Every finding on record at Abingdon Health & Rehab Center

Based on observation, staff interview, and facility document review, the facility staff failed to prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff stacked (nested) wet chafing pans together after washing. On 8/05/24 at 7:00 PM, the surveyor observed a shelving unit with multiple stacks of stacked (nested) small chafing pans. At the surveyor's request, Dietary Staff Member (DSM) #1 separated individual pans from three separate stacks and found water droplets between pans in each stack. DSM #1 stated staff would wash the pans again. On 8/06/24 at 4:48 PM, the survey team met with the Administrator, Director of Nursing, and the Clinical Services Specialist and discussed the concern of dietary staff nesting wet pans. On 8/07/24 at 9:54 AM, surveyor received a Staff In-service Education form dated 8/06/24 which read in part Reviewed Policy #FN.501 .air drying pot/pans/dishes after washing cycle - no wet nesting . which was signed by nine staff members. Surveyor received the facility policy titled Dishwasher Use and Temperature Monitoring with a reviewed/revised date of 1/15/24 and Reference Number of FN.501 which read in part .12. Dishes are left in racks until dry. Dietary staff should check all dishes, trays, bowls, and cups to ensure they are dry before stacking or placing in the proper storage area . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/07/24.

Based on staff interviews, clinical record review, and document review, facility staff failed to ensure provider ordered medications were administered for 1 of 23 current residents sampled. (Resident #31) The findings were: For Resident #31, facility staff failed to administer the resident four (4) doses of provider ordered Gabapentin in May 2024. Resident #31's diagnoses included but were not limited to Coalworker's Pneumoconiosis. Section C (cognitive patterns) of the minimum data set with an assessment reference date of 06/20/24 coded the resident's brief interview for mental status as 14 out of 15 points. Resident #31's clinical record contained an order for Gabapentin 600 mg, give 1 tablet by mouth four times a day for neuropathy began on 11/07/23 and was scheduled to be administered at midnight, 6:00 a.m., noon, and 6:00 p.m. daily. The medication administration record (MAR) for May 2024 indicated four doses of Gabapentin were not administered between 05/19/24 and 05/21/24: 1. 05/19/24 noon dose, 2. 05/19/24 6:00 p.m. dose, 3. 05/20/24 6:00 p.m. dose, and 4. 05/21/24 midnight dose. A registered nurse (RN) supervisor's progress note dated 05/19/24 at 12:23 p.m. read, called pharmacy to try to get a code to pull Gabapentin for resident- was told by pharmacist that resident did not have any more pills on his prescription to be able to get a code to pull one and that he needed a new prescription, messaged [Physician Assistant name omitted] to try to get a prescription faxed in and then tried to call a little while ago with no answer. The same RN supervisor wrote a progress note the same day at 7:05 p.m. which read, pharmacy stated that they had the e script for medicine but that it was not ready for me to get a code to pull it. The RN supervisor was unavailable for interview. The director of nursing (DON) was interviewed on 08/07/24 at 11:05 a.m. and acknowledged Resident #31 did not receive four doses of their scheduled Gabapentin doses in May 2024. The DON reported it took two days for the medication refill to arrive at the facility and their Cubex (backup medication system) ran out of Gabapentin. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 6 of 23 residents, Residents #100, 101, 115, 263, 36, and 57. The findings include: 1. For Resident #100, the facility staff failed to complete a preliminary consent to treat form in the residents clinical record. Resident #100's diagnoses included muscle wasting/atrophy and diabetes. Section C (cognitive patterns) of Resident #100's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/06/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. The clinical record included the following documents. Provider order dated 01/30/24 for a full code. A signed preliminary consent to treat and assignment of benefits form dated 01/30/24. The area that referenced the residents Do Not Resuscitate (DNR) and advance directive status had not been completed. On 08/06/24 at 2:40 p.m., during an interview with the Director of Admissions this staff confirmed part of this form was incomplete. The Administrator stated they would be providing education. On 08/06/24 at 4:45 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Clinical Service Specialist the issue with the incomplete document was reviewed. On 08/07/24, the Administrator provided the survey team with a copy of an in-service dated 08/06/24 indicating they had begun staff education regarding this issue. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #101, the facility staff failed to complete a preliminary consent to treat form in the residents clinical record. Resident #101's diagnoses included chronic kidney disease and hypertension. Section C (cognitive patterns) of Resident #101's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/30/24 included a brief interview for mental status (BIMS) score of 12 out of a possible 15 points. The clinical record included the following documents. Provider order dated 04/24/24 for a full code. A signed preliminary consent to treat and assignment of benefits form dated 02/28/24. The area that referenced the residents Do Not Resuscitate (DNR) and advance directive status had not been completed. On 08/06/24 at 2:40 p.m., during an interview with the Director of Admissions this staff confirmed part of this form was incomplete. The Administrator stated they would be providing education. On 08/07/24 the Administrator provided the survey team with a copy of an in-service dated 08/06/24 indicating they had begun staff education regarding this issue. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #115, the facility staff failed to complete a preliminary consent to treat form in the residents clinical record. Resident #115's diagnoses included acute on chronic systolic congestive heart failure and diabetes. There was no completed minimum data set (MDS) assessment for this resident, The clinical record included the following documents. Provider order dated 08/01/24 for a full code. Signed preliminary consent to treat and assignment of benefits form dated 08/01/24. The area that referenced the residents Do Not Resuscitate (DNR) and advance directive status had not been completed. On 08/06/24 at 2:40 p.m., during an interview with the Director of Admissions this staff confirmed part of this form was incomplete. The Administrator stated they would be providing education. On 08/07/24 the Administrator provided the survey team with a copy of an in-service dated 08/06/24 indicating they had begun staff education regarding this issue. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #263, the facility staff failed to complete a preliminary consent to treat form in the residents clinical record. Resident #263's diagnoses included age related osteoporosis with current pathological fracture. Section C (cognitive patterns) of Resident #263's minimum data set (MDS) assessment included a brief interview for mental status (BIMS) score of 12. The clinical record included the following documents. Provider order dated 07/29/24 indicating this resident had a Do Not Resuscitate (DNR) order in place. Signed preliminary consent to treat and assignment of benefits form dated 07/26/24. The area that referenced the residents Do Not Resuscitate (DNR) and advance directive status had not been completed. On 08/06/24 at 2:40 p.m., during an interview with the Director of Admissions this staff confirmed part of this form was incomplete. The Administrator stated they would be providing education. On 08/07/24, the Administrator provided the survey team with a copy of an in-service dated 08/06/24 indicating they had begun staff education regarding this issue. No further information regarding this issue was provided to the survey team prior to the exit conference. 28169 5. For Resident #36, facility staff failed to complete the advance directive portion of a preliminary consent to treat and assignment of benefits document found in the resident's clinical record. Resident #36's diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Section C (cognitive patterns) of the minimum data set with an assessment reference date of 05/30/24 coded the resident's brief interview for mental status as 00 (zero) out of 15 points. Resident #36's clinical record contained a document titled Preliminary Consent to Treat and Assignment of Benefits, dated 01-09-23 and signed by Resident #36's agent. The document's section titled, DNA Status and Advance Directive had blank spaces which had not been filled out. On 08/07/24 at approximately 10:30 a.m., the administrator acknowledged the form was not filled out completely and stated the concern was an opportunity for staff education. No further information was provided prior to the exit conference. 6. For Resident #57, facility staff failed to complete a preliminary consent to treat document found in the resident's clinical record. Resident #57's diagnoses included but were not limited to osteomyelitis of vertebra, lumbar region. Section C (cognitive patterns) of the minimum data set with an assessment reference date of 07/15/24 coded the resident's brief interview for mental status as 02 (two) out of 15 points. Resident #57's clinical record contained a document titled Preliminary Consent to Treat and Assignment of Benefits, dated 04-23-24. There is a signature at the Resident's Signature line however no signature at the Resident Agent's Signature line. The document's section titled, DNA Status and Advance Directive had blank spaces which had not been filled out. On 08/07/24 at approximately 10:30 a.m., the administrator acknowledged the form was not filled out completely and stated the concern was an opportunity for staff education. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review and in the course of a complaint investigation the facility staff failed to maintain and infection prevention program as evidenced by a staff member failing to properly wear PPE (personal protective equipment) for 1 of 4 residents, Resident #2. The findings included: For Resident #2 the facility failed to ensure facility staff were properly wearing PPE. Resident #2's face sheet listed dianoses not limite to [MEDICAL CONDITIONS], type 2 diabetes mellitus, [MEDICAL CONDITION], dementia, hypertension, and depression. Section C, cognitive patterns of Resident #2's annual MDS (minimum data set), with an ARD (assessment reference date) of 07/02/2020, indicated that the resident had both long and short term memory problems with severely impaired cognitive skills for daily decision making. Surveyor spoke with the facility administrator on 01/08/2021 at approximately 12:30 pm regarding Resident #2. Administrator stated that resident had been in the hospital and was readmitted to the facility on the observation unit on 06/29/2020. Administrator stated that residents on the observation unit were placed on contact precautions for 14 days prior to being moved. Administrator stated that Resident #2's daughter was upset that resident was not placed back in their regular room upon re-admission. Surveyor asked administrator if the resident had a room mate while on the observation unit, and the administrator said that she could have, due to the facility placing new admits with other new admits on the observation unit. Surveyor asked the administrator if there was an incident of a staff member entering Resident #2's room without [MEDICATION NAME] proper infection control, and the administrator stated that the resident's daughter had sent her a screen shot of a staff member in the resident's room with their mask pulled down below their chin on July 15th, after a staff memeber had been identified as testing positive for COVID-19. Administrator stated that the daughter said the screen shot was taken on July 3rd, but that there was really no way of knowing when it was taken. The administrator stated that the staff person in the picture was given a written counseling, re-educated on proper PPE (personal protective equipment) and infection control practices, as well as re-education provided for all staff of the facility. Administrator also stated that a plan of correction was done. Surveyor was provided with a written plan of correction dated 07/17/2020, which reads as follows: QA Action Plan Area of Concern: Proper wearing of PPE Task Force Chairman: , ADON (assistant director of nursing) Corrective Action (Specific): Employee was checked off on skills perfomance checklist for PPE and handwashing. Employee was counseled regarding incident. Persons Responsible for Implementing Correction: ADON Target Completion Date: 7/17/2020 How other resident at risk for related non-compliance will be identified & what corrective actions will be taken: Any resident had the potential to be affected if staff does not wear proper PPE. Frequent rounding by Infection Control Preventionist and Management Team to monitor for compliance of PPE. Any concerns identified will be addressed at the time of occurrence and corrective action will be followed according to corrective action policy. Persons Responsible for Implementing Correction: DON (director of nursing), ADON Target completion date: Ongoing System Changes to maintain compliance: DON or designee will re-educate staff on proper PPE use and handwashing Persons Responsible for Implementing Correction: DON, ADON Completion Date: 7/24/2020 Monitoring for effectiveness of New Systems & Compliance: Daily rounding on units by Infection Control Preventionist and Management Team. Any discrepancies will be addressed promptly and forwarded to the Quality Assurance Commitee for further review. Persons Responsible for Implementing Correction: DON, ADON, Management Team Target Completion Date: Ongoing This comcern of the staff not correctly wearing PPE was discussed with the administrative team (administrator, DON) during a meeting via telephone on 01/08/2021 at approximately 2:05 pm. No further information was provided prior to exit. This is a past non-compliance deficiency.

