Every finding on record at Summit Health & Rehab Center

Based on observation, interview, and facility policy review the facility failed to ensure a refrigerated antianxiety medication was counted and appropriately reconciled each shift by maintaining the documentation of an unopened, expired vial of (Generic) anti-anxiety medication in the narcotic book for 4 months to ensure accurate documentation and reconciliation to prevent the risk of misappropriation of resident owned narcotics. Findings include: 1.a. On 10/22/2024 at 2:07 PM, Licensed Practical Nurse (LPN) #5 stated, a resident's unopened antianxiety medication cannot be found in the narcotic book. Registered Nurse (RN) #6 revealed, the antianxiety medication was not transferred over from the previous narcotic book. Surveyor observed, the antianxiety medication expired 06/2024. b. On 10/22/2024 at 2:31 PM, RN#6 confirmed, she counts narcotics every day, including refrigerated narcotics. When asked how she counts the antianxiety medication without documentation from the narcotic book, RN #6 stated, she puts her hands on it at every narcotic count. RN #6 was shown the expiration date of 06/2024 and confirmed the medication should have been given to the Director of Nursing (DON) to return to the pharmacy. RN #6 provided a narcotic book dated 02/16/2024-06/26/2024, page 44 indicated,1 vial of antianxiety medication. RN #6 confirmed if the expired, unopened antianxiety medication disappeared from the locked refrigerator box she would not know where to look, because there has been no documentation. c. During an interview with the Director of Nursing (DON) on 10/23/2024 at 1:10 PM, DON confirmed that medication and the narcotic page must be in hand to reconcile a medication, and reconciliation cannot be done by placing a hand on the medication. DON confirmed, the antianxiety medication has not been documented in 4 months. DON confirmed, the medication had been at risk of misappropriation due to the lack of documentation. d. Review of an In-service titled Medication Administration, dated 05/26/2024, revealed controlled substances should be counted by the oncoming, and outgoing nurse at the beginning and ending of each shift. Expired medications should be given to the DON, and the surrendering nurse and the ADON/DON should sign the narcotic book, and the health department triplicate form. LPN #5, and RN #6 attended the in-service. e. Review of an in-service titled DON, dated 08/17/2023 revealed that all medications including the refrigerated narcotic box, and the Emergency box should be counted, and discrepancies should be reported to the DON/ADON immediately. f. Review of an in-service titled DON, dated 10/22/2024 revealed, the narcotic count will be done at the beginning of each shift with the oncoming and off going nurse, and the DON or Administrator will be contacted immediately if the count is not correct. Two nurses must verify the transfer of narcotics from one narcotic book to another, and both nurses need to confirm the narcotic count is correct in the new book and matches what was in the old narcotic book. RN #6 and LPN #5 signed the attendance. g. Review of a facility policy titled Medication Storage in the Facility, ID2 Controlled Substance Abuse, revised January 2018, revealed 2 licensed nurses are responsible for a physical inventory of all controlled medications at all shift changes, or if the keys are exchanged. Consultant pharmacist or designees should monitor controlled medication records, change of shift sheets, controlled substance accountability sheets and expiration dates during routine medication inspections.

Based on observation, interview, and facility policy review, the facility failed to ensure staff appropriately monitored refrigerator temperatures to ensure influenza, and TB vaccines, and insulins were stored at a temperature range of ,d+[DATE] degrees Fahrenheit to prevent freezing and deterioration of medications. Findings include: a. A review of facility policy titled Medication Storage in the Facility, ID1 Storage of Medications, revised [DATE], revealed medications are to be stored at supplier or manufacturer recommendations. Expired or deteriorated medications are to be removed from inventory and disposed of appropriately. A pharmacy designee or pharmacy consultant monitors medication storage conditions monthly. Medication storage areas should be free of extreme temperatures, and refrigerated medications should be stored at the Center of Disease Control (CDC) temperature range of ,d+[DATE] degrees Fahrenheit with a thermometer to monitor temperatures, and a temperature log should be maintained and checked at least twice a day if vaccines are stored there. b. On [DATE] at 1:44 PM, Licensed Practical Nurse (LPN) #5 confirmed the medication room refrigerator was at ,d+[DATE] degrees. LPN #5 stated, there was a small concern because the flu vaccine says to store at a temperature range of ,d+[DATE] degrees Fahrenheit, and not to freeze. c. On [DATE] at 9:32 AM, Registered Nurse (RN) #6 accompanied Surveyor to the mediation room and confirmed the large refrigerator temperature was 32 degrees and counted 55 flu vaccines, 0.5 milliliter (ml) single dose syringes, and confirmed temperatures were checked at midnight daily. RN #6 provided a temperature log showing a temperature of 23 degrees on [DATE], and 28 degrees on [DATE],[DATE],[DATE],[DATE], [DATE], and [DATE]. d. During an interview with Infection Preventionist (IP)#3 on [DATE] at 9:36 AM, IP #3 confirmed she and RN #2 are responsible for vaccines, and confirmed they are stored at ,d+[DATE] degrees to keep the vaccine from freezing or breaking down. IP #3 stated night shift was responsible for documenting temperatures in the small biohazard refrigerator, and the large medication refrigerator in the medication room. If there was a temperature concern, they should contact IP #3 and maintenance. IP #3 said no temperature concerns had been reported by staff to her. IP #3 reviewed temperature logs for the large refrigerator and confirmed staff had not reported to her the abnormal freezing temperatures as low as 23 degrees and stated they (staff) do not seem to understand why they are monitoring the refrigerator temperatures. IP #3 revealed she cannot guarantee the vaccines did not degrade or deteriorate. e. On [DATE] at 9:47 AM, IP #3 and Director of Nursing (DON) confirmed 55 flu vaccines (Store ,d+[DATE] degrees), 2 Tuberculosis vaccine vials (Do not freeze), 1 unopened short acting insulin pen (Do not freeze), and 4 unopened long-acting insulin pens (Do not freeze) were in the large refrigerator. The DON and IP #3 will reach out to the pharmacist consultant for assistance.

Based on observations and interview the facility failed to ensure food was labeled with a use by date to ensure food was not used beyond its safety period in accordance with professional standards for food service safety. The findings are: 1. On 10/21/24 at 10:00 AM, the surveyor observed food sitting on a shelf in the walk-in refrigerator did not have a use by date on some food items: a. A large, clear, storage bag that contained two prepared turkey sandwiches with a preparation date of 10/20/24, did not have a use by date noted on the bag. b. A large, clear, plastic container of beef vegetable soup with a prepared date of 10/21/24, did not have a use by date on the container. c. A clear, plastic, storage bag of cooked sausage with a prepared date of 10/21/24, did not have a use by date on the bag. d. A clear, plastic, storage bag of cooked bacon with a prepared date of 10/21/24, did not have a use by date on the bag. e. A clear, plastic, storage bag of cornbread with a prepared date of 10/20/24, did not have a use by date on the bag. f. A roll of ground beef, thawing on a tray, on the bottom shelf, with a pull date of 10/20/24, did not have a use by date on the package. g. A package of processed turkey slices with an open date of 10/20/24, did not have a use by date on the plastic bag or package of turkey. h. A bowl of prepared tuna salad, sitting on the shelf, with a prepared date of 10/20/24, did not have a use by date on the container. i. A clear, plastic, container of cornbread with a prepared date of 10/20/24, did not have a use by date on the container. 2. On 10/22/24 at 9:45 AM, the surveyor observed food sitting on the shelf in the walk-in refrigerator did not have a use by date on some food items: a. A clear, plastic, storage bag of ham labeled with two pull dates of 10/14/24 and 10/21/24, did not have a use by date. b. A package of processed turkey slices with a pull date of 10/20/24, did not have a use by date on the clear, plastic bag, or on the turkey package. c. A clear, plastic container of cornbread with a prepared date of 10/20/24, did not have a use by date on the container. 3. On 10/21/24 at 10:15 AM, the Dietary Manager (DM) stated a use by date should be noted on the food so everyone would know when to discard the food. The DM said, if the foods are not pulled timely, salmonella could start growing in the food and cause a resident to get sick if they consumed the food. The DM stated the tuna salad should be used within 3 days after being prepared, or it could have salmonella in it. The DM continued the turkey slices should be used within 3 days after opening, or a resident could get sick if they ate the tuna or turkey. 4. On 10/22/24 at 1:58 PM, the Administrator stated the facility did not have a policy for food storage.

Based on interviews, record review, observations, and facility policy review, the facility failed to ensure staff promoted dignity and provided privacy during peri care were not visible to fell ow residents and/or visitors, to maintain dignity for one (Residents #14) of one resident observed for incontinence care. Specifically, staff failed to pull the privacy curtain and close the door completely while providing peri care to Resident #14. The findings are: 1.Review of a Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/15/24 indicated Resident #14 was admitted by the facility with diagnoses of Parkinson's Disease, Anxiety, Depression, Schizophrenia. The MDS indicated, Resident #14 had a Brief Interview for Mental Status (BIMS) score of 01 (0-7 suggests severe cognitive impairment). Section H-Bowel and Bladder indicated the resident is always incontinent of urine and bowel. a. On 10/23/2024 at 10:20 AM, the surveyor interviewed Certified Nursing Assistant #1(CNA). regarding door not completely shut and curtain not pulled when incontinence care was provided to Resident #14. CNA #1 stated it was a privacy and dignity concern and issue, and she should have pulled the curtain and shut the door completely. b. On 10/23/2024 at 1:58 PM, the Administrator stated the facility had no policy for incontinence care. d. On 10/23/2024 at 2:50 PM, the surveyor interviewed the Infection Preventionist/Treatment Registered Nurse (RN) #2, who indicated for incontinence care the curtain should be pulled, the blinds shut, and the door closed completely to ensure dignity and privacy. e. On 10/24/2024 at 8:58 AM, the surveyor interviewed the Director of Nursing (DON) regarding proper procedure for performing incontinence care. The DON replied that staff should first knock on door, shut door behind you, shut the blinds, then perform care.

