Every finding on record at Heritage Hall - Brookneal

Based on record review, interview and review of facility policy, the facility failed to ensure residents had the right to formulate an advance directive and/or prominently displayed information in the medical record about whether or not the resident executed an advance directive. This affected five (Residents (R)4, R12, R18, R33 and R43) of five residents reviewed for advance directives. Additionally, R4 did not receive written information regarding advance directives in accordance with facility policy. Findings include: Review of the facility's policy titled Advance Directives © 2001 MED-PASS, Inc. (Revised [DATE]) directs Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Written information will include a description of the facility's policies to implement advance directives and applicable state law .The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. b. Living Will - a document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis. c. Durable Power of Attorney for Health Care (i.e., Medical Power of Attorney) - a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. f. Do Not Hospitalize - indicates that the resident is not to be hospitalized , even if he or she has medical condition that would usually require hospitalization . h. Life-Sustaining Treatment - treatment that, based on reasonable medical judgment, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. i. Feeding Restrictions - indicates that the resident, legal guardian, health care proxy, or representative (sponsor) does not wish for the resident to be fed by artificial means (e.g., tube; intravenous nutrition, etc.) if he or she is not able to be nourished by oral means, j. Medication Restrictions - indicates that the resident, legal guardian, health care proxy, or representative (sponsor) does not wish for the resident to receive life-sustaining medications (e.g. antibiotics, [CONDITION(S)], etc') k. Other Treatment Restrictions - indicates that the resident, legal guardian, health care proxy, or representative (sponsor) does not wish for the resident to receive certain medical treatments. Examples include, but are not restricted to, blood [CONDITION(S)], tracheotomy, respiratory intubation, etc. The staff development coordinator will be responsible for scheduling advance directive training classes for newly hired staff members as well as scheduling annual advance directive in-service training programs to ensure that our staff remains informed about the residents' rights to formulate advance directives and facility policy governing such rights. 1. Review of R4's Face Sheet located in the hard chart revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] and the Quarterly review with an ARD of [DATE] located in the electronic medical record (EMR) revealed R4 had a Brief Interview for Mental Status Score (BIMS) of 15 which indicated the resident is cognitively intact and received [CONDITION(S)]. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hard Chart and echart [sic][EMR] Informational Sheet located in the front of the Hard Chart revealed the Hard chart under the Advance Directives tab should contain the DDNR [Directive for DNR] .Advance Directive Acknowledgement .POA [Power of Attorney] Documents. Review of R4's Hard Chart revealed a Durable Do Not Resuscitate Order dated [DATE] was located under the Advance Directives tab that documented The patient is CAPABLE of making informed decisions about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment signed by the physician and R4; however, there was no information about whether or not the resident had formulated advance directives on this document or on any other document in the hard chart of EMR. During an interview and record review on [DATE] at 11:15 AM, with the Social Services Director (SSD) stated R4 was full code when he was admitted , that's why the Durable Do Not Resuscitate Order located in the hard chart is dated [DATE]. During the interview, the SSD obtained advance directives information from a 30 page Admission Agreement from a file located in her office for R4 and stated the advance directives agreement was obtained on admission and it's in his contract. The SSD provided the surveyor with an ADVANCE DIRECTIVE ACKNOWLEDGEMENT electronically signed by R4 on [DATE], acknowledged that on [DATE] she informed R4 that he was given written information explaining advance directives and his right to formulate an advance directive, and to her knowledge R4 did not have one. The SSD stated at some point she was directed by the former Director of Nursing (DON) to check all the resident's code status, across the board and stated that advance directives are reviewed with every care plan meeting. Upon further questioning about the Care Plan review for advance directives; the SSD acknowledged that only the code status was reviewed with the resident, and she equated the advance directives and code information as the same thing for this process. The SSD also obtained a VIRGINIA ADVANCE DIRECTIVE FOR HEALTH CARE document dated [DATE] and an undated Your Right to Decide pamphlet, a guide to communicating health care choices in Virginia, from her files and stated that she provides these documents to residents who state they are interested in formulating advance directives and did not provide them for those who state they were not interested. The SSD stated she was not aware that the facility's policy directed giving written advance directive information to all residents and acknowledged that she did not receive any training for advance directives form the facility. During an interview on [DATE] at 9:11 AM, R4 stated that prior to his initial admission to the facility he was newly diagnosed with kidney failure and required [CONDITION(S)]. R4 acknowledged the SSD talked to him about his code status; however, he did not recall anyone talking to him about advance directives and stated he did not receive written advance directive information from the facility. During the interview the resident asked for further information about what an advance directive was and wanted to talk to the surveyor about his medical conditions; however, he was referred to speak to his physician and healthcare staff regarding his medical care and advance directive decisions. During an interview on [DATE] 01:46 PM, the Medical Director, who is also R4's physician, stated that the facility offers advance directives to residents within ,d+[DATE] hours of admission by the SSD or the admitting nurses. The Medical Director stated he believed R4 decided his code status prior to admission to the facility and acknowledged that he did not discuss advance directives with R4 because the resident had multiple previous hospitalization s and he presumed the information was obtained by other healthcare staff and/or facility staff who are also qualified to obtain this information. 2. Review of R43's Face Sheet located in the hard chart revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission MDS with an ARD of [DATE] located in the EMR revealed R43 had a BIMS of 14 and on the Quarterly review with an ARD of [DATE] had a BIMS of 15 which indicated the resident is cognitively intact. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review on [DATE] at 11:15 AM, with the SSD obtained advance directives information from a 30 page Admission Agreement from a file located in her office for R43 and stated the advance directives agreement was obtained on admission. The SSD provided the surveyor with an ADVANCE DIRECTIVE ACKNOWLEDGEMENT electronically signed by R43 on [DATE], acknowledged that on [DATE] she informed R43 of his right to formulate an advance directive, and R43 did not formulate one. In addition, the SSD acknowledged that she did not know if this document was required to be in the medical record and directed the surveyor to check with the Medical Records Director. 3. Review of R12's Face Sheet located in the hard chart revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission MDS with an ARD of [DATE] located in the EMR and on the Quarterly MDS with an ARD dated of [DATE] revealed R12 had a BIMS score of 99 which indicated the resident did not respond and per staff assessment had moderately impaired cognition. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review on [DATE] at 1:23 PM, with the SSD obtained advance directives information from a 30 page Admission Agreement from a file located in her office for R12 and stated the advance directives agreement was obtained on admission. The SSD gave the surveyor an undated ADVANCE DIRECTIVE ACKNOWLEDGEMENT signed by R12's Responsible Party (RP), acknowledged R12's RP had executed advance directives prior to admission and the facility had not received a copy R12's advance directives. When asked how she ensures receipt of previously executed advance directives, the SSD stated once she asks for them, she follows through during the quarterly care planning process. During an interview on [DATE] at 4:46 PM, the resident's RP stated he had not been invited to attend an interdisciplinary team meeting since his mother was admitted and he hasn't had a chance to talk to staff regarding her advance directives, which were done with an attorney prior to admission, and was unsure if a copy had been provided. 4. Review of R18's Face Sheet located in the hard chart revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission MDS with an ARD of [DATE] located in the EMR and on the Quarterly MDS with an ARD dated of [DATE] revealed R18 had a BIMS score of 10 which indicated the resident had moderate cognitive impairment. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review on [DATE] at 1:23 PM, the SSD obtained advance directives information from a 30 page Admission Agreement from a file located in her office for R18 and stated the advance directives agreement was obtained on admission. The SSD gave the surveyor an ADVANCE DIRECTIVE ACKNOWLEDGEMENT signed by R18's RP on [DATE], acknowledged that R18's RP had executed advance directives prior to admission and that the facility has not received a copy R12's advance directives. 5. Review of R33 EMR undated Face Sheet, located under the tab titled Face Sheet, indicated the resident was admitted to the facility on [DATE]. Review of the EMR and hard clinical records failed to produce evidence R33 was provided advance directives. Review of a document provided by the facility titled Advance Directive Acknowledgement, dated [DATE] indicated R33's RP electronically signed this document. During an interview on [DATE] at 4:41 PM, SSD confirmed R33's advance directive was in her desk and not included in the EMR or hard chart. During an interview on [DATE] at 1:52 PM, the Administrator acknowledged the advance directives information was intended to be contained in the resident's hard chart because it was beneficial for staff to know the resident's wishes. The Administrator acknowledged the SSD was the individual responsible to provide advance directives information to residents and acknowledged staff are expected to follow the facility's policy on advance directives. During an interview on [DATE] at 11:57 AM, the Corporate Director of Operations acknowledged the facility utilizes Healthcare Academy, an online training program, for staff development and stated the Resident Rights training completed by staff only states the resident has the right to formulate advance directive; however, it does not give any more training specific to Advance Directives. The Corporate Director of Operations acknowledged the online training program does have a course specific to Advance Directives.