Based on observation, staff interview and facility policy review it was determined the facility staff failed to prepare and store foods in a clean and sanitary manner. ~ Staff failed to securely close and date opened frozen foods that were returned to the freezer. ~ Staff failed to discard milk products after the BEST BY date on the carton had passed. Findings: 1. On 12/4/18 at 1:00 PM the facility kitchen was reviewed by two surveyors and the DM (dietary manager). The walk-in freezer was observed to contain an opened box of mixed frozen vegetables. The card board box was opened at the top and the food inside was in a plastic bag that was not sealed. The box had not been dated as to when the food had been opened. The DM was asked about the opened box of food and she told the surveyor it did not have to be resealed when it was in a freezer. The DM then reached into the box and tied and knot in the top of the plastic bag which effectively sealed the food from air. After failing to find a date on the box, the DM then turned around and asked a staff member when the food had been opened. She told the surveyor the food had just been opened the day prior. The freezer was also observed to have accumulated icicles hanging from a pipe in the rear wall for the freezer. Three packages of prepared meals were observed on the shelf next to the piping and had icicles hanging from the packaging. The DM pulled the food off the shelving and discarded it. She said the freezer had been fixed already--but the ice had not been cleaned from the piping since the maintenance manager had repaired it. The sugar and flour bins in the kitchen floor under and shelf were observed to have food debris and crumbs on the sliding lids. The sugar bin was observed to have some dark stains on the inside walls above the sugar. These stains appeared to have been splashed or otherwise smeared on the inside of the bin. Facility staff removed the lids and cleaned the bins while the surveyor was on the initial tour of the kitchen. On 12/6/18 at 12:20 PM the surveyor received and reviewed the facility policy for Food and Supply Storage. It contained the following: Opened frozen foods are securely closed and dated with a use by date of 3 months from the date opened. After reviewing this policy with the DM, she still maintained the food was securely closed. The DM said the box had been dated prior to the surveyor's tour, but said she had to ask staff when the food had been opened just to confirm the date. The surveyor addressed the issue with the administrator, DON and CN (corporate nurse) prior to the survey exit. The surveyor noted the food in a freezer must be sealed against the air to prevent freezer burn, which would affect the flavor and the nutritional value of any food not properly stored. No additional information was provided prior to the survey team exit. 2. The facility staff failed to ensure that milk was discarded after the use by date on 1 of 3 units on the facility. On 12/06/18 at 10:00 am, the surveyor observed 4 cartons of strawberry milk with the date [DATE] in the unit refrigerator on the Art unit that was available for distribution. On 12/06/18 at 10:15 am, the surveyor showed the facility administrator the 4 cartons of strawberry milk dated [DATE] that had been observed in the unit refrigerator on the Art unit. The facility administrator observed the 4 cartons of strawberry milk and agreed that it was in the unit refrigerator past printed use by date. On 12/06/18 at 10:38 am, the surveyor spoke with the dietary services manager and the director of nutrition services. The dietary services manager stated that the 4 cartons of strawberry milk had been discarded and she does not know where the 4 cartons of strawberry milk came from. The facility policy on Food and Supply Storage contained documentation that included but was not limited to, . Refrigerated Foods 3. All dairy products whether opened or sealed, including milk, cottage cheese, and sour cream, must be used or discarded by the use by date specified by the manufacturer. On 12/6/18 at 1:00 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 12/6/18. Based on observation, staff interview, and facility document review, facility staff failed to store food in a safe, clean manner. FACILITY Kitchen 12/04/18 01:15 PM Initial tour Can opener cleaned Per dietary manager stove is cleaned daily and as needed. There is debris on the stove however staff is cleaning the kitchen following the lunch meal. Hood is clean Walk in temps collected appropriately Freezer temps collected appropriately Dry storage ok 12/04/18 04:40 PM Food arrives to Martha's Ridge dietary staff is observed sanitizing hands appropriately prior to handling food. 12/04/18 05:00 PM Tray line temps String beans-182 vag lasagna-162 Chicken patty with gravy-184 Mashed potato-204 gravy-186 Broccoli-131 reheat 168 Pureed bread-178 Pureed string beans-178 pureed chicken patty with gravy-193 Pureed veg lasagna-179 peanut butter pie-47- put back in cooler 38 pudding-45 put back in cooler 40 12/06/18 10:00 AM Observed 4 cartons of Strawberry milk with the Date [DATE] in the fridge on Unit 1 that was avaliable for distribution on art Unit. 12/06/18 10:15 AM Spoke with the facility administrator and showed her the milk and agreed that it was in the fridge past printed expiration date. 12/06/18 10:38 AM Kelly Brunicardi Unit Maniger and Director of nutrition services Marianne Ehrreich stated that they have been discarded and she does not know where it came from. Stated that she had to take 2 strawberry because there was none down there.

