BENTWOOD NURSING & REHAB

Based on interview and record review, the facility failed to maintain a surety bond
sufficient to ensure protection of resident funds. The census was 63.
Review of the facility’s Resident Trust General Ledger (cash sheet) for the period of
(MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of $18,000.00,
which would require a bond of $27,000.00.
Review of the Department of Health and Senior Services approved bond list, showed the
facility had an approved bond for $25,000.00
During an interview on 11/6/18 at 10:00 A.M., the Business Office Manager said the new
bond was approved on (MONTH) 5, (YEAR) for $35,000. She was responsible for ensuring the
bond was increased.
During an interview on 11/6/18 at 10:30 A.M., the administrator said he thought he had the
bond increased back in September. The issue must have been over looked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure hot water
temperatures reached at least 105 degrees Fahrenheit (F) for residents on three occupied
halls who complained of cool water temperatures. The census was 63.
1. Review of the maintenance work order log (a log completed by staff of items that needed
to be repaired and reviewed daily by the maintenance director), showed on 9/14/18, a staff
member wrote, the water did not get hot.
2. Observation on 11/8/18 at 7:20 A.M., of the bathroom between rooms[ROOM NUMBERS], and
shared by three residents, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water from the faucet reached a high temperature of 74.7 degrees F;
-At 8:06 A.M., the maintenance director re-tested the hot water from the bathroom faucet
and received a reading of 79.7 degrees F.
3. Observation on 11/8/18 at 7:25 A.M., of room [ROOM NUMBER], shared by two residents,
showed:
-The surveyor used a calibrated dial thermometer to take the temperature of the hot water
at the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for two minutes. The
water from the faucet reached a high temperature of 90 degrees F. The water was cool to
touch.
4. Observation on 11/8/18 at 7:30 A.M., of the bathroom between rooms [ROOM NUMBERS],
shared by four residents, showed:
-The surveyor used a calibrated thermometer to take the temperature of the water at the
bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water from the faucet reached a high temperature of 74.7 degrees F. During an interview, a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to adequately monitor, assess
and ensure the guidance and direction of the physician/Medical Director was obtained,
regarding a resident experiencing a change in condition. Over a four day period, staff
observed the resident with an elevated temperature, an increased heart rate and labored
breathing. On the fourth day the physician was made aware of the resident’s change, and
gave orders to send the resident to the hospital where he/she was admitted to the
intensive care unit (ICU). In addition, the facility failed to ensure adequate follow up
and physician notification regarding a resident with ongoing vaginal discharge (Residents
#202 and #201). The census was 62 residents.
Review of the facility’s policy and procedure on Change in Condition, updated 3/2017,
showed:
-Purpose: The facility will make every effort to inform the resident, consult with the
resident’s physician and notify, consistent with his or her authority, the resident
representative when there is following:
#2. A significant change in the condition, health, mental or psychosocial status, that is
a deterioration in health, mental or psychosocial status in either life threatening
conditions or clinical complications;
-Procedure:
1. If the physician cannot be reached, the Medical Director will be notified;
2. During medical emergencies, notifications will be made as soon as possible;
3. The facility will promptly notify the physician of laboratory results that fall
outside of the clinical reference ranges in accordance with Doctor parameters or
laboratory normal reference ranges;
4. Changes in condition will be evaluated for the need to complete a Significant Change
in condition MDS 3.0/RAI Assessment, in accordance to the RAI/MDS 3.0 Instruction Manual;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure hot water
temperatures remained at or below 120 degrees Fahrenheit (F) for residents on one hall,
fix the broken bathroom floor tiles for one resident, who complained of tripping over the
defective area and ensure a potentially hazardous cleanser was stored securely (Resident
#26). The census was 63.
1. Observation in 11/8/18 at 7:37 A.M., of room [ROOM NUMBER], an occupied semi-private
room, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water reached a temperature of 127.7 degrees F. During an interview, the resident residing
in the room said the water got too hot if you didn’t mix cold water in with it;
-At 8:10 A.M., the maintenance director tested the hot water faucet and obtained a
temperature of 117.5 degrees F.
2. Observation on 11/8/18 at 7:45 A.M., of room [ROOM NUMBER], an occupied semi-private
room, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water reached a temperature of 127.2 degrees F;
-At 8:12 A.M., the maintenance director tested the hot water faucet and obtained a
temperature of 132.8 degrees F.