Based on record review and interview, the facility failed to provide a Form CMS- (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and Form CMS- (Centers for Medicaid and Medicare Services) Notice of Medicare Non-Coverage (NOMNC) to two of three residents (Resident (R) 207 and R29) reviewed for beneficiary notices. This failure prevented R29 and R207 or their responsible party from making an immediate appeal of the decision to end Medicare coverage of services. Findings include: Review of the medical records revealed that R207 and R29 were given the incorrect forms when they were discharged from a Medicare covered Part A stay. These two residents were discharged back into the facility under skilled nursing. They received Form CMS- NOMNC which expired on [DATE] and was under the old QIO (Quality Improvement Organization). They also received Form CMS-R-131, which is an ABN form but not for skilled nursing. These individual forms did not contain the correct information and toll-free numbers in order to make an appeal. Interview on [DATE] at 3:23 PM with the Business Office Manager (BOM) revealed she handled all the Beneficiary Notices for the facility. When brought to her attention, she was not aware she was using the wrong forms. The BOM called the corporate office to confirm the correct forms to be used. Corporate office stated she was using the wrong forms and the correct forms are CMS- and CMS- .

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 15) out of 26 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/19, indicated, . Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. Review of R15's electronic medical record (EMR) undated Face Sheet, located under tab titled Face Sheet indicated R15 was admitted to the facility on [DATE]. Review of a document provided by the facility titled Physician's Interim Telephone Orders, dated 09/01/20 indicated R15 was given a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's annual MDS with an Assessment Reference Date (ARD) 04/04/21 indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/15/21 at 10:54 AM, the MDS Coordinator stated that she will only add a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator stated she just adds the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/15/21 at 11:22 AM, the Medical Director (R15's primary care physician) stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/16/21 at 1:01 PM, the Nurse Consultant confirmed the MDS assessment was to include active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/16/21 at 1:20 PM, the Regional Director of Clinical Services stated generally the physician will provide a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Clinical Services stated she did not see any behaviors to support the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Clinical Services stated it was not the facility's process to question the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure a resident's Care Plan was revised for one of 25 residents (Resident (R) 15) sampled which accurately reflected the resident's history of Post-Traumatic Stress Disorder ([CONDITION(S)]). The facility also failed to ensure R29's representative was invited to care plan meetings. Findings include: 1. Review of R15's electronic medical record (EMR) undated Face Sheet, located under the tab titled Face Sheet indicated R15 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document provided by the facility for R15 titled Brief Trauma Care Questionnaire, dated 12/12/19 indicated the resident had no trauma identified during this interview. The questionnaire directed the staff, if the resident answered any question in the affirmative, to refer the resident to a mental health provider and to alert the physician. The form also directed to the development of a person-center care plan to address the identified triggers associated with the trauma. Review of a document provided by the facility titled Physician's Interim Telephone Orders, dated 09/01/20 indicated R15 was given a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of documents provided by the facility and written by R15's primary care physician monthly from 09/30/20 to 11/29/21, failed to indicate the resident was under any distress from [CONDITION(S)]. Review of R15's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/04/21 indicated a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R15 was significantly cognitively impaired and exhibited no behaviors, such as behaviors that significantly impair the resident's interactions with others or to participate in activities. The assessment indicated a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's EMR Care Plan located under Care Plan tab dated 04/09/21, indicated R15 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication, in the care plan that addressed symptoms of [CONDITION(S)] such as anxiety, strong flashbacks/memories, or possible depression. Review of the EMR nursing notes titled Departmental Notes, for R15 from August 2020 to 12/07/21 failed to indicate the resident had any symptoms or behavioral issues associated with [CONDITION(S)]. During an interview on 12/15/21 at 10:49 PM, the Regional Director of Clinical Services stated she did not know the reason for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Clinical Services stated she could not identify any symptoms related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/15/21 at 10:54 AM, the MDS Coordinator stated when an order gets written by the physician, for a new diagnosis, she will complete a care plan for a resident. The MDS Coordinator stated typical symptoms of [CONDITION(S)] would be anxiety, mood changes and possibly feeling frightened. The MDS Coordinator stated she did not have any questions that came up when R15 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/15/21 at 11:22 AM, the Medical Director (R15's primary care physician) stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of R29's EMR undated Face Sheet, located under the tab titled Face Sheet, indicated R29 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R29's annual MDS with an ARD 05/13/21 indicated a BIMS score of three out of 15 which indicated R29 was significantly cognitively impaired. Review of R29's EMR Physician Orders, located under the tab Phys (Physician) Order dated 04/15/21, indicated the resident was not capable of understanding her rights/responsibilities due to dementia. Review of R29's EMR social services titled Departmental Notes, located under the tab Notes dated 05/27/21, indicated the resident was invited to her care conference but there was no evidence her responsible party was invited. Review of the EMR social services titled Departmental Notes, dated 11/04/21 failed to show R29's responsible party was invited to her care conference. During an interview on 12/13/21 at 1:16 PM, R29's representative stated she was not invited to the resident's care plan meetings. During an interview on 12/14/21 at 3:26 PM, Social Services stated she will call and leave an invite for the residents' representatives. During an interview on 12/16/21 at 1:01 PM, the Nurse Consultant stated R29's representative was not invited to the resident's care conference on 11/04/21 and was still researching the date of 05/27/21. Review of a policy provided by the facility titled Care Planning-Interdisciplinary Team, dated September 2013, indicated .The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team.The resident, the resident's family and/or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

Based on record review and interviews, the facility failed to assure one resident (R)22 of one reviewed for timely medication administration received ordered pain medication in a timely manner. The facility failed to reorder R22's pain medication in a timely manner. Findings include: Review of R22's electronic medical record (EMR) undated Face Sheet, located under the tab titled Face Sheet indicated R22 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] following cerebral infarction (stroke) and [CONDITION(S)]. Review of R22's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 10/28/21 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 had intact cognition. Review of R22s Care Plan located under Care Plan tab in the EMR dated 12/10/21, indicated R22 was at risk for pain due to muscle weakness, history of low back pain, fractures, and [CONDITION(S)] to his left side. Approach was to administer pain medications per current doctor's order. Review of R22's Physician Orders located under Physicians Orders tab located in the EMR dated 12/10/21, indicated R22 received [MEDICATION(S)] (a pain medication), 400 milligrams (mg), three times a day. Interview on 12/14/21 at 11:20 AM with R22 revealed he had not received his dose of pain medication that morning. He was told by the nurse that that he was out of refills. The resident was agitated and complaining of his lower back hurting. Interview on 12/14/21 at 1:43 PM with the acting Director of Nursing (DON) revealed R22 missed his morning pain medication due to no refills being left on his medication. When asked how medications are re-ordered, she stated that the sticker with the resident and medication information is pulled off the blister pack of pills and put on a Pharmacy Fax Form and faxed to the pharmacy. If a refill is needed, a fax is sent back to the facility asking for a doctor refill order. The DON stated she sent the fax this morning to the pharmacy and a refill order is needed by the physician. She notified the nurse practitioner who was in route to the facility, and she was to reorder the medication when she arrived. The nurse practitioner would also sign for the narcotic to be pulled out of the emergency narcotic box until the pharmacy replenishes the resident's medication. Interview on 12/14/21 at 2:10 PM with the Regional Director of Clinical Services revealed R22's medication was not sent to the pharmacy and a refill was not ordered resulting in the medication not being refilled. She stated, that this is a system failure.