Based on staff interview, and clinical record review, facility staff failed to provide written information concerning bed hold policy to the resident or resident's representative for 1 of 27 residents in the survey sample (Resident #61). The findings included: The facility staff failed to provide a written notice to the resident or resident's representative concerning a bed hold for Resident #61. The resident was discharged from the facility due to being admitted to the hospital. Resident #61 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #61 was also coded as requiring extensive assistance of 2 or more staff members for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #61's clinical record on 12/5/18. During this review, the surveyor noted that the resident was discharged on [DATE] to the hospital. There was no documentation in the clinical record, which reflected a written notice concerning a bed hold being given to the resident or resident's representative. At 5:15 pm, the surveyor asked the admissions staff #1 if Resident #61 or resident's representative was provided with written information concerning a bed hold. The resident was discharged from the facility on 10/23/18. The admissions staff #1 stated,I call the resident's representative and verbally tell them about a bed hold but I don't provide them with a written notice. At 5:30 pm, surveyor notified the interim administrator, director of nursing and the corporate nurse of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 12/6/18.

Based on observation, staff interview, and facility document review, facility staff failed to provide personal privacy while providing care for 1 of 27 Residents in the survey sample (Resident #16). The findings included: The facility staff failed to provide privacy for Resident #16 while receiving ADL care in the shower room. Resident # 16 was a [AGE] year-old- female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for resident # 16 was reviewed on 12/6/18 at 10:32 am. The most recent MDS (minimum data set) assessment for Resident # 16 was a quarterly assessment with an ARD (assessment reference date) of 11/21/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 16 had a BIMS (brief interview for mental status) score of 10 out of 15, which indicated that Resident # 16's cognitive status was moderately impaired. The plan of care for Resident # 16 was reviewed and revised on 10/9/18. The facility staff documented a focus area for Resident # 16 as, Resident # 16 requires supervision-limited assistance with adls (activities of daily living) due to mobility, hx (history) of [MEDICAL CONDITION], [MEDICAL CONDITIONS]. Her level of assistance varies r/t (related to) fatigue and weakness. Interventions included but were not limited to, Assist with/provide ADL care as needed. On 12/05/18 at 10:46 am, a Resident council meeting was held with facility residents. During the resident council meeting, two alert and oriented residents expressed concerns about privacy and dignity while receiving care in the shower room on Martha's Ridge. On 12/06/18 at 9:28 am, the surveyor entered the shower room on Martha's Ridge. Upon entering the shower room, the surveyor observed 2 residents, Resident # 16 and Resident # 8, and 2 CNAs (certified nursing assistants). The surveyor observed that the privacy curtain in the shower room had not been pulled to provide privacy. The surveyor observed CNA # 1 assisting Resident # 16 near the commode area. Resident # 16 was visible to the surveyor, CNA # 2 and Resident # 8. Resident # 16 was observed sitting in a wheelchair. Resident # #16's upper body was clothed and the surveyor observed that Resident # 16 had on a brief that had been pulled up to the mid-thigh area. When CNA # 2 noticed that the surveyor had entered the room, CNA # 2 pulled the privacy curtain. The surveyor observed CNA # 1 roll Resident # 16 in the wheelchair toward the back of the shower room near the shower area. Resident # 16 was observed in an area where the privacy curtain had not been pulled and was visible to Resident # 8 while wearing a brief that had been pulled to the mid-thigh area. When CNA # 2 realized that the surveyor was watching she pulled the privacy curtain in front of Resident # 16. On 12/06/18 at 9:47 am, the surveyor interviewed CNA # 2. The surveyor asked CNA # 2 if she was aware of the issue when the surveyor entered the shower room. CNA # 2 stated, Yes, the shower room had not in use and I just rolled on in there with Resident # 8. That's why I came out and switched the sign to in use. The surveyor asked CNA # 1 if she realized that Resident # 8 was able to see Resident # 16 in the wheelchair with a brief pulled to the mid-thigh area. CNA # 2 stated, Yes, that's why I pulled that curtain. The surveyor asked CNA # 2 if she saw when CNA # 1 rolled Resident # 16 toward the back of the shower room to an area where Resident # 16 was again visible to Resident # 8 with a brief that had been pulled up to the mid-thigh area. CNA # 2 stated, Yes, and I pulled the curtain but I couldn't get it to go the right way so I stood there and held it. On 12/06/18 at 10:18 am, the surveyor interviewed CNA # 1. Before the surveyor could ask CNA # 1 about the issues as stated above, CNA # 1 stopped the surveyor and stated, I know the shower room. I knew as soon as she rolled in there it was an issue. CNA # 1 agreed that the privacy curtains had not been pulled and Resident # 16 had been visible to Resident # 8 while wearing a brief that had been pulled up to the mid-thigh area. The facility policy on Dignity and Respect contained documentation that included but was not limited to: .Procedure 3. Cover the resident when providing care so only the necessarily exposed body part is visible to you. On 12/6/18 at 12:23 pm, the facility administrator was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 12/6/18.

Based on observation, staff interview, and facility record review, the facility staff failed to store medications in a secured, locked medication cart for 1 of 27 residents in the survey sample (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/1/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #60 was also coded as requiring extensive assistance of 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing. During the medication administration observation on 12/6/18 at 8:45 am, the surveyor observed LPN (licensed practical nurse) #1 leaving [MEDICATION NAME] 60 mg tablets on the top of the medication cart. LPN #1 walked completely in Resident #60's room and administered medications to the resident. The medication cart was left unattended by LPN #1. At approximately 9:05 am, the surveyor notified the interim administrator and the director of nursing of the above documented findings. The surveyor also requested the facility's policy on storage of medications. At 9:15 am, the interim administrator provided the surveyor with the facility's titled Medication Administration. The policy read in part, .The medication cart should be kept locked at all times unless in use . The interim administrator stated to the surveyor, This isn't very specific for the problem. But you are right, that's simple nursing and the medications should not be left on top of the cart. No further information was provided to the surveyor prior to the exit conference on 12/6/18.