3. Observation on 11/8/18 at 8:18 A.M., of the 100 Hall shower room (one of three facility
shower rooms, but only one of two shower rooms in use), shared by 30 residents residing on
the 100 and 300 halls, showed:
-The maintenance director tested the hot water at the bathroom sink and obtained a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of a supra pubic urinary catheter (a sterile tube inserted into the bladder
through the abdominal wall to drain urine) tubing and drainage bag for the only resident
the facility identified as having a suprapubic urinary catheter (Resident #23). The sample
size was 16. The census was 63.
Review of Resident #23’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff dated 8/12/18, showed:
-Severe impaired cognition;
-Total assistance with one to two persons for bed mobility, transfers, eating, hygiene and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain an
adequate supply of Med Pass, a supplemental health drink, for residents with weight loss
or were at risk of having weight loss. The facility ran out of the supplement, failed to
notify the residents’ physicians to see if a substitution could be made until their supply
was delivered. The facility identified 27 residents as receiving the supplement. Of those
27, 10 were sampled and all 10 did not receive their ordered supplement from 11/1/18
through 11/4/18 (Residents #52, #1, #8, #18, #23, #24, #30, #32, #37 and #38). The census
was 63.
1. Review of Resident #52’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/6/18, showed:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 6 out
of 15;
-BIMS score of 0-7, showed resident had severe impairment;
-Poor appetite occurred 2 to 6 days within the last two weeks;
-Height 63 inches, weight 123 pounds (lbs) with weight loss of 5 percent or more and not
on a physician’s prescribed weight loss regimen;
-Special treatment marked for speech therapy with start of care dated 10/3/18.
Review of the resident’s physician’s orders [REDACTED].
-An undated order, for regular diet;
-An order dated 10/19/18. to administer Med Pass (nutritional supplement) 90 milliliters
(ml) three times daily (TID) for [DIAGNOSES REDACTED].
Review of the resident’s Medication Administration Record [REDACTED] -An order dated 10/19/18, to administer Med Pass 90 ml TID (scheduled administration time
7:00 A.M., 1:00 P.M., 4:00 P.M. and 5:00 P.M.);
-From 11/1 through 11/4/18, staff documented 99 (hold see nurse’s notes).
Review of the resident’s documented weights, showed:
-4/10/18, 129.3 lbs;
-5/13/18, 132.2 lbs;
-6/1/18, 135.0 lbs;
-8/23/18, 120.6 lbs;
-8/24/18, 125.0 lbs;
-9/11/18, 129.5 lbs;
-9/25/18, 123.0 lbs;
-10/1/18, 123.0 lbs;
-11/7/18, 126.0 lbs;
-No other weights found.
Review of the facility’s Monthly Weight Report, dated (YEAR), showed the following weights
for the resident:
-May, 132.2 lbs;
-June, 135.0 lbs;
-July, 140.0 lbs, marked through as incorrect weight;
-August, 120.6 lbs;
-September, 129.5 lbs;
-October, 123.0 lbs;

Review of the resident’s progress notes, dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
4. Review of Resident #18’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Extensive assistance of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 123 lbs.
Review of the facility Monthly Weight Report, showed the resident weighed 123 lbs for
9/2018 and no weight for 10/2018.
Review of the resident’s current POS, showed an order dated 9/22/16, for Med Pass
supplement 120 mls four times a day.
Review of the resident’s current MAR, showed the resident did not receive Med Pass on 11/1
through 4/18.
Review of the resident’s progress notes, dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
5. Review of Resident #23’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Severely impaired cognition;
-Required total assistance with one to two persons for bed mobility, transfers, eating,
hygiene and bathing;
-Weight of 131 lbs.
Review of the resident’s POS, dated 11/1 through 30/18, showed:
-An undated order, for regular diet with nectar thickened liquids;
-An order dated 10/19/18, to administer Med Pass 90 ml BID (scheduled administration time
9:00 A.M. and 5:00 P.M.) for [DIAGNOSES REDACTED].
Review of the resident’s MAR, dated 11/1 through 30/18, showed:
-An order dated 10/19/18, to administer Med Pass 90 ml BID for weight loss (scheduled
administration time 9:00 A.M. and 5:00 P.M.) for weight loss;

12. During an interview on 11/9/18 at 8:25 A.M., the facility’s Corporate Nurse said
nursing staff should have documented why the resident’s Med Pass was held from 11/1
through 6/18 in the nurse’s notes. It is very important for nursing staff to administer
the Med Pass supplement for nutritional needs such as nutritional deficiency, maintain
nutritional parameters and prevent weight loss.