Based on observation, record review, and interview the facility failed to ensure staff wore Personal Protection Equipment (PPE) in droplet precaution rooms for 1 (Resident #16) resident of 1 sampled (Resident #16) observed on droplet precautions to prevent the spread of COVID 19. Findings include: A review of Medical Diagnosis revealed Resident #16 with diagnoses of dementia, type II diabetes, and heart disease. Review of The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/2024, section O0110, M1 shows Resident #16was under quarantine. a. Review of an Order Summary Report, dated 10/19/2024, revealed Resident #16 was on droplet isolation precautions for COVID 19 for 10 days. b. Review of Resident #16's Care Plan, revealed an intervention dated 10/21/2024 indicating staff were to maintain droplet isolation precautions when providing care to Resident #16. c. On 10/21/24 at 1:21 PM, Resident #16 revealed a diagnosis of COVID on Friday at the hospital. Personal Protection Equipment (PPE) was observed hanging on the outside of Resident #16's door with droplet precaution signage. d. On 10/22/24 at 2:23 PM, Certified Nursing Assistant (CNA) #4 was observed at the bedside talking to Resident #16, and sitting down a pitcher of water without gown, gloves, mask or eye shield. CNA #4 stated she was not concerned, because she already had COVID 3-4 times, and confirmed she had been in-serviced on infection control. e. On 10/23/24 at 11:34 AM, Director of Nursing (DON) stated staff are supposed to wear PPE when entering COVID rooms and dispose of PPE and wash their hands when exiting the room to prevent spreading the disease to others, and to keep themselves safe. COVID policy and procedures as well as in-services were requested. f. Review of an in-service titled Infection Control-Enhanced Barrier, dated 10/18/2024, the Infection Control In-service Training Guide revealed pathogens live in the lungs, blood and digestive tract, and exit an infected person's nose, mouth, eyes, or cuts on the skin, then can travel through the air, on hands and surfaces before entering the body of an uninfected person. Residents on droplet precautions require additional precautions to prevent the spread of disease including gowning, gloving, masking, and wearing face shields, or eye protection.

Based on interview and record review the facility failed to ensure the Minimum Data Set [MDS] accurately reflected the discharge status for 1 resident, (Resident #49). This failed practice had the potential to affect 14 residents who discharged in the last 30 days. 1 Resident #49 had a diagnoses of Malignant alignment Neoplasm of Right Kidney, Emphysema, and Hematuria. The Admission Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 10/27/2023 documented the Resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A Physician Order dated 10/30/2023 documented: Discharge home on 10/30/23 with current belongings and medication. Home care agency to evaluate and admit if appropriate. b. A Nursing Note dated 10/30/2023 at 10:07 AM, documented, Discharge home with her family with all of her medications and personal belongings. Voiced her understanding about [discharge] instructions. Resident will have a follow up with her PCP (Primary Care Provider) and urologist within the next 2 weeks. c. The Discharge MDS, with an ARD of 10/30/2023, was coded with Discharge Status as: Short-Term General Hospital (acute hospital, IPPS). d. On 11/14/2023 at 2:00 PM, the Administrator was asked for a policy on MDS Accuracy. On 11/14/2023 at 4:07 PM the Administrator stated, We don't have a policy on MDS accuracy. e. On 11/16/23 11:43 AM, Surveyor interviewed the Minimum Data Set [MDS] Coordinator regarding the MDS for Resident #49. The Surveyor asked the MDS Coordinator what point of reference do you use when filling out the MDS? MDS Coordinator stated, The RAI Manual to guide me. The Surveyor asked the MDS Coordinator why it was important to code the MDS correctly? The MDS Coordinator stated, For accurate care, for accurate billing, quality of life and quality of care. The MDS Coordinator was asked to look up Resident #49's MDS and tell this Surveyor how the Resident was coded for Discharge status? MDS Coordinator looked up Resident #49 and stated, That is incorrect, she went home.

Based on observation, interview and record review the facility failed to ensure person centered nail care was provided to promote good hygiene and reduce the risk for infection in 1 Resident #22 of 9 sampled Residents (Resident #1, #8, #10, #15, #22, #23, #26, #27, and #43) on 200 hall requiring fingernail care and had the potential to affect 23 residents residing on 200 hall. The findings are: a. A Care Plan with a revision date of 08/09/2023 documented, . The resident has an ADL [activities of daily living] selfcare deficit .Nail Care: Check nail length and trim and clean as necessary . b. On 11/13/23 at 10:24 AM, the surveyor observed Resident #22 drinking at the bedside, and fingernails appeared abnormally long and brown tinged, with chipped and broken nails. Resident #22 said he is not sure who to ask for help trimming his fingernails. Resident #22 said, Nobody has offered, and I would let them trim my nails, but I do not know who to ask. c. On 11/13/2023 at 12:20 PM, the Surveyor observed Resident #22 eating lunch with fingernails that are slightly long, brown tinged and chipped. d. On 11/14/23 at 12:53 PM, Resident #22 said he showered, but has still not found out who to ask to cut his nails. The Surveyor asked CNA (Certified Nursing Assistant) #1 if Resident #22 ever refuses care. CNA #1 said, No, I don't believe he refuses care. The Surveyor asked CNA #1 to describe Resident #22's fingernails at the bedside. CNA #1 said, They are just a little long, and some of them are shaped irregularly. CNA #1 said, Nurses trim diabetic nails. Resident #22 said to CNA #1 that he was not a diabetic. CNA #1 told the Resident that he usually asks for sugar substitutes, and she had just assumed he was a diabetic. e. On 11/14/23 at 4:07 PM, the Administrator told the surveyor they do not have a policy on ADLs. f. On 11/15/2023 at 3:02 PM, the Surveyor asked the DON (Director of Nursing) what is the process for providing nail care? The DON said nursing provides nailcare for diabetics, and CNAs or staff should provide fingernail care when showering residents, or when they see it needs to be done. The Surveyor asked the DON how does staff know how to care for residents? The DON said everyone has a task record from the Care Plan, and from the plan of care. The CNA should tell nursing when someone needs nailcare, and nursing can tell them if the resident is a diabetic. The DON said she expects staff to provide fingernail care if they see someone that needs it.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision while smoking affecting 2 Residents (#8, #9) of 5 sampled Residents #8, #9, #12, #26, and #28) with the potential to affect 6 Residents that require supervision when smoking. The findings are: 1. Resident #8 had diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified, Type 2 Diabetes Mellitus with Diabetic Neuropathy and End Stage Renal Disease. The annual minimum data set [MDS] with an assessment review date [ARD] of 08/07/23 showed the resident scored 14 on the Brief Interview for Mental Status [BIMS]. Section J1300 indicated current tobacco use. a. On 11/14/23 at 8:43 AM, observed CNA (Certified Nurisng Assistant) #2 in the smoking area. CNA asked a resident if he was ready to go inside and left Resident #8, and Resident #9 outside in the smoking area while smoking cigarettes. The Surveyor observed an uncovered plastic container of cigarettes sitting out. 2. Resident #9 Had diagnoses of Unspecified Dementia, Psychotic Disturbance and Obstructive Hydrocephalus. The annual minimum data set [MDS] with an assessment review date [ARD] of 06/20/2023 documented the resident scored 10 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status [BIMS]. Section J1300 indicated current tobacco use. a. Review of Resident #9's Smoking-Safety Screen dated 08/18/2023 documented, resident is safe to smoke with supervision and apron. b. A Care Plan with a revision date of 09/14/2023, documented .Resident #9 will smoke safely and have a decreased risk for injury . provide supervision with smoking and make sure that he is wearing a smoking apron at each smoke time . c. On 11/14/2023 at 8:43 AM, CNA #2 transported a resident via wheelchair into the common area, and left Resident #9, and Resident #8 smoking unattended. A white open container of cigarettes was sitting out on a table. d. On 11/14/23 at 8:44 AM, the Surveyor asked CNA #2 what the process was for smoking. CNA #2 said, We have a list of residents at the nursing station that require an apron, and we have to be out here with Residents and cannot leave them alone because something could happen. e. On 11/15/23 at 2:07 PM, the Administrator provided the resident smoking policy stating that it is the responsibility of staff to follow smoking safety and assessment policies. f. On 11/14/2023 at 4:00 PM, the policy titled Resident Smoking Policy (Undated) provided by the administrator documented, . Responsibility: It is the responsibility of all employees to follow the smoking safety and assessment policies, to monitor smoking safety practices of residents and to intervene appropriately to keep residents safe. Policy: It is the policy of this facility to have a smoking policy that protects the rights of individual residents while providing the safest possible environment for all residents. Every resident who desires to smoke is permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident . h. On 11/15/2023 at 3:02 PM, the Surveyor asked the Director of Nursing (DON) about the process to maintain safe smoking. The DON said residents are assessed for devices like smoking aprons, staff light the cigarettes, most of the time staff put the cigarette butts in the metal canister. The Surveyor asked if residents can smoke independently. The DON said that Resident #8 is the only resident that can smoke independently, but still requires someone to go out with him.