Based on observation, record review, interviews, policy review, review of the disinfectant label, and review of manufacturer's guidelines, the facility failed to ensure that two of four licensed nurses (Licensed Practical Nurse (LPN)1 and LPN2) cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing (accuchecks) between residents. The failure to ensure the staff cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing created a potential for the transmission of bacteria, viruses, and/or blood-borne pathogens between residents. Findings include: Review of the facility's policy titled Obtaining a Fingerstick Glucose Level © 2001 MED-PASS, lnc. revised October 2011 directs Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the User Instruction Manual for the Assure Prism Multi Blood Glucose Monitoring System, revised 02/2020, revealed the device manufacturer, . Validated Clorox Healthcare Bleach Germicidal Wipes .and Super Sani-cloth Germicidal Disposable Wipe [sic] for disinfecting the Assure Prism multi meter. During an observation on 12/14/21 at 4:49 PM LPN1 stated she had just performed a blood glucose check on Resident (R)39 with the Assure Prism glucometer that was on top of the medication cart. Continued observation revealed at 5:04 PM she took the glucometer and performed a blood glucose check on R48. When LPN1 was finished, she placed the glucometer on top of the medication cart with the used test strip still on the device and did not clean and sanitize the glucometer. At 5:07 PM LPN1 acknowledged she usually just uses one glucometer for the three residents that require blood glucose checks. Continued observation revealed at 5:15 PM. LPN1 stated she was done with her medication administration and discarded the used test strip from the glucose meter and placed it in the top drawer without cleaning and disinfecting it. Review of the three residents' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an additional interview on 12/14/21 at 5:32 PM, LPN1 acknowledged she did not clean the glucometer because she forgot and stated she's supposed to clean the glucometer with an alcohol wipe between each resident. When asked about training for the use of the glucometer, LPN1 stated she couldn't think of any, they've always done it that way. During an observation on 12/14/21 at 5:16 PM on medication cart 2, LPN2 had an Assure Prism glucometer on top of the medication cart with a dry alcohol wipe and cotton ball on top of the face of the glucometer. At 5:20 PM, LPN2 took the glucometer off the top of cart and performed a blood glucose check on R4. When she was done, she placed the glucometer on a tissue on top of the medication cart and used a Sani-Cloth AF3 wipe and wiped the glucometer twice for four seconds and put the glucometer back on the tissue. Within one minute the surveyor noted the glucometer was dry and asked LPN2 if the meter was dry. LPN1 acknowledged the glucometer was dry and stated that she would leave it there for three minutes. Continued observation revealed at 5:27 PM, LPN 2 performed a blood glucose check with the same device and when she was done, again placed the glucometer on a clean tissue on top of the medication cart. LPN2 then used a Sani-Cloth AF3 wipe and wiped the glucometer twice for four seconds and placed the glucometer back on the tissue. LPN2 acknowledged she used the same glucometer for the seven residents that require blood glucose checks and stated she cleans the device between resident use with bleach wipes or Saniwipes; both have 3-minute dry time. When asked to explain the dry time, LPN2 stated the glucometer did not have to remain wet for the entire three minutes and again acknowledged that the glucometer looked dry within one minute. LPN2 stated she received training on the glucometer from the previous Infection Preventionist (IP) nurse. Review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of product information for the Sani-Cloth AF3 obtained from https://pdihc.com/products/environment-of-care/sani-cloth-af3-germicidal-disposable-wipe revealed it is effective against 45 microorganisms in 3 minutes, including [CONDITION(S)]-CoV2. Review of https://pdihc.com/in-service/sani-cloth-af3-wipes revealed The contact time listed on the product label is the total amount of time that it takes to inactivate ALL of the microorganisms listed on the product label. This time is typically referred to in minutes, [sic]and should be communicated to staff members that are utilizing the disinfectant. In certain geographies and also in settings where temperature, relative humidity, and air changes may vary, it is possible that the surface may not remain visibly wet for the designated contact time. Current EPA guidance requires that the treated environmental surface or equipment remains wet for the contact time stated on product label. Additional wipes may be needed in order to comply with the EPA guidance, [sic] however the overall contact time does not change. During an interview on 12/16/21 at 12:30 PM, the Director of Nursing (DON) acknowledged the facility uses multiuse glucometers for accuchecks and confirmed that it is facility policy to clean and disinfect the glucose meters with a disinfectant and/or bleach wipes in accordance with the product label instructions.

Based on observation, interview, and facility policy review, the facility failed to post the nursing staffing information at the beginning of each shift in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents and visitors of the facility. Findings include: Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers © 2001 MED-PASS, Inc. (Revised July 2016) directs Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Upon entrance into the facility on [DATE] at 9:15 AM, no nurse staff posting was displayed on any bulletin board and/or in a prominent place visible to residents and visitors. Additional observation on 12/13/21 at 12:00 PM and 4:15 PM revealed there was no nurse staff posting displayed. Upon entrance into the facility on [DATE] at 8:45 AM revealed there was no nurse staff posting displayed on any bulletin board and/or in a prominent place visible to residents and visitors. Additional observations on 12/14/21 at 10:00 AM and 3:30 PM revealed there was no nurse staff posting displayed. During a concurrent observation and interview on 12/15/21 at 10:20 AM, the Medical Records Director was asked where the nurse staff posting was contained. The Medical Records Director went to her office and obtained a binder and stated the posting information is kept in a binder because there is a resident who takes it down all the time. The Medical Records Director showed the surveyor the empty bulletin board next to the beauty shop and stated that it used to be posted there; however, the former Director of Nursing (DON) and former Administrator told her to place the information in the binder and keep it in the office. During an interview on 12/15/21 at 10:20 AM, the Administrator acknowledged that she was aware the staff posting was contained in the binder in the Medical Records office because a resident was ripping it down. During the interview the Administrator stated she was aware of the requirement and facility policy that the posting is required to be posted prior to the start of every shift and acknowledged that it is a resident right to know the staffing.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to prepare, store, and distribute food under sanitary conditions in the dietary department and for 2 of 18 Residents, Residents #40 and #45. The findings included: 1. The facility failed to dispose of expired milk and the #2 refrigerator had an inside temperature of 50 degrees. This refrigerator was in use at the time of the survey. On [DATE] at approximately 9:35 a.m., the surveyor toured the dietary department (kitchen) with the dietary manager. The refrigerator included milk with an expiration date of [DATE]. The dietary manager placed the loose cartons of expired milk together in a cardboard case that held 48 cartons. The dietary manager stated there was 45 cartons of milk in this box and she would dump them. Refrigerator #2 had an outside temperature of 41 and an inside temperature of 50 degrees. The dietary manager stated the inside of the refrigerator felt warm and she would have it checked. This refrigerator contained pimento cheese, mayonnaise, pot roast, bacon, lettuce, spaghetti sauce, pickles, cherries, relish, uncooked oatmeal, turkey, and BBQ sauce. On [DATE] at 11:22 a.m., the maintenance director stated he was attempting to adjust the thermostat and stated the inside temperature was reading 52. The maintenance director stated he did not know if the inside temperature was correct. However, they were going to clean out the refrigerator until they knew which temperature reading was the correct one. On [DATE] at 3:22 p.m., the maintenance director verbalized to the surveyor that the coils were frozen in the top of the refrigerator and they had thrown all the items in the refrigerator in the trash. The maintenance director stated due to the coils being frozen it was not circulating air. On [DATE], the maintenance director provided the surveyor with a copy of the work order regarding the refrigerator. Problem description Reach in Fridge-evaporator. Coil is Freeing Up. Work description Once I got there customer had already thawed ice off coils. And had cleaned coils. So I plugged unit back up and started it up and checked running operation and there were no access fittings to check pressures. Temp in cooler was 59 degrees after running about 20 minutes it pulled temp down to set point of 32.5 degrees. Then I watched it cycle as it maintained set point . The issues in the kitchen were reviewed with the administrative staff on [DATE] at 4:34 p.m. and again on [DATE] at 2:00 p.m. No further information regarding these issues were provided to the survey team prior to the exit conference. 2. Based on observation, and resident interview it was determined the facility staff failed to serve meals in a clean and sanitary manner for 2 of 51 residents in the survey sample(Residents #40 and #45). On [DATE] at 12:45 AM the surveyor did a dining observation in the main dining room. Staff were observed to hand out trays and assist residents to set up their meals. CNAs I and II were observed to set up meals for Residents #40 and #45. The CNAs were cutting up sandwiches for the residents. They were observed to perform this task with their bare hands, without donning gloves prior to touching the resident's food. The surveyor asked for and received a copy of the facility policy for safety and sanitation which addressed glove use during meal service. The policy included When direct contact with food occurs, gloves must be worn. Before handling ready-to-eat foods such as salads, fruit, sandwiches, meats, bread, or ice, put on gloves as a barrier to the bacteria on hands . The facility administrator was informed of this observation on [DATE] at 4:12 PM.