Based on staff interview, and clinical record review, facility staff failed to accurately code the resident's status for 1 of 27 residents in the survey sample (Resident #115). The findings included: Resident #115 was admitted to the facility on [DATE]. There was an entry MDS (Minimum Data Set) completed when the resident was admitted to the facility on [DATE] and then the next MDS that was completed was dated 9/20/18 when the resident was discharged from the facility. During the closed record review, the surveyor noted a progress note that was dated and timed for 9/20/18 at 11:33 am that read in part, Patient discharged home with son . The surveyor reviewed the discharged MDS with ARD (Assessment Reference Set) of 9/20/18. Under Section A2100, the MDS was coded that the resident was discharged to the hospital. On 12/06/18 at 10:26 am, the surveyor notified RN (registered nurse) #1 of the above documented findings. RN #1 stated, I will go on there and get this corrected. The interim administrator, director of nursing and corporate nurse was notified of the above documented findings on 12/6/18 at 11 am. No further information was provided to the surveyor prior to the exit conference on 12/6/18.

Based on staff interview, and clinical record review, facility staff failed to provide a written notice of transfer to the resident or resident's representative for 1 of 27 residents in the survey sample (Resident #61). The findings included: The facility staff failed to provide a written notice of transfer to the resident or resident's representative for Resident #61. Resident #61 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #61 was also coded as requiring extensive assistance of 2 or more staff members for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #61's clinical record on 12/5/18. During this review, the surveyor noted that the resident was discharged on [DATE] to the hospital. There was no documentation in the clinical record that reflected a written notice of transfer was given to the resident or resident's representative. At 5:30 pm, surveyor notified the interim administrator, director of nursing and the corporate nurse of the above documented findings. The interim administrator stated, The nurses fill out the Enteract form but they do not give a copy of this to the resident. No further information was provided to the surveyor prior to the exit conference on 12/6/18.

Based on staff interview, and clinical record review, the facility staff failed to provide a copy of the comprehensive care plan goals to the receiving facility for 1 of 27 residents in the survey sample (Resident #61). The findings included: The facility staff failed to provide a copy of the comprehensive care plan goals to the receiving facility for Resident #61. Resident #61 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #61 was also coded as requiring extensive assistance of 2 or more staff members for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #61's clinical record on 12/5/18. During this review, the surveyor noted that the resident was discharged on [DATE] to the hospital. There was no documentation in the clinical record that reflected a copy of the comprehensive care plan goals being given to the receiving facility. At 5:30 pm, surveyor notified the interim administrator, director of nursing and the corporate nurse of the above documented findings. The interim administrator stated, We do not send the Comprehensive care plan goals when the resident is transferred out to the hospital. No further information was provided to the surveyor prior to the exit conference on 12/6/18.