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands and/or changed gloves before handling food items; failed to ensure expired food items were promptly removed and or discarded by the expiration or use by dates; failed to ensure that food items were covered and stored properly to prevent food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect fifty residents who received their meals from one of one kitchen according to a list provided by the administrator on [DATE] at 1:45 PM. The findings are: a. On [DATE] at 11:53 AM, four pitchers of tea and 1 pitcher of water were sitting on top of an insulated tray cart. The lids of the pitchers were turned in a manner leaving the liquid open to air and potential contaminants. One additional pitcher of water that was open to air was located on the counter by the drink machine. b. On [DATE] at 11:55 AM, twelve dinner plates were located on the top shelf of a rolling cart. The plates were stored serving side up. c. On [DATE] at 12:00 PM, an oscillating fan was blowing toward the dish-room. The back safety grate which covered the fan was coated in dust as was the front cover of the fan. A second oscillating fan was located by the range area blowing toward the kitchen preparation area. The front and back safety grates of the fan were dust covered. d. On [DATE] at 12:03 PM, a container of freeze-dried chives was located on the wall in the spice rack. The container was open to air and contaminants. e. On [DATE] at 12:05 PM, the refrigerator and freezer were observed in the kitchen area. The vents located at the bottom were covered in a layer of dust and grime. The shelf above the range was covered in the same dust/grime combination. There was a dry erase board above the steam table that was suspended from the ceiling by chains. The frame of the dry erase board and the suspension chains were covered in a coating of dust/grime. f. On [DATE] at 12:10 PM, there was condensation on the air conditioner vent located above the steam table. There was water dripping from the vent onto the steam table. g. On [DATE] at 12:15 PM, Dietary Assistant #2 was washing her hands prior to approaching her tray loading area. The Assistant proceeded to arrange her necessary items including the divided container for condiments, the plastic tub of drinks and the container of plastic wrap. The Assistant did not wash her hands prior to serving trays. h. On [DATE] at 12:17 PM, Dietary Employee #2 placed 4 corn dogs into the microwave. The food items were placed directly on the rotating glass tray located inside the microwave which could expose the food items to contaminants. I. On [DATE] at 12:19 PM, Dietary Employee #1 observed picked up the lunch plates and placed her contaminated fingers onto the surface of the plate just before she added food to the plate. j. On [DATE] at 12:20 PM, a Certified Nursing Assistant CNA approached the entrance to the kitchen with a cart containing an ice chest. The contaminated cart was rolled into the kitchen to be filled with ice. The Dietary Manager moved the dessert cart, then placed her hands on the handle of the ice cart. She took the ice scoop from the holder on the wall and scooped the ice into the ice chest. She did not wash her hands at the completion of this task. k. On [DATE] at 12:25 PM, a cup that contained ice was located on the middle shelf of the freezer. The Surveyor asked who the cup belonged to, the Manager stated, .I'm sure that belongs to the new girl . A bag that contained approximately 2.5 pounds of chicken strips was located on the middle shelf of the freezer. There was no date on the bag, a bag that contained,d+[DATE] rolls had no date on the bag. l. On [DATE] at 12: 30 PM, one-and one-half tray of cinnamon rolls were on the top shelf of the walk-in refrigerator. The Dietary Manager reported that the dough must be placed on trays and allowed to rise prior to their use in the evening meal. The trays contain no date. A large clear plastic container was on the bottom shelf of the walk-in refrigerator. The dietary manager was asked to identify the food item. She stated, .that is homemade cream cheese icing . The date on the container was [DATE]. Two zip lock bags containing bologna was on the bottom shelf of the walk- in refrigerator. The date on the bags was ,d+[DATE]. The Dietary Manager stated, .I tell them to change the date on the bag when they get more out of the freezer . m. On [DATE] a package containing 4 tortillas was on the middle shelf in the dry storage area. The use by date was [DATE]. On the bottom shelf in the dry storage area was 3 large plastic containers. The first container had a date of [DATE] and two were dated [DATE]. The Surveyor asked the Dietary Manager to identify the food item in the containers. She stated, .that is our fish oil . n. On [DATE] at 1:18 PM, a Certified Nursing Assistant (CNA) was carrying a breakfast tray down the hallway. When she approached the Dietary Manager she stated, .this was left on the cart from this morning . The CNA was asked if the tray was from the morning meal and remained on the cart with the lunch trays she stated, .yes . o. On [DATE] at 11:45 AM, a tray of carrot cake was on the top of the convection oven. The cake was uncovered and open to air and contaminants. A tray of yellow cake with chocolate icing was on top of the convection oven was, uncovered and open to air and contaminates. p. On [DATE] at 11:46 AM, Dietary employee #2 retrieved 2 half pint cartons of milk. The employee failed to wash hands prior to before she returned to pureeing the dessert item for the lunch meal. q. On [DATE] at 12:00 PM, the Surveyor asked the Dietary Manager (DM) about the breakfast tray that was left in the insulated cart on [DATE]. The DM identified the cart as the one carrying trays for 100 & 300 hall. Dietary Manager described the cart as tall and thin with a divider in the middle. She reported that if the tray a tray was under the divider, it could easily be overlooked. She continued, .I've already talked to the dishwasher about being sure the cart is empty . r. On [DATE] at 12:12 PM, Dietary Employee #2 loaded the steam table, touched multiple surfaces, obtained the serving utensils for the lunch meal. She proceeded to take the temperature of each item on the lunch menu. At no time between clean and dirty tasks did employee wash her hands. s. On [DATE] at 10:15 AM, The Surveyor asked CNA #1 if the breakfast tray she discovered on the insulated cart while serving lunch had been served to the resident or if it remained uncontaminated. She stated, .oh no, it had been eaten . t. On [DATE] at 11:44 AM, the Administrator provided the Food and Nutrition Services policy. Section IV Personal Hygiene, D, 1. Stated, .wash hands carefully with soap and water whenever they become soiled. Section V. Food Storage G. stated, Old stock is rotated and used first. Section VI stated, Utensils, cups, glasses and dishes must be handled in such a way as to avoid touching surfaces with which food and drink will come in contact. u. On [DATE] at 2:06 PM, The Surveyor asked the DM, what should take place between the completion of a clean and dirty task. She stated, .you should wash your hands . The Surveyor asked if a contaminated item such as an ice cart should enter the clean side of the kitchen. She stated, .we usually just roll it on in to fill it . The cart that we send to the hall are wiped down before we sent them back out .

Based on observation and interview, the facility failed to ensure the resident's environment was free from accident hazards by allowing hazardous material to be kept on top of personal protective equipment (PPE) bins on hallways 100, 200, and 300 and within reach of any mobile residents for 1 (Resident#29) of the 23 sample residents that reside in Nursing Facility. This failed practice had the potential to affect 3 residents with cognitive impairments and that were mobile in the hallways, according to a list provided by the Administrator on 8/24/22. The findings are: 1. Resident #29 had diagnoses of Disorientation unspecified, Presence of Artificial Hip Joint, Bilateral, Other Intervertebral Disc Degeneration, [CONDITION(S)] Without Behavioral Disturbance, and other [CONDITION(S)] Disease of Basal Ganglia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/22 documented a score of 3 (Severely Impaired) on the Staff Assessment for Mental Status (SAMS) and requires limited assist with locomotion, and extensive assist with transferring and bed mobility. a. On 08/22/22 at 12:13 PM, on entrance to Nursing Facility, the Surveyor observed containers of Sani-cloth wipes on each PPE Bin outside of 4 resident's rooms on the 100 hall, 1 resident room on the 300 hall, and 2 resident rooms on the 200 hall. b. On 08/23/22 at 08:15 AM, the Surveyor observed containers of Sani-cloth wipes each PPE Bin outside of 4 resident's rooms on the 100 hall, 1 resident room on the 300 hall, and 2 resident rooms on the 200 hall rooms. The Sani-Cloth germicidal disposable wipes, Warning label on front stated .Warning keep out of reach of children . Top warning label in red letters stated .For use on hard surfaces only-not a skin wipe . c. On 08/24/22 at 09:16 AM, the Surveyor observed each PPE Bin outside of 4 resident's rooms on the 100 hall, 1 resident room on the 300 hall, and 2 resident rooms on the 200 hall rooms had a can of disinfectant spray sitting on top of Bins all within reach of resident's mobile in hallways. Disinfectant Spray with warning on front .Caution Keep out of reach of children . d. On 08/24/22 at 01:45 PM, the surveyor asked, Licensed Practical Nurse (LPN)#1 should the Sani-cloth wipes be out in the hall on the PPE Bins within reach of any resident in the hallways? She said, No. The surveyor asked, what could happen with them being in reach of a confused resident? she stated, they could get them and use them on their skin or do anything with them. Surveyor asked, and what about the disinfectant spray sitting on top of the Bins, should it be there within reach? She stated, they could get it and spray themselves or someone else. e. On 08/24/22 at 01:52 PM, the surveyor asked, LPN#2 should the Sani-cloth wipes be out in the hall on the PPE Bins within reach of any resident in the hallways? She said, No ma'am they should not. The surveyor asked, what could happen with them being in reach of a confused resident? she stated, they could get them and do anything with them, really they should be inside the door and that is where they use to be until we took down the COVID-19-unit dividers, we had them between the plastic dividers or inside the rooms out of reach till recently. Surveyor asked, and what about the disinfectant spray sitting on top of the Bins, should it be there within reach? She stated, that is the same way, we use to keep it out of reach as well and would use in when we came out of the COVID-19 unit but when we took the plastic down, we put them on the Bins. They really should be put in the drawer or somewhere out of reach. f. On 08/24/22 at 01:57 PM, surveyor asked the ADON, should the Sani-cloth wipes be out in the hallways within reach of any resident, especially within reach of a confused/disorientated resident? She stated, No, they should not. Surveyor asked, what could happen if a resident gets one of the wipes? She stated, they could get them use them inappropriately, and get hurt. g. On 08/24/22 at 01:59 PM, surveyor asked the Administrator should the Sani-cloth wipes be out in the hallways within reach of any resident, especially within reach of a confused/disorientated resident? He stated, No. Surveyor asked, and the can of disinfectant spray should it be out on top of the bins within reach of the residents? He stated, no, we should really put them in the bins probable, we will do that right now. h. On 08/24/22 at 03:19 PM, surveyor asked the Administrator, do you have a policy regarding the hazardous material being within reach of residents? He stated, I don't know let me check with my nursing consultant. Nursing Consultant came out of the Director of Nursing office and stated, no we do not have one.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who receive a mechanical soft diet and 22 residents who receive an enhanced diet and 4 residents receiving a no added salt diet, according to a List provided by the Administrator on 8/24/22 at 2:00 PM and 8/25/22 at 7:45 AM. The findings are: a. On 8/22/22 at 12:05 PM, a review of the day's menu showed residents receiving a mechanical soft diet calls for chicken enchilada casserole ground, refried beans, tossed salad chop, Tortilla/bread, salsa, brownie, coffee/tea. The residents receiving pureed diet were to receive chicken enchilada casserole pureed, pureed refried beans, tortillla/bread pureed, salsa pureed, brownie pureed, coffee and tea. The super calorie diets require shredded cheese (cheese sauce was substituted) to be added. b. On 8/22/22 at 12:10 PM, the cook was asked to describe how the regular Mexican casserole was different from the casserole being served to the resident's prescribed a mechanical soft diet. Dietary employee #2 stated, .I ground the chips and placed them in the bottom of this one . When asked if ground chicken was used in the mechanical soft casserole she stated, .no its diced chicken, since the pieces are so small it is the same . c. On 8/22/22 at 12:33 PM, a tray that specified Mechanical Soft, Thin Liquids, Supercal/High kcal was loaded on the tray line. The tray contained Mexican casserole, refried beans, chopped salad and a brownie. Whole chunks of chicken were observed in the casserole. The was no Cheese sauce on the plate. d. Dietary employee #1 who served the hot food items asked dietary employee #2, .should I be putting that on there .? (Employee points to cheese sauce). Dietary employee #2 explained that the cheese sauce should placed on top of the casserole for residents who received a high calorie tray. c. On 8/23/22 at 12:26 PM, a tray specifying a regular diet with no added salt was served on the tray line. Dietary employee placed two salt packets on the tray. d. On 8/23/22 at 12:27 PM a tray specifying Supercal/high kcal was served on the tray line. The tray contained a pork chop, green, black-eyed peas, fried squash and hash browns. Margarine, which is the enhanced item of the day was not on the tray. At 12:28 PM a second tray specifying Supercal/high kcal was being filled on the tray line. The enhanced item of margarine was not placed on the tray. At 12:29 PM, a third tray specifying Supercal/high kcal was being filled on the tray line with no margarine added. e. On 8/24/22 at 2:10 PM, the Surveyor asked the DM to discuss the purpose of a planned menu. DM stated, .that way we know they are getting all of their nutrients, to make sure they are getting a balanced meal . When asked to identify the problems associated with not following the menu she stated, .they might not get all their nutrition, they might slip through the cracks and keep losing weight . The Surveyor asked the Dietary manager to identify the enhanced or high calorie item that was to be added to the noon meal on 8/22/22. She stated, .I'm sure it was shredded cheese . the Dietary manager was shown a picture of a tray served on Monday that called for a high kcal diet and asked if the shredded cheese/cheese sauce was present on the tray. She stated, .no . Dietary manager was shown a copy of the menu for the lunch meal on Tuesday which identified margarine as the enhanced item. DM described, .we usually have melted butter that is added to the greens . The Surveyor observed the tray line and melted butter was not added to the trays.

