Based on interviews, medical record review, and facility policy review, the facility failed to provide a discharge summary for one (Resident #1) of three residents reviewed for discharge, out of a sample of 7 residents. At discharge, Resident #1 was given another person's discharge paperwork potentially hindering him from receiving continuous and coordinated, person-centered care. The findings include: A review of the medical record for Resident #1 revealed an admission date of 6/16/23, and the resident was discharged home on 7/8/23. The resident's diagnoses included hemiplegia (affecting left side), CVA, a fib, seizures, GERD, and major depressive disorder. An admission Minimum Data Set (MDS) assessment, dated 6/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. Resident #1 required extensive assistance with activities of daily living (ADLs). A review of Resident #1's nursing summary of stay stated, Resident is discharging home with spouse on 7/8/23. Discharge instructions to be given. A copy of the discharge summary provided by the Administrator did not reveal the resident or resident's representative signature. On 8/22/23 at 4:15 pm, a phone interview was conducted with the wife of Resident #1. She stated that when her husband was discharged from the facility on 7/8/23, he was given someone else's paperwork. She explained they didn't realize it wasn't his discharge summary until two days later when he was at his primary care physician for his follow up appointment. She explained that she called the facility to tell them about the error and the facility asked her to shred the paperwork. During the call she also requested the facility send her the correct paperwork. However, she still has not received her husband's discharge paperwork, and that has delayed his outpatient therapy. On 8/23/23 at 2:40 pm, an interview was conducted with the Administrator. When she was asked what residents receive in regard to discharge paperwork. She replied, They get a list of their medications and a summary of their stay with their home health information, durable medical equipment, where they are going, and upcoming appointments. When asked if the resident or their representative sign the discharge paperwork, she replied, Yes, they are supposed to sign it. When asked if there were there two copies of the discharge paperwork, she replied, Typically, we should keep a signed copy, sometimes the nurses will end up giving them both copies. When asked if a resident doesn't receive a copy of their discharge paperwork at discharge, can they get a copy after discharge, she replied, Yes, and if their physician calls, we can also fax them a copy. When asked if any residents had ever received the the wrong discharge paperwork, she replied, Yes, that did happen once recently. I spoke with her and asked her to please shred the paperwork or bring it to me, she choose to shred it. I believe we emailed her the correct paperwork. I'll have to check. On 8/23/23 at 3:45 pm, a follow up interview was conducted with the Administrator. She stated, I can't find the email. I remember it was (Resident #1), her husband discharged on 7/8/23, and she called us on 7/10/23, because they were at his doctor for a follow up and that's when she realized she had someone else's paperwork. She said she needed his paperwork for the doctor. We spoke with her and apologized, and I asked her to shred the paperwork she had or to bring it back here, she said she would shred it. She never called back after that, so I assume there was no further problems. I can't remember if I faxed the paperwork or emailed it, but I can't find it now, so I'm not sure if I sent it, but she didn't call back asking for it. When asked if the discharge paperwork is reviewed with the patient and family by the nurse prior to discharge, she replied, Very briefly but yes. They mainly go over their medications. When asked if the patient or family signed the discharge paperwork, she stated, I don't know. When she was asked if there was a signed copy of the discharge paperwork for Resident #1. She stated, I'll have to check. No, I can't find any signed discharge paperwork. When asked if Resident #1 has ever received her discharge paperwork, she replied, I can neither confirm nor deny if they ever received it. A review of the facility's policy titled, Transfer or Discharge, Resident-Initiated (revised October 2022) read: Policy Interpretation and Implementation: 2. Discharge refers to the movement of a resident form a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Information Conveyed to Receiving Provider: 1. If the resident is being transferred and return is expected, the