Every finding on record at SW VA M H Inst Geri TRT CTR

Based on staff interview, clinical record review and facility document review the facility staff failed to periodically review with the resident/resident representative advance directives for all residents of the facility. The findings included:The facility staff failed to ensure that advance directives were periodically reviewed with the resident and/or the resident representative.During clinical record review, surveyors could not locate evidence that each residents advance directive had been reviewed with either the resident or the resident's representative. During an end of day meeting on 12/29/25 at 4:15 pm, the issue of advance directives was discussed with the administrator, registered nurse (RN) #1, and social worker/administrator-in-training (SW/AIT). SW/AIT stated that advance directive information was discussed with the resident/resident representative on admission, a change in the resident's status, and upon resident or family request. Surveyor requested and was provided with a facility policy entitled Advance Directives with an effective date of 09/01/24, which read in part, It is the policy of . (facility name omitted) to comply with applicable statutes and regulations relative to advance directives. Individuals will be informed of their rights regarding health-care decisions, including the right to execute an advance medical directive .1. The patient registrar will inquire whether the individual has an advance directive and will document the response on the face sheet .c. If the individual is unable to produce the advance directive, he/she should be referred to the Programs Director for Extended Rehab Service (ERS) to complete a new form . B. Responsibilities of Treatment Team Members 1. The individual will be informed of the right regarding advance directive through the Patient Rights Program during a meeting with the team social worker. 2. DNR (do not resuscitate) status will be discussed with the individual and or surrogate decision maker upon every admission to . (facility) . 4. If an advance directive has not been completed, or if the individual is unfamiliar with advance directives, the social worker will ask the individual if they would like to receive further information. This policy does not indicate that a periodic review of residents advance directives should be completed. During a meeting with the administrator, RN #1, SW/AIT, and unit nurse coordinator on 12/30/25 at 8:20 am, SW/AIT stated that no resident currently has an advance directive. The administrator stated, We have had them in the past, but not currently. SW/AIT stated that residents are educated on advance directives upon admission and discharge, and that DNR status is reviewed upon a change in condition. The concern of not periodically reviewing advance directives with residents/resident representatives was discussed with the administrator, SW/AIT, RN #1 and unit nurse coordinator on 12/30/25 at 1:20 pm.No further information was provided prior to exit.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to develop comprehensive care plans (CCPs) that included the residents current code status for all residents in the survey sample. The findings included:The facility staff failed to develop CCPs that included the residents current code status. During the clinical record review, the surveyors were unable to locate information on the resident's CCPs that referenced their current code status. On 12/29/2025 at 4:15 p.m., during an end of the day meeting with the Administrator, Registered Nurse (RN) #1, and Social Worker/Administrator in Training the issue with the code status not being on the resident's current CCP's was reviewed. RN #1 stated they did not think they included the code status on the CCPs. On 12/30/25 RN #1 provided the survey team with a copy of their policy titled, Treatment Planning with an effective date of 08/01/24. This policy read in part, .The purpose of the Comprehensive Treatment Plan (CTP) is to involve the individual in developing an interdisciplinary services plan document and process that is person centered.On 12/30/25 at 8:20 a.m., during a meeting with the Administrator, RN #1, Social Worker/Administrator in Training, and the Unit Nurse Coordinator the issue regarding the resident's current code status not being included on the CCPs was reviewed. The Unit Nurse Coordinator stated they had not been care planning the individuals code status but as of now they were care planned. 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 the facility staff failed to ensure that monthly medication regimen reviews were reviewed by the physician and/or the director of nursing and that pharmacist recommendations were acted upon for all residents of the facility. The findings included: While reviewing the monthly Medication Regimen Review (MRR) forms for five residents selected for review of psychotropic medication use, it was found that the MRR forms were not being reviewed by the physician and/or the director or nursing and that pharmacist recommendations were not being acted upon. Surveyor spoke with the unit manager on 08/30/23 at 11:30 regarding MRR's. Unit manager stated they get an email notification that the MRR has been completed, and they review it. Unit manager stated the pharmacist either emails or call the physician with recommendations. Surveyor spoke with the facility pharmacist on 08/30/23 at 3 pm regarding MRR's and how they communicate recommendations to the physician. Pharmacist stated they put their recommendations into the form for each resident, then send a monthly email to the physician, psychiatrist, administrator, and unit manager once each unit is complete, with a summary of recommendations. Pharmacist stated most MRR's go to the psychiatrist. Pharmacist stated they sometimes call the psychiatrist to let them know what the recommendations are. Surveyor spoke with the administrator and unit manager on 08/30/23 regarding MRR's. Surveyor asked how they know if the physician has reviewed and/or followed up on pharmacy recommendations, and administrator stated they look the next month, and if not changed, they send it back. Surveyor spoke with the psychiatrist on 08/31/23 at 9:25 am. Psychiatrist stated they make a regular monthly note, but it is not specifically related to the MRR, and that they had never made a specific response to an MRR. Psychiatrist stated that until recently, they were never sure when a MRR was completed. Psychiatrist stated, They have started putting them under expiring meds, until then I had to hunt for them. On 08/31/23 at 10:20 am, the unit manager stated the procedure for conducting MRR's was done through the Message Center, in the electronic health record. The MRR was to be completed by the pharmacist, then sent to the physician/psychiatrist in the message center. Physician/psychiatrist can read the MRR, make notes, and save their response. Then it should automatically be put into the clinical record. Unit manager stated they don't know if the psychiatrist is doing that. Surveyor requested and was provided with a facility policy entitled Pharmacist Medication Regimen Review which read in part, Procedures: E. The pharmacist shall document the review and provide this original to the attending medical professional for review and response. G. If irregularities are identified, they are deemed either insignificant or significant. 