Based on observation, resident and staff interview and clinical record review it was determined the facility staff failed to provide Resident #19 with physician ordered adaptive eating equipment. Findings: Resident #19 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #19's physician's orders [REDACTED]. The latest MDS (minimum data set) assessment, dated 11/23/18, coded the resident as cognitively unimpaired. She could eat her meals with set-up and over site by staff members. She was coded with limited ROM (range-of-motion) in upper and lower limbs, bilateral. The CCP (comprehensive care plan), reviewed and revised on 1/22/19, documented the resident at risk for continued health concerns due to her refusal to get out of bed and refusing to sit up to eat. The interventions included, Adaptive utensils at meals as requested per MD order. On 01/23/19 at 01:06 PM the surveyor gowned, gloved and masked to enter Resident #19's room and observed the resident eating unassisted. She had regular utensils with this meal. The resident told the surveyor should have been getting the adaptive equipment for meals, but did not receive it for that meal. The tray card said, Adaptive utensils at meals. On 01/23/19 at 01:35 PM the DON was asked about the adaptive equipment. She stated, If memory serves it is a thick handled fork or spoon that she uses as she wishes. I beleive she has them in her room and uses them when she wants to. She went to check the room and see if resident had them. The DON reported to the surveyor the resident did not have/receive adaptive equipment for the lunch meal, but said she could eat her sandwich without it. The DON said she interpreted the order to be as needed but she didn't request it. On 01/23/19 at 01:54 PM the DON reported the kitchen dietary manager said she thought the resident had the rubber utensils in her room so she could use them as she wished. They didn't know she didn't have them in her room, so they are going to send the built-up utensils in on her tray from now until the order is canceled. Resident did get a sandwich for lunch--but she still had soup and pears requiring the use of equipment she didn't have. The facility policy for assistance with meals was reviewed. It contained , Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. On 1/23/19 at 4:00 PM this information was reported to the administrator. No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to ensure that a copy of the comprehensive care plan goals were sent upon transfer to the emergency room for 1 of 18 Residents in the survey sample, Resident # 210. The findings included: The facility staff failed to ensure that a copy of the comprehensive care plan goals were sent with Resident # 210 upon transfer to the emergency roiagnom on [DATE]. Resident # 210 was an [AGE] year-old male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 210 was reviewed on 1/23/18 at 10:30 am. The most recent MDS (minimum data set) assessment was a discharge assessment with an ARD (assessment reference date) of 3/14/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 210 had a BIMS (brief interview for mental status) score of 0 out of 15, which indicated that Resident # 210's cognitive status was severely impaired. The plan of care for Resident # 210 was reviewed and revised on 3/12/18. The facility staff documented a focus area for Resident # 210 as Falls: Resident is at risk for falls r.t (related to) dx (diagnosis) of muscle weakness and dementia. Resident has a w.c (wheelchair) used for locomotion. Interventions included but was not limited to: Assist resident as needed with ADLs (activities of daily living), transfers, and mobility, and Personal alarm. An order was written on 3/14/18 at 12:45 am. The order for Resident # 210 was documented as Send out to (Facility name withheld) ER (emergency room ) 911 for eval/tx (treatment) 3/13/18 mobile x ray results right femoral neck fracture. The surveyor did not locate any documentation that reflected that a copy of the comprehensive care plan goals were sent with Resident # 210 upon transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 1:00 pm, the surveyor spoke with the director of nursing and asked if she could provide documentation to support that a copy of the comprehensive care plan goals were sent with Resident # 210 upon transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 1:46 pm, the director of nursing made the surveyor aware that she was unable to locate documentation that reflected that a copy of the comprehensive care plan goals were sent with Resident # 210 upon transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 2:00 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 1/24/19.

Based on staff interview and clinical record review, the facility staff failed to give written notice of reason for transfer and discharge for 1 of 18 Residents in the survey sample, Resident #210. The findings included: The facility staff failed to ensure that the Resident # 210 and his representative received a written notice for reason of transfer to the emergency roiagnom on [DATE]. Resident # 210 was an [AGE] year-old male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The closed clinical record for Resident # 210 was reviewed on 1/23/18 at 10:30 am. The most recent MDS (minimum data set) assessment was a discharge assessment with an ARD (assessment reference date) of 3/14/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 210 had a BIMS (brief interview for mental status) score of 0 out of 15, which indicated that Resident # 210's cognitive status was severely impaired. The plan of care for Resident # 210 was reviewed and revised on 3/12/18. The facility staff documented a focus area for Resident # 210 as Falls: Resident is at risk for falls r.t (related to) dx (diagnosis) of muscle weakness and dementia. Resident has a w.c (wheelchair) used for locomotion. Interventions included but was not limited to: Assist resident as needed with ADLs (activities of daily living), transfers, and mobility, and Personal alarm. An order was written on 3/14/18 at 12:45 am. The order for Resident # 210 was documented as Send out to (Facility name withheld) ER (emergency room ) 911 for eval/tx (treat) 3/13/18 mobile x ray results right femoral neck fracture. The surveyor did not locate any documentation that Resident # 210 or Resident # 20's representative was made aware in writing of the reason for transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 1:00 pm, the surveyor spoke with the director of nursing and asked if she could provide documentation to support that Resident # 210 and his representative was made aware in writing of the reason for transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 1:46 pm, the director of nursing made the surveyor aware that she was unable to locate documentation that reflected that Resident # 210 and his representative was made aware of the reason for transfer to the emergency roiagnom on [DATE]. On 1/24/19 at 2:00 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 1/24/19.

Based on observation, staff interview, and facility document review, the facility staff failed to dispose of an expired medication and failed to store drugs in a sanitary environment in 1 of 1 medication rooms. The findings included: The facility staff failed to discard expired [MEDICATION NAME] solution and failed to ensure that the refrigerator in the medication room was clean and defrosted. On [DATE] at 9:55 am, the surveyor reviewed medication room along with the unit manager, LPN # 1 (licensed practical nurse). The surveyor observed mildew on the upper strip of the medication refrigerator. The surveyor brought the mildewed area that was observed on the upper strip of the medication refrigerator to the attention of LPN # 1. LPN # 1 observed the area and agreed that there was a mildew on the upper strip of the medication refrigerator. The surveyor also observed a large amount of ice in the freezer area of the medication refrigerator. LPN # 1 observed the large amount of ice in the freezer area of the medication refrigerator and agreed that the refrigerator needed to be defrosted. The surveyor reviewed the medications that were in the medication refrigerator. The surveyor observed an opened vial of [MEDICATION NAME] Purified Protein Derivative, Diluted [MEDICATION NAME] 5TU (titer unit)/0.1 ml (milliliter) solution with opened date of ,[DATE] written on the box. The surveyor showed LPN # 1 documentation that was written on the box of [MEDICATION NAME] solution that stated, Once entered vial should be discarded after 30 days. LPN # 1 agreed that the [MEDICATION NAME] solution had not been discarded appropriately. The facility policy on Disposal/Destruction of Expired or Discontinued Medication contained documentation that included but was not limited to, .Procedure 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. The facility policy on Storage of Medications contained documentation that included but was not limited to, .9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. The medication room refrigerator should be cleaned weekly and kept free of ice buildup. On [DATE] at 2:00 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on [DATE].

Based on observation, staff interview and clinical record review, it was determined the facility staff failed to perform hand washing appropriately during wound care. Findings: Resident #24 was admitted to the facility on [DATE]. Her clinical record was reviewed on 1/23/19 at 2:00 PM. The resident's latest MDS (minimum data set) dated 12/23/18 coded the resident as cognitively intact. She was coded with a stage IV pressure ulcer. 01/23/19 at 1:30 PM LPN I is in the resident's room to change the dressing on her back. The dressing is observed on the right side of her buttocks. The dressing is saturated with drainage and is not dated. LPN I got the dressing materials together to change the dressing. The facility DON was to assist with the wound care. LPN I notes the pressure ulcer is a stage 4 and the wound doctor had changed it yesterday onsite. LPN I washed her hands and donned gloves. LPN I cleaned the wound with derma clenz in a clockwise motion inner to outer edges. She then placed a 4x4 gauze soaked in Dakins inside the wound. LPN I did not change her gloves or wash/clean hands between cleaning the wound and placing 4x4 with Dakins packed into wound. The surveyor informed the LPN and DON she did not wash her hands in between cleaning the dressing and packing with gauze and placing outer dressing on wound. The surveyor asked for policy on wound care and hand washing. The facility policy for handwashing/hand hygiene was reviewed. It contained instructions to the nursing staff to wash their hands and don gloves, Before handling clean or soiled dressings, gauze pads, etc .After handling used dressings contaminated equipment .) The administrator was informed on 1/23/19 at 2:00 PM.

Based on observation, staff interview, and clinical record review it was determined that the facility staff failed to provided effective housekeeping services with regard to bed coverings for 2 of 18 residents in the survey sample Resident #4 and Resident #5. The findings include: 1. Resident #4 was originally admitted to the facility on [DATE] with 8/2/17 listed as a date of readmission. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (assessment reference date) of 8/10/17 has the resident the cognitive status of the resident documented as severely impaired. On 10/18/17 at 8:35 am the clinical record for Resident #4 was reviewed. According to the physician's orders [REDACTED]. On 10/18/17 at 3:35 pm Resident #4 was noted to be lying in bed. Air mattress was in place on bed. Resident was noted to be lying on the air mattress with no sheet in between the bed coverings and the resident. On 10/19/17 at 10:15 am surveyor spoke with environmental services personnel about the how often the air mattresses were cleaned. EVS#1(environmental service staff) stated that the CNAs will ask us to clean the beds when they get the residents out of the bed. But then you have some residents that don't want to get out of the bed. On 10/19/17 at 10:30 am Resident #4 was noted to be in her room fully dressed and sitting in her wheelchair. Resident #4 bed was noted to be made. An assessment of the air mattress was conducted with resident permission. When the blanket and top sheet were removed from the bed there were large greasy areas noted all over the surface of the air mattress. White spots and flaky white and off white particles were noted on the mattress surface. On 10/19/17 at 11:10 am surveyor spoke with the administrator about the resident lying directly on the air mattress with no sheet in between the bed coverings and the resident and requested information on how often the air mattresses were cleaned. The administrator informed the surveyor that the doctor does not want residents that have orders for air mattresses to have sheets underneath of the resident. There was no definitive answer given as to how often the air mattresses were cleaned. 2. Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 10/8/17 has the resident's cognitive status as moderately impaired and requiring extensive to total assistance for activities of daily living and transfers. On 10/19/17 at 8:45 am Resident #5 was noted lying in bed on air mattress with no sheet in between the resident and bed coverings. On 10/19/17 at 10:10 am Resident #5 was noted to be out of bed and out of the room. The air mattress on Resident # 5 bed was assessed and was noted to have several white spots on the surface of the air mattress covering and a large amount of white, off white, and light brown particles noted on the surface of the air mattress. On 10/19/17 at 11:10 am surveyor spoke with the administrator about the resident lying directly on the air mattress with no sheet in between the bed coverings and the resident and requested information on how often the air mattresses were cleaned. The administrator informed the surveyor that the doctor does not want residents that have orders for air mattresses to have sheets underneath of the resident. There was no definitive answer given as to how often the air mattresses were cleaned. On 10/19/17 at 12:38 pm the administrator, director of nursing, and consultant nurse were made aware of the findings listed in the statements above. No further information regarding this issue was given to the survey team prior to the exit conference.