following information is conveyed to the receiving provider: a. Contact information of the practitioner who is responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All special instructions and/or instructions for ingoing care as appropriate; e. The resident's comprehensive care plan goals; f. All other information necessary to meet the resident's needs which includes but may not be limited to: (1) Resident status, including baseline and current mental status, behavioral and functional status; (2) Reason for transfer, recent vital signs; (3) Diagnosis and allergies; (4) Medications (including when last received); (5) Most recent relevant labs, other diagnostic tests, recent immunizations 2. The above information is conveyed as close as possible to the actual time of transfer. 3. Information may be conveyed using a universal transfer form or an electronic health record summary, as long as the method contains the required elements, the resident's privacy is protected, and the receiving facility has the capacity to receive and use the information. 4. For residents being discharged (return not expected) all of the information above is conveyed to the receiving provider, along with a copy of all the required information found at 483.21(c)(2) Discharge Summary (F661) as applicable. 5. Communication of this required information will occur as close as possible to the time of discharge. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and a review of the facility's policy and procedure for Enteral Tube Feeding via Continuous Pump, the facility failed to maintain acceptable parameters of nutritional status, by failing to 1) Obtain resident weights with the frequency prescribed by the physician, and 2) Provide enteral feeding formula as ordered to address the resident's nutritional needs for one (Resident #346) of one resident reviewed for enteral nutrition, from a total of 22 sampled residents. The findings include: On 05/22/23 at 12:36 PM, Resident #346 was observed sitting in a wheelchair receiving enteral nutrition via tube feeding (feeding tube used to supply liquid nutrition) by pump. Resident #346 was non-verbal. He mumbled in response to attempts to engage him in conversation and was unable to be interviewed. The enteral formula bag documented a handwritten date and time when the feeding was started: 5/22/23 at 9:00 AM. The name of the formula on the label read, Nutren 1.5. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr. (milliliters per hour), flush 150 ml every 1 hr. On 05/23/23 at 10:20 AM, Resident #346 was observed resting in bed with his eyes closed. The feeding tube was not connected. The enteral formula bag was hanging on the pole. The label read, Nutren 1.5. On 05/24/23 at 12:17 PM, Resident #346 was observed sitting in his wheelchair. He responded to greetings with unintelligible mumbling. The feeding pump was running and delivering nutrition to Resident #346. The label on the nutrition bag read, Nutren 1.5. On the back of the bag was a handwritten date and time of 05/24/23 at 7:00 AM. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr., flush 150 ml every 1 hr. (Photographic evidence obtained) On 05/25/23 at 11:56 AM, Resident #346 was observed sitting in his wheelchair receiving enteral nutrition. The label on the nutrition bag read, Nutren 1.5. A review of Resident #346's medical record found he was originally admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included unspecified sequelae of cerebral infarction (stroke), type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, severe protein-calorie malnutrition, acute posthemorrhagic anemia, muscle weakness (generalized), aphasia following cerebral infarction, dysphagia following cerebral infarction, hypovolemic shock, iron deficiency anemia, gastro-esophageal reflux disease without esophagitis, encounter for attention to gastrostomy, and duodenal ulcer unspecified as acute or chronic, without hemorrhage or perforation. A review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 05/13/23, revealed that Resident #346 had a brief interview for mental status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident was documented as totally dependent on staff for eating with use of a feeding tube. A review of the resident's active physician's orders revealed an order dated 05/07/23, which read: Weight on admission, repeat x 3 days. The Order Summary read as follows: Weight on admission, repeat x 3 days, every day shift for 3 weeks. Weight on admission, repeat weekly x 3 weeks. A physician's order dated 05/08/23, read: Four times a day, give 1 carton Nutren 2.0 via bolus over 1 hour (250 ml/hr.). This