Based on record review and interview, the facility failed to ensure written notification of transfer/discharge to the hospital was provided to the resident and/or resident's representative to protect resident rights for 1 (Resident #7) of 2 (R#7 and #198) sampled residents who were transferred to the hospital in the last 120 days. This failed practice had the potential to affect 10 residents who were transferred to the hospital in the last 120 days as documented on a list provided by the Assistant Director of Nursing on 8/24/22 at 02:45 PM. The findings are: 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/22 documented that the resident scored 15 (13- 15 Indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was dependent for transferring, required extensive assistance with bed mobility, dressing, toileting, personal hygiene and was independent with eating. a. The Hospital Discharge Summary dated 6/24/22 documented, . Hospital Course: . You were admitted to (Name of Facility) on 6/23/22 00:48 with principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. On 8/23/22 at 12:10 PM, the Surveyor asked the Administrator, Do you have a copy of the Notice of Transfer and Bed Hold when (Resident #7) went to the hospital on 6/22/22? The Administrator stated, I will look for that and bring it to you. c. On 8/24/22 at 09:45 AM, the Surveyor asked the Assistant Director of Nursing (ADON), Was the administrator able to find a copy of the Notice of Transfer and Bed Hold when (Resident # 7) went to the hospital on 6/22/22? The ADON stated, We were not able to find a Notice of Transfer or Bed Hold for that date. The Surveyor asked the ADON, Who is responsible for sending the Notice of Transfer and Bed Hold to the family when the residents are sent out to the hospital? The ADON stated, I am not sure if that is supposed to be done by the Business Office or Nursing. d. On 08/24/22 at 10:55 AM, the Surveyor asked the Administrator, Who is responsible for sending out the Notice of Bed Hold and Transfer to the resident and resident representative when (Resident #7) went to the hospital on 6/22/22? The Administrator stated, The Social Worker is responsible. The Surveyor asked the Administrator, Is the Social Worker here today. The Administrator stated, She is not. She is off this week. The Surveyor asked the Administrator, Do you know why the notice was not sent out? The Administrator stated, I do not. The Surveyor asked, Should a notice have been sent out? The Administrator stated, Yes Ma'am. The Surveyor asked, Do you have a policy for notification of the resident and resident representative of the bed hold policy and the reason for transfer/discharge when a resident is sent to the hospital? The Administrator stated, Yes we have a policy and the bed hold policy is in the admission packet. e. On 08/24/22 at 11:20 AM, the facility policy titled ADMISSION, TRANSFER, & DISCHARGE provided by the Administrator documented, . TRANSFER AND DISCHARGE Definition: For the purpose of this policy, transfer and discharge include movement of a Resident/Elder to a bed outside the certified nursing facility . Notice before transfer. Before a Resident/Elder is transferred, the nursing facility will notify the Resident/Elder, and if known, a family member or legal representative of the transfer .

Based on record review and interview, the facility failed to ensure written information regarding the facility Bed Hold policy was provided to the resident and/or resident's representative when the resident was transferred to the hospital to protect resident rights for 1 (Resident #7) of 2 (R#7, and #198) sampled residents who were transferred to the hospital in the last 120 days. This failed practice had the potential to affect 10 residents that had been transferred to the hospital in the last 120 days as documented a list provided by the Assistant Director of Nursing on 8/24/22 at 2:45 pm. The findings are: 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/22 documented that the resident scored 15 (13- 15 Indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was dependent for transferring, required extensive assistance with bed mobility, dressing, toileting, personal hygiene and was independent with eating. a. The Hospital Discharge Summary dated 6/24/22 documented, . Hospital Course: . You were admitted to (Facility) on 6/23/22 at 00:48 with principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. On 8/23/22 at 12:10 PM, the Surveyor asked the Administrator, Do you have a copy of the Notice of Transfer and Bed Hold when (Resident #7) went to the hospital on 6/22/22? The Administrator stated, I will look for that and bring it to you. c. On 8/24/22 at 09:45 AM, the Surveyor asked the Assistant Director of Nursing (ADON), Was the administrator able to find a copy of the Notice of Transfer and Bed Hold when (Resident #7) went to the hospital on 6/22/22? The ADON stated, We were not able to find a Notice of Transfer or Bed Hold for that date. The Surveyor asked, Who is responsible for sending the Notice of Transfer and Bed Hold to the family when the residents are sent out to the hospital? The ADON stated, I am not sure if that is supposed to be done by the Business Office or Nursing. d. On 8/24/22 at 10:55 AM, The Surveyor asked the Administrator, Who is responsible for sending out the Notice of Bed Hold and Transfer to the resident and resident representative when (Resident #7) went to the hospital on 6/22/22? The Administrator stated, The Social Worker is responsible. The Surveyor asked, Is the Social Worker here today. The Administrator stated, She is not. She is off this week. The Surveyor asked, Do you know why the notice was not sent out? The Administrator stated, I do not. The Surveyor asked, Should a notice have been sent out? The Administrator stated, Yes Ma'am. The Surveyor asked, Do you have a policy for notification of the resident and resident representative of the bed hold policy and the reason for transfer/discharge when a resident is sent to the hospital? The Administrator stated, Yes we have a policy and the bed hold policy is in the admission packet. e. On 8/24/22 at 11:10 AM, the facility policy titled, BED-HOLD POLICY provided by the Administrator documented, . Procedure . 8. Notice. Except in the case of an emergency, before the Nursing Facility transfers the Resident/Elder to the hospital . the nursing facility will provide written information, acknowledging the terms of the bed-hold policy, to the Resident/elder and the Resident representative .

Based on observations, record review and interview, the facility failed to ensure dietary staff washed their hands and changed gloves before handling food items; ice scoop holder and ice machine were maintained in a clean and sanitary condition; failed to ensure expired food items were promptly removed and or discarded by the expiration or use by dates, to prevent food borne illness and failed to ensure food items stored in the freezer were covered or sealed, to retain their freshness, taste, and nutrient levels for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 34 residents who received meals from the kitchen (Total Census: 35), according to the list provided by the Dietary Supervisor on [DATE] at 11:28 a.m. The findings are: 1. On [DATE] at 10:10 a.m., the following observations were made in the kitchen area: a. Dietary Employee #1 was wearing gloves on her hands when she pushed a utility cart that contained a container of mashed potato flakes towards the stove. Without changing gloves, she picked up a turkey roast from a pan and sliced it, to be served to the residents for lunch. b. There was brown looking residue at the bottom of the scoop holder on the wall by the ice machine. The ice scoop was stored in direct contact with the residue. The Dietary Supervisor was asked to wipe the wet brown residue at the bottom of the ice scoop. The wet brown residue easily transferred to the paper towel. She was asked who uses the ice from the ice machine and how often do you clean the ice machine. She stated, The CNAs [Certified Nursing Assistants] use this to fill the water pitchers in the residents' rooms and to fill beverages served to the residents. We clean it daily. The Dietary Supervisor was asked does it look that it has been cleaned daily? She stated, It does not. 2. On [DATE] at 10:16 a.m., the following observations were made in the freezer. a. One open bag of pie shell was stored on a shelf in the freezer. The bag was not sealed. b. A bag of onion rings was stored on a shelf in the freezer. The bag had no date when it was received or when opened. c. One open box of pork patties was stored on a shelf in the walk-in freezer. The box was not covered or sealed. The Dietary Supervisor was asked, Should the box be covered or sealed? She stated, Yes, it is supposed to be taped close. 3 On [DATE] at 10:20 a.m., a box that contained ten bottles of citrus juice was stored on a shelf in the walk-in refrigerator. The bottles of citrus juice had an expiration date of [DATE]. 4. On [DATE] at 10:21 a.m., there were three gallons of water that was stored on a rack in the kitchen with an expiration date of [DATE]. 5. On [DATE] at 10:47 a.m., the spout to the ice machine located in the dining room had a yellow residue, and around the area of the spout was accumulation of black, gray, and rust colored residue. The Dietary Supervisor was asked to wipe off the yellow reside inside the spout, when she did the yellow residue easily transferred to the tissue. Then she was asked to describe the appearance of what was found around the spout. She stated, Black mold. She was asked how often you clean it. She stated, Once a week. She was asked, Does it look like it has been cleaned. She stated, No. 6. On [DATE] at 11:00 a.m., Dietary Employee #2 picked up a clip board that contained a menu from the top of the microwave and placed it on the counter and contaminated her hands. She then picked up a loaf of bread from the bread rack and placed it on the counter without washing her hands. She removed gloves from the box and placed them on her hands, contaminating the gloves and then removed slices of bread from the bag placed them in individual bags to be served to the residents for lunch. 7. On [DATE] at 11:14 a.m. Dietary Employee #3 removed a tissue from her pocket and wiped up spilled juice from the counter. Without washing her hands, she picked up beverage filled glasses by the rim and covered the glasses with saran wrap to be served to the residents for lunch. 8. On [DATE] at 11:32 a.m., Dietary Employee #4, removed a carton of milk from the refrigerator and placed it on the counter. Without washing her hands, she picked up bowls to be used to portion food and placed them on the counter with her fingers touching the interior surface of the bowls. On [DATE] at 12:37 p.m. Dietary Employee, #4, was asked, What should have done after touching dirty objects and before handling clean equipment? She stated, Changed gloves and washed my hands. 9. On [DATE] at 12:18 p.m., Dietary Employee #2, was on the tray line serving the lunch meal. She picked up tray cards and placed them on the trays. Without washing her hands, she picked up plates and touched the interior surfaces of the plates and placed them on the trays to be used to serve the residents their lunch meals. On [DATE] at 1:37 p.m. Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment or food, and she stated, Wash my hands. 10. On [DATE] at 12:19 p.m. Dietary Employee #1 was wearing gloves on her hand, picked up a bag of rolls from the walk-in refrigerator and placed it on the counter. She opened the refrigerator and removed a container of spaghetti and placed it in the microwave with contaminated gloves, She unzipped the zip lock bag and removed rolls from the bag and placed them in the blender to be pureed for the residents on pureed diets. 11. On [DATE] at 11:28 a.m., the facility hand washing policy provided by the Dietary Supervisor, documented, Food service personnel shall wash hands: after working with unclean equipment, work surfaces, clothing, wash cloths, etc. [et cetera] before and after removing gloves; (Note: Gloves can cause contamination. Gloves should be changed frequently).

Based on observation, record review and interview the facility failed to ensure the use of oxygen was documented on the Baseline Care Plan for 1 (Resident #235) of 3 (Residents #235, #237, and #8) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #235 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/31/21 was In Process. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 06/03/21 the resident's Electronic Health Record does not reveal a Care Plan or interventions for the use of oxygen therapy. c. On 06/03/21 at 04:30 p.m., the Administrator was asked, Do you have a policy on Care Plans? He stated, No, we don't have a policy regarding Care Plans. d. On 06/04/21 at 08:54 a.m., Licensed Practical Nurse (LPN) #1 was asked, If a newly admitted resident has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes it should. e. On 06/04/21 at 09:00 a.m., the Director of Nursing (DON) was asked, If a newly admitted resident has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes.

