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Based on observation, interview, and record review, the facility failed to have an updated advance directive in the medical record for 1 (#18) of 22 sampled patients; this deficient practice had the potential for the facility to provide life-sustaining treatments against the patient's wishes. Findings include:

Review of patient #18's EHR showed the patient's Code Status as "unconfirmed."

During an interview on 9/15/21 at 9:50 a.m., staff member B stated patient #18 was a readmission, so his code status should be somewhere in his past medical record. She also stated the nurses on the floor should know the patient's code status.

During an interview and observation on 9/15/21 at 2:30 p.m., staff member T walked to patient #18's room to find his code status. She stated that the yellow circle on his door might indicate his code status. The patient's code status was not found in his room. Staff member T went to patient #18's medical record to look for the code status, and she stated she was "locked out" of the computer.

During an interview on 9/15/21 at 2:45 p.m., staff member T stated if patient #18 "coded" right now, she would not start CPR because she knew he was a DNR because she knew his daughter.

A review of the facility's Admitting Patient Checklist, dated 7/19/21, showed:

"...2. Placing orders: You will need an ADMIT order and CODE status order for every stay... 8. Consent to treat/CODE status: ... If patient is IP/SKSW/LTC/OBS [sic] you will need consent form..., MT POLST..."

Based on observation, interview, and record review, the dietary department failed to utilize a therapeutic breakdown for a pureed diet and portion sizes for 1 (#20) of 22 sampled patients. This deficient practice failed to facilitate the facility's ability to verify the patients caloric or nutrient intake provided by the dietary department. Findings include:

During an interview on 9/14/21 at 10:30 a.m., staff member N stated the dietary spreadsheets for the weekly menu were in the computer, and he would need to purchase an ink cartridge to print them.

Review of the dietary spreadsheets provided by staff member N on 9/15/21, showed the pureed diet was not included on the spreadsheets.

During a lunch observation and interview on 9/14/21 at 12:20 p.m., patient #20 received four bowls of pureed food. He did not know what foods were in the bowls.

During an interview and observation on 9/14/21 at 12:21 p.m., staff member R pointed to each bowl to identify the food items: pureed blueberries, pureed fruit cocktail, pureed meat, and pureed cauliflower. She stated the meat was red because she added tomato sauce to the puree. Patient #20 stated he would not eat the blueberries or the fruit cocktail. Staff member R asked the patient if he would like her to make the pureed foods thinner. He said no, he was done eating.

Review of the lunch menu for 9/14/21 showed, "Pepper Cabbage, Beef Pot Roast, Baked Potato, Parslied Carrots, Dinner Roll, and Chocolate Cake." The spreadsheet for the pureed meal was still not available to show what patient #20 should have received for the lunch meal.

During an interview on 9/15/21 at 9:10 a.m., staff member N had not located the pureed spreadsheets and stated he would call the contracted company for the information. He stated every item on the menu should be pureed but did not understand the cooks would need the information prior to service, to prepare the specified pureed meal items, and serve the written portion sizes.

During a lunch observation on 9/15/21 at 12:25 p.m., patient #20 received pureed chicken, pureed lima beans, and pureed beets.

Review of the provided dietary spreadsheets for the pureed diet, received on 9/15/21 at 2:10 p.m., showed patient #20 should have received cabbage, pot roast, baked potato, carrots, dinner roll, lettuce garnish, and chocolate cake; all pureed, for lunch on 9/14/21.

Review of the provided dietary spreadsheets for the pureed lunch menu on 9/15/21, showed patient #20 should have been provided pureed rice, a dinner roll and cheesecake.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure to develop a comprehensive care plan based on the patient care needs for 2 (#s 2 and 20) of 22 sampled patients. Findings include:

A review of the facility's policy and procedure titled, Care Planning, showed, "Policy: It is the policy of this facility that members of the interdisciplinary team and the resident meet initially within seven days of completion of the comprehensive resident admission assessment to develop a comprehensive care plan..."

1. During an observation and interview on 9/15/21 at 1:20 p.m., resident #2 was sitting up in her bed, and had a pillow under her back which elevated her left buttock off the bed. She stated she was at the facility to receive care to help heal the wound on her backside. She said she had a wound vac for the wound and staff were completing regular dressing changes. She also stated she had type II diabetes but had lost weight so her A1C levels were now normal. She said it was important to her that she maintain the weight that she was currently, in order to manage her type II diabetes.

Review of patient #2's EHR showed the patient was admitted on 8/26/21 for Sacral Decubitus Ulcer. Review of the patient's care plan showed a single nursing diagnosis was created for, "Risk for Infection", related to her sacral pressure ulcer. There were no further nursing diagnoses developed for patient #2.

During an interview on 9/15/21 at 10:00 a.m., staff member B stated patient #2 had additional care areas which would warrant further nursing diagnoses on her care plan. She stated the patient's wound care needs would be an example of an additional nursing diagnoses, which should have been addressed on patient #2's care plan.

2. Review of patient #20's care plan titled, Prevent weight loss, constipation and dehydration showed, the patient was to receive soft foods with thin liquids, and to monitor for swallowing problems. The correct diet of a pureed texture with nectar thick liquids had not been updated on the patient's care plan. The implementation of a PEG tube in September 2021, was also not updated on patient #20's care plan.

During an interview on 9/15/21 at 10:10 a.m., staff member B stated it was the expectation for nursing staff to develop a comprehensive care plan for all patients admitted to the facility. The care plan should be based on the patient's nursing care needs, not just based on their admitting diagnosis.

Based on interview and record review, the facility failed to follow their established Medical Staff Bylaws and Medical Staff Policy and Procedures for ensuring a medical doctor sign and assume full responsibility for the H&P, when a patient was admitted by a mid-level practitioner for 3 (#s 2, 21, and 22) of 22 sampled patients. Findings include:

A review of the facility's Medical Staff Bylaws-2007 Revision, showed: Section II - Medical staff Rules and Regulations, Part 1 - Admission of Patients, Section 4 - Admission Information, Paragraph 2, "Whenever a patient is admitted to the facility by a physician assistant or nurse practitioner, a supervising physician is notified of the fact, by phone or otherwise, within 24 hours after the admission and a written notation of the consultation and of the physician's approval or disapproval is kept in the patient's record."

1. Review of patient #2's medical record showed an admission date of 8/26/21, with an admission H&P completed by staff member J on 8/27/21. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

2. Review of patient #21's medical record showed an admission date of 7/27/21, with an admission H&P completed by staff member J on 7/27/21. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

3. Review of resident #22's medical record showed an admission date of 7/5/21, with an admission H&P completed by staff member U on 7/5/21. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

During an interview on 9/14/21 at 4:00 p.m., staff member V stated the facility grants mid-level practitioners the privilege of admitting patients. He said he was responsible to review and co-sign documentation of mid-level practitioners to ensure appropriate care of patients admitted to the facility.

During an interview on 9/15/21 at 10:30 a.m., staff member B stated it was an expectation the MD evaluated a patient's care provided by a mid-level practitioner when a patient was admitted to the facility. She said staff member V was to review and co-sign all admitting H&P's completed by mid-level practitioners. She said their EHR was designed to send staff member V the necessary documents and orders created by a mid-level practitioner, for his review and co-signature. She said however, the prompt in the EHR was turned off, so the documents were no longer being sent to staff member V.