Based on staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to assess and document a skin tear for 1 of 6 residents (Resident #1). The findings included: The facility staff failed to assess a skin tear to Resident #1's left arm initially after the incident occurred on 4/25/18, failed to write the physician order [REDACTED]. Resident #1's clinical record was reviewed 8/8/18 and 8/9/18. Resident #1 was admitted to the facility 2/27/16 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/23/18 assessed the resident with short-term memory impairment, long-term memory impairment, and severely impaired cognitive skills for daily decision-making. Functional Status (Section G) assessed no impairment/limitation in range of motion of any extremity. Bladder and Bowel (Section H) assessed the resident to be incontinent always of urine and frequently incontinent of bowel. Skin Conditions (Section M) assessed the resident to be at risk for developing pressure ulcers. Resident #1 was assessed to have a skin tear. The current comprehensive care plan initiated 3/1/16 and revised 3/15/18 identified the resident to be at risk for additional impairments in skin integrity r/t (related to) fragile skin, decreased mobility, and incontinence. Interventions: Apply protective cream/ointment as needed, apply Renew skin repair lotion to bilateral arms daily, and keep skin clean and dry. The complaint allegation stated that Resident #1 had been injured the morning of 4/25/18 and was bleeding and no one even attempted to dress it or put any type of medication on it. The 4/25/18 10:50 a.m. progress note read, This (sic) notified of skin tear by C.N.A. (certified nursing assistant). Resident has skin tear to left lower arm. Dressing applied and family aware. MD (medical doctor) and unit manager notified. Will continue to monitor this shift. Signed by licensed practical nurse #1. The surveyor interviewed the director of nursing on 8/9/18 at 8:00 a.m. and stated the assistant director of nursing had details about the incident on 4/25/18. The surveyor interviewed the assistant director of nursing (ADON) on 8/9/18 at 8:37 a.m. The ADON stated, L.P.N. #1 had assessed the area and the unit manager registered nurse #1 had assessed the area but the administrator wanted the ADON to look at Resident #1's arm. The ADON stated she was not familiar with the wound care protocol. The ADON stated it looked like a clear dressing. The ADON stated she took it off, cleaned the area with normal saline got steri strips and applied them. The ADON stated the area on the arm was approximately 3-4 inches long. The ADON stated she would check the area every day and do the dressing changes until the area healed. The ADON stated she spoke with the complainant's husband and then with the complainant. The ADON stated the complainant did not verbalize any concerns after that. The ADON stated she didn't document any of the dressing changes that she did and stated The DON (director of nursing) was big on documentation. The ADON was asked if she should have documented the care she provided and stated Absolutely. Witness statement completed by the assistant director of nursing (ADON) on 4/25/18 read, Called to unit by administrator to assess Resident #1's skin tear. Upon entering room, complainant was upset with nursing staff, stating that no one had done anything with her mother's skin tear. Resident had hydrogel and clear dressing applied to LFA (left forearm). I removed the bandage, cleaned the area with saline and approximated the edges. Skin tear was approximately 3.5 cm (centimeters). I applied steri-strips and wrapped with kerlix. Complainant was very much appreciative after that. I explained to her that the unit manager registered nurse #1 had followed protocol for skin tears, which is to apply hydrogel and non-adhesive dressing (dsg). Witness statement completed by the assistant director of nursing (ADON dated 5/1/18 read, I checked resident's arm daily to ensure no s/sx (signs/symptoms) of infection. I wanted to speak with complainant to follow up on concern. Ran into complainant's husband in the hall and asked if she would be visiting that day. He said no, so I asked if he would have her call me. He called her on his cell phone and I was able to speak with her. She was very appreciative of what I had done for her mother. The surveyor interviewed licensed practical nurse #1 on 8/9/18 at 9:35 a.m. L.P.N. #1 stated, The aide went in to change the resident and said she had a skin tear to right arm. The aide (identified as C.N.A. #3 and no longer employed at the facility) had put a wipe over it. I was told that C.N.A. #3 had called the daughter and told her about the skin tear. I had pills on my cart and I told C.N.A. #3 I would take care of it in a second. The unit manager had left. In the meantime, the daughter came in and I told her I was going to dress the area. The unit manager had left and then came back to the unit after I called him and I told him I needed help because there was a new wound protocol. L.P.N. #1 stated the unit manager dressed the wound. I held the supplies. I then went on with my medication pass. I wrote my statement and turned it in to the director of nursing (DON) before I left that evening. L.P.N. #1 stated the wound care nurse took care of the area after that. Witness statement provided by the facility and L.P.N. #1 was dated 4/25/18 and read This nurse was doing her morning medication pass when C.N.A. #3 said she had to go change resident after she had eaten because she had wet through her brief onto the floor and her shirt was wet with urine as well. The C.N.A. #3 took resident to her room and changed her brief and shirt. Upon coming back out of residents room, C.N.A. #3 told this nurse that the resident had a skin tear on her arm. This nurse was preparing another residents medication when she was alerted about the skin tear. This nurse told C.N.A.#3 that she would tend to it and proceeded to take the medication that she had in her hands on the the (sic) residents room. C.N.A. #3 at this time covered residents skin tear with a wipe and brought her back to the open area of the nurses station. When (sic) back to the medication cart from taking medication (sic) to a different resident the residents family member came in to the open area at the nurses station. I had not addressed the skin tear at this time because I had just arrived back at my med cart and was checking off the medication that I had just given. The family member begain (sic) to ask me what was wrong with her mothers arm I told her she had received a skin tear when her shirt had been changed but I had not addressed it yet to which I immediately went over to the resident and looked at this skin tear and told the family member that I would call the unit manager and the wound care nurse to come and assess because at this time the family member was atament (sic) that it needed steri-strips. The family member asked the resident who did this to you at which the resident said the nurse did it when she took my shirt off. The family member repeated several times the nurse did it to which the nurse said it was the C.N.A. #3 that had changed her shirt. Upon walking away to call I turned around to see the residents family taking her cell phone out of her purse and taking a picture of the area. I tried to reach the wound care nurse but was unable to get her at the time. I had told the unit manager several minutes earlier when he was over to check on things that the resident had a skin tear so when I called him he came over immediately to help this nurse with dressing the area. At this time, the unit manager spoke to the resident's family member to whom he new and told her we would take care of it. The unit manager and this nurse went to the wound care cart as the residents family member took the resident back to her room. Wound care supplies were obtained and taken to the residents room and residents skin tear to her (L) arm was cleaned and dressed. Resident showed no s/s (signs/symptoms) or distress or pain at this time. Family member talked (sic) to the unit manager breifly (sic) about the situation and thanked us for taking care of her mother. Residents family member did state that we would need to be careful with her skin as it was very fragile to which the unit manager and this nurse both agreed. This nurse and the unit manager exited the room with nothing else being said. The unit manager was not available for an interview 8/8/18 or 8/9/18. However, the facility provided the unit manager registered nurse #1's witness statement to the surveyor. The statement read, (MONTH) 25th I was notified at 0850 by L.P.N. #1 that the nurse aids (sic) told her Resident #1 had a skin tear to her left forearm. It wasn't until I received a call at 1050 by L.P.N. #1 asking for me to come see Resident #1's daughter was here and was upset because her mother had a skin tear. The complainant was concerned because she did not have a dressing to her skin tear. I cleaned the skin tear and applied hydrogel and covered with an [MEDICATION NAME] dressing per policy and procedure. The complainant seemed fine at this point and made no further complaints to me. C.N.A #3 was no longer employed at the facility. However, the facility provided the surveyor with the witness statement written by C.N.A. #3 on 4/26/18 and read I C.N.A. #3 on 4-25-18 around 8:20-8:30 set down at breakfast to help Resident #1 with her breakfast. I notice she needed some bathroom attention so I took her to get cleaned up that's when I notice a pot of blood on her shirt. When I took it off that's when I seen a skin tear on her left arm so I cleaned her up & took her straight to the nurse around 8:45 the nurse said she would take care of it. A witness statement dated (MONTH) 26, (YEAR) read DON and ADON interviewed C.N.A. #3. C.N.A. #3 reported that she was assisting Resident #1 with her breakfast and noticed she was wet and needed to be changed. She assisted her to the bathroom to clean her up and noticed a spot of blood on her shirt. When she removed her shirt is when she discovered the skin tear. She finished cleaning her up and then went and reported it to L.P.N. #1. C.N.A. #3 stated She may have hit her arm under the table when I pushed her up to it and I didn't realize it. The facility did send a Facility Reported Incident (FRI) to the Office of Licensure and Certification on 4/25/18 which read Resident #1 received a skin tear to her left forearm on 4/25/18. First observed after taking her shirt off at 8:50 am. Area cleansed with NS (normal saline) and wound cleanser, [MEDICATION NAME] hydrogel and non-adhesive bandage applied and covered with kerlix per facility policy. Investigation initiated and will be completed within the 5-working day timeframe. Responsible party and physician notified 4/25/18 and APS (adult protective services) notified 4/26/18. Employees involved: L.P.N. #1 and C.N.A. #3. May 2, (YEAR) This is the final report of an unknown origin incident reported to your office on (MONTH) 26, (YEAR). Resident #1 was admitted to Abingdon Health & Rehab on 2/27/16 with a [DIAGNOSES REDACTED]. On (MONTH) 25, (YEAR), Resident #1 received a skin tear to her left forearm. It was first observed by C.N.A. #3 after taking her shirt off at 8:30 a.m. Area was cleaned with NS and wound cleanser, [MEDICATION NAME] hydrogel and non-adhesive dressing applied and covered with kerlix by the unit manager registered nurse #1. DON and ADON began investigation on 4/25/18 after discussion with resident and resident's daughter to determine the cause of the skin tear. Resident #1 has very thin skin and tears easily. Her C.N.A. reported that resident may have hit her arm on the table while resident was fed her breakfast that morning and C.N.A. did not realize it. Education provided to staff regarding her care and to use caution when pushing her up to the table. Renew skin repair lotion will be applied to Resident #1's arms daily to help prevent skin tears. We are unable to determine the exact cause of the skin tear. Completed by the administrator. The surveyor reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) treatment administration records (TARS). The TARS did not have documentation of the wound care provided by the unit manager registered nurse #1 or the wound care provided by the assistant director of nursing on 4/25/18 or the physician orders [REDACTED]. The surveyor interviewed the director of nursing on 8/9/18 at 2:01 p.m. The DON stated the nurse entered the order in the computer on 4/28/18. The order read to cleanse the skin tear on left arm with wound cleanser, pat dry. Apply Hydrogel to wound bed, cover with dressing until resolved. Change on shower days and prn (whenever necessary). One time a day every wed (Wednesday), Sat (Saturday) for skin tear. Order Date: 4/28/18 Start Date 5/2/18. The surveyor asked the DON why there was a delay in treatment of [REDACTED]. The DON stated the L.P.N. #2 did the treatment to Resident #1's left arm on 4/28/18 but didn't chart the treatment. The DON was asked if the care provided by L.P.N. #2 should be documented. The DON stated it should. The DON was asked if orders for the wound care protocol used by the unit manager registered nurse #1 and the care provided by the ADON should be written and documented. The DON stated It should. The surveyor requested the facility policy on skin assessments/wound care from the DON. The surveyor reviewed the Quick Reference Guideline for Topical Wound Care on 8/9/18. The Skin Tear guidance read Cleanse and protect periwound skin as directed below. Apply [MEDICATION NAME] Hydrogel and cover with non-adhesive dressing. Wrap with Kerlix and secure with tape. Leave in place for 5 days and then re-assess. The surveyor was unable to locate the treatment as outlined in the guidance above for Resident #1's skin tear. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern in the delay of treatment for 2 hours, the lack of documentation of wound care orders and the care provided to Resident #1on 8/9/18 at 2:05 p.m. No further information was provided prior to the exit conference on 8/9/18. Complaint deficiency

