**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were safe from accidents for one (1) of twenty-seven (27) sampled residents. Resident #59 was assessed by the facility to need nectar thicken liquids and was noted to have access to thin liquids. The findings include: Review of the facility policy titled, Dysphagia Diets , not dated, revealed The National Dysphagia Diet provides overall guidelines for managing Dysphagia. Further review revealed, Four levels of liquids, Thin, Nectar-like, Honey-like, Spoon-thick. The Speech Language Pathologist is responsible for evaluating and treating an individual with dysphagia. The policy defined Nectar-like as The beverage coats and drips off a spoon similar to unset gelatin. Record review revealed the facility admitted Resident #59 on 07/27/2020 with diagnosis to include: Cognitive Communication Deficit, Dysphagia, Unspecified Dementia with Behavioral Disturbance, and Alzheimer's Disease with late onset. Review of Resident #59 Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not attempt a BIMS interview due to the resident being rarely/never understood. The facility determined the resident's cognition to be severely impaired, and the resident rarely/never made decisions regarding task of daily living. Further review of Resident # 59 MDS revealed the resident was assessed on their admission MDS, dated [DATE] in section K (Swallowing, Nutritional Status) to hold food in mouth/cheeks or residual food in mouth after meals. The facility also assessed the resident with coughing or choking during meals or when swallowing medications. These areas where not assessed on the resident's quarterly MDS. Further review of the resident's MDS also revealed under section G (Functional Status) to require extensive assist of one staff member for eating as well as for walking. The facility had also assessed the resident to be a wander and had a wander bracelet around their ankle. Review of Resident #59's care plan with a target date of 11/02/2020, revealed the resident was care planned for Elopement Risk related to: wandering Alzheimer's. The resident was also care planned for Potential for Altered Nutrition related to impaired cognition hypothyroidism, vitamin deficiency, dysphagia with intervention for Diet per MD order. Puree Nectar thicken liquids and observe for the following: Dysphagia pocketing choking coughing, drooling, holding food in mouth. Review of Speech Therapy note dated 08/24/2020 revealed, Pt (Patient) presents with decreased control and s/s (signs/symptoms) aspiration noted with trials of thin liquids and ST (Speech Therapy) recommends pt continue nectar thick liquids at this time. Observation of Resident #59 on 10/21/2020 at 9:25 AM revealed the resident shared a room with Resident #12 who was totally dependent on staff for all activities of daily living. A picture of thin liquids was observed on Resident #59 bedside table. Observation of Resident #59 on 10/21/2020 at 10:46 AM revealed Resident #59 going into another resident's room, staff redirected. Observation of Resident #59 on 10/22/2020 at 9:13 AM revealed Resident #59 standing next to roommate's bedside table with pitcher of thin liquids. The resident grabbed the handle of the pitcher but staff redirected the resident. Observation of Resident #59 on 10/22/2020 at 3:08 PM revealed the resident in another resident's room with pitcher in hand in the process of taking the pitcher to their mouth. Staff stopped the resident before the resident could take a drink from the pitcher. Interview on 10/22/2020 at 9:01 AM with State Registered Nursing Assistant (SRNA) #3 revealed Resident #59 was assisted with all meals, mostly due to their cognition; you have to tell them to eat. The SRNA stated the resident would be able to pick up a glass and put it to their mouth. The SRNA stated that she had never seen the resident take a drink out of another resident's glass. Interview on 10/21/2020 at 9:10 AM with State Registered Nursing Assistant (SRNA) #1 revealed while the SRNA was looking for a water pitcher for another resident stated, The pitcher of water was sitting on the Resident #12 overbed table, Resident #59 is not suppose to have a pitcher because they are on thicken liquids. Interview on 10/22/2020 at 10:07 AM with SRNA #11 revealed the resident is assisted with meals but will occasionally pick up food and drink without assist. We try to keep an eye on them and keep them out of other resident's room. The SRNA continued by saying she had seen the resident pick up stuff that someone set down at the nursing station, such as a soda can. Interview on 10/22/2020 at 10:15 AM with Licensed Practice Nurse (LPN) #6 revealed Resident #59 was assisted with meals and was on a nectar thicken liquids. The LPN stated she had seen the resident pick up a cup and drink out of it. However, the LPN stated she had never known of the resident to drink out of a cup that was not thicken liquids. She further stated if Resident #59 drank thin liquids they would assess the resident and inform the MD. Interview on 10/23/2020 at 1:30 PM with Clinical