1. For clinically insignificant irregularities, the pharmacist will refer it for review by the attending medical professional, who will take action by the time of the subsequent review and return the form to the program director. 2. For clinically significant irregularities or those requiring immediate attention, the pharmacist will contact the attending medical professional in person or by telephone, who will review the findings and take action. If the attending medical professional is unavailable, the pharmacist will notify the medical director. All documentation regarding communication shall be noted on the review form, if necessary. The concern of the physician/psychiatrist/director of nursing not reviewing and/or acting upon pharmacist recommendations was discussed with the administrator and unit manager on 08/31/23 at 1:30 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review the facility staff failed to ensure one of 16 residents was free from unnecessary psychotropic medications, Resident #17. The findings included: For Resident #17, the facility failed to provide a discontinue date or re-evaluate the resident for continued use for the as needed (prn) medication Zyprexa. Zyprexa is an antipsychotic medication used to treat severe agitation associated with schizophrenia and/or bipolar mania. Resident #17's clinical record listed diagnoses which included but not limited to major neurocognitive disorder due to probable Alzheimer's disease, severe, with other behavioral disturbances, adjustment disorder with anxious mood, and Alzheimer's dementia. Resident #17's most recent minimum data set with an assessment reference date of 08/07/23 assigned the resident a brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitive impaired. Resident #17's comprehensive care plan contained a plan for Behavioral symptoms. Interventions for this plan included administer medications per order. Resident #17's clinical record was reviewed and contained physician's order summary which read in part, Olanzapine (Zyprexa Zydis) 5 mg= 1 tab, Oral, Tab-Dis, every 8 hr for 365 days, PRN, agitation . This order had a stop date of 06/04/24. Resident #17's medication administration record (MAR) for the month of August 2023 was reviewed and indicated the prn Zyprexa was administered 2 times. The MAR's for June and July 2023 indicated the resident did not receive any prn Zyprexa. Resident #17's clinical record contained Drug Regimen Review forms for the months of June, July, and August 2023. Each of these forms read in part, Medication Regimen Review Findings: Duration of medication review needed. Drug Regimen Comments From Findings: Patient has PRN Olanzapine > (greater than) 14 days. Please evaluate continued need and limit to 14 days if still needed. The concern of not providing a discontinue date and/or re-evaluating the resident for continued use of PRN Zyprexa was discussed with the administrator and unit manager on 08/31/23 at 1:30 pm. No further information was provided prior to exit.

Based on observations, staff interviews, and clinical document review, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were six (6) medication errors in 32 opportunities resulting in a medication error rate of 18.75%. (The residents involved in these medication errors were: Resident #14, Resident #4, and Resident #1.) The findings include: Medication errors were observed while completing the Medication Administration Task on the morning of 2/24/21. There were six (6) errors in 32 opportunities resulting in a medication error rate of 18.75%. Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/14/20, had the resident assessed as able to make self understood and as usually able to understand others. Resident #14's Brief Interview for Mental Status (BIMS) summary score was a 12 out of 15. Resident #14 was assessed as requiring limited assistance with transfers and supervision with eating and personal hygiene. Resident #14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/6/21, had the resident assessed as usually able to make self understood and as usually able to understand others. Resident #4's Brief Interview for Mental Status (BIMS) summary score was a seven (7) out of 15. Resident #4 was assessed as requiring supervision with dressing, eating, and toilet use. Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/7/20, had the resident assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was a one (1) out of 15. Resident #1 was assessed as requiring supervision with bed mobility, eating, transfers, dressing, and toilet use. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/21 at 7:47 a.m., Licensed Practical Nurse (LPN) #1 was observed administering medications to Resident #14. The following three (3) medications were included in the medications provided to Resident #14 during this observation: (a) [MEDICATION(S)] 1000 mg one (1) tablet by mouth, (b) [MEDICATION(S)] N insulin 35 units as a subcutaneous injection, and (c) [MEDICATION(S)] 88 mcg one (1) tablet by mouth. These three (3) medications were administered after breakfast and without food. Resident #14's clinical record included the following orders: - insulin [MEDICATION(S)] (NPH) 35 units subcutaneous daily before breakfast; - [MEDICATION(S)] 88 mcg one (1) tablet daily before breakfast; and - [MEDICATION(S)] 1000 mg one (1) tablet twice a day with meals. During an interview on 2/24/21 at 9:50 a.m., LPN #1 confirmed the aforementioned medications were given after breakfast. During an interview on 2/24/21 at 10:10 a.m., the facility's Unit Nurse Manager (UNM) reported the [MEDICATION(S)] should have been administered with food. On 2/24/21 at 8:03 a.m., LPN #1 was observed administering medications to Resident #4. LPN #1 was observed to give Resident #4 [MEDICATION(S)] 30 mg one (1) tablet by mouth; this medication was not administered with food. Resident #4's clinical record included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/21 at 08:07 a.m., LPN #1 was observed administering medications to Resident #1. LPN #1 was observed to crush the following medications prior to administering them to Resident #1: (a) [MEDICATION(S)] ER 25 mg one (1) tablet and (b) [MEDICATION(S)] 3 mg one (1) tablet. The packaging of [MEDICATION(S)] included the phrase DO NOT CRUSH. On 2/24/21 at 12:50 p.m., Registered Nurse (RN) #5 provided a copy of a Do Not Crush List to the survey team; this document included [MEDICATION(S)] ER tablet due to it being a sustained release medication. The following information was found in a facility policy/procedure with the subject of Medication Administration (with a review date of August 1, 2021): - The medication nurse is responsible for ensuring the 6 Rights (i.e., drug, dose, patient, route, time, and documentation) . - If medications are ordered by the medical professional to be crushed, the nurse administering medications is responsible to check the Do Not Crush List prior to crushing and administering medications. The aforementioned medication administration observations were discussed with the facility Unit Nurse Manager (UNM) on 2/25/21 at 4:30 p.m. These observations were also discussed with the facility's Administrator, UNM, and Director of Acute Treatment Services on 2/6/21 at 3:52 p.m.

