (sign/symptom) of dysphagia..." Medical record review of the physician's orders [REDACTED].@ (at) lunch only - Supervised..." Observation on March 25, 2014, at 11:00 a.m., in the resident's room revealed the resident with a [MEDICAL CONDITION] attached to an oxygen concentrator. Further observation revealed a tube feeding infusing via a machine pump. Continued observation of the bedside table within reach of the resident revealed an empty container of applesauce and a glass of unthickened water. Interview with resident #52 on March 25, 2014, at 11:05 a.m., in the resident's room revealed the Speech Therapist had used the applesauce for therapy. Further interview revealed "...a CNA (Certified Nursing Assistant) had left that (the water) for me...sometimes they do..." Interview with Licensed Practical Nurse #2 on March 25, 2014, at 11:20 a.m., in the resident's room confirmed the unthickened water on the bedside table was not on the therapeutic diet.

Based on medical record review, observation, and interview, the facility failed to ensure two residents (#23, #136) received proper fluids of thirty-six residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan updated on January 24, 2014, revealed "...Potential for dehydration...no s/s (signs and symptoms) of dehydration...moist mucous membranes daily...Resident has ADL (activity of daily living) self-care deficit..." Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed a BIMS (brief interview for mental cognition) score of 12 indicating the resident as cognitively intact. Observation and interview with the resident on March 24, 2014, at 1:10 p.m., in the resident's room revealed the resident did not always have fluids between each meal. Continued observation and interview revealed the resident's water pitcher at the bedside was empty. Resident #136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan updated March 13, 2014, revealed "...risk for dehydration...no s/s dehydration...moist mucous membranes daily...Resident has ADL self-care deficit..." Observation and interview with the resident on March 24, 2014, at 12:51 p.m., in the resident's room revealed the resident did not always have cold water between each meal. Continued observation and interview revealed the water pitcher at the bedside had no ice and was warm to the touch. Interview with Certified Nursing Assistant #6 on March 24, 2014, at 4:10 p.m., on the 100 hall confirmed the resident's water pitcher was empty and the resident did not have any cold water.

Based on medical record review, observation, and interview, the facility failed to obtain dental services for one resident (#136) of two residents reviewed for dental services of thirty-six residents reviewed. The findings included: Resident #136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan updated on March 13, 2014, revealed "...resident is at nutrition risk potential for weight loss...dental consult prn (as needed)..." Medical record review of the Vital Signs and Weight Record revealed the resident's admission weight was 111 pounds. Continued medical record review revealed the residents current weight was 115 pounds. Interview with the resident on March 24, 2014, at 12:54 p.m., in the residents room revealed the resident did not wear dentures because a place in the dentures bothered the resident. Continued interview revealed the resident would try to wear dentures if they were fixed. Interview with Certified Nursing Assistant (CNA) #7, on March 25, 2014, at 1:41 p.m., at the south skilled nurse's station revealed the CNA was aware the resident had a concern with the dentures. Interview with the Assistant Director of Nursing on March 25, 2014, at 2:02 p.m., in the facility conference room confirmed a dental consult had not been obtained.

Based on observation and interview, the facility failed to post nurse staffing data daily prior to the beginning of each shift. The findings included: Observation on March 24, 2014, at 5:35 a.m., revealed the nurse staffing data posted was dated March 21, 2014. Observation and interview on March 24, 2014, at 5:40 a.m., with the Assistant Director of Nursing, in the front hallway confirmed the current nurse staffing data was not posted.

Based on medical record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident (#14) of forty-eight residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required supervision with dressing. Medical record review of the Annual MDS dated [DATE], revealed the resident required extensive assistance of one person for dressing. Medical record review of the Care Plan dated October 10, 2012, revealed the resident required assistance with dressing. Medical record review of the monthly nursing assessments for September and October 2012, revealed the resident required extensive assistance with dressing. Observation of the resident on January 22, 2013, at 11:30 a.m., revealed the resident was in the restorative dining room eating a meal without assistance. Interview with Certified Nursing Assistant #1 on January 23, 2013, at 2:00 p.m., on the station 2 hallway, revealed the resident could hold arms out for a shirt to be put on, but was not capable of assisting with dressing any other way and could not perform any self care activities except feeding. Interview with the MDS Coordinator on January 23, 2013, at 3:32 p.m., in the MDS office, confirmed the resident had always required extensive assistance with dressing and the quarterly MDS dated [DATE], was inaccurate.

Based on observation, review of Nutrition Facts, and interview, the facility failed to store food and equipment in a sanitary manner for one of two nourishment rooms. The findings included: Observation of the nourishment room on nursing station 2, on January 24, 2013, at 2:00 p.m., revealed the following in the refrigerator: one 46 ounce container of thickened lemon flavored water dated as opened January 13, 2013; one 46 ounce container of thickened tea, opened, with no date of when opened. Observation of the microwave in the nourishment room on January 24, 2013, at 2:00 p.m., revealed the microwave had a large accumulation of food splatters on the top, sides, and rotating plate of the microwave. Review of the Nutrition Facts for the thickened liquids provided by the Dietary Manager revealed, "...Once opened, store under refrigeration for up to 10 days..." Interview with the charge nurse on January 24, 2013, at 2:00 p.m., in the nourishment room and at the nursing station confirmed the thickened liquid items were available for resident use beyond the expiration date, and the microwave was in need of cleaning.