Health inspection·July 20, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 2 residents sampled for nutrition, Resident #19. Residents Affected - Few Findings include: During an observation on 7/17/2023 at 12:33 PM, Resident #19 was eating lunch independently in her room, with the meal ticket reading NAS (no salt added). During an observation on 7/18/2023 at 8:41 AM, Resident #19 was eating breakfast independently in her room, with the meal ticket reading NAS. Review of Resident #19's dietary order dated 11/22/2022 reads, NAS (No Added Salt) diet, Regular texture, Regular consistency. Review of Resident #19's Annual Minimum Data Set (MDS) dated [DATE] revealed no information under Section K Swallowing/Nutritional Status. K0510 Nutritional Approaches . D. Therapeutic diet (e.g. low salt, diabetic, low cholesterol). Review of Resident #19's Medicare-5 day MDS dated [DATE] revealed no information under Section K Swallowing/Nutritional Status. K0510 Nutritional Approaches . D. Therapeutic diet (e.g. low salt, diabetic, low cholesterol). During an interview on 7/19/2023 at 10:59 AM, the MDS Coordinator stated, [Resident #19's name] was getting a NAS diet since 11/22/2022. I think the staff meant to click the box on top of the not assessed. I am not sure why he did that. The therapeutic diet was not addressed on the MDS dated [DATE] also. Review of the policy and procedure titled MDS Assessment Coordinator last reviewed on 7/14/2023, reads, Policy Statement: A registered nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Policy Interpretation and Implementation . 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. dating and signing the assessment (MDS). Page 1 of 3 105770 105770 07/20/2023 Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure resident records were accurate for 1 of 7 residents reviewed for advanced directives, Resident #67, and 1 of 2 residents reviewed for nutrition, Resident #19. Finding include: 1. Review of Resident #67's records revealed Resident #175's DNR (Do not Resuscitate) form uploaded into the electronic medical record. Review of Resident #67's care plan initiated on 4/25/2023 reads, [Resident #67] has advanced directives: Full Code, HCS. Review of the physician order dated 4/22/2023 for Resident #67 reads, Full Code. During an interview on 7/17/2023 at 1:18 PM, Resident #67 stated, I want to be resuscitated. During an interview on 7/17/2023 at 1:28 PM, the Director of Nursing stated, Mr. [Resident #67's name] is a full code, and that DNR was incorrectly uploaded into his medical record. 2. Review of Resident #19's Weights and Vitals Summary read, 06/14/2023, 160.8 Lbs [pounds] (Wheelchair) . 05/17/2023, 161.8 Lbs (Standing) . 04/2/2023, 169.6 Lbs (Wheelchair) . 02/15/2023, 170.2 Lbs (Wheelchair). Review of Registered Dietician's noted dated 6/29/2023 at 11:14 AM for Resident #19 reads, Rt's [Resident's] appetite and intake is fair is fair but fluid intake is poor around 500 ml [milliliters] per day. Weighs 161.8 lbs on 5/17/23 and lost about 8.4 lbs (5%) in 3 months. Wt [weight] loss may be due to lasix use and fair appetite. Being on remeron may also help improve her appetite and weight. Continues on NAS [No Salt Added], NCS [No Concentrated Sweets] diet with 90 ml SF medpass tid [three times a day] to help improve weight, total proteins and maintain albumin levels. On MVM [multivitamin/mineral] supplement to help with anemia. Plan: Continue on current diet and medpass and MVM supplements. Recommend to have TSH [Thyroid Stimulating Hormone] levels done due to being on Synthroid. Continue to monitor weights and labs and adjust diet and supplements accordingly. Review of Registered Dietician's note dated 6/29/2023 at 11:48 AM for Resident #19 reads, Rt's wt is at 131.6 lbs. on 6/8/223. lost about 14.6 lbs (10%) in 3 months. Appetite and intake is fairly good and ate 100% at lunch today. Continues on 90 ml medpass tid and 30 ml liquid protein qd [once a day] to help maintain weight and albumin levels. Labs indicate anemia, low albumin, and high glucose & BUN [Blood Urea Nitrogen]. Plan: Continue on current diet and supplements. Encourage fluids for hydration. Monitor weights and adjust diet as needed. During an interview on 7/19/2023 at 1:55 PM, the Registered Dietician stated, I was working in the facility and the internet was not great. I was copying and pasting quickly and in a hurry to lock in the notes before it would delete. The correct one is the 161.8 pounds. The other one was for another resident whom also was on the weight lost list. During an interview on 7/19/2023 at 2:15 PM, the Administrator stated, I expect documentation to be 105770 Page 2 of 3 105770 07/20/2023 Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693

F 0842 accurate and staff revise their work. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedures titled Charting Errors and/or Omissions last reviewed on 7/14/2023 reads, Policy Statement: Accurate medical records shall be maintained by this facility. Residents Affected - Few 105770 Page 3 of 3