13. During an interview on 11/09/18 at 8:26 A.M., the Director of Nurses said their sister
facility (about one mile away) does have Med Pass 2.0. Her staff know to call them if they
run out of anything to see if it can be borrowed. If their sister facility does not have
enough to loan, staff know they can go to the local grocery or drug store and buy what
they need or a comparable substitute until their supply is delivered. She does not know
why staff failed to do this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments and ongoing monitoring for residents who received [MEDICAL TREATMENT] services. The facility identified three residents who received [MEDICAL TREATMENT]. Of
those three, one was selected for the sample and problems were identified (Resident #37).
The sample size was 16. The census was 63.
Review of Resident #37’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 9/22/18, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain
physician’s orders and properly assess two sampled residents that used bed rails.
(Residents #8 and #38). In addition, the facility identified 24 residents who used bed
rails and the facility did not assess them or obtained physician orders. The census was
63.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/23/18, showed the following:
-Rarely/never understood/understands;
-Total dependence of one person for bed mobility and transfers;
-[DIAGNOSES REDACTED].
-Bed rails not used.
Observation on 11/6/18 at 5:59 A.M., showed the resident lay in bed. The bed was
positioned against the wall. The exit side of the bed had one quarter length bed rail
raised.
Review of the resident’s medical record, showed no physician’s order or assessment for the
bed rail.
2. Review of Resident #38’s quarterly MDS, dated [DATE], showed the following:
-Usually understood/understands;
-Total dependence of one person for bed mobility and transfers;
-[DIAGNOSES REDACTED].
-Bed rails not used.
Observation on 11/6/18 at 5:31 A.M., showed the resident lay in bed. The bed was
positioned against the wall. The exit side of the bed had one quarter length bed rail
raised.
Review of the resident’s medical record, showed no physician’s order or assessment for the
bed rail.
3. During an interview on 11/9/18 at 9:19 A.M., the maintenance director said he is
responsible for checking bed rails monthly. He does not complete safety assessment form
for each resident using a bed rail and he does not document the assessment has been done.
4. During an interview on 11/9/18 at 10:56 A.M., the Regional Nurse Consultant said the
facility had 24 residents that used bed rails and none of those 24 had physician’s orders.
Assessments should be completed on admission and quarterly thereafter. The last time
assessments were completed were 3/2018.
5. Review of a Restraint – Physical (Quarterly/Annual Evaluation) form, showed the
assessment did not address safety factors such as the risk of entrapment in the bed rail
or between the bed rail and the mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the physician, who was
also the facility Medical Director, responded timely to nursing staff calls. This affected
three residents, one regarding a change in condition, in which after four days the
resident was sent to the hospital and admitted to the Intensive Care Unit, another
resident with ongoing vaginal discharge and a newly admitted resident in need of admission
order approval (Residents #202, #201 and #203). The census was 62 residents.
Review of the Medical Director Independent Contractor Agreement, signed by the Medical
Director on 2/28/17, showed:
-Services and Qualifications:
-Physician specifically acknowledged and affirms that Physician is an independent
contractor and understands the duties and responsibilities resulting from such status;
-Physician shall comply with all facility and medical staff bylaws, including, without
limitation, those relating to the conduct, standards of medical care and record
compliance;
-Physician shall at all times comply with all state and federal laws and regulations with
respect to the operations of the facility and physician services provided hereunder;
-Specific Responsibilities:
-Assure availability of physician services 24 hours a day in case of emergency;
-Develop and maintain systems to ensure that other licensed practitioners who may perform
physician-delegated tasks act within regulatory requirements and within the scope of
practice as defined by state law;
-Develop procedures and general clinical guidance for facility staff regarding when to
contact practitioners, including information that should be gathered prior to contacting
the practitioners regarding a clinical issue, question, or change in condition;
-Develop mechanisms for communicating and resolving issues related to medical care.
1. Review of Resident #202’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/8/18, showed:
-[DIAGNOSES REDACTED].
-Severely impaired cognition;
-Required total staff assistance for all activities of daily living (ADLs);
-Incontinent of bowel and bladder;
-Mechanically altered diet;
-Life expectancy of six months or less: No.
Review of the resident’s nurse’s notes, showed:
-Readmitted to the facility on [DATE] at 3:38 P.M. Alert but does not speak. Grunts when
name is called and makes eye contact. Vital signs (VS): blood pressure (B/P) 123/76
(normal 120/80), pulse (P) 79 (normal 60 – 100), respiration (R) 16 (normal 12 – 16),
temperature (T) 99.7 (normal 98.6). oxygen saturation (O2 Sats) 96% (normal 95 – 100%).