Coordinator, Nurse Consultant revealed that the expectation is that staff will ensure that all residents are kept safe from any accidents and they had already started training staff. The Nurse Consultant stated the resident wanders and it is a concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure one (1) of two (2) residents (Resident #55) who received respiratory care out of a sample of twenty-seven (27) residents received respiratory care consistent with professional standards of practice and the comprehensive care plan. Resident #55 was observed on 10/21/2020 and 10/22/2020, receiving oxygen via nasal cannula at two (2) liters per minute (LPM). Review of the physician orders revealed an order dated 02/08/2019 for oxygen to be delivered via nasal cannula at three (3) LPM. The findings include: Review of the facility policy, Oxygen Use, undated, revealed no guidance for monitoring oxygen for proper flow rate setting. Interview on 10/23/2020 at 2:48 PM with Clinical Coordinator/Director of Nursing Liaison revealed nursing staff on the floor are responsible to check oxygen for proper flow rate every shift. She further revealed if observed on the incorrect setting the nurse would complete a respiratory assessment on the patient and notify the physician. Observation of Resident #55 on 10/21/2020 at 9:27 AM revealed the resident was lying in bed, receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed the setting was at two (2) LPM. Observation on 10/21/2020 at 10:27 AM revealed the oxygen remained at two (2) LPM. Further observation on 10/22/2020 at 9:43 AM and 10/22/2020 at 9:49 AM, revealed the oxygen concentrator setting was at 2.5 LPM. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Alzheimer Disease and Anxiety. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/23/2020, revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. The MDS further revealed the resident was on oxygen therapy. Review of the physician orders for Resident #55 revealed an order dated 02/08/2019, which stated the resident was to receive oxygen at three (3) LPN via nasal cannula for diagnosis of COPD. Review of the care plan for Resident #55, revealed the facility identified that the resident had diagnosis of COPD, and included the intervention to administer oxygen at three (3) LPM per nasal cannula. Review of the Treatment Administration Record (TAR), dated October 2020, revealed staff were required to check the resident's oxygen saturation every shift and check to ensure oxygen was set at three (3) LPM. Review of the TAR further revealed on 10/21/2020, staff initialed that the task was completed. Interview with Licensed Practical Nurse (LPN) #1 on 10/21/2020 at 10:50 AM, confirmed that Resident #55 oxygen concentrator was set at two (2) LPM. Further interview revealed that Resident #55 was ordered to receive oxygen at three (3) LPM; however, she was unaware why the settings were incorrect. She also stated that Resident #55 was unable to adjust the setting of the concentrator. She further revealed that she checks the oxygen every shift to ensure the correct setting. Interview with LPN #2 on 10/22/2020 at 9:49 AM, confirmed that Resident #55 oxygen was set at 2.5 LPM. She further revealed that the resident was ordered oxygen at three (3) LPM. Continued interview revealed the nursing staff was responsible for checking every shift to ensure oxygen was set at the correct settings. Interview with the Clinical Coordinator/Director of Nursing Liaison on 10/23/2020 at 2:48 PM revealed she was able to identify an assessment and physician notification was completed on 10/22/2020 related to observation of oxygen on the incorrect setting. However, she was unable to provide documentation that a respiratory assessment and/or physician notification had occurred on 10/21/2020.

Based on observation, interview and review of facility policy, the facility failed to ensure controlled drugs were stored in a permanently affixed compartment as required in one (1) of two (2) refrigerators in the medication rooms. Observation of the second floor medication room revealed a controlled medication for Resident #63 in the refrigerator. However, the medication was not stored in permanently affixed locked narcotic box. The findings include: Review of the facility policy titled Medication Dispensing Controlled Substances, undated revealed that all controlled substances will be stored under double lock, separate from other medications. Observation of the second floor medication room on 10/21/2020 at 4:56 PM revealed the medication Dranabinol (is a man-made form of tetrahydrocannabinol (THC), a psychoactive substance found in cannabis) 10 mg (milligram) ordered twice daily labeled Controlled for Resident #63 located in the refrigerator in the second floor medication room. The medication (Dranabinol) was lying on top of other medications and not stored in the permanently affixed locked narcotic box. Interview with Licensed Practical Nurse (LPN) #1 on 10/21/2020 at 4:56 PM revealed the medication should have been stored in the locked narcotic box; however, the packaging would not fit into the locked box. Interview with the Clinical Coordinator/Director of Nursing Liaison on 10/23/2020 at 2:47 PM revealed controlled medication should be under double lock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to address the monitoring of hydration status for three (3) of twenty seven (27) sampled residents (Resident #174, #12, and #28). The findings include: Review of the facility's policy titled, Using The Care Plan, revised 08/01/2013, revealed the care plan would be used in developing the resident's daily care routines and would be available to staff who had the responsibility for the provision of care or services to the resident. 