order was discontinued on 05/24/23. A new order, dated 05/24/23, read: Four times a day give 1 carton Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times daily. A review of one of Resident #346's care plans, initiated on 04/14/23 and revised on 05/23/23, revealed that he required tube feeding for nutrition related to his diagnosis of dysphagia (difficulty swallowing). Review of another care plan, initiated on 05/08/23, revealed that he was at nutritional risk related to his nothing by mouth (NPO) status due to dysphagia with tube feeding (TF) to meet estimated nutritional needs with a diagnosis of protein-calorie malnutrition. Interventions included diet/TF as ordered, monitor weights as ordered. (Copy obtained) A review of Resident #346's weights from 05/07/23 to 05/15/23, revealed a weight loss of more than 4% for that period of time (8 days): On 05/07/23, the resident's recorded weight was 140.0 lbs. (pounds) On 05/12/23, the resident's recorded weight was 134.5 lbs. On 05/15/23, the resident's recorded weight was 134.2 lbs. These three weights were the only recorded weights for this resident between the dates of 05/07/23 and 05/24/23. (Copy obtained) A review of the resident's electronic medication administration record (eMAR) for the month of May 2023 (05/08 to 05/24), revealed that twelve different nurses signed off as having administered Nutren 2 via bolus over 1 hour (250 ml/hr.) four times a day during that time. (eMAR copy obtained) A Nutritional Risk Review, dated 05/08/23, revealed: [Resident #346] is at nutritional risk related to NPO due to dysphagia with TF to meet estimated nutritional needs. Diagnosis: protein-calorie malnutrition. Goal: Meet estimated nutritional needs with adequate oral food/beverage intake. Recommend: 1. Discontinue Nutren 1.5. 2. Give Nutren 2.0 via bolus 4 cartons/day to provide 2000 kcals (kilocalories), 84 g (grams) protein, 692 ml (milliliters) water. 3. Flush PEG (feeding tube) with 150 ml water before and after each bolus administration (300 ml each administration x 4 administrations = 1200 ml). 4. Clarify Juven order to be mixed with 8 oz. (ounces) water at each administration BID (twice daily). 5. Speech Therapy (ST) consult. Monitor: TF tolerance, wound healing, weight trends, labs as indicated. Registered Dietitian (RD) to follow. A review of a Skin/Wound Note, dated 05/19/23, revealed: Patient seen by Wound Care MD (physician) and Nursing Practitioner. Right heel unstageable pressure wound measures L (length): 1.5 cm (centimeters) x W (width) 0.5 cm x D (depth): unstageable full thickness skin or tissue loss - depth unknown (UTD - unable to determine). Right hip unstageable pressure measures L: 3.5 cm x W: 2.5 cm x D: UTD. Continue treatment plan. Offloading implemented. A review of a Nursing Progress Note, dated 05/20/23, revealed: Patient is admitted after cerebrovascular accident (CVA - stroke) affecting right side. Patient receives G-tube feedings. Medications are crushed and given via G-tube (feeding tube). Patient is alert and oriented to person. A review of a Physician's Progress Note, dated 05/24/23, revealed: Per staff, patient has been receiving incorrect feeding. Patient was originally to be on Nutren 2.0. No injuries to report, will monitor. (Copy of progress notes obtained) A Nutritional/Dietary note, dated 05/24/23, revealed: RD notified of inability to receive Nutren 2.0. Nutren 1.5 available and will be substituted. Current BW (05/15) 134.2 lbs. Note trend down (<5%) since admission weight os 140 lbs. Receiving treatment for US to R heel and R hip. Increased nutrient needs to promote wound healing. BMI WNL (Body Mass Index Within Normal Limits). Estimated nutrition needs (61 kg (kilograms): 1830-2135 kcals (30-35 kcals/kg), 91-122 g protein (1.5-2 g/kg - grams per kilogram), 1830 ml fluid (30 ml/kg). Recommendations: 1. DC (discontinue) Nutren 2.0 2. Give Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times/day. This will provide 1875 kcals, 85 g protein, 955 ml water. 3. Give 175 ml water flush every 4 hours. 4. Give 30 ml Prosource Plus once/day via feeding tube. This will provide an additional 15 g protein and 100 kcals. total nutrition provided (TF + Prosource Plus + flushes) will be: 1975 kcals, 100 g protein, 955 ml water (TF) + 1050 ml (flush) = 2005 ml water. 