Tylenol given;
-1/5/19 at 5:20 A.M.: VS: T 100.0, P 100, R 18, B/P 111/56, O2 Sats 94%, alert, readmit,
Tylenol given for temperature, head of bed elevated, lungs sounds clear to auscultation
(the action of listening to sounds from the heart, lungs, or other organs, typically with
a stethoscope, as a part of medical diagnosis), oxygen applied at 2 liters (L) per minute
for shortness of breath (SOB) and comfort;
-1/6/19 at 5:20 A.M.: VS: T 99.7, P 110, R 16, B/P 118/75. O2 Sats 94% with oxygen at 2 L;

-1/6/19 at 12:58 P.M.: While on break, another charge nurse reported the resident was not
looking good. VS: B/P 118/75, P 110, O2 Sats 93% on 2 L of oxygen, T 99.5, R 24 and blood
glucose of 132. Resident was SOB with slight wheezing. Call placed to the resident’s
physician (also the facility Medical Director), awaiting call back. Resident is a full
code;
-1/6/19 at 3:20 P.M.: VS: B/P 122/77, O2 Sats 94%, R 18, resident still has elevated
temperature. Awaiting call back from the physician. Called times two;
-1/6/19 at 9:00 P.M.: No documentation whether the physician returned the call to the
facility;
-1/7/19 at 10:39 P.M.: Resident has had an active decline. Temperature was unstable at
103.1, was given Tylenol and ice packs were placed to lower temperature. When nurse
returned to reassess, resident was noted to be SOB, remained on oxygen at 2 L per nasal
cannula. Unable to obtain O2 Sats, temperature remains unstable at 101.4. No documentation
whether the staff contacted the physician or whether the physician returned the call from
1/6/19;
-1/8/19 at 1:11 A.M.: VS: T 102.0, P 107, R 22, B/P 90/54. Resident was SOB, with pursed
lip breathing (a breathing technique that consists of exhaling through tightly pressed
(pursed) lips and inhaling through the nose with the mouth closed), using facial and
abdominal muscles to breath, head of bed elevated. Tylenol given for temperature.
Physician called. The physician asked staff if the resident was a hospice patient, staff
replied no. Order received to send to the hospital for evaluation. Ambulance called and
gave instructions to call 911 due to resident being in respiratory distress. Resident on
O2 at 3 L, while having increased SOB, color pale. Resident transported to the hospital.
During an interview on 1/8/19 at 11:42 A.M., Nurse M said he/she worked the day shift on
Sunday 1/6/19. While the resident’s nurse was on break, Certified Nurse Aide (CNA) Q and
CNA U reported the resident wasn’t looking good. When he/she entered the room, the
resident was pursed lip breathing and using his/her abdominal muscles to breath. The
resident’s respirations were 22 to 24 and O2 Sats were 95% on 2 L of oxygen. He/she was
very concerned about the resident’s condition and wanted to call 911, because the
resident’s respirations were labored and his/her skin was sweaty and clammy, but he/she
wasn’t the resident’s nurse. He/she and Nurse D returned to the room to assess the
resident. He/she left the room at that time, but knows Nurse D placed a call to the
physician. The resident’s physician didn’t call back on their shift.
During an interview on 1/8/19 at 1:59 P.M., Nurse D said while on break during the day
shift on 1/6/19, Nurse M reported the resident was breathing hard, his/her pulse was
elevated and O2 Sats and B/P were normal. He/she assessed the resident and noted slight
wheezing and an elevated temperature of 99.5. He/she raised the HOB higher and placed a
call to the physician at about 11:00 A.M. or 12:00 P.M. He/she notified the Assistant
Director of Nurses (ADON) and was told to call the physician. The physician did not return
the call prior to the end of his/her shift on 1/6/19.
During an interview on 1/8/19 at 4:00 P.M., Nurse T said he/she took care of the resident
on the evening shift of 1/6/19. He/she saw the resident during rounds and noted a decline.
He/she had pursed lip breathing which lasted 5 to 7 minutes at various times. The
physician didn’t return the call on his/her shift.
During an interview on 1/8/19 at 2:27 P.M., the ADON said she expected staff to continue
to try to reach the physician and document it in the medical record.
During an interview on 1/8/19 at 3:10 P.M., the Administrator said he expected staff to
notify the physician anytime there is a change in the resident’s condition.

Based on observation and interview, the facility failed ensure serving trays used for meal
service were dry prior to use, use proper sanitizing practices when wiping down counters
and clean the thermometer used to test the temperature of the food. This had the potential
to affect residents who ate from the facility’s kitchen. The census was 63.
Observation of the kitchen on 11/5/18, showed:
-8:09 A.M., dietary staff used five wet serving trays during meal service;
-8:13 A.M., the dietary manager wiped counters with a white cloth towel. There was no
sanitizer water made in the kitchen;