1. Review of a closed record for Resident #174 revealed the facility admitted the resident on 10/10/2013 with diagnoses which included Diabetes mellitus, Atrial Fibrillation, Dysphagia, and Alzheimer's Disease. Review of Resident #174's care plan, revealed on 09/27/2018, the facility developed a care plan for the resident for hydration. Further review of the care plan, revealed interventions included to encourage fluids daily, keep water at bedside, monitor laboratory tests as ordered by the physician, administer medications as ordered by the physician, and to monitor intakes and outputs as ordered. Review of a Registered Dietician (RD) assessment dated [DATE], revealed Resident #174 had been assessed to require thirteen hundred and eighty six (1386) milliliters (ml) of fluid per day of fluid. Review of physician's orders for Resident #174, revealed an order dated 11/13/2019, to encourage fluids every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required the limited assistance of one (1) person for eating. Review of the fluid intake records for Resident #174, revealed the facility documented the resident had not met his/her fluid requirement on 09/01/2020 with 840 ml, 09/02/2020 with 960 ml, 09/03/2020 with 600 ml, 09/04/2020 with 720 ml, 09/05/2020 with 1200 ml, 09/06/2020 with 420 ml, 09/07/2020 with 840 ml, 09/08/2020 with 720 ml, 09/09/2020 with 840 ml, 09/10/2020 with 1080 ml, 09/11/2020 with 840 ml, 09/13/2020 with 960 ml, 09/15/2020 with 1080 ml, 09/16/2020 with 1080 ml, 09/17/2020 with 1080 ml, 09/18/2020 with 1080 ml, 09/20/2020 with 480 ml, 09/21/2020 with 1200 ml, 09/22/2020 with 480 ml, 09/23/2020 with 480 ml, 09/24/2020 with 840 ml, 09/25/2020 with 720 ml, 09/26/2020 with 180 ml, 09/27/2020 with 720 ml, 09/28/2020 with 502 ml, 09/29/2020 with 600 ml, 09/30/2020 with 1080 ml, 10/01/2020 with 840 ml, 10/02/2020 with 840 ml, 10/03/2020 with 100 ml, 10/04/2020 with 840 ml, 10/05/2020 with 210 ml, 10/06/2020 with 180 ml, 10/07/2020 with 540 ml, and 10/08/2020 with 180 ml. The fluid intake records for Resident #174 revealed the resident had not met daily fluid requirements for thirty seven (37) out of thirty eight (38) days. Review of the nurses notes for Resident #174, revealed an entry dated 10/05/2020 at 1:03 PM which stated resident very lethargic this morning, does awaken with some effort. Advanced Registered Nurse Practioner (ARNP) notified to evaluate the resident. The nurses note further revealed the ARNP ordered laboratory blood tests, a CBC (complete blood count) and BMP (basic metabolic panel) to be drawn on 10/06/2020. The nurses notes also revealed an entry dated 10/06/2020 at 3:17 PM, which revealed the laboratory tests completed for Resident #174 had critical results and the ARNP had been notified with new orders received to administer a 500 ml bolus of normal saline intravenously and then continue administering normal saline intravenously at 100 ml per hour for 2000 ml, and to hold Lasix (diuretic) and acetazolamide (medication to treat heart failure) for the resident for three (3) days, and to recheck a BMP (blood laboratory test) for the resident on 10/08/2020. The nurses note further revealed the resident's responsible party had been notified. Review of laboratory reports for Resident #174 dated 10/06/2020 at 5:19 AM, revealed the resident had a Blood Urea Nitrogen (BUN) level of 156 (normal 7-25 mg/dl); Creatinine level of 4.2 (normal 0.6-1.3 mg/dl); BUN/Creat Ratio of 37 (normal 6-25). Further review of Resident #174's laboratory reports dated 10/08/2020 at 7:32 AM, revealed the resident had a BUN of 126, Creatinine level of 3.6, and BUN/Creatinine Ratio of 35. Further review of Resident #174's nurses notes, revealed an entry dated 10/07/2020 at 3:03 PM, revealed the resident's physician had assessed the resident. A nurses note dated 10/08/2020 at 2:15 PM, revealed the ARNP saw the resident and due to the intravenous line being out and staff were unable to restart the intravenous line, the resident was sent to the acute care hospital. The nurses note further revealed the resident's laboratory tests revealed the resident still had dehydration. Interview conducted with State Registered Nursing Assistant (SRNA) #5 on 10/22/2020 at 10:15 AM, revealed she was required to review care plans at the beginning of every shift. The SRNA stated she was responsible for documenting the fluid intakes in the computer every