Based on observation, record review and interview the facility failed to ensure an overbed table was in good repair and free from detached molding/wood exposure to prevent the potential for skin tears for 1 of (Resident #8) 1 sampled resident and failed to ensure smoking aprons were provided prior to smoking for 2 (Residents #11 and #27) of 5 (Residents #11 #19 #27 #29 and #31) sampled residents who smoked. These failed practices had the potential to affect 6 residents in the facility who smoked according to the list given by the Assistant Director of Nursing (ADON) on 6/4/21, and 35 residents in the facility with overbed tables according to the Resident Census and Condition of Residents form dated 6/1/21. The findings are: 1. Resident #8 had diagnoses of [CONDITION(S)] (COPD), [CONDITION(S)] in arms, hands, [CONDITION(S)], and Arteriosclerosis Heart Disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/21 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognition intact), required supervision with activities of daily living and used oxygen while a resident. a. On 06/01/21 at 12:40 PM, the overbed table had the end molding coming loose, and flapping, a potential for skin tears. b. On 06/03/21 at 02:20 PM, the Administrator was notified about the overbed table with molding that had come loose on the end of the table. He stated he would go and remove it. 2. Resident #11 had diagnoses of [CONDITION(S)], [CONDITION(S)], and Dementia. The Admission MDS with an ARD of 3/10/21 documented a BIMS score of 4 (0-7 indicates cognition severely impaired), required supervision to extensive assistance with activities of daily living. a. The Plan of Care dated 3/16/21 documented, Smoking Safety-Resident will not suffer injury from unsafe smoking practices through the review date. Educate resident about the facility policy on smoking: locations, times, safety concern. Resident requires one-on-one assistance with smoking. The resident requires a smoking apron while smoking. b. The Resident's Smoking evaluation dated 5/25/21 documented, Requires supervision and smoking apron. c. On 06/01/21 at 01:13 PM, the resident was outside in smoking area, smoking, holding a cigarette and was able to extinguish ashes. The resident had no smoking apron on. 3. Resident #27 had diagnoses of Dementia, Depression and [CONDITION(S)]. The Quarterly MDS with an ARD of 5/5/21 documented a BIMS score of 15 (13-15 indicates cognition intact), was independent in most activities of daily living with extensive assistance required for dressing and bathing with one-person physical assist. a. The Plan of Care dated 5/3/21 documented, The Resident is a smoker and he enjoy going outside to smoke on scheduled smoke breaks. He has been assessed and determined to need supervision and wear a smoking apron to prevent dropping cigarettes or ashes on himself. Provide supervision with smoking and make sure that he is wearing a smoking apron at each smoke time. b. The Resident's Smoking assessment dated [DATE] documented, Requires supervision and smoking apron. c. On 06/01/21 at 01:14 PM, the resident was outside smoking currently, holding a cigarette independently. Was able to extinguishes ashes in red container provided. d. On 06/01/21 at 01:15 PM, the resident had finished his cigarette, had no apron on. Two staff members came after he finished smoking to place an apron on. The resident would not let them put it on, he was finished smoking. e. On 06/03/21 several direct care staff were interviewed and asked, When do you suppose to place the smoking apron on a resident if they require one when smoking: 3:20 PM Certified Nursing Assistant (CNA) #1 stated, The apron should be put on before they start smoking. CNA #2 stated, Before they start smoking. CNA #3 stated, They should have the apron on before they light the cigarette. f. On 06/04/21 at 8:20 AM, The Facility's Smoking Policy provided by the Assistant Director of Nursing documented, It is the Policy of this facility to have a smoking policy that protects the rights of individuals while providing the safest possible environment for all residents .

Based on observation, record review and interview the facility failed to ensure oxygen was being administered at the setting ordered by the physician to prevent potential respiratory complications for 2 (Residents #8 and #237) of 3 (Residents #8 #235 and #237) sampled residents and failed to ensure oxygen tubing was dated for 1 (Resident #235) of 3 (Residents #8 #235 and #237) sampled residents who used oxygen. These failed practices had the potential to affect 3 residents in the facility who used oxygen according to the list provided by the Assistant Director of Nursing (ADON). The findings are: 1. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/21 documented a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognition intact), required supervision with activities of daily living and received oxygen while a resident. a. The Plan of Care dated 9/16/20 documented, Resident has altered respiratory status/difficulty breathing r/t [CONDITION(S)]. Administer medication/treatment as ordered . Oxygen SETTINGS: O2 via nasal cannula as ordered. b. The June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 06/01/21 at 07:44 AM, the resident was sitting up in a recliner in the room with O2 on at 3 LPM/NC. d. On 06/01/21 at 12:40 PM, the resident was in his room in a recliner. O2 was in use at 3 LPM/NC. e. On 06/02/21 at 12:35 PM, the resident was sitting on the beside, O2 was on at 3 LPM/NC. f. On 06/04/21 at 8:00 AM, the Facility's Oxygen Administration Policy provided by the ADON documented, Check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Set the flow meter to the rate ordered by the physician. Label humidifier with date and time opened. Change humidifier and tubing weekly. 2. Resident #237 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-Day Admission MDS with an ARD of 5/24/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Interview for Mental Status (SAMS) and used oxygen while a resident. a. On 06/01/21 at 11:49 AM, O2 going at 2LPM/NC. There was no tubing change date on the tubing or on the humidifier bottle. b. On 06/03/21 at 12:48 PM, there is still no date on the oxygen tubing. c. On 06/03/21 at 03:35 PM-3:40 PM, Nurses were asked if there should be a date on the oxygen tubing and humidifier bottle? 3:35 PM, LPN #4 stated, Yes it should be dated. 3:40 PM, LPN #2 stated, Yes, it should be. 3:45 PM, the ADON was shown the oxygen tubing and humidifier bottle and there was still no date. When asked if the tubing should be dated? She stated, Yes. 3. Resident #235 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/31/21 was In Process. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 06/01/21 at 07:06 AM, Resident #235 was lying in the bed with oxygen in use by nasal cannula. The concentrator was set at 3 liters per minute. c. On 06/02/21 at 11:59 AM, Resident #235 was resting in her room with oxygen in use by nasal cannula. The concentrator was set at 2.5 liters per minute. d. On 06/03/21 at 07:55 AM, Resident #235 was sitting up in a recliner in her room with oxygen in use by nasal cannula during the medication pass. The concentrator was set at 3 liters per minute. e. On 06/04/21 at 08:54 a.m., Licensed Practical Nurse (LPN) #1 was asked, Who is responsible for checking a resident's oxygen flow rate? She stated, The nurses. She was asked, How often should a resident's oxygen flow rate be checked? She stated, At least every 2 hours. She was asked, How are correct oxygen flow rate settings relayed from 1 staff member to another? She stated, During report. f. On 06/04/21 at 09:00 a.m., the Director of Nursing (DON) was asked, Who is responsible for checking a resident's oxygen flow rate? She stated, The nurses. She was asked, How often should a resident's oxygen flow rate be checked? She stated, Every shift and as needed. She was asked, How are correct oxygen flow rate settings relayed from 1 staff member to another? She stated, During shift report, also the settings are on the Medication Administration Report and in the Physician orders.

Based on observation, record review and interview, the facility failed to ensure Licensed Nurses consistently signed the Narcotic Book to document when they counted the narcotics at the beginning and ending of their shift to promote accurate narcotic medication counts in 1 of 1 facility. This failed practice had the potential to affect 19 residents who received medications from Cart #2, as documented on a list provided by the Assistant Director of Nursing (ADON) on 6/3/21 at 11:00 AM. The findings are: 1. On 6/3/21 at 8:15 AM, the Narcotic Book for Cart #2 was inspected with Licensed Practical Nurse (LPN) #1, in attendance. There were five (5) areas where no licensed nurses signed that they counted the narcotics at the beginning or ending of the shift: a. On 6/2/21 at 6:00 AM, LPN #3 signed as the off going nurse. No oncoming nurse signed that they counted with LPN #3. b. Dated entry of 6/2/21 with no time documented, had no oncoming nurse signed that they counted with the off going nurse, LPN #2. c. Dated entry of 6/2/21 with no time documented, had no off-going nurse's signature that they counted with the oncoming nurse, LPN #2. d. There was a blank line after the above entry which had no date, no time and no nurses' signature for the on-coming nurse and no signature for the off-going nurse to signify that the narcotic count was performed on 6/3/21. 2. A Policy titled, Controlled Substances provided by the ADON on 06/02/21 at 11:00 AM documented, .Controlled substances shall be reconciled using a perpetual inventory method within a bound narcotic book with numbered pages . reconciliation shall occur . visual count if assuming responsibility/key controlled substances . 3. On 06/03/21 at 8:20 AM, LPN #1 was asked, Did you count when you came in this morning? She answered, Yes. She was asked, Should you have signed this book when you counted? She answered, Yes, right there on that line. She pointed to the third blank line to the right of LPN #2's signature. She was asked, Should someone have signed that they counted in these other blank spaces? She answered, Yes. That should have been [Nurse name]. 4. On 06/03/21 at 09:28 AM, the ADON was shown the signature page of the Narcotic Book and was asked, Should someone have counted the narcotics with LPN #3 on 6/2/21 at 6:00 a.m.? She answered Yes. That would have been LPN #1 at 6:00 a.m. She was asked, Should someone have counted at 2:00 pm with the person who signed this spot, and whose signature is this? She answered, Yes. LPN #1 should have counted with LPN #2. That is LPN #2's signature. He counted as the oncoming nurse at 2:00 yesterday and as the off going nurse at 4:00 p.m. yesterday with LPN #3. She was asked, Should LPN #3 have signed that she counted with LPN #2 yesterday at 4:00 p.m.? She answered, Yes. She was asked, Should someone have counted with LPN #3 this morning at 6:00 a.m.? She answered, Yes that should have been LPN #1. She was asked, Should the nurses sign this page when they count narcotics? She answered, Yes. They are being in-serviced now about it. The Director of Nursing stated, If it was not documented, it was not done. 5. On 06/03/21 at 10:55 AM, LPN #2 was asked, When do you count narcotics? He answered, At the beginning and end of a shift. He was asked, Should you sign the narcotic book when you count? He answered, Yes. He was asked, Why should you sign the narcotic book? He answered, To show that you counted, and the count is correct.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications and improve palatability for residents who required a pureed diet for 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who received pureed diets, according to the Diet List provided by the Dietary Supervisor on 6/2/21 at 08:15 a.m., The findings are: a. On 06/01/21 at 11:18 a.m., Dietary Employee #1 pureed turkey roast and poured it into a pan. She covered it with a piece of saran wrap and placed it in the oven to be served to the residents who received pureed diets for the lunch meal. The consistency of the pureed turkey roast was not smooth, it had lumps in it. b. On 06/01/21 at 11:36 a.m., Dietary Employee #4, placed four servings of brownie in the blender and added a carton of warm milk and pureed the brownies. At 11:44 AM, she poured pureed brownie into two bowls and covered them with saran wrap and placed them on the counter. The consistency of the pureed brownie was not smooth. It had lumps. c. On 06/01/21 at 11:45 a.m., Dietary Employee #1 pureed corn to be served to the residents on pureed diets. The pureed corn was not smooth. It had lumps and had pieces of corn visible in the mixture. d. On 06/01/21 at 12:19 p.m., Dietary Employee #1, pureed bread to be served to the residents on pureed diets. The consistency of the pureed bread was dry. e. On 06/01/21 at 12:41 p.m., Dietary Employee #2 was asked to describe the consistency of the pureed food items served to the residents on pureed diet. She stated, Pureed meat should have been smoother and was not pudding consistency, it looked like ground; the pureed corn was not smooth, it looked chopped, it should have been smoother. f. On 06/01/21 at 12:56 p.m., Dietary Employee, #2 was asked to describe the consistency of the pureed bread. She stated, It is dry. g. On 06/01/21 at 1:01 p.m., the Dietary Supervisor was asked to describe the consistency of the pureed bread. She stated, It is dry.