Based on staff interview and clinical record review it was determined that the facility staff failed to ensure complete and accurate Minimum Data Set (MDS) assessments for 2 of 18 Residents in the sample survey, Resident # 3 and Resident #11. The Findings Included: 1. For Resident #3 the facility staff failed to ensure a complete and accurate Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/6/17. The facility staff inaccurately coded Section N. Medications on Quarterly MDS. The facility staff coded - (a dash) instead of a numerical number between 0 and 7. Resident #3 was an [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS located in the clinical record was a Quarterly MDS assessment with an ARD of 8/6/17. The facility staff coded that Resident #3 had a Cognitive Summary Score of 6. The facility staff also coded that Resident #3 required extensive (3/2) to total nursing care (4/2) with Activities of Daily Living (ADL's). In Section N. Medications N0300. Injections the instructions read to Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. If 0 -? Skip to N0410, Medications received. The facility staff coded - (dash). In Section N0350. Insulin the instructions read A. Insulin injections-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. The facility staff coded - (a dash). B. Orders for insulin-Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days. The facility staff coded - (a dash). In Section N0410 Medications Received the instructions read Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during that last 7 days or since admission/entry or reentry if less than 7 days. Enter 0 if medication was not received by the resident during the last 7 days. The facility staff coded - for Antianxiety, Antidepressant, Hypnotic, Anticoagulant, Antibiotic and Diuretic. On October 18, 2017 at 12:45 p.m. the surveyor reviewed Resident #3's clinical record. Review of the clinical record produced signed physician orders dated 10/6/17. Signed physician orders did not include physician orders for injections, insulin, antianxiety medications, antidepressants, hypnotics, antibiotics or diuretics during the look back period for the Quarterly MDS assessment with the ARD of 8/6/17. The surveyor noted that Section N. Medications areas should have been coded as 0 for the fields of injections, insulin, antianxiety medications, antidepressants, hypnotics, antibiotics and diuretics. On October 18, 2017 at 1:35 p.m. the surveyor interviewed the MDS Nurse, who was a Licensed Practical Nurse (LPN #1). The surveyor reviewed the Quarterly MDS with the ARD of 8/6/17 with the MDS Nurse. The surveyor specifically pointed out that Section N was inaccurately coded with - (dashes). The surveyor informed the MDS Nurse that the fields should have been coded with a numerical number between 0-7. The surveyor asked the MDS Nurse who had completed the Quarterly MDS. The MDS Nurse stated that she did not know but would check and see who had completed the MDS. On October 18, 2017 at 1:45 p.m. the MDS Nurse approached the surveyor and informed the surveyor that she, the MDS Nurse, had completed the Quarterly MDS. The MDS Nurse stated that she had completed the MDS on her second day of employment at the facility. The MDS Nurse stated that she was sorry. The surveyor notified the MDS Nurse that the MDS was inaccurate. On October 18, 2017 at 2:40 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and Corporate Compliance Nurse (CCN). The surveyor informed the Administrative Team (AT) that Resident #3's Quarterly MDS with the ARD of 8/6/17 was inaccurate. The surveyor notified the AT that Section N. Medications on the MDS was coded with a dash. The surveyor notified the AT that the MDS should have been coded with a numerical number of 0-7. No additional information was provided to the survey team prior to exiting the facility as to why the facility staff failed to ensure a complete and accurate MDS assessment for Resident #3. 2. For Resident #11 the facility staff failed to ensure a complete and accurate Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/3/17. The facility staff inaccurately coded in Section K. 0200 Height and Weight. The facility staff coded that Resident #11's height was 00. Resident #11 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was an Annual MDS assessment with an ARD of 9/3/17. The facility staff coded that Resident #11 had short and long term memory impairment (1/1) and was severely impaired with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #11 required extensive (3/2) to total nursing care (4/2) with ADL's. In Section K. 0200 Height and Height the facility staff coded that Resident #11's Height was 00. On October 18, 2017 at 3 p.m. the surveyor reviewed Resident #11's clinical record. Review of the clinical record produced documentation that Resident #11's height was 60 inches on admission. On October 18, 2017 at 3:15 p.m. the surveyor interviewed the MDS Nurse, who was a Licensed Practical Nurse (LPN #1). The surveyor reviewed the Admission MDS with the ARD of 9/3/17 with the MDS Nurse. The surveyor specifically pointed out that Resident #11's height was documented as 00. The surveyor reviewed the clinical record with the MDS Nurse and pointed out that Resident #11's height was 60 inches on admission. The MDS Nurse stated she had completed the MDS and was not sure why the height was documented as 0's. The surveyor notified the MDS Nurse that the MDS was inaccurate. On October 19, 2017 at 12:15 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and Corporate Compliance Nurse (CCN). The surveyor informed the Administrative Team (AT) that Resident #11's Admission MDS with the ARD of 9/3/17 was inaccurate. The surveyor notified the AT that Section K Height on the MDS was coded as zero's (00). The surveyor notified the AT that Resident #11's height was documented as 60 inches on admission. No additional information was provided to the survey team prior to exiting the facility as to why the facility staff failed to ensure a complete and accurate MDS assessment for Resident #11.