shift. The SRNA stated she was required to notify the nurse if the resident was not eating or drinking as well. The SRNA stated Resident #174 had been declining and the nurses were aware. Interview conducted with SRNA #4 on 10/22/2020 at 10:20 AM, revealed she was required to review the care plan at the beginning of every shift. The SRNA stated she was required to document resident's fluid intake in the computer. The SRNA stated if the resident did not eat or drink well, she was required to notify the nurse. The SRNA stated the nurses were aware Resident #174 was not eating or drinking well. Interview conducted with Licensed Practical Nurse (LPN) #4 on 10/22/2020 at 10:45 AM, revealed she was not sure where to look to find what fluid requirements a resident required. The LPN stated she did not look daily to ensure residents were meeting their daily fluid requirements. The LPN stated the weekly nursing assessment which she completed on the computer automatically populated the fluid requirement needs of the resident and she was required to look back for the previous week. The LPN stated she probably should have notified the physician and the RD, but she had not and did not know why she had not. Interview conducted with LPN #1 on 10/22/2020 at 10:55 AM, revealed she was unable to state where fluid requirements were documented. The LPN stated she did not check resident's fluid requirements daily. The LPN stated she just asked the SRNAs if the resident was drinking okay. The LPN stated she was required to check the care plans at the beginning of every shift and was expected to follow it. Interview conducted with the MDS Coordinator on 10/23/20 at 3:00 PM, revealed. she was responsible for the development of resident's care plans. The MDS Coordinator stated she utilized physician's orders, progress notes, history and physical, and any information she could obtain from the family. The MDS Coordinator stated Resident #174 had a care plan developed for hydration and staff were expected to follow the care plan. The MDS Coordinator stated staff were required to review care plans at the beginning of every shift prior to providing care for the residents. Interview conducted with the Corporate Nurse (CN) who was the liaison for the Director of Nursing (DON) who was unavailable due to sickness on 10/23/2020 at 3:05 PM, revealed staff were required to review care plans at the beginning of every shift and prior to providing care for the residents. The CN stated if the resident was not meeting the fluid requirements the physician would be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed the facility admitted Resident #55 on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Alzheimer Disease and Anxiety. Review of the Minimum Data Set (MDS) quarterly assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. The assessment further noted the resident was sometimes able to make himself/herself understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the care plan, undated, revealed the facility had assessed the resident to be at risk for dehydration and added an intervention to encourage fluid intake. Review of the Weekly Nursing assessment revealed Resident #55's daily fluid needs was 1300 - 1500 milliliters per day. Review of Resident #55's intake records for [DATE] through [DATE], revealed the resident met his/her fluid needs one (1) day ([DATE]) out of this fifteen (15) day observation period. Observation of Resident #55 on [DATE] at 10:10 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were no visible signs of dehydration. Further review of Resident #55's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. 4. Review of the medical record revealed the facility admitted Resident #28 on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, Legal Blindness and Hypertension. Review of the MDS, dated [DATE], revealed a BIMS score of 11 indicating moderately impaired cognition. The assessment further noted the resident was able to make self himself/herself understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the resident's comprehensive care plan revealed no intervention to address Resident #28's fluid/hydration status. Interview with the Dietician on [DATE] at 11:58 AM revealed in [DATE], she assessed Resident #28 to need 1600 mls of fluid daily. Review of Resident #28's intake report for [DATE] to [DATE], revealed the resident did not meet his/her assessed hydration needs any day throughout this fifteen (15) day observation period. Observation of Resident #28 on [DATE] at 10:08 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were not visible signs of dehydration. Further review of Resident #28's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. 