Based on observation, record review and interview, the facility failed to ensure mechanical soft meat was prepared and served according to the planned, written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received mechanical soft diets, according to the Diet List provided by the Dietary Supervisor on 6/2/21 at 8:15 a.m. The findings are: 1. On 06/02/21, the menu for the noon meal documented residents on mechanical soft diets were to receive ground turkey roast. On 6/01/21 at 12:45 p.m., Dietary Employee, #2 was on the line and placed a serving of regular meat on a plate to serve to a resident on a mechanical soft diet, she then used a fork to separate it into strips when she was ready to send the plate out to the resident. She was stopped and was asked what is the texture of the meat that she was serving. She stated, It is for a mechanical soft diet. We did do not have mechanical soft meat prepared. The Dietary Supervisor was called and was asked to describe the texture of the meat. She stated, it looks like chopped meat.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the physician was consulted regarding the onset of bowel incontinence and severe diarrhea to facilitate prompt initiation of treatment for 1 (Resident #1) of 4 (Residents #1, #2, #5 and #6) case mix residents who who were at risk for dehydration. The failed practice resulted in a pattern of actual harm to Resident #1, who was admitted to the hospital with [REDACTED]. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5-Day Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/3/11 documented the resident scored 6 (0-7 severely impaired) on a brief interview for mental status (BIMS), required limited assistance of staff for eating and toileting, was continent of bowel and had an indwelling urinary catheter. a. The Physician orders [REDACTED]. b. The resident's Admission assessment dated [DATE], Medicare Nurse's Notes dated 5/13/11 through 5/22/11, Admission assessment dated [DATE] and Medicare Nurse's Notes dated 5/25/11 through 6/1/11, contained no documentation that the resident had been incontinent of bowel. The Nurse's Notes dated 6/1/11 at 5:20 p.m. documented, "...Resident to start Bactrim DS (1) PO BID (times) 7 days..." The Physician order [REDACTED]." The resident's June 2011 BM (Bowel Movement) Record documented, "(6/1/11 on 3:00 p.m. to 11:00 p.m. shift) - X (extra) L (large)/L (loose) ...(6/1/11 on 11:00 p.m. 7:00 a.m. shift) - XL/L" c. The resident's Medicare Nurse's Note form dated 6/3/11 documented, "6:00 p.m. ...continues (with) Bactrim DS. (No) adverse reactions noted..." The 6/3/11 form contained no documentation the Physician was notified the resident experienced diarrhea. The resident's June 2011 BM Record documented, "(6/3/11 on 3:00 p.m. to 11:00 p.m. shift) - XL/L" d. The Medicare Nurse's Note form dated 6/4/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurse's Note narratives dated 6/4/11 documented, "...1:(00) (a.m.) ...on Bactrim/UTI with adverse reaction... (1:05 p.m.) ...incontinent of bowel (times) 1 this shift, incontinent care provided per staff..." The 6/4/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, (6/4/11 on 3:00 p.m. to 11:00 p.m. shift) - "XXXL/L" e. The Medicare Nurses Note form dated 6/5/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note 6/5/11 narrative documented, "12:25 (a.m.)... Foley cath (catheter) patent... cont (continent feces)... On Bactrim/UTI, (No) adverse reactions noted)... 3:30 (p.m.) F/C patent... remains on Bactrim DS (without) adverse reaction..." The 6/5/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, "(6/5/11 on 3:00 p.m. to 11:00 p.m. shift) - XXXL/L" f. The Medicare Nurses Note form dated 6/6/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narratives dated 6/6/11 documented, "1:10 (a.m.)... On Bactrim/UTI, (no) adverse reactions noted... 12:57 p.m. Unable to keep dsg (dressing) to buttocks in place... (late entry) 9:(00) a.m. documented, "(Resident) c/o (complaint of) diarrhea. [MEDICATION NAME] 2 mg (two) tab (tablets) given per prn (as needed) order..." The 6/6/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, "(6/6/11 on 3:00 p.m. to 11:00 p.m. shift) - XXL/L ...(11:00 p.m. 7:00 a.m. shift - XXL/L" g. The Medicare Nurse's Notes form dated 6/7/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narrative dated 6/7/11 documented, "9:10 a.m. documented, "Received following TO (telephone order): 1) Culture for [MEDICAL CONDITIONS], 2) [MEDICATION NAME] 500 mg PO (by mouth) BID (twice a day) (times) 7 days. 3) [MEDICATION NAME] 400 mg PO BID... (10:00 a.m.) Alert..." The resident's June 2011 BM (Bowel Movement) Record documented, "(6/7/11 on 3:00 p.m. to 11:00 p.m. shift) - "XXL/L" A Grievance Report dated 6/7/11 documented, "(Resident #1's) daughter... states that resident has had diarrhea for days and she had to call the Dr. (doctor) herself. Wants to know if she was responsible for contacting the doctor. Also states that the nurse on (duty) today said she wasn't here yesterday and didn't know (Resident #1) had diarrhea... Nurse on duty stated she did talk to (resident's daughter), but (resident's daughter) had already contacted MD (Medical Doctor) herself before the nurse had a chance to." h. The Medicare Nurses Note form dated 6/8/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narratives dated 6/8/11 documented, "3:15 a.m. ...No s/sx (signs or symptoms) of adverse reactions noted to ABT (antibiotic therapy), Bactrim DS for UTI... 9:30 (a.m.) ...Continues on Bactrim DS/ UTI (urinary tract infection) (without) adverse reaction noted, continues to have soft, jelly like, foul smelling BM (bowel movement), started on [MEDICATION NAME] 500 mg this a.m., stool specimen collected for [MEDICAL CONDITION] culture..." The Nurse's Note narrative dated 6/8/11 at 12:55 p.m. documented,"...F/C (Foley Catheter) patent (and) draining amber colored urine ...peri care given due to bowel incont (incontinence)..." The Medicare Nurses Note narratives dated 6/8/11 documented, (3:15 p.m.)... When asked how he was doing, (resident) states "I don't feel good... Blood drawn collected for a CBC (complete blood count) and CMP (complete metabolic profile)... (3:20 p.m.) Blood in red vacutainer noted to have clotted. DON (Director of Nursing) aware. (3:45 p.m.) - resident being sent out to ER (emergency room ) via ...ambulance for (decreased) LOC (level of consciousness), possible dehydration..." i. The hospital History and Physical dated 6/9/11 documented, "...Date of Admission 6/8/11... ICU (intensive care unit)... Chief complaint: Decrease level of consciousness, possible dehydration. History of Present Illness ...Evaluation in the emergency room include a clinical [DIAGNOSES REDACTED]. The family confirms this as well. ...The family says this has been going on for some 4-5 days... Impression: Intravascular Volume Depletion, probably secondary to diuretics and poor oral intake... Severe Protein [MEDICAL CONDITION] Acute [MEDICAL CONDITION] (present creatinine 2.6; baseline is upper 1's)... Mild [MEDICAL CONDITION], probably secondary to combination of Acute [MEDICAL CONDITION] and Exogenous Potassium... History of Heart Failure with Small Bilateral Pleural Effusions... Atelectasis, right lower lobe... urinary tract infection... Foley catheter... Probable Clostrium Difficile [MEDICAL CONDITION]" j. On 6/29/11 at 8:43 a.m., the Director of Nursing (DON) was asked how long the resident had diarrhea before he was sent to the hospital. She stated, "He wasn't sent for diarrhea, but I think for a few days." When asked when she was first informed of the diarrhea, the DON stated, "I think it was a day or two before he went to the hospital and at the time I was told, they had already called the Physician and gotten orders." The DON was asked where it would be documented that a resident was having loose stools. The DON stated it was documented on the Bowel Movement Record. When asked about abbreviations used on the BM Record and what XXL/L meant, she stated XXL/L meant diarrhea. At 11:40 a.m., the DON was asked at what point she expected nurses to notify the physician, when a resident was having multiple episodes of loose stools. The DON stated, I would wait and see if the [MEDICATION NAME] worked. After a couple of days of loose stools." The DON stated, "I have my night nurses checking the BM sheets for constipation; they're not looking at loose stool. I guess I'll have them start checking for that." 1) On 6/29/11 at 8:52 a.m., Certified Nursing Assistant (CNA) #1 was asked where it would be documented if a resident was having loose stools. The CNA stated it would be documented on the BM Record and she would then tell a nurse. The CNA stated that the abbreviations of XL/L and XXL/L meant diarrhea. 2) On 6/29/11 at 8:55 a.m., CNA #2 was asked where it would be documented if a resident was having loose stools. The CNA stated it would be documented in the BM book. The CNA stated XXL/L and XXL/L in the BM book meant heavy diarrhea. 3) On 6/29/11 at 9:07 a.m., CNA #3 was asked where it would be documented if a resident was having loose stools. The CNA stated it would be documented in the BM book and she would them tell the charge nurse. She stated that if a resident had XXL/L or XXXL/L stools she would call it diarrhea if it was more than one time. 4) On 6/29/11 at 10:12 a.m., CNA #4 (a CNA who worked with the resident on the evening shift) was asked if the resident ever had diarrhea when she was taking care of him. The CNA stated, "Yes, ma'am. It was quite a bit before he went to the hospital. I don't remember the dates. She stated, "I carried him to the bathroom and tried to keep him clean and give him water because I was afraid he would dehydrate. I told the nurse (Licensed Practical Nurse (LPN) #2 and LPN #1)." 5) On 6/29/11 at 10:28 a.m., CNA #6 (a CNA who worked with the resident on the night shift) was asked if the resident ever had diarrhea when she was taking care of him. The CNA stated, "Yes, he did right before he went to the hospital. I had to put a diaper on him. The CNA stated she told LPN #3 about the resident's loose stools. 6) On 6/29/11 at 12:11 p.m., CNA #7 (a CNA who worked with the resident on the evening shift) was asked if the resident ever had diarrhea when she was taking care of him. She stated, "Yes, before he went to the hospital. The CNA stated the resident had loose stools on 6/3/11, 6/4/11, 6/5/11 and 6/7/11. She stated she reported the loose stools to Registered Nurse (RN) #1. 