Based on staff interview, clinical record review and in the course of a complaint investigation the facility staff failed to provide update timely safety interventions after a fall for 1 of 7 residents in the survey sample, (Resident #6). Findings: The facility staff failed to provide updated/timely fall precautions for Resident #6. Resident # 6 had a fall on 2/5/18, two days after her admission, but fall precautions/interventions (bedside mats) were not added until 2/7/18 following a request by a family member. Resident #6 was admitted to the facility on [DATE] and was discharged on [DATE]. The resident was admitted from a hospital, following a left [MEDICAL CONDITION] and to receive orthopedic aftercare. Additional [DIAGNOSES REDACTED]. Resident #6's MDS (minimum data set) assessment, was incomplete at the time of discharge. She was assessed with [REDACTED]. Her ADL (activities of daily living) assessment documented the resident required the assistance of at least one member of the nursing staff for all activity. Resident #6's CCP (comprehensive care plan) was initiated on 2/3/18. She was CCP for the following issues: 1. Patient has pain. The interventions included administering pain medications as ordered and reporting breakthrough pain and/or unrelieved pain for further assessment and treatment. Pain assessments were ordered every shift. 2. Resident is at risk for falls r/t to decreased mobility and potential side effects of medication. The interventions included orienting the patient to the call bell, lighting and room and encouraging the use of the call bell to request assistance from staff. The interventions were updated on 2/11/18 to include Fall mats placed at bedside. On 2/5/18 at 10:52 AM, a nursing staff member documented Resident #6's fall from her bed onto the floor. When nurse entered room, resident at side of bed, sitting on bottom with right leg bent underneath her. No apparent injuries ROM to all extremities. No complaints of pain. Apparently trying to get up from bed. There was only one note referring to the fall in the nursing progress notes. The resident was not documented with any injuries. On 2/7/18 an Area of Care Concern was documented by nursing staff describing the suggested interventions for her surgical wound. The recommendation/interventions suggested were: Wound vac. Fall mats per RP (responsible party) request. This was the only documentation referring to safety mats found in the clinical record. On 8/9/18 at 8:45 PM the fall was discussed with the facility DON. She said she didn't know why the fall mats weren't placed at the bedside sooner. The DON said they always had a meeting in the morning to address issues that occurred in the previous 24 hours. The DON said the CCP was not updated until 2/11/18, but the fall mats were placed, after a request from the RP, at the bedside on the seventh. No other information was provided prior to the survey team exit. This was a complaint deficiency.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide the highest practical well-being to 1 of 27 residents in the survey sample (Resident #17). The findings included: The facility staff failed to document on the [MEDICAL TREATMENT] communication sheets prior to Resident #17 leaving the facility and then not following up with [MEDICAL TREATMENT] to obtain documentation once the resident was returned back to the facility. Resident #17 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The resident was coded on the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/18/17 with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #17 was also coded as requiring extensive assistance of 1 staff member for eating, personal hygiene and bathing. The surveyor reviewed the clinical record of Resident #17 on 9/7/17. It was noted by the surveyor that for the months of July, August and September, 2017 the communication sheets that goes with the resident to [MEDICAL TREATMENT] was not completely filled out either by the nursing facility staff or by the [MEDICAL TREATMENT] center staff. The missing documentation was either missing pre and post [MEDICAL TREATMENT] weights as well as vital signs before and after [MEDICAL TREATMENT]. At 1 pm, on 9/7/17, the surveyor showed the director of nursing the missing documentation on the [MEDICAL TREATMENT] communication sheets. The director of nursing stated, These areas should be filled out by our staff and then these areas should be filled out by the [MEDICAL TREATMENT] staff. Let me call the [MEDICAL TREATMENT] center and see what documentation they have on this resident. At 1:45 pm, the administrative team was notified of the above documented findings by the surveyor in the conference room. The surveyor requested a copy of the facility's policy regarding residents receiving [MEDICAL TREATMENT]. The director of nursing returned to the surveyor at 4:30 pm with copies of the resident's [MEDICAL TREATMENT] Treatment form from the [MEDICAL TREATMENT] center. The time and stamp mark on the copies provided to the surveyor were 9/7/17 at 16:16 (4:16 pm). The treatment forms had documentation of the pre and post weights and of the vital signs of the resident for the months of July, August and September, 2017. The director of nursing stated, I had to call the [MEDICAL TREATMENT] center and get them to fax these to me. The surveyor also received the policy that the facility has for residents receiving [MEDICAL TREATMENT]. Under Procedure, it read in part .6. Complete the [MEDICAL TREATMENT] Communication Form and send with the resident to the [MEDICAL TREATMENT] Center. Review the communication form on return to the nursing home for any changes in condition, medication or treatment . No further information was provided to the surveyor prior to the exit conference on 9/7/17.