5. Review of the medical record revealed the facility admitted Resident #72 on [DATE] with diagnosis that include Chronic Respiratory Failure, Dysphagia following Cerebral Infarction and Chronic Kidney Disease. Review of the MDS, dated [DATE], revealed a BIMS score of 07 indicating severely impaired cognition. The assessment further noted the resident is sometimes understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the care plan, undated, revealed the facility had assessed the resident to be at risk for dehydration and added an intervention to encourage fluid intake. Further review of the record for Resident #72 revealed the resident minimum fluid needs to be 1900-2000 according to the hydration assessment completed on [DATE]. Review of intake report for [DATE] to [DATE], revealed the resident did not meet his/her assessed hydration needs any day throughout this observation period. Observation of Resident #72 on [DATE] at 10:18 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were not visible signs of dehydration. Further review of Resident #72's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. Interview on [DATE] at 11:04 AM with the facility Dietician revealed due to COVID concerns they were just getting back into the facility, and had been doing assessment via point click care (computer system). She stated that she was given a list of residents to look at or do assessments on. Per the Dietician, the lists included referrals of residents with decreased intake, weight loss, wound, and residents on the MDS schedule. The facility dietician stated, If resident had not met fluids needs in 3 days I would expect the facility to reach out to me. I would expect the facility was monitoring the fluid intake 2. Record review revealed the facility admitted Resident #12 on [DATE] with diagnosis to include: Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, Type II Diabetes Mellitus, and Chronic Diastolic Congestive Heart Failure. Review of Resident #12 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not attempt a BIMS interview due to the resident being rarely/never understood. The facility determined the resident's cognition to be severely impaired, and the resident rarely/never made decisions regarding task of daily living. Further review of the MDS revealed the resident was assessed to be totally dependent on staff for eating and mobility. Review of Resident #12 Dietary Consultants Comprehensive Nutritional Assessment, dated [DATE] revealed the resident was assessed for estimated ml/fluid per day need of 2,112 to 2,535 ml's. Review of the facility Look Back Report for [DATE] thru [DATE] revealed Resident #12 averaged 1,401 ml of fluid per day. On [DATE], Resident #12 consumed 360 ml, on [DATE] only 680 ml and on [DATE] the resident consumed only 480 ml of fluid. Review of Acute Monitoring nursing notes for Resident #12 dated [DATE] at 1:46 AM revealed in bed on right side t/r (turn and reposition) per staff of 2 max assist eating at meals with no difficulty skin recoil good, mucous membranes moist pink no s/s of dehydration. Further review on nursing notes revealed Acute Monitoring note on [DATE] at 11:40 AM Residents daughter called concerning resident. Asked about labs and urine, informed family member that they were pending but that the labs should be back today. Family member stated they wanted the resident sent out to the ER. Resident was sent to ER. Review of Discharge Summary for Resident #12 dated [DATE] revealed labs on [DATE] BUN 50 (Blood urea nitrogen - a medical test that measures the amount of urea nitrogen found in blood. Normal range for BUN is 6-20 mg), Creatinine 1.13 (normal is 0.6-1.2.) Resident #12 was admitted and upon discharge the labs for [DATE] were BUN 14 and Creatinine 0.47. Diagnoses for admission was: Acute Metabolic Encephalopathy likely to Acute Urinary Tract Infection, Acute Renal Failure and Dehydration, likely due to lack of oral intake, present on admission and resolved, and Acute Hypernatremia, present on admission and resolved prior to discharge. Further review of the hospital discharge summary revealed Important issues to note: Patient will need frequent reminders for oral hydration and would recommend to try and keep at least 1500-2000 cc of fluid daily. Review of Resident #12 Care plan, with a target date of [DATE], revealed Resident #12 was care planned with a focus Potential for Altered Nutrition related to Diabetes, Impaired cognition, vitamin D deficiency, Anemia, and Dysphagia with Intervention Resident to be offered 240 ml fluids every 2 hours. Further investigation revealed the intervention was put into place on [DATE]. The resident also had an intervention for I (in's) and O (out) as ordered. Observation on [DATE] at 9:58 AM revealed Resident #12 in Geri Chair neatly dressed with no fluids at bedside. Attempted interview with resident at this time revealed the resident did not respond to any questions. Observation on [DATE] at 12:30 PM of Resident #12 revealed the resident in Geri Chair with staff totally assisting the resident to eat. Resident ate 100% of meal and drank 240 ml of fluids. Observation on [DATE] at 9:10 AM of Resident #12 revealed the resident in bed on back with eyes closed, no fluids at bedside. Interview with family member of Resident #12 on [DATE] at 3:30 PM revealed the family member had concerns due to the resident being hospitalized in March with dehydration. The family member said prior