7) On 6/29/11 at 10:22 a.m., LPN #1 (a nurse who worked with the resident on the day shift) was asked if he was ever told that the resident had diarrhea. He stated, "Yes, just once." When asked what he did about the resident having diarrhea, he stated he gave the resident [MEDICATION NAME]. When asked at what point he would notify the physician of diarrhea, he stated, "If it had been going on for a couple of days - a trend." The LPN was asked where he would document the diarrhea, physician consult and any treatment. He stated, "Would document it on the Nurse's Notes and on the MAR (Medication Administration Record)." The LPN was asked if he reviewed BM Records for his residents. He stated, "Yes, I try to get it out and look at it every couple of days." At 11:50 a.m., LPN #1 was asked if he had reviewed this resident's BM Record after being informed that the resident had diarrhea. He stated "No ma'am, I don't believe I did." 8) On 6/29/11 at 12:09 p.m., LPN #3 (a nurse who worked with the resident on the night shift) was asked if she was ever informed that this resident had diarrhea. She stated, "Yes, as an older person, I have diarrhea a lot of times at night. Generally, if they tell me that the resident has had more than two, I do something. I'm sure if he had diarrhea, they told me." When asked at what point she would notify the physician of diarrhea, the LPN stated, "Generally, if it continues, I give [MEDICATION NAME] and pass it on to the day shift... I don't really notify the Doctor; I pass it on." The LPN was asked where she would document the diarrhea and any treatment provided. She stated, "I document it in the chart - Nurse's Notes." The LPN was asked if she reviewed the BM Records for her residents. She stated, "Yes - I don't check for BMs, diarrhea - only constipation. I guess I'll start. I've never paid any attention to the loose stools, only constipation." 9) On 6/29/11 at 12:25 p.m., LPN #2 (a nurse who worked with the resident on the day shift) was asked at what point she would notify the Doctor if a resident was having diarrhea. She stated, "First thing, if the resident was showing signs and symptoms of being ill. Or if it's a common case of diarrhea due to something they ate, give them an antidiarrheal. Maybe 2 times." The LPN was asked if she reviewed the BM Records for her residents. She stated, "Yes, periodically, I look at it when the night nurse gives me a list of residents needing laxatives and if a resident's appetite is decreased or looking bloated, or complains of stomach ache." When asked if she looked at the BM Book for diarrhea, she stated, "The aides are usually good to tell me if a resident is having diarrhea. Honestly no." When asked how long the resident had diarrhea before he was sent to the hospital, the LPN stated "The first I heard of it, the daughter said he had had diarrhea for two days. I told her if I had been aware of it I would have addressed it. She stated she attempted to call the Physician but got an answering machine. The LPN stated it was approximately 10:00 p.m. She stated the Physician's nurse did give orders for stool culture, they obtained the culture and sent it to the lab. When asked where she would document that a resident was having loose stools she stated she would document it in the Nurse's notes. 10) On 6/29/11 at 2:52 p.m., Registered Nurse (RN) #1 (a nurse who worked with the resident on the evening shift) was asked if she had ever been informed that this resident was having diarrhea. She stated "I remember I was told once. He was on an antibiotic. I gave him [MEDICATION NAME]. The CNA told me. I guess I didn't chart it, I don't know when it was." The RN was asked at what point she would notify the physician of diarrhea. She stated, "If it persists more than a week, or 4 to 5 days." The RN was asked if she reviewed BM Records for her residents. She stated, "Sometimes. I don't look at it unless there's something wrong. They usually tell me. I chart it and write it on the MAR." On 6/29/11 at 3:05 p.m., RN #1 reviewed the Nurses Notes for this resident and was unable to locate any documentation regarding loose stools or consultation with the physician regarding diarrhea. k. On 6/29/11 at 4:30 p.m., Physician #1 was asked if the facility had notified him of the resident's diarrhea. He stated, "I don't recall being called." When asked at what point he would want to be notified of ongoing diarrheal stools, he stated, "...48 to 72 hours, because a normal bout of diarrhea would have subsided by then..." l. On 6/30/11 at 9:48 a.m., Physician #2 was asked if the facility had notified him of the resident's diarrhea. He stated, "I didn't know until he came to the hospital." m. On 6/30/11 at 10:05 a.m., the DON was asked to provide any documentation that the physician was consulted regarding the resident's diarrhea. The DON was unable to locate any such documentation.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to develop or implement interventions to ensure sufficient fluids were provided to prevent dehydration, to ensure fluid intake was monitored closely during a 7-day period when the resident was experiencing diarrhea, and to ensure monitoring was conducted for signs/symptoms of dehydration for 1 (Resident #1) of 4 case mix residents (Resident's #1, #2, #5 and #6) who were at risk for dehydration. This failed practice resulted in a pattern of actual harm to Resident #1, whose inadequate fluid intake and continued diarrheal stools contributed to a hospitalization for Intravascular Volume Depletion, and was likely to result in more than minimal harm for 17 residents who were at risk for dehydration, as documented by the Director of Nursing (DON) on 6/30/11 at 9:34 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5-Day Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/3/11 documented the resident scored 6 (0-7 severely impaired) on a brief interview for mental status (BIMS), had an acute change in mental status, had a poor appetite or over ate nearly every day, required limited physical assistance of one person for eating and toilet use, had an indwelling urinary catheter and received a therapeutic diet. The Discharge Summary dated 6/8/11 documented the resident was hospitalized [DATE] with respiratory distress, was treated for [REDACTED]. a. The Physician orders [REDACTED]. b. The Care Plan dated 5/25/11 documented, "5/24/11 At risk for fluid (and) electrolyte imbalance r/t (related to): Dx (Diagnosis) [MEDICAL CONDITION], Dx [MEDICAL CONDITIONS], Diuretic use... 6/1/11 UTI (Urinary Tract Infection)... (Goal)... Maintain adequate hydration... (Approaches) ... Lab as ordered... fluid intake monitored, monitor for s&s (sign and symptoms) dehydration: poor skin turgor, dry mucous membranes, sunken eyes, dark colored urine." c. The Nutritional Evaluation History and Data Collection form dated 5/12/11 (most recent) documented, "Weight 164 (pounds) ...Estimated Fluids Needs: 74 (weight in kilograms) ...2220 (milliliters) fluid" The form was signed by the Dietary Service Manager (DSM). The Dietary Progress Notes, dated 5/16/11, 5/25/11, 5/26/11 and 5/31/11 and signed by the DSM, did not document assessments of the resident's daily fluid needs versus fluid intake or fluid output. d. The resident's Admission assessment dated [DATE], Medicare Nurse's Notes dated 5/13/11 through 5/22/11, Admission assessment dated [DATE] and Medicare Nurse's Notes dated 5/25/11 through 6/1/11, contained no documentation that the resident was incontinent of bowel. The Nurse's Notes dated 6/1/11 at 5:20 p.m. documented, "...Resident to start Bactrim DS (1) PO BID (times) 7 days..." The Physician order [REDACTED]." The resident's June 2011 BM (Bowel Movement) Record documented, "(6/1/11 on 3:00 p.m. to 11:00 p.m. shift) - X (extra) L (large)/L (loose) ...(6/1/11 on 11:00 p.m. 7:00 a.m. shift) - XL/L" e. A Weight Record dated 6/2/11 documented the resident weighed 156.5 pounds (lbs), which indicated his minimal daily fluid needs were 2134 cubic centimeters (cc ) per day (156.5 lbs equals 71.13 kg times 30 cc = 2134 cc/day see below). (The Centers for Medicare and Medicaid Services (CMS)Interpretive Guidelines at F327 documented, "...Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid fluid intake) and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates. A general guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kg (kilograms) times 30 cc (cubic centimeters) (2.2 lbs (pounds) = 1 kg... Signs of possible dehydration can be represented by abnormal laboratory values (e.g. (for example), elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], transferrin, blood urea nitrogen (BUN), or urine specific gravity.") f. The resident's Medicare Nurse's Note form dated 6/3/11 documented, "6:00 p.m. ...continues (with) Bactrim DS. (No) adverse reactions noted..." The 6/3/11 form contained no documentation the Physician was notified the resident experienced diarrhea. The resident's June 2011 BM Record documented, "(6/3/11 on 3:00 p.m. to 11:00 p.m. shift) - XL/L" g. The Medicare Nurse's Note form dated 6/4/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurse's Note narratives dated 6/4/11 documented, "...1:(00) (a.m.) ...on Bactrim/UTI with adverse reaction... (1:05 p.m.) ...incontinent of bowel (times) 1 this shift, incontinent care provided per staff..." The 6/4/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, (6/4/11 on 3:00 p.m. to 11:00 p.m. shift) - "XXXL/L" h. The Medicare Nurses Note form dated 6/5/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note 6/5/11 narrative documented, "12:25 (a.m.)... Foley cath (catheter) patent... cont (continent feces)... On Bactrim/UTI, (No) adverse reactions noted)... 3:30 (p.m.) F/C patent... remains on Bactrim DS (without) adverse reaction..." The 6/5/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, "(6/5/11 on 3:00 p.m. to 11:00 p.m. shift) - XXXL/L" i. The Medicare Nurses Note form dated 6/6/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narratives dated 6/6/11 documented, "1:10 (a.m.)... On Bactrim/UTI, (no) adverse reactions noted... 12:57 p.m. Unable to keep dsg (dressing) to buttocks in place... (late entry) 9:(00) a.m. documented, "(Resident) c/o (complaint of) diarrhea. [MEDICATION NAME] 2 mg (two) tab (tablets) given per prn (as needed) order..." The 6/6/11 form contained no documentation the Physician was notified the resident experienced diarrhea or was incontinent of bowel. The resident's June 2011 BM (Bowel Movement) Record documented, "(6/6/11 on 3:00 p.m. to 11:00 p.m. shift) - XXL/L ...