Based on staff interview and clinical record review, the facility staff failed to ensure 4 of 15 residents were free of unnecessary [MEDICAL CONDITION] medications that affected Resident #4, Resident #7, Resident #19, and Resident #20. The findings included: 1. The facility staff failed to discontinue or review the use of the prn (as needed) medication [MEDICATION NAME] for Resident #4. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4's most recent quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 1/24/19 assessed the resident with a brief interview for mental status (BIMS) as 1/15. There were signs of delusions, inattention and disorganized thinking. Resident #4's clinical record was reviewed 3/12/19 through 3/14/19. The (MONTH) 2019 physician's orders [REDACTED].= 1 tab q 12h (every 12 hours) PRN agitation/restlessness for 365. The order for the prn [MEDICATION NAME] did not have an end date and there was no documentation in Resident #4's clinical record that the physician had re-evaluated the resident for continued use of the prn medication. The surveyor informed the registered nurse unit coordinator, the administrator, and the assistant administrator/licensed clinical social worker of the above concern on 3/13/19 at 4:12 p.m. regarding Resident #4. The registered nurse unit coordinator informed the surveyor on 3/14/19 at 8:08 a.m. that the order had been changed 3/14/19. The R.N. unit coordinator stated Resident #4 had a locum but never got the prn medication. No further information was provided prior to the exit conference on 3/14/19. 2. The facility staff failed to document the indications for use and the targeted behaviors when Resident #7 was administered [MEDICATION NAME] on 2/28/19 and 3/8/19. The clinical record of Resident #7 was reviewed 3/12/19 through 3/14/19. Resident #7 was admitted to the facility 12/22/17 with [DIAGNOSES REDACTED]. Resident #7's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/11/19 assessed the resident with a brief interview for mental status (BIMS) as 13/15. There were no signs of [MEDICAL CONDITION]. Resident #7 was assessed with [REDACTED]. Resident #7's (MONTH) 2019 and (MONTH) 2019 physician orders [REDACTED].=1 tab oral q12h (every 12 hours) psychotic agitation for 14 days for mood disorder or [MEDICAL CONDITION]. The surveyor reviewed the (MONTH) 2019 and (MONTH) 2019 electronic medication administration record. Resident #7 was administered [MEDICATION NAME] 5 mg on 2/28/19 at 11:36 a.m. and on 3/8/19 at 7:52 a.m. The surveyor was unable to locate the indications for use or the targeted behaviors in the clinical record. The surveyor informed the head nurse registered nurse #2 on 3/14/19 at 10:27 a.m. The head nurse R.N. #2 stated there were no notes written for those specific days. The surveyor asked if the nursing staff should document why medications were administered and the head nurse R.N. #2 stated yes. The surveyor informed the administrator, the registered nurse program coordinator, and the assistant administrator/licensed clinical social worker of the above concern with administration of antipsychotic medication to Resident #7 without adequate monitoring and indication for use in the end of the day meeting on 3/14/19 at 12:35 p.m. No further information was provided prior to the exit conference on 3/14/19. 3. The facility staff failed to document reasons in the nursing notes for the administration of prn (as needed) [MEDICATION NAME] (an antipsychotic) for Resident #19. Resident #19 received [MEDICATION NAME] on 3/8/19 at 8:26 a.m., 3/10/19 at 8:53 a.m., 3/11/19 at 11:02 a.m., and 3/12/19 at 7:29 a.m. without indications for use. The comprehensive treatment plan did not include targeted behaviors for [MEDICATION NAME] administration, and did not include non-pharmacological interventions prior to administration. The clinical record of Resident #19 was reviewed 3/12/19 through 3/14/19. Resident #19 was admitted to the facility 2/16/18 with [DIAGNOSES REDACTED]. Resident #19's annual MDS with an assessment reference date (ARD) of 1/15/19 assessed the resident with a brief interview for mental status in Section C0500 as 4/15. Resident #19 was assessed with [REDACTED]. Resident #19's comprehensive treatment plan dated 1/30/19 included focus area for psychiatric/psychological areas. Active: paranoid, delusional, preoccupied with religion and having babies, intrusiveness, agitation and threatening behaviors toward staff and other residents. Interventions/goals included to take medications as prescribed, be free of intruding in others rooms, personal space, and be free of verbal aggression. Resident #19 will share one coping skill she can use when she feels upset in the community. Above interventions discussed with the resident. There were no specific non-pharmacological interventions on the comprehensive treatment plan dated 1/30/19. The (MONTH) 2019 physician's orders [REDACTED]. Start date: 2/5/19 and Stop date: 12/30/19. The physician order [REDACTED].>The surveyor was unable to locate the reasons for the administration of [MEDICATION NAME] on 3/8/19, 3/10/19, 3/11/19 and 3/12/19 and informed the head nurse of the unit registered nurse #2 on 3/13/19 at 9:28 a.m. R.N. #2 informed the surveyor on 3/13/19 at 9:55 a.m. the nurses who administered the [MEDICATION NAME] failed to document the reasons the medication was administered. R.N. #2 stated some of the nurses were part time but expected the nursing staff to document the reasons why medications were administered. The surveyor informed the administrator, the registered nurse program coordinator, and the assistant administrator/licensed clinical social worker of the above concern with administration of antipsychotic medication to Resident #19 without adequate monitoring, no end date to the current physician order [REDACTED]. No further information was provided prior to the exit conference on 3/14/19. 4. The facility staff failed to document the reasons Resident #20 was administered [MEDICATION NAME]. The clinical record of Resident #20 was reviewed 3/12/19 through 3/14/19. Resident #20 was admitted to the facility 1/21/17 with [DIAGNOSES REDACTED]. Resident #20's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/28/19 assessed the resident with a brief interview for mental status (BIMS) as 7/15. There were no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Resident #20 was assessed to have verbal behaviors, other behavioral symptoms, and rejection of care during the look back period. Resident #20's comprehensive treatment plan dated 12/28/18 identified behaviors of aggression, agitation, yelling, and suicidal ideation and thoughts of self-harm. Interventions: Observe and document behaviors by ward staff, engage in conversation every shift and 1-1, and weekly reminiscing road trip. Resident #20's (MONTH) 2019 and (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) electronic Medication Administration Record [REDACTED]#20 received prn [MEDICATION NAME] (an antipsychotic). The surveyor informed the head nurse registered nurse #2 on 3/13/19 at 2:57 p.m. of the above concern. The head nurse R.N. #2 informed the surveyor on 3/13/19 at 3:10 p.m. that the nurses had failed to document the reasons for the administration of [MEDICATION NAME] to Resident #20 on 2/2/19, 2/5/19, 2/17/19 and 3/12/19. The surveyor asked if the nurses who administered Resident #20 [MEDICATION NAME] should document the reasons why, R.N. #2 stated yes and the nursing staff would be receiving education. The surveyor informed the administrator, the registered nurse program coordinator, and the assistant administrator/licensed clinical social worker of the above concern with administration of antipsychotic medication to Resident #20 without adequate monitoring and indication for use in the end of the day meeting on 3/14/19 at 12:35 p.m. No further information was provided prior to the exit conference on 3/14/19.