5. Obtain weight every Monday, Wednesday, and Friday. On 05/24/23 at 12:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. She was asked what type of enteral nutrition and calorie density Resident #346 was receiving. LPN A stated she had nothing to do with calorie density; the Registered Dietitian calculated that. She was asked to compare the formula that was hanging and running with the one ordered by the resident's physician. She opened the computer and stated, It is Nutren 2. Are those the calories? It is just the name of the formula. The kcals (kilocalories) per milliliter was explained to LPN A. She was then asked where she obtained the enteral nutrition if she needed it. She stated, From the nutrition room. They brought two (bags) last night. She was asked to point out the enteral nutrition designated for Resident #346. She stated there was none in the nutrition room. I work 7 to 7 shift and administer the tube feeding for [Resident #346] three times. On 05/24/23 at 12:42 PM, an interview was conducted with LPN B/Unit Manager. She was asked how she knew what type of formula should be administered to a resident receiving enteral nutrition. She stated, I verify the order, and if questionable, I talk to the RD. When asked where she obtained the enteral nutrition if needed, LPN B replied, Normally we keep it in central supply. She was asked to look at the formula that was hanging and that Resident #346 was receiving. She went into the resident's room and confirmed that the name of the nutritional formula was Nutren 1.5. She was asked to verify the doctor's order for Resident #346's tube feeding and she confirmed it was Nutren 2. She stated she was not aware of the situation and had to verify that with the dietitian. If we don't have 2.0, we use 1.5. LPN B was asked what the process was for weighing residents on her unit. She stated there should be one weight obtained on admission and then one weight weekly for three weeks. She was asked to look at the order for obtaining Resident #346's weights. She confirmed that thus far, for the resident's 17-day stay, he had three weights recorded in his chart. On 05/24/23 at 1:11 PM, an interview was conducted with the Central Supply Coordinator (CSC). He was asked to describe the process for sending enteral nutrition to the nursing units, and if the formula for a resident was changed, how that was addressed. The CSC stated the RD and/or admission Coordinator sent him an email and text about formula needs, and/or if there was a change in the formula. He then sent the formula to the nursing units. The CSC said there were supplier issues with Nutren 1.5. He was asked to provide a copy of the email communication regarding the enteral nutrition for Resident #346. (Copies obtained) On 05/24/23 at 1:33 PM, an interview was conducted with the Registered Dietitian (RD). She stated Resident #346 was switched from Nutren 1.5 to Nutren 2 due to the supplier's issues, not due to an increase in caloric needs. She was not aware of how long Resident #346 was on the Nutren 1.5. She stated she needed to reassess Resident #346's nutritional needs, and they would need to re-up the current Nutren 1.5, increasing the frequency of feedings to compensate for the caloric difference. On 05/24/23 at 1:57 PM, an interview was conducted with the DON. She stated Resident #346 originally came to the facility with the Nutren 1.5 order, and they switched him to Nutren 2 due to supplier issues with the Nutren 1.5. From the 8th of May he was receiving Nutren 2. The DON was asked where the facility obtained the cartons of Nutren 1.5 if there was a shortage, and how long was Resident #346 receiving the Nutren 1.5. She stated, I don't know. We have to do some investigation. Officially we switched him to 1.5 today. On 05/24/23 at 4:18 PM, an interview was conducted with Agency LPN C. She was asked how she knew what type of enteral nutrition formula she had to use for a resident receiving tube feedings. We go by orders. If no formula is available, we call the doctor or RD for something compatible. A review of email documentation from 05/08/23 between the RD and CSC revealed that the CSC wrote, We have everything except the Nutren 1.5. We have the cartons of Nutren 2. The RD wrote, Ok, thank you! I will convert the orders for [Resident #346] to reflect 2.0. (Copies obtained) A review of the facility's policy and procedure titled Enteral Tube Feeding via Continuous Pump (revised in November 2018) revealed, 2. Check the enteral nutrition label against the order before administration. Check the following information: b. Type of formula. Documentation: the person performing this procedure should record the following information in the resident's medical record: 3. Amount and type of enteral feeding. According to the National Library of Medicine website at ncbi.nlm.nih.gov/pmc/articles/PMC5930532 (accessed on 05/27/23 at 2:40 PM), Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and Vitamins A, C, and E have been documented. .