Based on observation, staff interview and clinical record review it was determined the facility staff failed to keep the facility environment hazard -free for 1 of 18 residents (Resident #10). Findings: Facility staff failed to ensure Resident #10's environment was hazard free. The record was reviewed on 10/18/17 at 4:00 PM. Resident #10 was admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's MDS (minimum data set) assessment, dated 9/24/17, coded the resident with significant cognitive impairment. He required the assistance of a least one nursing staff member to accomplish all the ADLs (activities of daily living). This included bed mobility and transfer assistance. Facility staff failed to ensure Resident #10 had a hospice care plan on file in his clinical record. The record was reviewed on 10/18/17 at 4:00 PM. Resident #10 was admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's MDS (minimum data set) assessment, dated 9/24/17, coded the resident with significant cognitive impairment. He required the assistance of a least one nursing staff member to accomplish all the ADLs (activities of daily living). The MDS coded one staff member was required for the resident's bed mobility. The resident was unable to reposition himself in bed using a side rail without the help of at least one staff member. Resident #10's CCP (comprehensive care plan) reviewed and revised on 9/25/17, documented the resident had an ADL (activities of daily living) self care deficit. He required the assistance of one staff member for all ADLs. The interventions included: 2 1/2 SR (side rail) to bed for mobility and positioning. The CNA care plan, posted inside the resident's closet and dated 9/21/17 documented the resident was to have side rails .half. The document did not indicated the number of siderails or the positioning of same. The resident's physician's orders [REDACTED]. On 10/19/17 at 8:30 AM, the resident was observed in his bed. The bed was flush against the wall on the left side. The right side rail was up in the center of the bed & a fall mat was placed on the floor to the right side of the bed. The resident's eyes were closed and he did not answer when addressed. The resident had multiple jerking episodes with his arms and legs. These motions were involuntary and purposeless. CNA I entered the room and the surveyor asked about the siderail up in the center of the bed. CNA I stated, I only been here three weeks. He's trying to get out of bed, that's why I put it up. The CNA said the siderails were always up in the center of the bed when she came to work at 7 AM and that is why she put them back up that way when putting him in the bed. The CNA then pulled up the bottom half of the side rail and left the room. On 10/19/17 at 8:35 AM RN I was asked where the facility about the resident's siderail placement. She looked into the room and saw two side rails up on Resident #10's bed. She stated, I hadn't realized that--he shouldn't have two up. The CNA told me he's jumping and jerking a lot more than usual, but he shouldn't have the bottom one up. On 10/19/17 at 8:45 AM LPN I was interviewed about the jerking motions and the full side rails up on the bed. She said he had Parkinson's and the jerking motions were sometimes worse, but only the upper rail should be positioned at the head of the bed. The bottom rail should not be up. Our rails don't flip up so they do cover the middle of the bed. We definitely can't do that to keep them in bed. On 10/19/17 at 9:30 AM the facility DON (director of nursing) was interviewed. The surveyor told her of the jerking motions and the unpadded side rails on the right side of the bed and the bed being up against the wall. The surveyor expressed concern about the resident involuntarily hitting the unpadded side rail or wall. The DON accompanied the surveyor to Resident #10's room and did a head-to-toe skin assessment to determine whether the resident had struck the wall or side rails and injured himself. When the DON and surveyor arrived in the room, the right side rail had been padded and there was a cushion between the resident and the wall on the left side of the bed. The DON observed the jerking motions and agreed there was the possibility he could injure himself if the cushions were not in place. On 10/19/17 at 10:00 AM the DON brought the surveyor a copy of a telephone order provided by Resident #10's physician at 9:10 AM. The order read, 2 1/2 SR (siderails) c (with) padding due to spasms. It was written and signed by LPN I. On 10/19/17 at 12:45 PM, the facility administrator, DON and corporate nurse were informed of the findings. No additional info was provided prior to survey team exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for 1 of 18 residents in the survey sample, Resident #4. The findings include: Resident #4 was originally admitted to the facility on [DATE] with 8/2/17 listed as a date of readmission. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (assessment reference date) of 8/10/17 has the resident's cognitive status documented as severely impaired. On 10/18/17 at 8:35 am the clinical record for Resident # 4 was reviewed. The clinical record contained a physician's orders [REDACTED]. Resident # 4 had an order for [REDACTED]. On 10/18/17 at 2:42 pm the administrator, director of nursing, and nurse consultant were made aware of the findings as stated above. On 10/18/17 at 3:29 pm the Infection Control Nurse provided the surveyor with a History and Physical from the clinical record that was dated 7/31/17. Under allergies [REDACTED]. ICF (infection control nurse) stated that the physician was called and made aware that Resident #4 was receiving Aspirin 325 mg as ordered while having an active allergy to Aspirin according to the signed physician's orders [REDACTED]. ICF stated The doctor gave us an order to d/c (discontinue) the Aspirin allergy. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review it was determined that the facility staff failed to coordinate Hospice Services for 2 of 18 Residents in the sample survey, Resident #11 and #10. The Findings Included: 1. For Resident #11 the facility staff failed to coordinate a Hospice Plan of Care between the facility and Hospice Agency. Resident #11 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was an Annual MDS assessment with an ARD of 9/3/17. The facility staff coded that Resident #11 had short and long term memory impairment (1/1) and was severely impaired with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #11 required extensive (3/2) to total nursing care (4/2) with ADL's. In Section O. Special Treatments, Procedures, and Programs the facility staff coded that Resident #11 was receiving Hospice Services. On October 17, 2017 at 6 p.m. the survey team entered the facility and the surveyor requested copies of the facility's contracts with Hospice Services. On October 18, 2017 at 3 p.m. the surveyor reviewed Resident #11's clinical record. Review of the clinical record produced signed physician orders [REDACTED]. (sic) Continued review of the clinical record produced a Hospice Admission Contract signed by the Hospice Agency and Resident #11's wife on 8/23/17. The admission agreement identified that Resident #11 was to receive nursing 2 X wk (two times a week) X 2 wks, 1 x wk x 1 wk, 10 PRN (as needed) visits dyspnea, agitation, safety issues, hospice aide 1-2 wk x 13 wks, social work, chaplain, bereavement. (sic) Further review of the clinical record produced the Hospice Agency notes documenting visits from the Hospice Agency staff. Additional review of the clinical record failed to produce the Hospice Care Plan to coordinate services between the Hospice Agency and the facility staff. On October 19, 2017 at 8:20 a.m. the surveyor observed a Licensed Practical Nurse (LPN) sitting at the nurses' station. The surveyor asked the LPN if the facility had binders/folders containing Hospice notes and care plans for Residents who were receiving Hospice Services. The LPN stated, No. On October 19, 2017 at 9:25 a.m. the surveyor notified the Director of Nursing (DON) that Resident #11 was receiving Hospice Services and that a Hospice Care Plan to coordinate care and services provided by the Hospice Agency could not be located in the clinical record. The surveyor requested a copy of the facility's contract with the Hospice Agency. On October 19, 2017 at 10 a.m. the surveyor reviewed the facility contract with the Hospice Agency that was providing Hospice Services to Resident #11. The contract was signed on 2/14/06 by the Hospice Agency and on 2/22/06 by the facility's President and Chief Operating Officer. The Hospice Agency contract read in part . 2.6 Hospice Plan of Care means a written care plan established, maintained, reviewed and modified, if necessary, at intervals established by the Interdisciplinary Group, which includes: . 2.7 Hospice Services means those services provided to a Hospice Patient for the palliation and management of such Hospice Patient's terminal illness, either directly or under arrangement by Hospice, as specified in the Hospice Plan of Care. Hospice Services include nursing care and services by or under the supervision of a registered nurse; medical social services provided by a qualified social worker under the direction of a physician; physician services to the extent that these services are not provided by the Attending Physician; counseling services (including bereavement, dietary and spiritual counseling) ; physical therapy, occupational therapy and speech-language pathology services; home health aide; medical supplies; drug and biological; use of medical appliances; and inpatient care when needed for pain control and symptom management. Hospice provides Bereavement Care up to one year, which consists of counseling and support. This service includes a social worker, volunteer and pastoral care. 3.2 Design and Maintenance of Hospice Plan of Care a. The Nursing Facilities Residents: In accordance with applicable Federal and state laws and regulations, Hospice shall develop a Hospice Plan of Care for each new Residential Hospice Patient. Promptly upon consent of the Residential Hospice Patient (or his/her legal representative), Hospice shall furnish The Nursing Facility with a copy of the Hospice Plan of Care. On October 19, 2017 at 12:15 p.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to coordinate Hospice Services with the Hospice Agency. The surveyor notified the AT that a Hospice Plan of Care for Resident #11 could not be located in the clinical record. No additional information was provided as to why the facility and Hospice Agency failed to coordinate Hospice Services that were being provided to Resident #11. For additional information on Resident #11 refer to F Tag 278. 2. Facility staff failed to ensure Resident #10 had a hospice care plan on file in his clinical record. The record was reviewed on 10/18/17 at 4:00 PM. Resident #10 was admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's MDS (minimum data set) assessment, dated 9/24/17, coded the resident with significant cognitive impairment. He required the assistance of a least one nursing staff member to accomplish all the ADLs (activities of daily living). Resident #10's CCP (comprehensive care plan) reviewed and revised on 9/25/17 indicated the resident was documented as receiving hospice services. The CCP recapped the hospice services--but was not specific as to the actual care/services hospice would provide. Resident #10's clinical record also contained an agreement consent for hopice services, signed by the resident's RP (responsible party). No hospice care plan was observed in the clinical record. The resident's physician's orders [REDACTED]. On 10/19/17 at 8:45 AM LPN I was asked where the facility stored the hospice care plan documents. The LPN said the hospice service placed them on the chart. She looked but did find them in Resident #10's record. On 10/19/17 at 9:30 AM the facility DON (director of nursing) was interviewed. She said the facility could not find the hospice care plan in the clinical record and they were going to have some sent over from the provider. The DON provided the facility agreement for hospice services. It contained the following: .Design and maintenance of Hospice Plan of Care. a. The Nursing Facility Residents: In accordance with applicable Federal and state laws and regualtions, Hospice shall develop a Hospice Plan of Care for each new Residential Hospice Patient. Promptly on consent of the Residential Hospice Patient (or his/her legal representative), Hospice shall furnish The Nursing Facility with a copy of the Hospice Plan of Care On 10/19/17 at 12:45 PM, the facility administrator, DON and corporate nurse were informed of the findings. No additional info was provided prior to survey team exit.