to COVID shut down the family came to the facility daily and fed the resident and encouraged the resident to drink and was concerned that since they were no longer at the facility the resident was not drinking enough. Interview on [DATE] at 9:10 AM with State Registered Nursing Assistant (SRNA) #1 revealed Resident #12 was total assist with all activities of daily living, which included eating and drinking. The SRNA stated the resident would not be able to pick up a glass and drink it but that they did keep a pitcher of fluids at the bedside and offer the resident fluids throughout the day. The SRNA went into Resident #12 room and returned with a pitcher and stated The pitcher of water was sitting on the roommate's overbed table, the roommate is not supposed to have a pitcher because the roommate was on thicken liquids. The SRNA took the pitcher out of the room and replaced it with a clean one. The SRNA further revealed that they only chart fluids that the resident intakes during meals. Interview on [DATE] at 9:30 AM with SRNA #2 revealed Resident #12 should have a pitcher of water. She further stated that the nurses offer the resident fluids every couple of hours. She stated the resident eats and drinks well. Interview on [DATE] at 10:08 AM with Licensed Practice Nurse (LPN) #1 revealed Resident #12 is a total assist and there are orders for her to be offered by nursing staff 240 ml of fluids every 2 hours. The LPN stated that sometime the resident refuses the fluids but mostly drinks what is offered. The LPN was unable to find the fluid needs of the resident and stated they do not calculate fluid needs daily and rely on SRNA to inform them if a resident is not eating or drinking well. Interview on [DATE] at 11:00 AM with the Administrator and Corporate Nurse (CN) who was the liaison for the Director of Nursing revealed they look at labs everyday. They stated they do not do strict intake and outputs on every resident just the resident that show signs and symptoms of dehydration based on their policy. When asked if someone tallies up the daily fluid intake on each resident they replied only if they met the criteria stated in the policy. The administrator was looking at weekly skin assessment for Resident #12 during the interview and stated they all say skin turgor good and mucus membranes moist. Interview on [DATE] at 11:04 AM with the facility Dietician revealed due to COVID concerns she was just getting back into the facility, and had been doing assessment via point click care (computer system). She stated that she was given a list of residents to look at or who need assessments. Per the Dietician, the lists of residents includes referrals for decreased intake, weight loss, wound, or a resident on the MDS schedule. The Dietician stated those are the residents she see when she visits the facility. The facility Dietician stated, If resident had not met fluids needs in 3 days I would expect the facility to reach out to me. I would expect the facility was monitoring the fluid intake. I was not made aware that Resident #12 had not met fluid needs back in March. Interview on [DATE] at 12:14 PM with Resident #12 physician revealed, he monitored fluid intake when he visited the resident every month. He further revealed that the estimated fluid needs for Resident #12 were too high based on the resident's diagnosis of Congestive Heart Failure, he stated he would rather see the resident with CHF be a little dry. He further stated that he would expect the facility to notify the MD or the Nurse Practitioner within 3-5 days of resident's not meeting their fluid needs. Interview on [DATE] at 10:30 AM with Clinical Coordinator, Nurse Consultant revealed that the facility had identified concerns with hydration and had started doing inservices and education on the problem. Interview on [DATE] at 10:30 AM with Corporate Nurse (CN) who was the liaison for the Director of Nursing revealed the facility had identified concerns with hydration and had reassessed everyone in the building for hydration needs and that they had started education for staff on hydration. When asked if their computer system tallies the total fluid intake on residents they said it did not. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents maintained sufficient fluid intake to maintain proper hydration and health for five (5) out of twenty seven (27) sampled residents (Resident #174, #12, #28, #72, and #55). The findings include: Review of the facility's policy titled, Hydration Fluid Volume Policy and Protocol, revised [DATE], revealed the facility would provide each resident with sufficient fluid intake to maintain proper volume and hydration for health. The policy revealed each resident's fluid requirements would be calculated by a Registered Dietician (RD) and re-evaluated based on the resident's needs. Review of the facility policy titled, Hydration Policy and Protocol, revision date 01/16, revealed Each resident will have a head to toe physical assessment by a licensed nurse upon admission including the evaluation for signs and symptoms of dehydration