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure food preparation equipment was clean and maintained. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A follow-up tour of the kitchen was conducted on 5/24/23 at 10:52 a.m. The bottom of the oven and door was covered with food grime. The can opener pixel was greasy and filled with food debris. The inside door area and left side of the convection oven next to the fryer was covered with food grime and grease buildup. The right and left side of the fryer sitting next to the convection oven was covered with grease build up. The right and left side of the tilt skillet was covered with grease build up, and two oven trays were filled with food debris. (Photographic evidence obtained) Another tour of the kitchen was conducted on 5/25/23 at 10:04 a.m. The observations of the kitchen equipment noted above at 10:52 a.m. were made again. (Photographic evidence obtained) An interview was conducted on 5/25/23 at 10:28 a.m. with Kitchen Coordinator/Cook D. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens and oven trays, she replied, The cooks are responsible for cleaning kitchen equipment weekly. An interview was conducted on 5/25/23 at 10:44 a.m. with [NAME] E, who reported she had worked for the facility for two years. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens, and oven trays, she replied, Cooks clean as we go. Ovens are not cleaned often enough. Most deep cleaning is completed by the night shift. The outside of the oven is sprayed down at night, and the inside of the oven is cleaned every three weeks or as needed. An interview was conducted on 5/25/23 at 11:24 a.m. with Certified Dietary Manager (CDM) F, who confirmed that the Dining Supervisor was responsible for ensuring kitchen equipment was cleaned daily. The kitchen Cleaning Schedule dated from 4/30/23 to 6/1/2023 did not identify cleaning of the stove or oven. (Copy obtained) A review of the facility's policy and procedure titled Cleaning Schedules (Undated), revealed: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 5/31/23) Chapter 4. Equipment, Utensils, and Linens. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 4-20. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to meet professional standards of quality by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The Florida Nurse Practice Act, Chapter 464.003, (3)(a) in part defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Additionally, the Act defines the practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders. Upon repositioning the resident after the wound care, it was observed that Resident #130 had a bloody discharge from his penis oozing from around the indwelling catheter. The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses included metabolic encephalopathy, sepsis, diabetes type II, unspecified protein-calorie malnutrition, gastrostomy status, muscle weakness, difficulty walking, dysphasia oropharyngeal phase, major depressive disorder, benign prostrate hyperplasia without lower urinary tract symptoms, anemia in chronic kidney disease, adult failure to thrive, hypertension, unspecified dementia without behavioral disturbance, chronic kidney disease, hyperlipidemia, pain, and glaucoma. He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. (Photographic evidence obtained) On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and services in accordance with professional standards of practice, by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders. Upon repositioning the resident after the wound care, it was observed that Resident #130 had a bloody discharge from his penis oozing from around the indwelling catheter. The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses included metabolic encephalopathy, sepsis, diabetes type II, unspecified protein-calorie malnutrition, gastrostomy status, muscle weakness, difficulty walking, dysphasia oropharyngeal phase, major depressive disorder, benign prostrate hyperplasia without lower urinary tract symptoms, anemia in chronic kidney disease, adult failure to thrive, hypertension, unspecified dementia without behavioral disturbance, chronic kidney disease, hyperlipidemia, pain, and glaucoma. He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. (Photographic evidence obtained) On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained) .

Based on observation and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 3 of 4 days observed. The findings include: On 9/07/2021 at 3:23 p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 8/18/2021. On 9/08/2021 at 2:21p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/7/2021. On 9/09/2021 at 11:58 a.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/8/2021. During an interview and observation of the posted nurse staffing data on 9/09/2021 at 12:13 p.m. with Employee L, Staffing Coordinator, she stated each day she posted the staffing for the day before, so that she didn't have to make corrections on the form if someone didn't show up. The documentation was reviewed with her, pointing out the area that specifically stated daily staffing. She stated she had not noticed that information prior to this, and she had been doing staffing for about a month now. She stated she received limited training in the position. She was referred to the Administrator and/or Director of Nursing for additional education. .