Based on Resident interview, staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 4 of 27 Residents, Residents #6, #20, #2, and #5. The findings included. 1. For Resident #6, documentation in the clinical record indicated the Resident had received the narcotic pain medication [MEDICATION NAME]-[MEDICATION NAME] 19 times for the months of August and September 2017. Resident #6 stated to the surveyor that she had not had any pain medication in a while. The record review revealed that Resident #6 had been admitted to the facility 03/21/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/26/17 included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section J (health conditions) was coded to indicate the Resident frequently had pain that made it hard for her to sleep. The numeric rating on a scale of 1-10 was documented as a 4. The Residents CCP (comprehensive care plan) included the focus area Risk for unresolved pain related to recent surgery, CAD, kidney impairment, [MEDICAL CONDITIONS], Gerd, others. Date initiated 04/21/17. The Residents current POS (physician order sheet) included orders for the pain medications [MEDICATION NAME] 650 mg 1 tab by mouth every 6 hours as needed for general discomfort and for the narcotic [MEDICATION NAME]-[MEDICATION NAME] 5-325 1 tablet by mouth every 6 hours as needed for pain. This POS had been signed by the physician on 07/03/17. A review of the Residents eMARs (electronic medication administration records) for August 2017 included documentation to indicate that Resident #6 had been administered the narcotic pain medication [MEDICATION NAME]-[MEDICATION NAME] 5-325 17 times and that LPN (licensed practical nurse) #1 had administered this medication 14 of these 17 times. For September the clinical record included documentation to indicate the [MEDICATION NAME]-[MEDICATION NAME] 5-325 had been administered 2 times both of these administration times were documented by LPN #1. There was no documentation to indicate the facility had provided any prn (as needed) [MEDICATION NAME] to Resident #6. Resident #6 was observed by the surveyor in the hallway and in her room of the facility. During these observations the Resident was alert and orientated and did not complain of any pain. On 09/07/17 at approximately 12:45 p.m. the surveyor spoke with Resident #6 in her room. When asked about the pain medication she had been administered and if the facility provided any non-pharmacological interventions prior to administering such as repositioning etc .Resident #6 stated they did not but she had not taken any pain medication in a while. During a meeting with the administrative staff on 09/06/17 at approximately 1:45 p.m. the administrative staff was asked if Resident #6 was alert and orientated to which the DON (director of nursing) replied yes. The administrative staff was then made aware that Resident #6 had verbalized to the surveyor that she had not had any pain medication in a while but the clinical record included documentation to indicate the Resident had received the narcotic pain medication [MEDICATION NAME]-[MEDICATION NAME] 5-325 17 times in August and 2 times in September. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility staff failed to ensure a complete and accurate clinical record for Resident #20. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set was not complete at the time of the survey. The resident was identified by staff as alert and oriented. Resident #20 was interviewed on 9/7/17 at 3:15 p.m. The resident stated she was admitted for therapy following her gall bladder surgery. The clinical record was reviewed. The nursing admission assessment was reviewed. The nurse failed to document the presence of a surgical wound upon admission at approximately 2:00 p.m. on 8/31/17. The nurse documented on the Body Assessment of the admission that there were no wounds, skin tears, bruises, and /or surgical incisions present. The physician documented on his admission history and physical that the resident presented for aftercare for a cholesystectomy. A skilled nursing summary note at 10:54 p.m. noted the skin not intact. Surgical incision, not fully healed present. No signs or symptoms of wound infection or inflammation. The corporate nurse consultant reviewed the clinical record and agreed the nurse should have documented the presence of the surgical wound upon admission. The administrator, assistant administrator, director of nursing, and corporate nurse consultant were informed of the findings during a meeting with the survey team on 9/7/17 at 1:05 p.m. 3. The facility staff failed to maintain a complete and accurate clinical record for Resident #2. Resident #2 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The resident was coded on the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/22/17 as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #1 was also coded as requiring extensive assistance of 2 or more staff members for dressing, toilet use and personal hygiene. A clinical record review was performed by the surveyor on 9/6/17 and 9/7/17. It was noted by the surveyor that a telephone order had been written on Resident #2's electronic clinical record which was dated and timed for 6/20/17 at 1700 (5 pm) that stated, [MEDICATION NAME] 0.5 mg (milligram) po (by mouth) x (times) 1 dose now. The surveyor also reviewed the MAR (Medication Administration Record) record for the month of June, 2016 and the surveyor noted the following documented as being given to Resident #2 on 6/20/17 at 1727 (5:27 pm) which stated, [MEDICATION NAME] 0.5 mg by mouth x 1 dose now. The surveyor reviewed the nursing notes for 6/20/17 at 16:15 (4:15 pm) which stated , .Very agitated, yelling, wanting other residents to get her out of here, rolling around in w/c (wheelchair) and hitting other residents with her w/c. Unable to redirect or reorient resident, [MEDICATION NAME] 25 mg given per order. The next nursing note was dated and timed for 6/20/17 at 1712 (5:12 pm) which stated, New order received and noted daughter ____ (Name of daughter) here and aware and voices understanding. Daughter _____ (Name of daughter) ask for resident to have [MEDICATION NAME] for her behavior. The administrative team was notified of the above documented findings by the surveyor on 9/7/17 at 1:45 pm. The surveyor asked the director of nursing if the physician had been called by the facility staff and notified of the resident's behaviors and of the resident had already received [MEDICATION NAME] prior to the staff notifying the physician. The director of nursing stated, I feel confident that the nurse did call the physician and report this to him because the nurse has to have a code to unlock the Stat box to be able to give a medication like this. It just wasn't documented completely. No further information was provided to the surveyor prior to the exit conference on 9/7/17. 4. For Resident #5 the facility staff failed to ensure physician's orders were complete and accurate Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD) assessment reference date of 07/10/17 coded the Resident as having problems with both long and short term memory problems, and severely impaired cognitive skills for daily decision making in section C, cognitive status. This is a quarterly MDS. Resident #5's clinical record was reviewed on 09/06/17. It contained a signed physician's order summary which read in part Folic acid tablet-give 1 tablet by mouth one time a day for supplement. The original order date was 11/15/16 and there was no dosage amount indicated in the order. Surveyor spoke with the pharmacist via telephone on 09/07/17 at approximately 0850 regarding Resident #5's folic acid order. Pharmacist stated that the order should read Folic Acid 1 mg. Pharmacist also stated that the order had been clarified on 11/15/16 by LPN (licensed practical nurse) #1. Surveyor spoke with LPN #2 on 09/07/17 at approximately 0915 regarding Resident #5's folic acid order. Surveyor asked LPN #2 how she knew how much folic acid to administer, and LPN #2 stated the package from the pharmacy is 1mg and that is what the order is for. LPN #2 then pulled the order and looked at it, then stated You are right, it doesn't say how much, I'll get that clarified. The concern of the incomplete order was discussed during a meeting with the administrative staff during a meeting on 09/07/17 at approximately 1655. No further information was provided prior to exit.

Based on observation, staff interview and clinical record review, the facility staff failed to meet the resident's individual needs in regards to form of food served to 1 of 27 residents in the survey sample (Resident #1). The findings included: The facility staff failed to meet the resident's individual needs in regards to form of food served to Resident #1 for breakfast during a meal observation made by the surveyor on 9/7/17. Resident #1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/17, Resident #1 was coded as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. The resident was also coded as requiring extensive assistance of 2 staff members for dressing and toilet use and extensive assistance of 1 staff member for personal hygiene. Resident #1 was also coded as requiring limited assistance of 1 staff member to assist with eating. The surveyor made a meal observation on 9/7/17 at 8:20 am in the Martha's Ridge dining room in which Resident #1 was seated to have breakfast. The resident was served a breakfast tray that consisted of pieces of biscuits with gravy over it, ground up sausage and scrambled eggs and oatmeal. The resident was assisted by having her tray set up for her. The surveyor observed the resident sitting with a blank stare looking at her breakfast. The surveyor spoke to the resident and the resident replied Hi. At 8:30 am, the surveyor observed the assistant administrator go over to Resident #1 and speak to the resident then verbally encourage the resident to eat her biscuits and gravy but did not assist in feeding the resident. The resident continued to sit and look at breakfast tray in front of her. At 8:32 am, CNA (certified nursing assistant) #1 came over to Resident #1 and began talking to the resident about eating breakfast and fed the resident (1) bite of biscuits and gravy and (1) bite of sausage which was in a grounded texture. At 8:40 am, CNA #1 came back to Resident #1 and encouraged her to eat some more of her breakfast. CNA #1 attempted to feed the resident a bite of biscuits and gravy but resident refused. At 8:42 am, CNA #1 went over to the tray line where breakfast was being served in the dining room and asked for a biscuit and piece of sausage for Resident #1. The CNA returned to Resident #1's table and sat down a whole biscuit and a whole piece of sausage in front of the resident and encouraged the resident to try eating this. The surveyor observed the resident attempting to feed herself. The resident took a bite from the biscuit and then a bite from the sausage patty. CNA #1 left the table with Resident #1 and went to help another resident to eat. The surveyor conducted a clinical record review of Resident #1's electronic clinical record. It was noted by the surveyor that Resident #1's diet order by the physician was to be on a Regular Diet, mech (mechanical) soft (ground meat) texture, Thin consistency . The physician had written to begin this diet on 2/14/17. At 1:40 pm, the surveyor interviewed the Consultant Dietician #1 in the conference room. The surveyor showed the Consultant Dietician #1 the physician order [REDACTED]. The surveyor asked if the resident should have received a biscuit and a whole piece of sausage for breakfast without it being a ground meat texture. The Consultant Dietician #1 stated, The resident is allowed a regular diet but everything has to be mechanically soft with ground beef texture. The biscuit would be ok but the sausage patty needed to be ground meat texture. The administrative team was notified of the above observations and documented findings as above on 9/7/17 at 1:45 pm. No further information was provided to the surveyor prior to the exit conference on 9/7/17.