Based on staff interview and clinical record review, the facility staff failed to provide the receiving provider with care plan goals when the resident was transferred for 1 of 15 residents in the survey sample, Resident #12. Findings included: Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of Resident #12's most recent MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/20/18 included a BIMS (brief interview for mental status) summary score of 03 out of a possible 15 points. On 03/12/19 at 12:00pm the surveyor interviewed Resident #12. During the interview, Resident #12 voiced he was recently hospitalized for [REDACTED]. On 03/13/19 the surveyor reviewed Resident # 12's clinical record. It contained a nurse progress note dated 01/29/19 at 8:56am that read in part: .evaluation at local hospital via 911/ambulance transport. His LAR (legal authorized representative) was notified of the change in patient condition and ER (emergency room ) evaluation at 0830 by RN .Resident #12 left facility at 0847. Report called to local hospital by RN. Resident #12 left facility at 0847 via local fire and rescue, accompanied by PCT (patient care technician) . The surveyor reviewed a physician order [REDACTED]. On 03/13/19 at 4:30 pm, the surveyor spoke to RN (registered nurse) #1 during an end of day meeting with the facilities administrative team. The surveyor asked RN#1, What health information was sent with Residents upon transfer to the local hospital? RN #1 stated MARs (medication administration records), the physician calls report to the ER physician and the nurse calls report to the ER nurse. There is a packet we send. Contact information and code status is also sent. The surveyor asked if the comprehensive care plan goals are sent with the Resident, RN #1 stated No, we do not. No further information regarding this issue was provided to the survey team prior to the exit conference on 03/14/19.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment for 1 of 15 residents (Resident #19). The findings included: The facility staff failed to code Resident #19's fall on the 1/15/19 MDS. The clinical record of Resident #19 was reviewed 3/12/19 through 3/14/19. Resident #19 was admitted to the facility 2/16/18 with [DIAGNOSES REDACTED]. Resident #19's annual MDS with an assessment reference date (ARD) of 1/15/19 assessed the resident with a brief interview for mental status in Section C0500 as 4/15. Section G Functional Status assessed the resident to need supervision of one person for transfers and supervision only to walk in room. Section J Health Conditions did not have any falls coded. The nursing progress note dated 12/28/18 11:46 a.m. read Resident #19 was in her room sitting in wheelchair and reports she leaned over to retrieve some items off of the floor and fell out of chair onto her knees. Not witnessed. Denies pain. Assessed by staff, assisted back into wheelchair. The comprehensive MDS with an ARD of 1/15/19 did not have any falls coded. The surveyor interviewed registered nurse #1 on 3/14/19 at 9:15 a.m. R.N. #1 reviewed the nursing progress note and the MDS. R.N. #1 stated in the computer there were no falls coded for the 1/15/19 MDS. R.N. #1 stated the psychiatrist are responsible for Section I, J, N and some of S. R.N. #1 stated a locum was the psychiatrist responsible for the 1/15/19 MDS. The surveyor informed the administrator, the registered nurse program coordinator, and the assistant administrator/licensed clinical social worker of the above concern of Resident #19's inaccurate MDS assessment in the end of the day meeting on 3/14/19 at 12:35 p.m. No further information was provided prior to the exit conference on 3/14/19.

Based on staff interview and clinical record review the facility staff failed to sustain an accurate clinical record for 1 of 15 Residents, Resident #15. Findings included: For Resident #15, the facility failed to ensure accurate code status in physician's orders [REDACTED]. Per clinical record review Resident #15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of Resident #15's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/18/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. On 03/12/19 at 2:59pm the surveyor reviewed Resident 15's clinical record. The Resident's clinical record included a DDNR (durable do not resuscitate) order form dated 09/26/18 from the Virginia Department of Health. The clinical record included an active physician's orders [REDACTED]. On 03/13/19 at 12:15pm the surveyor asked RN (registered nurse) #1 if Resident #15 was a DNR and voiced the concern of Resident #15's inaccurate clinical record. RN#1 stated I will have to look into this and see. RN #1 verified that Resident #15's clinical record was inaccurate. RN#1 stated This was an oversight and did not get changed. I will have that done. The administrative team was made aware of the above findings on 03/13/19 at 4:30pm at the end of day meeting. No further information regarding this issue was provided to the survey team prior to the exit conference on 03/14/19.

Based on observation, resident interview and staff interview, the facility staff failed to post the diet menu at a level that was visual by residents seated in wheelchairs and non-ambulatory residents. The findings included: The facility staff failed to post the diet menus at a level that could be viewed by residents seated in wheelchairs and those residents that were non-ambulatory. The surveyor met with the resident council on 3/12/19 at 2:30 p.m. The four members that attended the resident council requested the therapeutic recreational therapist join the meeting. When the surveyor asked the group about the food, one member of the resident council (Resident #16) stated, You have to call the staff over to find out what's on the menu. If you are in a wheelchair, you can't see the menus. Upon completion of the resident council meeting, the therapeutic recreational therapist and the surveyor viewed the area where the diet menus were kept. The diet menus, along with the Resident Rights poster and state survey results, were kept in a locked Plexiglas display cabinet near the entrance to the unit. The cabinet was above the handrails. The therapeutic recreational therapist stated the menus are way too high and the font is way too little on the menus for someone in a wheelchair to see. The surveyor was unable to read the menus from a wheelchair. The therapeutic recreational therapist stated the entire bulletin board needed to be lowered so everything would be at eye level. The surveyor informed the administrator, the assistant administrator/licensed clinical social worker and the registered nurse program coordinator of the above concern on 3/13/19 at 4:12 p.m. The R.N. coordinator stated the resident rights and the survey results are located in the visitor's room near the front entrance to the unit. The surveyor and the registered nurse program coordinator checked the visitor's room after the end of the day meeting. The survey results were located in a notebook and the Resident Rights poster was placed on the wall at eye level. RN Program Coordinator stated, The administrator is taking care of the Plexiglas for the menus. No further information was provided prior to the exit conference on 3/14/19.