(11:00 p.m. 7:00 a.m. shift - XXL/L" j. The Medicare Nurse's Notes form dated 6/7/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narrative dated 6/7/11 documented, "9:10 a.m. documented, "Received following TO (telephone order): 1) Culture for [MEDICAL CONDITIONS], 2) [MEDICATION NAME] 500 mg PO (by mouth) BID (twice a day) (times) 7 days. 3) [MEDICATION NAME] 400 mg PO BID... (10:00 a.m.) Alert..." The resident's June 2011 BM (Bowel Movement) Record documented, "(6/7/11 on 3:00 p.m. to 11:00 p.m. shift) - "XXL/L" A Grievance Report dated 6/7/11 documented, "(Resident #1's) daughter... states that resident has had diarrhea for days and she had to call the Dr. (doctor) herself. Wants to know if she was responsible for contacting the doctor. Also states that the nurse on (duty) today said she wasn't here yesterday and didn't know (Resident #1) had diarrhea... Nurse on duty stated she did talk to (resident's daughter), but (resident's daughter) had already contacted MD (Medical Doctor) herself before the nurse had a chance to." k. The Dietary Progress notes dated 6/7/11 and signed by the DSM documented, "...14-day quarterly progress note... Resident is on a Regular NAS (no added salt) diet... Resident weight is 161 (pounds). Intake is 25%... Lab data available 5/4/11 [MEDICATION NAME] 2.2 (low), 6/1/11 glucose 66 (low), BUN (Blood Urea Nitrogen) 24 (elevated), creatinine 2.30 (elevated), hbg (hemoglobin) 8.7 (low), hematocrit 28.4 (low). Physician aware of lab data. (No) new orders. Will continue (with) current plan of care. ...Will place resident on RD (Registered Dietician) referral list for the month of June (2011) due to abnormal lab data. Refuse most of his meal. Will continue (with) current plan of care." There was no documentation that the DSM or RD was aware of the resident's frequent loose stools. The Dietary Progress notes did not address fluid needs versus fluid intake. l. The resident's June 2011 Intake and Output (I&O) Record and June 2011 Consumption Record from 6/1/11 to 6/8/11 documented: 1) 6/1/11 I&O Record - Fluid Intake 260 cc total, Fluid Output 300 cc. There was no intake or output documented for one of the three shifts. The resident's 24-hour fluid intake and output had not been totaled by the facility. 6/1/11 Consumption Record - Fluid Intake 600 cc total. There was no documentation of fluids for Lunch Hydration or afternoon (PM) Snack Hydration; the bedtime (HS) Snack fluid consumption was documented as "1", instead of a cc amount. There was no documentation of fluid intake for the 11-7 (11:00 p.m. to 7:00 a.m.) shift. The resident's 24-hour fluid intake had not been totaled by the facility. 2) 6/2/11 I&O Record - Fluid Intake 560 cc total, Fluid Output 400 cc. The resident's 24-hour fluid intake and output had not been totaled by the facility. 6/2/11 Consumption Record - Fluid Intake 840 cc total. There was no documentation of fluids for AM (morning) Snack Hydration, Lunch Hydration or PM Snack Hydration; the HS Snack fluid consumption was documented as "1", instead of a cc amount. There was no documentation of fluid intake for the 11-7 shift. The resident's 24-hour fluid intake had not been totaled by the facility. 3) 6/3/11 I&O Record - Fluid Intake 880 cc total, Fluid Output 950 cc. 6/3/11 Consumption Record - Fluid Intake 780 cc total. There was no documentation of fluids for AM (morning) Snack Hydration, Lunch Hydration or PM Snack Hydration; the HS Snack fluid consumption was documented as "1", instead of a cc amount. There was no documentation of fluid intake for the 11-7 shift. The resident's 24-hour fluid intake had not been totaled by the facility. 4) 6/4/11 I&O Record - Fluid Intake 600 cc total, Fluid Output 650 cc. 6/4/11 Consumption Record - Fluid Intake 360 cc total. The HS Snack fluid consumption was documented as "1", instead of a cc amount. There was no documentation of fluid intake for the 11-7 shift. The resident's 24-hour fluid intake had not been totaled by the facility. 5) 6/5/11 I&O Record - Fluid Intake 480 cc total, Fluid Output 1000 cc. The resident's 24-hour fluid intake and output had not been totaled by the facility. 6/5/11 Consumption Record - Fluid Intake 840 cc total. There was no documentation of fluid intake for the 11-7 shift. The resident's 24-hour fluid intake had not been totaled by the facility. 6) 6/6/11 I&O Record - Fluid Intake 360 cc total, Fluid Output 425 cc. There was no intake or output documented for one of the three shifts. 6/6/11 Consumption Record - Fluid Intake 600 cc total. There was no documentation of fluids for AM (morning) Snack Hydration, Lunch Hydration or PM Snack Hydration; the HS Snack fluid consumption was documented as "1", instead of a cc amount. There was no documentation of fluid intake for the 11-7 shift. The resident's 24-hour fluid intake had not been totaled by the facility. 7) 6/7/11 I&O Record - Fluid Intake 700 cc total, Fluid Output 1050 cc. The resident's 24-hour fluid intake and output had not been totaled by the facility. 6/7/11 Consumption Record - Fluid Intake 840 cc total. There was no documentation of HS Snack fluid consumption. The resident's 24-hour fluid intake had not been totaled by the facility. 8) 6/8/11 I&O Record - Fluid Intake 580 cc total, Fluid Output 500 cc. The resident's 24-hour fluid intake and output had not been totaled by the facility. 6/8/11 Consumption Record - Fluid Intake 420 cc total. There was no documentation of consumption for Breakfast Hydration, AM (morning) Snack fluid, Lunch Hydration or PM Snack hydration. The resident's 24-hour fluid intake had not been totaled by the facility. m. The Medicare Nurses Note form dated 6/8/11 documented, "...Days (7:00 a.m. to 3:00 p.m. shift) ...Incontinent (yes)..." The Medicare Nurses Note narratives dated 6/8/11 documented, "3:15 a.m. ...No s/sx (signs or symptoms) of adverse reactions noted to ABT (antibiotic therapy), Bactrim DS for UTI... 9:30 (a.m.) ...Continues on Bactrim DS/ UTI (urinary tract infection) (without) adverse reaction noted, continues to have soft, jelly like, foul smelling BM (bowel movement), started on [MEDICATION NAME] 500 mg this a.m., stool specimen collected for [MEDICAL CONDITION] culture..." The Nurse's Note narrative dated 6/8/11 at 12:55 p.m. documented,"...F/C (Foley Catheter) patent (and) draining amber colored urine ...peri care given due to bowel incont (incontinence)..." The Medicare Nurses Note narratives dated 6/8/11 documented, (3:15 p.m.)... When asked how he was doing, (resident) states "I don't feel good... Blood drawn collected for a CBC (complete blood count) and CMP (complete metabolic profile)... (3:20 p.m.) Blood in red vacutainer noted to have clotted. DON (Director of Nursing) aware. (3:45 p.m.) - resident being sent out to ER (emergency room ) via ...ambulance for (decreased) LOC (level of consciousness), possible dehydration..." n. The hospital History and Physical dated 6/9/11 documented, "...Date of Admission 6/8/11... ICU (intensive care unit)... Chief complaint: Decrease level of consciousness, possible dehydration. History of Present Illness ...Evaluation in the emergency room include a clinical [DIAGNOSES REDACTED]. The family confirms this as well. ...The family says this has been going on for some 4-5 days... Impression: Intravascular Volume Depletion, probably secondary to diuretics and poor oral intake... Acute [MEDICAL CONDITION] (present creatinine 2.6; baseline is upper 1's)... Mild [MEDICAL CONDITION], probably secondary to combination of Acute [MEDICAL CONDITION] and Exogenous Potassium... History of Heart Failure with Small Bilateral Pleural Effusions... Atelectasis, right lower lobe... urinary tract infection... Foley catheter... Probable Clostrium Difficile [MEDICAL CONDITION]" o. On 6/29/11 at 8:40 a.m., the Director of Nursing (DON) was asked, "(On) what residents do you monitor I&O?" She stated, "Only on residents with a Foley catheter or if the physician orders [REDACTED].?" She stated, "We treat everybody, offer fluids, get fluids with meds (medications), meal trays, with each time they provide care, snack carts that have juice and fluids." The DON was asked, "Who is supposed to monitor the I&O Records?" She stated, "The night nurse. The DON and Assistant DON (ADON) pick up the completed record at the end of the month and look at it..." The DON was asked at what point the nurse should notify the physician if a resident had stopped fluid intake or decreased intake of fluids. She stated "Within a couple of days." At 8:43 a.m., the Director of Nursing (DON) was asked how long the resident had diarrhea before he was sent to the hospital. She stated, "He wasn't sent for diarrhea, but I think for a few days." When asked when she was first informed of the diarrhea, the DON stated, "I think it was a day or two before he went to the hospital and at the time I was told, they had already called the Physician and gotten orders." The DON was asked where it would be documented that a resident was having loose stools. The DON stated it was documented on the Bowel Movement Record. When asked about abbreviations used on the BM Record and what XXL/L meant, she stated XXL/L meant diarrhea. At 11:40 a.m., the DON was asked at what point she expected nurses to notify the physician, when a resident was having multiple episodes of loose stools. The DON stated, I would wait and see if the [MEDICATION NAME] worked. After a couple of days of loose stools." The DON stated, "I have my night nurses checking the BM sheets for constipation; they're not looking at loose stool. I guess I'll have them start checking for that." p. On 6/30/11 at 2:30 p.m., the Minimum Data Set (MDS) Coordinator was asked, "How do you assess a resident on admission for potential problems/concerns?" She stated, "Normally when they first come in we're not always here. We have different assessment tools - Braden, falls, smoking, infection, incontinence, transfers, and elopement." When asked if the facility had an assessment tool for hydration/dehydration, she stated "We don't." The MDS Coordinator was asked, "How do you assess for possible dehydration risk?" She stated, "If they have a certain [DIAGNOSES REDACTED]. (Resident #1) was at risk." The MDS Coordinator was asked, "How would you assess for dehydration?" She stated, "Intake, meds, and skin turgor." She was then asked, "Who fills out the CNA care plans?" She stated, "The nurses do on admission so the CNAs will know how to take care of them." When asked, "If you identify other problems do you update the CNA care plans?", she stated, "Yes, if something changes." The MDS Coordinator was asked, "How are you aware of resident's changes?" She stated, "Make rounds, nurses discuss at standup meetings, and the shift to shift report." q. On 6/30/11, LPN #1 and LPN #4 were asked the following questions and gave the following responses: How do you monitor for signs and symptoms (s/s) of dehydration and fluid intake? How do you monitor if the resident's fluid intake is adequate? If you provide the resident with fluids, where do you document it? At 4:00 p.m., LPN #4 stated, "Skin turgor, mucous membranes, look at consumption records and I&O sheets, outputs or Foley catheter outputs, or if incontinent, and changes during the shift... On the I&O, in the consumption book or tell the CNA to add it with hers for that shift and sometimes in the Nurse's Notes." The LPN was shown this resident's I&O Record and asked if it was accurate. The LPN stated, "No, I guess not because it's not filled in". At 4:40 p.m., LPN #1 stated, "I&Os, consumption sheets, skin, confusion, and decreased level of consciousness. I compare the I&Os. I chart it in the Nurses's Notes or add it to the I&O sheet." The LPN was shown this resident's I&O Record and was asked if it was accurate. The LPN stated, "It would be difficult to tell".