If a resident is assessed to show symptom of de-hydration they will have an interdisciplinary hydration assessment completed. Each resident must have an interdisciplinary hydration assessment completed within fourteen (14) days of admission. Reassessment will be done based on resident clinical status. The fluid requirement (estimated fluid need) for each resident is calculated by the registered dietician and re-evaluated based on resident's needs. The total of the estimated fluid need volume is offered via the meal trays, snacks, and water at bedside. In Addition: These risk factors for dehydration include, but are not limited to: a.) Residents with Foley Catheters, b.) Resident with gastrostomy tubes. c.) Resident receiving intravenous fluids, d.) residents who are on ordered fluid restriction. Abnormal laboratory test values will be reviewed and monitored as an indicator of dehydration along with physical assessment. Further review of the policy revealed under Interventions/Strategies to Maintain Hydration: 1. Ensure that resident receives daily required fluid intake. 1. A review of a closed record for Resident #174 revealed the facility admitted the resident on [DATE] with diagnoses which included Diabetes Mellitus, Atrial Fibrillation, Dysphagia, and Alzheimer's Disease. A review of Resident #174's care plan, revealed on [DATE], the facility had developed a care plan for the resident for hydration. Further review of the care plan, revealed interventions to encourage fluids daily, keep water at bedside, monitor laboratory tests as ordered by the physician, administer medications as ordered by the physician, monitor intakes and outputs as ordered. A review of a RD assessment dated [DATE], revealed Resident #174 had been assessed to require thirteen hundred and eighty six (1386) milliliters (ml) of fluid per day of fluid. A review of physician's orders for Resident #174, revealed an order dated [DATE], to encourage fluids every shift. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required the limited assistance of one (1) person for eating. A review of the fluid intake records for Resident #174, revealed the facility documented the resident had not met his/her fluid requirement on [DATE] with 840 ml, [DATE] with 960 ml, [DATE] with 600 ml, [DATE] with 720 ml, [DATE] with 1200 ml, [DATE] with 420 ml, [DATE] with 840 ml, [DATE] with 720 ml, [DATE] with 840 ml, [DATE] with 1080 ml, [DATE] with 840 ml, [DATE] with 960 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 480 ml, [DATE] with 1200 ml, [DATE] with 480 ml, [DATE] with 480 ml, [DATE] with 840 ml, [DATE] with 720 ml, [DATE] with 180 ml, [DATE] with 720 ml, [DATE] with 502 ml, [DATE] with 600 ml, [DATE] with 1080 ml, [DATE] with 840 ml, [DATE] with 840 ml, [DATE] with 100 ml, [DATE] with 840 ml, [DATE] with 210 ml, [DATE] with 180 ml, [DATE] with 540 ml, and [DATE] with 180 ml. The fluid intake records for Resident #174 revealed the resident had not met daily fluid requirements for thirty seven (37) out of thirty eight (38) days. A review of the nurses notes for Resident #174, revealed an entry dated [DATE] at 1:03 PM which stated resident very lethargic this morning, does awaken with some effort. Advanced Registered Nurse Practioner (ARNP) notified to evaluate the resident. The nurses note further revealed the ARNP ordered a CBC and BMP (laboratory blood tests) to be drawn on [DATE]. The nurses notes also revealed an entry dated [DATE] at 3:17 PM, revealed the laboratory tests which had been completed for Resident #174 had critical results and the ARNP had been notified with new orders received to administer a 500 ml bolus of normal saline intravenously and then continue administering normal saline intravenously at 100 ml per hour for 2000 ml. The ARNP also ordered to hold Lasix (diuretic) and acetazolamide (medication to treat heart failure) for the resident for three (3) days, and to recheck a BMP (blood laboratory test) for the resident on [DATE]. The nurses note further revealed the resident's responsible party had been notified. A review of laboratory reports for Resident #174 dated [DATE] at 5:19 AM, revealed the resident had a Blood Urea Nitrogen (BUN) level of 156 (normal 7-25 mg/dl); Creatinine level of 4.2 (normal 0.6-1.3 mg/dl); BUN/Creat Ratio of 37 (normal 6-25). Further review of Resident #174's laboratory reports dated [DATE] at 7:32 AM, revealed the resident had a BUN of 126, Creatinine level of 3.6, and BUN/Creatinine Ratio of 35. Further review of Resident #174's nurses notes, dated [DATE] at 3:03 PM, revealed the resident's physician had assessed the resident. A nurses note dated [DATE] at 2:15 PM, revealed the ARNP saw the resident and due to the intravenous line being out and staff were unable to restart the intravenous line, the resident was sent to the acute care hospital. The nurses note further revealed the resident's laboratory tests revealed the resident still had dehydration. A interview conducted with State Registered Nursing Assistant (SRNA) #5 on [DATE] at 10:15 AM, revealed she was responsible for documenting the