Based on staff interview and clinical record review the facility staff failed to ensure 3 of 14 Residents were free of unnecessary [MEDICAL CONDITION] medication, #16, #17 and #10. The findings included: 1. For Resident #16 the facility staff failed to discontinue or review the use of the prn (as needed) medication [MEDICATION NAME]. Resident #16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/05/18 coded the Resident as 01 out of 15 in section C, cognitive status. This is a quarterly MDS. The Resident's clinical record was reviewed on 03/27/18. It contained a physician's orders [REDACTED].= 1 tab oral Q8H (every 8 hours) PRN for aggression and severe agit (agitation) for 297, for agitation and aggression. The Resident's eMAR (electronic medication record) was reviewed and contained an entry, which read in part [MEDICATION NAME] 2.5 mg = 1 tab oral Q8H PRN for aggression and severe agit for 297 days. There was no documentation in the Resident's clinical record that the physician had re-evaluated the Resident for continued use of the prn medication. The surveyor spoke with the treatment team on 03/29/18 at approximately regarding Resident #16. Unit manager stated that the electronic record system automatically inputs the length of time for PRN orders as 365 days from the order date. The physician stated that each Resident's PRN medication usage is reviewed by the treatment team every 28 days and that if they have not had any PRN administrations, the medication is discontinued. The concern of the PRN medication [MEDICATION NAME] not having a stop date, and the Resident not having been evaluated for continued PRN usage was discussed with the administrative team during a meeting on 03/29/18 at approximately 1530. No further information was provided prior to exit. 2. For Resident #17 the facility staff failed to discontinue or review the use of the prn (as needed) medication, [MEDICATION NAME] ([MEDICATION NAME]). Resident #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 03/13/18 coded the Resident as 3 out of 15 in section C, cognitive patterns. This is an admission MDS. Resident #17's clinical record was reviewed on 03/27/18. It contained a physician's orders [REDACTED].= 1 tab oral Q6H (every 6 hours) prn agitation for 365 days. The Resident's eMAR (electronic medication record) was reviewed and contained an entry, which read in part [MEDICATION NAME] 2mg = 1 tab oral Q6H PRN agitation for 365 days. There was no documentation in the Resident's clinical record that the physician had re-evaluated the Resident for continued use of the prn medication. The surveyor spoke with the treatment team on 03/29/18 at approximately regarding Resident #17. Unit manager stated that the electronic record system automatically inputs the length of time for PRN orders as 365 days from the order date. The physician stated that the treatment team reviews each Resident's PRN medication usage every 28 days and that if they have not had any PRN administrations, the medication is discontinued. The concern of the PRN medication [MEDICATION NAME] not having a stop date, and the Resident not having been evaluated for continued PRN usage was discussed with the administrative team during a meeting on 03/29/18 at approximately 1530. No further information was provided prior to exit. 3. The facility staff failed to provide a stop date of 14 days or a rationale for continue use of a prn (as needed) antipsychotic medication for Resident #10. Resident #10 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/3/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 7 out of a possible score of 15. Resident #10 was also coded as requiring limited assistance of 1 staff member for dressing and personal care and extensive assistance of 1 staff member for bathing. The surveyor performed a review of Resident #10's clinical record on 3/29/18. During this review, the surveyor noted that the resident had a physician order [REDACTED].O. (by mouth) . The order date for this medication was noted to be 11/8/17. There was no documentation of a rationale for the medication to be continued past 14 days but a stop date was found to documented as .for 206 days . On 03/29/18 at approximately 1:49 pm, the Treatment Team was notified of the antipsychotic medication, [MEDICATION NAME] 5 mg BID prn ordered by the physician for Resident #10 by the survey team. The survey team explained that this order does not meet the regulation that states the physician will evaluate the resident for continuation of an antipsychotic medication with a rationale of why this medication is to be continued greater than 14 days with duration included. The Unit Coordinator stated, We as a team look at this every 28 days but not at the 14 day mark. The amount of days given on this order is done by our pharmacy. No further information was provided to the surveyor prior to the exit conference on 3/29/18.

Based on observation, facility document review and staff interview, the facility staff failed to store, prepare and serve food in a sanitary manner in the facility kitchen. The findings included: On 3/29/18 at approximately 12:30 pm, the surveyor toured the facility kitchen and noted that a dietary aide was making sandwiches and the facial hair of the employee was not covered. The surveyor upon the observation on 3/29/18 at approximately 12:30 pm by the surveyor notified unit Coordinator and the Director of Food Operations of this finding. The Unit Coordinator stated to the dietary aide, Please throw that sandwich away that you just made and go and get a beard cover. The surveyor requested a copy of the facility policy regarding facial hair in the facility kitchen. On 3/29/18 at approximately 2:45 pm, the Unit Coordinator provided the surveyor with a copy of the facility policy titled, Workplace Appearance. Under section D of the policy with the sub title of this section being Staff in the Food Service Department have the following additional standards of employee attire and grooming: stated the following: .4. Food service employees must wear effective hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, equipment and utensils . No further information was provided to the surveyor prior to the exit conference on 3/29/18.