Based on kitchen food service observations, staff interviews, and facility document review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The dish machine was not sanitizing the dishes properly. The facility failed to ensure that the dietary staff were trained and knowledgeable about the proper procedures for the safe operation of the dish machine. Failing to sanitize the dishes could lead to negative health outcomes for the residents who receive meals from the kitchen. The findings include: On 09/07/2021 at 11:10 AM, Dietary Employee A was observed operating the dish machine. The wash cycle temperature was 150 degrees Fahrenheit (F) to 153 degrees F, and the rinse temperature was 159 degrees F. The Registered Dietician (RD) and Certified Dietary Manager (CDM) explained that the dish machine was a hybrid machine. It could run as a high-temperature machine or a low-temperature machine. Currently, they were operating it as a low-temperature machine with a chemical sanitizer, chlorine bleach. A digital thermometer was run through the machine and read 157 degrees F. The CDM tested the water using a chlorine bleach test strip. The test strip remained white, indicating no bleach in the water. She confirmed it was 0 parts per million (ppm). She looked up at the dispensing unit on the wall and stated the tubing for the bleach sanitizer was not attached to the dispensing unit. She stated she was unaware that the tubing had become detached from the dispensing unit. She was not sure how long it had been detached. On 09/08/2021 at 8:55 AM during an interview with Dietary Employee A, he stated he had worked in this facility for 11 years. There was a language barrier and several questions had to be reworded so that he understood the questions. He stated he had had training on how to run the dish machine. When asked what type of sanitizer was used and what type of machine the facility used, he hesitated and then when asked if the machine was a high-temperature machine or low-temperature machine, he stated it was a low-temperature machine which used chlorine bleach. He stated he knew how to use the test strips. He stated he thought the chemical tubing was unhooked from the dispensing unit three or more months ago when the representative from the contracted dish machine maintenance company was in the kitchen working on the machine. On 09/09/2021 at 11:15 AM a second tour of kitchen was conducted. The dish machine was tested by Employee C, Dietary Director (DD). The first time he used the test strip it remained white, indicating no chlorine bleach in the water. He then reached up to the dispensing pump on the wall and pushed the button twice to prime the pump. He stated the machine worked fine and sometimes needed to be primed as he just demonstrated. He then tested the water again and the test strip was a dark purple, indicating the water was toxic. He stated he would run the machine a couple of times to dilute the sanitizer. He ran it two more times and the test strip showed 100 ppm. The dish machine operator, Dietary Employee A, was then asked to test the machine. He was not able to demonstrate an understanding of exactly what to do with the test strips. He was cued by the Director about how to do it. He then put the test strip on the coffee cup and the test strip turned a light shade of green indicating 100 ppm. Dietary Employee A did not hold the test strip up to the canister indicator chart to verify the amount of sanitizer on the test strip. The Director instructed him to hold the test strip up to the canister and then to record it on the clip board. Dietary Employee A then documented the amount of chlorine on the test strip in the wrong column on the log. He wrote 100 in the column for the temperature reading of the water. The CDM observed that the readings were documented inaccurately on the log, and she immediately changed them and initialed the log. On 09/10/2021 the dish room employees were observed from 12:40 PM until 1:10 PM. The CDM was asked to test the dish machine sanitizer. The first test strip registered 0 ppm. She then took a test strip from another vial of test strips, and it registered 0 ppm. The DD then pushed the primer button on the pump attached to the wall above the dish machine. A new rack of pans was sent through the machine. The DD used another test strip to test the sanitizer level. It registered between 50-75 ppm. The DD was asked who else had been trained in the dietary department on the operation of the dispensing pump on the wall. He stated no one else had been trained. When asked who would know when to push the pump to prime it if the sanitizer level got low, he stated he was always at the facility and he was the one to prime it. He had not conducted any type of training for the dietary staff on how to run the primer pump. He had no policy and procedure for the operation of the dispensing unit on the wall. On 09/10/2021 at 2:53 PM during an interview with the DD, RD, and Nursing Consultant, they provided the logs for the dish machine and a new log for the staff to use to record the testing of the sanitizer level of the dish machine. The DD stated they were going to start having the dish machine workers test the sanitizer level at least two times during each meal service. The DD stated the service provider for the dish machine was at the facility right now. They were not sure why the sanitizer did not come into the machine consistently. A review of the dietary in-service, dated 07/29/2021, revealed that Dietary Employee A had received training entitled Temperature Log/Procedures, that included completion of the temperature logs, reading thermometers, recording temperatures, and reporting any variance in temperature of 1-2 degrees to a supervisor for review. No documentation was provided verifying that Dietary Employee A had received training on how to test the machine for the sanitizer level. .