Based on staff interview and clinical record review the facility staff failed to obtain a level I PASRR ( preadmission assessment and Resident review) for 1 of Residents, Resident #12 The findings included: For Resident #12 the facility staff failed to obtain a level I PASRR within 30 days of admission. Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 06/07/17 coded the Resident as 6 of 15 in section C, cognitive status. Resident # clinical record was reviewed on 09/07/17. The surveyor could not locate a level I PASRR. The surveyor spoke with the DON (director of nursing) on 09/07/17 at approximately 1345 regarding the location of the PASRR and the DON stated that the PASRR for Resident #12 could not be located. The concern of the missing PASRR was discussed with the administrative team during a meeting on 09/07/17 at approximately 1655. No further information was provided prior to exit.

Based on staff interview and clinical record review the facility staff failed to obtain a physician ordered laboratory test for 1 of Residents, Resident #12 The findings included: For Resident #12 the facility staff failed to obtain the physician ordered lab for a [MEDICATION NAME] level and HgA1C (hemoglobin A1C- a test for diabetes). Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 06/07/17 coded the Resident as 6 of 15 in section C, cognitive status. This is a quarterly MDS. Resident #12's clinical record was reviewed on 09/06/7. It contained a signed physician's orders [REDACTED]. The surveyor could not locate the results of the test for the month of December 2016. The surveyor spoke with the DON (director of nursing) on 09/07/17 at approximately 1345 regarding the missing test results. DON stated that she had done a complete chart audit, but did not go back past January 2017. She also stated that she could not locate the results for December 2016. The concern of the missing test results was discussed during a meeting with the administrative staff on 09/07/17 at approximately 1655. No further information was provided prior to exit.

Based on a medication pass and pour observation, staff interview, and facility document review, the facility staff failed to follow infection control policy and procedures during a medication pass on 1 of 3 units. The findings include: The facility staff failed to follow infection control policy and procedure during a medication pass on 9/7/17 at 7:30 a.m. conducted on one unit in the facility. A staff nurse (LPN#1) was observed on the ART unit to perform accuchecks (blood sugar monitoring) on several residents on the unit. LPN#1 was observed to enter a resident's room carrying equipment to perform a blood sugar check. The nurse carried a glucometer and an accucheck lancet. LPN#1 was observed to drop the lancet on the floor and pick it up and use it on the resident to obtain a blood sample. LPN#1 was interviewed and stated she thought it was ok to use because the needle was not exposed. The infection control policy was obtained from the director of nursing on 9/7/17. The General Infection Control Policies was reviewed. The policy stated , no item (clean or soiled linen, clothing, personal items,etc) are to touch the floor. The administrator, assistant administrator, director of nursing, and corporate nurse consultant were informed of the findings during a meeting with the survey team on 9/7/17 at 1:05 p.m.

Based on staff interview and closed clinical record review, it was determined that the facility staff failed to ensure that 2 of 4 Residents in the sample survey were free of unnecessary medications, Resident #1 and Resident #4. The Findings Included: 1. For Resident #1 the facility staff failed to monitor for antidepressant drug use, [MEDICATION NAME] and [MEDICATION NAME], to include specific behaviors, interventions. side effects and effectiveness. Resident #1 was an [AGE] year old male who was admitted on [DATE] and discharged to a hospital on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the closed clinical record was a Quarterly MDS assessment with an Assessment Reference Data (ARD) of 2/5/17. The facility staff coded that Resident #1 had a Cognitive Summary Score of 2. The facility staff also coded that Resident #1 required extensive assistance (3/3) with Activities of daily Living (ADL's). In Section N. Medications the facility staff coded that Resident #1 received 7 days of an antidepressant. On March 21, 2017 at 2:30 p.m. the surveyor reviewed Resident #1's closed clinical record. Review of the closed clinical record produce physician order [REDACTED]. Signed physician orders [REDACTED]. [MEDICATION NAME] HCl Tablet 50 MG Give 1 tablet by mouth for [MEDICAL CONDITION]. (sic) Further review of the closed clinical record produced the Comprehensive Care Plan (CCP). The CCP identified the following Focus and Interventions/Tasks. Focus: (Name of resident withheld) is at risk for adverse effects of [MEDICAL CONDITION] medications due to depression, anxiety and dementia with disturbances. HX (history) of hallucinations. Interventions/Tasks: Administer medications as ordered; observe for side effects and effectiveness of medications. See MAR. Observe target behaviors for decrease or escalation that may indicate need for medication review. Utilize non-pharmacological interventions whenever possible to address symptoms/behaviors. See behavior plan, See activities plan. (sic) Continued review of the closed clinical record produced the February and March 2017 Medication Administration Records (MAR's). Review of the February and March 2017 MAR's documented that Resident #1 was receiving the physician order [REDACTED]. Further review of the closed clinical record failed to produce monitoring for the use of the antidepressants, [MEDICATION NAME] and [MEDICATION NAME], to include specific behaviors, interventions, side effects and effectiveness. On March 22, 2017 at 8:05 a.m. the surveyor notified the Regional Compliance Nurse (RCN). The surveyor informed the RCN that Resident #1 had physician orders [REDACTED]. The surveyor notified the RCN that review of the February and March 2017 MAR's documented that the facility staff were administering the medications as ordered by the physician. The surveyor notified the RCN that review of the closed clinical record failed to produce monitoring for the use of the [MEDICATION NAME] and [MEDICATION NAME]. The surveyor reviewed the closed clinical record with the RCN. The surveyor pointed out the specific physician orders [REDACTED]. The surveyor then reviewed the February and March 2017 MAR's. The surveyor pointed out that the facility staff had administered the medications as ordered by the physician, however, no monitoring of specific behaviors, interventions, side effects and effectiveness could be located. On March 22, 2017 at 12:15 p.m. the survey team met with the Administrative Team (AT) which consisted of the Administrator (Adm), Acting Director of Nursing (ADON), RCN, Corporate MDS Nurse, QAPI Nurse, Assistant Administrator (AAdm) and a Medical Records staff person. The surveyor notified the AT that Resident #1 was receiving Antidepressants, [MEDICATION NAME] and [MEDICATION NAME], and that medication monitoring for specific behaviors, interventions, side effect or effectiveness could not be located in the clinical record. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure that Resident #1 was free from unnecessary medications. The facility staff had not done medication monitoring for [MEDICATION NAME] and Trazadone. 2. For Resident #4, the facility staff failed to assess and monitored for behaviors ensuring she was free from an unnecessary medication. The clinical record of Resident #4 was reviewed on 3/21/17 through 3/22/17. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) assessment, completed on this resident was a quarterly assessment with an ARD (assessment reference date) of 03/09/17. Section C (cognitive patterns) of this assessment coded the resident as 8 out of 15. In section B, the resident was coded to understand and to be understood. Review of Resident #4's physicians summary of orders revealed the order for [MEDICATION NAME] tablet 2 mg give 1 tablet by mouth in the morning related to paranoid [MEDICAL CONDITION]. She also was taking [MEDICATION NAME] 10 mg 1 tablet by mouth at bed time for dementia. Review of the March 2017, Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation in the January, February, or March 2017, progress notes that identified assessment of or the targeted behavior that Resident #6 exhibited prior to the administration of either of the medications. On 3/22/17 at 11:45 am, the interim director of nurses was asked if Resident #4 should have behavior monitoring sheets. She replied, Yes. On 3/22/17 at approximately 12:00 noon, the administration staff was informed of the failure to monitor and document behaviors and or the non-pharmacological interventions prior to the starting of the medications and continuing administration of the medications. No further information was provided to the surveyor prior to exit on 3/20/2017.