Based on observation and staff interview, the facility staff failed to prominently display any written information about how to apply for and use medicare and medicaid benefits, and how to receive refunds for previous payments covered by medicare and medicaid benefits. The Findings Included: On 02/08/17 beginning at approximately 8:10 a.m. during an initial tour of the facility the surveyor was unable to locate any information regarding how to apply for medicare/medicaid and how to receive refunds for previous payments covered by medicare/medicaid. On 02/09/17 at approximately 10:35 a.m. SW (social worker) #1 was asked about the information regarding medicare/medicaid. SW #1 acknowledged there was not a posting on the unit and verbalized to the surveyor that the admissions packet was not specific in regards to medicare and medicaid. The administrative staff were notified of the missing posting(s) regarding the medicare/medicaid information during a meeting with the survey team on 02/09/17 at approximately 11:40 a.m. During this meeting the administrative team verbalized to the survey team that the postings were now up on the unit and in the visitor's room. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview the facility staff failed to ensure a complete, accurate, and readily accessible clinical record. The findings included: The facility staff failed to ensure electronic clinical records were readily assessable for surveyor review. The survey team entered the facility on 02/08/17 at approximately 0800. The survey team leader met with the facility administrator at this time. The survey team leader was informed by the facility administrator that the facility now uses electronic documentation. The team leader requested access to the clinical records for the survey team. At approximately 1125 on 02/08/17, the assistant director informed the survey team that she had contacted(NAME)requesting computer access for the survey team. Asst. director stated that she was informed two days' notice was needed to establish access. She also stated if surveyors had a COV (Commonwealth of Virginia) account, she would be able to get access. Surveyors informed asst. director that they do have COV accounts. Asst. director stated she would return with requested access. At approximately 1140 on 02/08/17, the asst. director came to survey team, requesting personal information in order to establish computer access. At this time, the survey team contacted their supervisor at the Office of Licensure and Certification. At approximately 1215 on 02/08/17, a conference call was held with the survey team, facility administrative team, and the Office of Licensure and Certification. The facility administrative team stated they would supply staff assistants to the survey team in order to grant access to the clinical records. At approximately 1330 on 02/08/17, the survey team gained access to the Resident clinical records with the assistance of facility staff. At approximately 1545, the surveyors were provided with individual login credentials.

Based on observation and staff interview, the facility staff failed to ensure items in the kitchen were stored, labeled, and stored in the kitchen in a sanitary manner. The kitchen also was using unpasteurized hard shell eggs. The findings include: A tour of the kitchen was conducted on 4/12/16 at 11:50 a.m. with the food director and food manager. The large thaw cooler refrigerator was observed. There was observed a tray of mixed vegetables sitting on a food storage rack. The tray was uncovered and not labeled. There also was a small foam container of cooked mixed vegetables sitting on a food cart along with another small foam container of cooked potatoes. These items were covered, but not labeled. The food manager stated the items should be covered and labeled. The refrigerator lower food storage shelf was observed to have three large boxes of fresh eggs sitting on the shelf. The food director was asked if the eggs were pasteurized and stated the vendors they bought the eggs from did not supply pasteurized eggs and was unaware that the eggs were required to be pasteurized for use. The geriatric program director and Registered Nurse Coordinator were informed of the findings during a meeting with the survey team on 4/13/16 at 3:00 p.m. They stated the food director had purchased pasteurized eggs for use from the local grocery store.

Based on staff interview and clinical record review, the facility staff failed to submit the Minimum Data Set (MDS) for 2 of 9 residents in the survey sample (Residents # 1 and #7). 1. The facility staff failed to submit the MDS for Resident #1. 2. The facility staff failed to submit the MDS for Resident #7. The findings included: 1. The facility staff failed to submit the MDS for Resident #1. Resident #1 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The quarterly MDS (an assessment protocol) with an ARD (Assessment Reference Date) of 3/22/16 coded the resident as having a BIMS (Brief interview for Mental Status) score of 5 out of 15. Under Section D, the resident was scored at 16 for mood. The resident was also coded as only needing one person assist with bathing, dressing and personal hygiene. During the clinical record review of Resident #1 ' s chart, it was noted by the surveyor that the above documented MDS with an ARD of 3/22/16 had not be submitted electronically for approval. The MDS nurse was interviewed on 4/13/16 at approximately 1:30 pm in the MDS office by the surveyor. The MDS nurse stated This MDS that you are looking at has not been submitted or exported but I will do it right now. I know it is late by looking over this now with you. At 2:10 pm, the MDS nurse gave the surveyor a copy of the submission of the above documented MDS. The copy stated MDS 3.0 File Submission .Your submission has been received .Submission Date: 4/13/2016 at 14:00:02 (2:00 pm) . On 4/13/16 at 3:15pm, the Geriatrics Program Director and the RN (Registered Nurse) Coordinator was notified of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/14/16. 2. The facility staff failed to submit the MDS for Resident #7. Resident #7 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The comprehensive assessment MDS with an ARD (Assessment Reference Date) of 3/17/16 coded the resident as having a BIMS (Brief Interview Mental Status) score of 0 out of a possible score of 15. Under Section D for Mood, the resident received a score of 4. Resident #7 was coded as needing limited assistance of one staff member for bathing, personal hygiene and toileting. During the clinical record review of Resident #7 ' s chart, it was noted by the surveyor that the above documented MDS with an ARD of 3/17/16 had not be submitted electronically for approval. The MDS nurse was interviewed on 4/13/16 at approximately 2:45 pm in the MDS office by the surveyor. The MDS nurse stated This MDS that you are looking at has not been submitted or exported but I will do it right now. I know it is late by looking over this now with you. At 2:55 pm, the MDS nurse gave the surveyor a copy of the submission of the above documented MDS. The copy stated MDS 3.0 File Submission .Your submission has been received .Submission Date: 4/13/2016 at 15:46:16 . On 4/13/16 at 3:15pm, the Geriatrics Program Director and the RN (Registered Nurse) Coordinator was notified of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/14/16.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to observe proper hand hygiene while performing a dressing change on 1 of 9 residents in the survey sample (Resident #2). The findings included: Resident #2 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the resident ' s quarterly MDS (Minimum Data Set, an assessment protocol) with an ARD (Assessment Reference Date) of 2/11/16 scored the resident as having a BIMS (Brief Interview for Mental Status) a 2 out of a possible score of 15. Resident #2 is totally dependent on staff members for all activities of daily living. A review of Resident #2 ' s clinical record was performed. A Stage II intergluteal pressure area was noted in the treatment notes. On 4/12/16 at 2:40 pm, Registered Nurse (RN) #1 came into the conference room with gloves on her hands and stated the resident had soiled himself and they had to change his dressing. The surveyor went with RN #1 into the resident ' s room. The resident had already been cleaned up and the dressing had already been removed. RN #1, using the same gloves that were worn into the conference room was also used to redress the resident ' s pressure area. RN #1 removed her gloves after the dressing change, put the gloves in the trash can and exited the resident ' s room. There was no handwashing performed by RN #1 observed by the surveyor. At 3:30 pm in the conference room, the Infection Control Coordinator was notified of the above documented findings. The Infection Control Coordinator stated, The nurse should always wash her hands after the soiled dressing is removed, then after cleaning the wound as ordered. Then anytime she removes her gloves for any reason, she should wash her hands. The Infection Control Coordinator provided the surveyor with a copy of the policy and procedure titled Hand Hygiene at 4 pm. Under the section of Hand Hygiene Indications #10 states Perform hand hygiene after removing gloves. The Infection Control Coordinator also provided a copy of what the facility uses as a standard of practice from the text book of Perry and Potter, 8th edition, Clinical Nursing Skills & Techniques, page 957 under section Implementation #14 states Remove gloves and perform hand hygiene. On 4/13 16 at approximately 3:15 pm, the Geriatrics Program Director and the director of nursing was notified of the above documented findings. The director of nursing stated This is will be addressed with this nurse. No further information was provided to the surveyor prior to the exit conference on 4/14/16.