Based on staff interview and clinical record review it was determined that the facility staff failed to develop a Comprehensive Care Plan (CCP) for 4 of 17 Residents in the sample survey, Resident #1, Resident #5, Resident #7 and Resident #9. The Findings Included: 1. For Resident #1 the facility staff failed to develop a Comprehensive Care Plan (CCP) for pain as identified and triggered on an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/26/16. Resident #1 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS located in the clinical record was a Quarterly MDS assessment with an ARD of 8/9/16. The facility staff coded that Resident #1 had a Cognitive Summary Score of 4. The facility staff also coded that Resident #1 required extensive (3/2) to total nursing care (4/2) with Activities of Daily Living (ADL's). On October 13, 2016 at 7:45 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record produced an Annual MDS assessment with an ARD of 2/26/16. The facility staff coded that Resident #1 had a Cognitive Summary Score of 4. The facility staff also coded that Resident #1 required limited (2/2) to total nursing care (4/2) with ADL's. In Section J. Health Conditions the facility staff coded that Resident #1 received scheduled pain medication and received PRN (as needed) pain medication over the past 5 days. In Section J the facility staff also coded that Resident #1 stated that she frequently had pain, had pain during the night and that the pain limited her day to day activities because of the pain. In Section V. Care Area Assessment Summary (CAA's) Resident #1 triggered for pain. The facility staff documented that a Comprehensive Care Plan (CCP) would be developed to address Resident #1 ' s pain. Continued review of the clinical record produced the CCP that was initiated on 3/3/16. Review of the CCP failed to produce a care plan that addressed Resident #1's pain. On October 13, 2016 at 8:35 a.m. the surveyor notified the Director of Nursing (DON) that the facility staff failed to develop a CCP for Resident #1. The surveyor notified the DON that the facility staff failed to develop a care plan that addressed Resident #1's pain. The surveyor and DON reviewed Resident #1's Annual MDS assessment with the ARD of 2/26/16. The surveyor pointed out that in Section V. CAA's Resident #1 triggered for pain and that the facility staff documented that a care plan would be developed to address Resident #1's pain. The surveyor and DON reviewed Resident #1's CCP dated 3/3/16. The DON was unable to locate a care plan that addressed Resident #1's pain. On October 13, 2016 at 4:20 p.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to develop a CCP to include a care plan for pain for Resident #1. The surveyor notified the AT that Resident #1 triggered for pain on the Annual MDS assessment with the ARD of 2/26/16. The surveyor notified the AT that the facility staff documented that a care plan would be developed to address Resident #1's pain. The surveyor notified the AT that review of the CCP, dated 3/3/16, failed to produce a care plan for pain. No additional information was provided prior to exiting the facility as to why the facility staff failed to develop a CCP for Resident #1. 2. For Resident #5, facility staff failed to use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data assessment with assessment reference date 9/14/16, the resident scored 4/15 on the brief interview of mental status and exhibited symptoms of inattention, disorganized thinking, and daily wandering. The resident's annual MDS assessment with assessment reference date 6/20/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The administrator and director of nursing were notified of the concern. The director of nursing stated that the information would be recorded on the CAA worksheets or CAA summaries in the future. 3. For Resident #7, facility staff failed to use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment (MDS) with assessment reference date 2/10/16, the resident scored 9/15 on the brief interview for mental status and was 4/8 on the assessment for [MEDICAL CONDITION]. The comprehensive admission MDS assessment with assessment reference date 2/1/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. Clinical record review on 10/14/16 revealed a physician's orders [REDACTED]. Quetiapine [MEDICATION NAME] is an antipsychotic medication (also called [MEDICATION NAME]). The surveyor was unable to locate documentation of a [DIAGNOSES REDACTED]. The surveyor was unable to locate documentation of the behaviors for which the antipsychotic medication had been ordered. The clinical record indicated that the resident had been receiving the medication at least since the last readmission from the hospital on [DATE]. Behavior monitoring was documented from 1/25/16 through the end of the survey on 10/17/16. Physician notes did not document [DIAGNOSES REDACTED]. The resident's [MEDICAL CONDITION] Quarterly Evaluations were blank under the section Behavior warranting the use of medication. Clinical record review on 5/14/16 revealed a restorative nursing order dated 5/3/16 for don resting hand splints to both hands for 4 hours per day. Restorative nursing records indicated the resident received the treatment 20 days in July 2016, 24 days in August 2016, and 20 days in September 2016. The surveyor asked the restorative aid on 10/13/16 about the days the resident's hands were not splinted. The aid stated that the resident had received the treatment on the days the restorative aid worked. The aid was unaware of procedures for days when she did not work. The surveyor asked the resident's medication nurse if the resident's splinting was tracked and the nurse referred the surveyor to the restorative aid record. The surveyor interviewed the occupational therapist on 10/14/16 at 8:15 AM. The therapist stated that the expectation was for the splinting to be done daily to maintain condition. The therapist stated that the long-term treatment alternated between periods of active treatment, when splinting was not used (the resident was receiving active treatment from September 28 through the time of the survey) and passive treatment with splinting. He stated that failure to splint every day could contribute to deterioration of the resident's condition, but that it would not change the active-passive treatment cycles. The resident's comprehensive care plan did not address the symptoms to be treated by the antipsychotic medication or the resident's contractures of both hands requiring occupational therapy. The surveyor discussed the concern with restorative therapy and the lack of indication for the antipsychotic medication and the incomplete CAA summaries and worksheets on 10/13/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/14/16. 4. For Resident #9, facility staff failed to use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment (MDS) with assessment reference date 7/25/16, the resident scored 7/15 on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting others. The comprehensive annual MDS assessment with assessment reference date 2/12/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. During clinical record review on 10/14/17, the surveyor noted the resident's comprehensive care plan updated 7/28/16 indicated under Problem/Need: Occasional episodes of urinary incontinence related to loss of bladder muscle tone, on restorative nursing and under Goal: continue with RNP (restorative nursing plan). The surveyor asked for the resident's restorative notes, which were not available in the restorative documentation binder. During an interview on 10/17/16, the restorative aid reported that the resident's restorative plan had ended on March 28 and that therapy had not addressed toileting. The director of nursing was unable to provide an explanation for the comprehensive care plan listing restorative toileting. The surveyor discussed the concern with restorative therapy the incomplete CAA summaries and worksheets on 10/17/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/17/16.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure complete and accurate Care Area Assessments (CAA's) for 9 of 17 Residents in the sample survey, Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9. The Findings Included: 1. For Resident #1 the facility staff failed to ensure a complete and accurate Care Area Assessment (CAA) on an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/26/16. Resident #1 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS located in the clinical record was a Quarterly MDS assessment with an ARD of 8/9/16. The facility staff coded that Resident #1 had a Cognitive Summary Score of 4. The facility staff also coded that Resident #1 required extensive (3/2) to total nursing care (4/2) with Activities of Daily Living (ADL's). On October 13, 2016 at 7:45 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record produced an Annual MDS assessment with an ARD of 2/26/16. The facility staff coded that Resident #1 had a Cognitive Summary Score of 4. The facility staff also coded that Resident #1 required limited (2/2) to total nursing care (4/2) with ADL's. In Section V. Care Area Assessment Summary (CAA's) Resident #1 triggered for the following care areas: Cognition, Vision, Urinary Incontinence, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Falls, and Nutritional Status. In the column titled, Location and Date of CAA documentation the facility staff documented Current Care Plan Continued . (sic) The column did not document the location and date of the supporting documentation for the care plan decision making for Cognition, Vision, Urinary Incontinence, Behavioral Symptoms and Falls. The surveyor continued to review the Annual MDS assessment with the ARD of 2/26/16. The surveyor reviewed the CAA summary worksheets. Review of the CAA summary worksheets did not document the date and/or location of the supporting documentation for the care planning decision making for Cognition, Vision, Urinary Incontinence, Behavioral Symptoms and Falls. On October 13, 2016 at 8:35 a.m. the surveyor notified the Director of Nursing (DON) that Resident #1's CAA's were not complete and accurate. The surveyor and DON reviewed Resident #1's Annual MDS assessment with the ARD of 2/26/16. The surveyor pointed out that Section V. CAA's and the CAA worksheets did not document the date and location of the supporting documentation for the decision making process regarding care plans. The DON stated that she would check with the MDS Nurse. On October 13, 2016 at 9:20 a.m. the DON approached the surveyor and informed the surveyor that the MDS Nurse stated that she was not aware that she needed to document the specific date and location of the supporting documentation for the care plan decision making process. On October 13, 2016 at 4:20 p.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to ensure complete and accurate CAA's for Resident #1. The surveyor notified the AT that the facility staff failed to document the date and location of the supporting documentation regarding the care plan decision making. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate CAA's for Resident #1. 