fluid intakes in the computer every shift. The SRNA stated she was required to notify the nurse if the resident was not eating or drinking as well. The SRNA stated Resident #174 had been declining and the nurses were aware. A interview conducted with SRNA #4 on [DATE] at 10:20 AM, revealed she was required to document resident's fluid intake in the computer. The SRNA stated if the resident did not eat or drink well, she was required to notify the nurse. The SRNA stated the nurses were aware Resident #174 was not eating or drinking well. A interview conducted with Licensed Practical Nurse (LPN) #4 on [DATE] at 10:45 AM, revealed she was not sure where to look to find what fluid requirements a resident required. The LPN stated she did not look daily to ensure residents were meeting their daily fluid requirements. The LPN stated the weekly nursing assessment which she completed on the computer automatically populated the fluid requirement needs of the resident and she was required to look back for the previous week. The LPN stated she probably should have notified the physician and the RD regarding Resident #174's fluid intake, but she had not and did not know why she had not. The LPN stated she had been trained on signs and symptoms of dehydration such as poor skin turgor, dry mucus membranes, abnormal laboratory values. The LPN stated she was required to notify the physician if the resident exhibited any signs or symptoms of dehydration. Interview conducted with LPN #1 on [DATE] at 10:55 AM, revealed she was unable to state where fluid requirements were documented. The LPN stated she did not check resident's fluid requirements daily. The LPN stated she just asked the SRNAs if the resident was drinking okay. The LPN stated she had been trained on signs and symptoms of dehydration such as poor skin turgor, dry mucus membranes, abnormal laboratory values. The LPN stated she was required to notify the physician if the resident exhibited any signs or symptoms of dehydration. Interview conducted with the ARNP for Resident #174 on [DATE] at 3:15 PM, revealed the resident had been declining the last few months. The ARNP stated she expected the staff to monitor intakes and if the resident was not meeting fluid intakes she would have expected staff to notify her. The ARNP stated staff had told her on [DATE] the resident was not drinking. The ARNP could not recall who it had been that had reported the resident was not drinking. The ARNP stated she should have been notified of the resident not meeting his/her fluid requirements because the resident could have died. Interview conducted with the Registered Dietician (RD) on [DATE] at 11:04 AM, revealed after COVID 19 began she had only been back seeing residents at the facility since [DATE]. The RD revealed prior to [DATE], she had been working from home using the computer system to review residents nutritional status. The RD stated after returning to the facility in [DATE], when she comes into the facility she receives a list of referrals to see, such as those with decreased intake, weight loss, wounds, and if they have a MDS assessment coming up. The RD stated she reviewed everyone on the referral list. The RD stated if the resident was not on the list she would not reviewed their intakes. The RD stated if a resident had not met fluid needs for three (3) consecutive days she expected to be notified. The RD stated she would have expected Resident #174 to have been on the list for her to review and the resident was not on the list. The RD stated she had not been aware Resident #174 was not meeting his/her fluid requirements and should have been notified. Interview conducted with Resident #174's physician on [DATE] at 12:14 PM, revealed, he monitored fluid intakes when he visited the resident every month. The physician stated he had been aware the resident was not meeting his/her fluid requirements. The physician stated the resident not eating or drinking as well was a natural progression of his/her disease process. The physician stated the resident was at the end stage of his/her disease process and decreased fluid intake was unavoidable as the resident was entering the palliative phase. An interview conducted with the Corporate Nurse (CN) who was the liaison for the Director of Nursing (DON) who was unavailable due to sickness on [DATE] at 3:05 PM, revealed staff were required to review care plans at the beginning of every shift and prior to providing care for the residents. The CN stated if the resident was not meeting the fluid requirements the physician would be notified. The CN stated prior to the survey, the facility had not identified any concerns with residents fluid intakes not being monitored. The CN stated the nurses look at labs every day, but do not monitor strict intake and outputs on every resident just the residents that show signs and symptoms of dehydration and are at high risk for dehydration based on their policy. The CN stated only if a resident showed signs and symptoms of dehydration would a nurse be expected to notify the physician and RD for dehydration.