Based on staff interview and clinical record review, the facility staff failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 5 of 10 residents (Resident #1, Resident #3, Resident #4, Resident #2, and Resident #5). The findings include: 1. The facility pharmacist failed to ensure monthly pharmacy reviews were completed for Resident #1. Resident #1 was admitted to the facility 7/25/12 with [DIAGNOSES REDACTED]. The most recent quarterly minimum data set (MDS) assessment with an assessment reference date of 2/2/15 assessed the resident with impaired cognitive skills for both short and long memory and severe cognitive skills for daily decision making. Resident #1's clinical record was reviewed 4/21/15 and 4/22/15. The monthly pharmacy reviews were not on the clinical record and had to be requested from the administrator on 4/21/15. The monthly pharmacy reviews revealed dates they were printed and included 8/5/14, 8/20/14, 9/18/14, 10/10/14, 11/10/14, 12/5/14, 12/31/14, 1/30/15, 3/3/15, and 4/1/15. The surveyor discussed the pharmacy reviews with the administrator and the unit nurse coordinator on 4/22/15 at 4:15 p.m. He stated the printed date at the bottom of the review was the date the pharmacy did their reviews. The pharmacist then provided a review summary to the unit secretary and a note was generated to the physician. The physician was then provided the monthly pharmacy review with recommendations. Upon completion of the monthly drug regimen review, the unit secretary then checks and marks off the reviews when they are returned to ensure the monthly reviews have been completed. The administrator provided to the surveyor the dates of the June 2014 reviews for all the residents. The monthly drug regimen reviews for June 2014 were 7/24/14 and 7/25/14. He stated the date of the review was 8/5/14. He was informed that the June 2014 drug regimen review was greater than a month when the review occurred. The administrator then provided the surveyor with the dates of the July 2014 review which were 8/19/14 and 8/20/14 with the July 2014 monthly drug regimen review completed on 8/20/14. The monthly drug regimen reviews provided to the surveyor by the administrator did not include the month of the drug regimen review, only the date printed and the date reviewed and signed by the physician. The monthly reviews were completed after the month had passed and on one occasion 5 weeks after the month had passed (June 2014 with pharmacy review completed 8/5/14). The administrator stated the pharmacy review summary sheets with all the residents identified and the dates of the reviews were not part of the clinical record. No further information was provided prior to the exit conference on 4/22/15. 2. The facility staff failed to ensure drug regimen reviews were done each month by the facility pharmacist for Resident #3. The clinical record of Resident #3 was reviewed 4/21/15 and 4/22/15. Resident #3 was admitted to the facility 6/12/14 with [DIAGNOSES REDACTED]. pylori infection. Quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/1/14 indicated Resident #3 had a summary score of 11 out of 15. The monthly pharmacy reviews revealed dates they were printed and included 8/5/14, 8/20/14, 9/18/14, 10/10/14, 11/10/14, 12/5/14, 1/30/15, 3/3/15, and 4/1/15. The surveyor discussed the pharmacy reviews with the administrator and the unit nurse coordinator on 4/22/15 at 4:15 p.m. He stated the printed date at the bottom of the review was the date the pharmacy did their reviews. The pharmacist then provided a review summary to the unit secretary and a note was generated to the physician. The physician was then provided the monthly pharmacy review with recommendations. Upon completion of the monthly drug regimen review, the unit secretary then checks and marks off the reviews when they are returned to ensure the monthly reviews have been completed. The administrator provided to the surveyor the dates of the June 2014 reviews for all the residents. The monthly drug regimen reviews for June 2014 were 7/24/14 and 7/25/14. He stated the date of the review was 8/5/14. He was informed that the June 2014 drug regimen review was greater than a month when the review occurred. The administrator then provided the surveyor with the dates of the July 2014 review which were 8/19/14 and 8/20/14 with the July 2014 monthly drug regimen review completed on 8/20/14. There was no drug regimen review completed by the pharmacist for the month of December 2014. The administrator was unable to provide the surveyor with the December drug regimen review. The monthly drug regimen reviews provided to the surveyor by the administrator did not include the month of the drug regimen review, only the date printed and the date reviewed and signed by the physician. The monthly reviews were completed after the month had passed and on one occasion 5 weeks after the month had passed (June 2014 with pharmacy review completed 8/5/14). The administrator stated the pharmacy review summary sheets with all the residents identified and the dates of the reviews were not part of the clinical record. No further information was provided prior to the exit conference on 4/22/15. 3. The facility staff failed to ensure the drug regimen reviews were completed by the facility pharmacist for each month for Resident #4. The clinical record of Resident #4 was reviewed 4/21/15 and 4/22/15. Resident #4 was admitted to the facility 3/27/14 with [DIAGNOSES REDACTED]. Resident #4's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/2/15 assessed the resident with a cognitive summary score of 2 out of 15. He was not interviewable. The monthly pharmacy reviews revealed dates they were printed and included 8/20/14, 9/18/14, 11/10/14, 12/5/14, 12/31/14, 1/30/15, 3/3/15, and 4/1/15. No reviews were provided for June 2014 and September 2014. The surveyor discussed the pharmacy reviews with the administrator and the unit nurse coordinator on 4/22/15 at 4:15 p.m. He stated the printed date at the bottom of the review was the date the pharmacy did their reviews. The pharmacist then provided a review summary to the unit secretary and a note was generated to the physician. The physician was then provided the monthly pharmacy review with recommendations. Upon completion of the monthly drug regimen review, the unit secretary then checks and marks off the reviews when they are returned to ensure the monthly reviews have been completed. The administrator provided to the surveyor the dates of the June 2014 reviews for all the residents. The monthly drug regimen reviews were 7/24/14 and 7/25/14. He stated the date of the review was 8/5/14. The administrator then provided the surveyor with the dates of the July 2014 review which were 8/19/14 and 8/20/14 with the July 2014 monthly drug regimen review completed on 8/20/14. The administrator was informed that the June 2014 drug regimen review was not provided to the surveyor as well as the September 2014 drug regimen review. The monthly drug regimen reviews provided to the surveyor by the administrator did not include the month of the drug regimen review, only the date printed and the date reviewed and signed by the physician. The administrator stated the pharmacy review summary sheets with all the residents identified and the dates of the reviews were not part of the clinical record. No further information was provided prior to the exit conference on 4/22/15. 