2. For Resident #2 the facility staff failed to ensure a complete and accurate Care Area Assessment (CAA) on an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/10/16. Resident #2 was an [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 10/11/16. The facility staff coded that Resident #2 had short and long term memory impairment (1/1) and was severely impaired (3) with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #2 required total nursing care (4/2) with ADL's. On October14, 2016 at 7:45 a.m. the surveyor reviewed Resident #2's clinical record. Review of the clinical record produced an Admission MDS assessment with an ARD of 5/10/16. The facility staff coded that Resident #2 had short and long term memory impairment (1/1) and was severely impaired (3) with daily decision making regarding ADL's. The facility staff also coded that Resident #2 required extensive (3/2) to total nursing care (4/2) with ADL's. In Section V. Care Area Assessment Summary (CAA's), Resident #2 triggered for Cognitive Loss, Communication, Urinary Incontinence, Psychosocial Well-Being, Mood State, Activities, Falls and Nutritional Status. In the column titled, Location and Date of CAA documentation the facility staff documented New Care Plan Started . (sic) The column did not document the location and date of the supporting documentation for the care plan decision making for Cognition, Communication, Urinary Incontinence, Mood State and Falls. The surveyor continued to review the Admission MDS assessment with the ARD of 5/10/16. The surveyor reviewed the CAA summary worksheets. Review of the CAA summary worksheets did not document the date and/or location of the supporting documentation for the care planning decision making for Cognition, Communication, Urinary Incontinence, Mood State and Falls. On October 14, 2016 at 9 a.m. the surveyor notified the Director of Nursing (DON) that Resident #2's CAA's were not complete and accurate. The surveyor and DON reviewed Resident #2's Admission MDS assessment with the ARD of 5/10/16. The surveyor pointed out that Section V. CAA's and the CAA worksheets did not document the date and location of the supporting documentation for the decision making process regarding care plans. The DON stated that she had spoken with the MDS Nurse on 10/13/16 and that probably all of the comprehensive assessments CAA ' s would be inaccurate. On October 14, 2016 at 10 a.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to ensure complete and accurate CAA's for Resident #2. The surveyor notified the AT that the facility staff failed to document the date and location of the supporting documentation regarding the care plan decision making. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate CAA's for Resident #2. 3. For Resident #3 the facility staff failed to ensure a complete and accurate Care Area Assessment (CAA) on an Admission and 5 Day Medicare Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/26/16. Resident #3 was a [AGE] year old male was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a 30 Day Medicare MDS assessment with an Assessment Reference Date (ARD) of 9/14/16. The facility staff coded that Resident #3 had a Cognitive Summary Score of 13. The facility staff also coded that Resident #3 required set up (1/1) to limited assistance (2/2) with Activities of Daily Living (ADL's). On October 13, 2016 at 9:25 a.m. the surveyor reviewed Resident #3's clinical record. Review of the clinical record produced an Admission and 5 Day Medicare MDS assessment with an ARD of 8/26/16. The facility staff coded that Resident #3 had a Cognitive Summary Score of 13. The facility staff also coded that Resident #3 required set up (1) to limited assistance (2/2) with ADL ' s. In Section V. Care Area Assessment Summary (CAA ' s) Resident #3 triggered for Cognitive Loss, Visual Function, ADL Function, Urinary Inconstancy, Psychosocial Well-Being, Falls and Nutritional Status. In the column titled, Location and Date of CAA documentation the facility staff documented Current Care Plan Cont (continued) . (sic) The column did not document the location and date of the supporting documentation for the care plan decision making for Cognition, Vision, ADL Function, Urinary Incontinence, Psychosocial Well-being and Falls. The surveyor continued to review the Admission and 5 Day Medicare MDS assessment with the ARD of 8/26/16. The surveyor reviewed the CAA summary worksheets. Review of the CAA summary worksheets did not document the date and/or location of the supporting documentation for the care planning decision making for Cognition, Vision, ADL Function, Urinary Incontinence, Psychosocial Well-being and Falls. On October 13, 2016 at 11 a.m. the surveyor notified the Director of Nursing (DON) that Resident #3's CAA's were not complete and accurate. The surveyor and DON reviewed Resident #3's Admission and 5 Day Medicare MDS assessment with the ARD of 8/26/16. The surveyor pointed out that Section V. CAA's and the CAA worksheets did not document the date and location of the supporting documentation for the decision making process regarding care plans. The DON stated that she had spoken with the MDS Nurse on 10/13/16 and that probably all of the comprehensive assessments CAA's would be inaccurate. On October 13, 2016 at 4:20 p.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to ensure complete and accurate CAA's for Resident #3. The surveyor notified the AT that the facility staff failed to document the date and location of the supporting documentation regarding the care plan decision making. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate CAA's for Resident #3. 4. For Resident #4 the facility staff failed to ensure a complete and accurate Care Area Assessment (CAA) on an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/3/16. Resident #4 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. On October 13, 2016 at 1:20 p.m. the surveyor reviewed Resident #4''s clinical record. Review of the clinical record produced the most current MDS. The most current Minimum Data Set (MDS) located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 10/3/16. The facility staff coded that Resident #4 had a Cognitive Summary Score of 14. The facility staff also coded that Resident #4 required total nursing care (4/2) with Activities of Daily Living (ADL's). In Section V. Care Area Assessment Summary (CAA's) Resident #4 triggered for Communication, ADL Function, Incontinence, Falls, Nutritional Status, Dehydration, Dental Care, Pressure Ulcer, [MEDICAL CONDITION] Drug Use and Pain. In the column titled, Location and Date of CAA documentation the facility staff documented Current Care Plan Cont (continued) . (sic) The column did not document the location and date of the supporting documentation for the care plan decision making for Communication, ADL Function, Incontinence, Falls, Nutritional Status, Dehydration, Dental Care, Pressure Ulcer, [MEDICAL CONDITION] Drug Use and Pain. The surveyor continued to review the Annual MDS assessment with the ARD of 10/3/16. The surveyor reviewed the CAA summary worksheets. Review of the CAA summary worksheets did not document the date and/or location of the supporting documentation for the care planning decision making for Communication, ADL Function, Incontinence, Falls, Nutritional Status, Dehydration, Dental Care, Pressure Ulcer, [MEDICAL CONDITION] Drug Use and Pain. On October 13, 2016 at 2:50 p.m. the surveyor notified the Administrator (Adm) and Director of Nursing (DON) that Resident #4's CAA's were incomplete/inaccurate. On October 13, 2016 at 4:20 p.m. the survey team met with the Administrator Adm, DON and Corporate Compliance Nurse (CCN). The surveyor notified the Administrative Team (AT) that the facility staff failed to ensure complete and accurate CAA's for Resident #4. The surveyor notified the AT that the facility staff failed to document the date and location of the supporting documentation regarding the care plan decision making. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate CAA's for Resident #4. 5. For Resident #5, facility staff failed to ensure documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data assessment with assessment reference date 9/14/16, the resident scored 4/15 on the brief interview of mental status and exhibited symptoms of inattention, disorganized thinking, and daily wandering. The resident's annual MDS assessment with assessment reference date 6/20/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The administrator and director of nursing were notified of the concern. The director of nursing stated that the information would be recorded on the CAA worksheets or CAA summaries in the future. 6. For Resident #8, facility staff failed to ensure documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). Resident #8 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On the quarterly minimum data set (MDS) assessment with assessment reference date 8/23/16, the resident scored 3/15 on the brief interview for mental status, 4/8 on for signs of [MEDICAL CONDITION], no signs of [MEDICAL CONDITION], and physical and verbal behavior 1-3 days of the week. The resident's annual MDS assessment with assessment reference date 12/28/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The surveyor discussed the concern with the incomplete CAA summaries and worksheets on 10/13/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/14/16. 7. For Resident #7, facility staff failed to ensure documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment (MDS) with assessment reference date 2/10/16, the resident scored 9/15 on the brief interview for mental status and was 4/8 on the assessment for [MEDICAL CONDITION]. The comprehensive admission MDS assessment with assessment reference date 2/1/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The resident's comprehensive care plan did not address the symptoms to be treated by the antipsychotic medication or the resident's contractures of both hands requiring occupational therapy. The surveyor discussed the concern with restorative therapy and the lack of indication for the antipsychotic medication and the incomplete CAA summaries and worksheets on 10/13/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/14/16. 8. For Resident #6, facility staff failed to ensure documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment (MDS) with assessment reference date 5/5/16, the resident was assessed with [REDACTED]. The comprehensive annual MDS assessment with assessment reference date 8/5/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The surveyor discussed the concern with restorative therapy and the lack of indication for the antipsychotic medication and the incomplete CAA summaries and worksheets on 10/13/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/14/16. 9. For Resident #9, facility staff failed to ensure documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly minimum data set assessment (MDS) with assessment reference date 7/25/16, the resident scored 7/15 on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting others. The comprehensive annual MDS assessment with assessment reference date 2/12/16 was not completed to include assessment documentation on the Care Area Assessment (CAA) worksheets or the CAA summary section of the assessment. During an interview on 10/12/16, the director of nursing stated that the former MDS coordinator had not put that information on the CAA summaries or CAA assessment worksheets. She stated she had interviewed the new MDS coordinator and the new coordinator reported that she also did not put that information in the MDS assessments. The surveyor discussed the concern with restorative therapy and the lack of indication for the antipsychotic medication and the incomplete CAA summaries and worksheets on 10/13/14, and reported to the administrator, director of nursing, and a corporate clinical consultant on 10/14/16.