4. For Resident # 2, the facility staff failed to ensure the pharmacist completed monthly drug regimen reviews; specifically the June and July 2014 reviews. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS assessment completed on this resident was a quarterly assessment with an ARD of 03/23/15. The facility staff assessed the resident to usually understand and to be understood. She was coded in section C to have a cognitive score of 11 out of 15. On 4/21/15, during the clinical record review the surveyor was unable to locate any documentation to indicate the resident ' s drug regimen reviews were completed monthly. The administrator provided the reviews out of his files. The administrator stated the pharmacy review summary sheets with all the residents and the dates of the reviews were not part of the clinical record. On 4/22/15 at 9:10 am, Pharmacist #1 spoke with the surveyor stating we were working with the new computer system and we got behind 2-3 weeks. On 04/22/15 at 4:15 p.m., a meeting with the administrative staff; to include the administrator and unit manager was held. The surveyors issue regarding drug regimen reviews was discussed. The administrator stated, the June drug reviews were done on July 24th and 25th and July was done on July August 19th and 20th. They were late. He stated the printed date at the bottom of the review was the date the pharmacy did their reviews. The monthly drug regimen reviews provided to the surveyor by the administrator did not include the month of the drug regimen review, only the date printed at the bottom and the date reviewed and signed by the physician. The monthly reviews were completed after the month was over not during the actual month. The facility staff was not able to provide to the surveyor supporting documentation to indicate the drug regimen reviews were completed in the months of June and July 2015. No further information regarding the drug regimen review was provided to the survey team prior to the exit conference. 5. For Resident # 5, the facility staff failed to ensure the pharmacist completed monthly drug regimen reviews; specifically the June and July 2014 reviews Resident #5 was admitted to the facility on [DATE]. Resident #5 ' s [DIAGNOSES REDACTED]. Resident #5's minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/15 assessed him to understand and usually understood. He was coded to have a cognitive pattern summary score of 14. On 4/21/15, during the clinical record review the surveyor was unable to locate any documentation to indicate the resident ' s drug regimen reviews were completed monthly. The administrator provided the reviews out of his files. The administrator stated the pharmacy review summary sheets with all the resident and the dates of the reviews were not part of the clinical record. On 4/22/15 at 9:10 am, Pharmacist #1 spoke with the surveyor stating we were working with the new computer system and we got behind 2-3 weeks. On 04/22/15 at 4:15 p.m., a meeting with the administrative staff; to include the administrator and unit manager was held. The surveyors issue regarding drug regimen reviews was discussed. The administrator stated, the June drug reviews were done on July 24th and 25th and July was done on July August 19th and 20th. They were late. He stated the printed date at the bottom of the review was the date the pharmacy did their reviews. The facility staff was not able to provide to the surveyor with supporting documentation to indicate the drug regimen reviews were completed in the months of June and July 2015. The monthly drug regimen reviews provided to the surveyor by the administrator did not include the month of the drug regimen review, only the date printed at the bottom and the date reviewed and signed by the physician. The monthly reviews were completed after the month was over not during the actual month. No further information regarding the drug regimen review was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to obtain a physicians order prior to obtaining a lab for 1 of 10 Resident's, Resident #5. The findings include: For Resident #5 the facility staff failed to obtain a physicians order for a CBC (complete blood count) and CMP (comprehensive metabolic panel) lab test. Resident #5 was admitted to the facility on [DATE]. Resident #5 ' s [DIAGNOSES REDACTED]. Resident #5's minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/15 assessed him to understand and usually understood. He was coded to have a cognitive pattern summary score of 14. Resident #5 ' s clinical record was reviewed on 4/22/15. On his physician order [REDACTED]. The laboratory section of the clinical record revealed the results of an obtained CBC and a CMP report dated 1/8/15 and the results of an obtained CBC and a CMP report dated 1/15/15. However, an order to obtain one of the labs was not located in the clinical record. RN #2 was asked to assist in locating an order for [REDACTED].#2 returned to the surveyor and stated, We have the same order for both of the labs the one on 1/8/15 an the one on 1/15/15. The 1/8/15 was the one we had the order for every 4 months. On 4/22/15 at 4:15 pm, the administrator, and director of nurses were informed of the lab test performed without an order. Prior to exit on 4/22/15, no further information related to the lab order was provided to the surveyor.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 10 residents (Resident #3 and Resident #4). The findings include: 1. The facility staff failed to ensure an accurate DDNR (Durable Do Not Resuscitate) form for Resident #3. The clinical record of Resident #3 was reviewed 4/21/15 and 4/22/15. Resident #3 was admitted to the facility 6/12/14 with [DIAGNOSES REDACTED]. pylori infection. Quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/1/14 indicated Resident #3 had a summary score of 11 out of 15. The clinical record revealed the Virginia Department of Health Durable Do Not Resuscitate Order form dated 7/2/14. The form had been signed by the physician and the person authorized to consent on the patient's behalf. The form had not been marked if Resident #3 was capable of making an informed decision about his medical treatment or incapable of that decision making or part 2 of the form that read in part If you checked 2 above, check A, B, or C below: None of the boxes had been marked. The clinical record did reveal a signed telephone order dated 7/2/14 11:45 a.m. that read in part Do Not Resuscitate. The surveyor informed the administrator and the unit nurse coordinator of the above finding on 4/22/15 at 4:15 p.m. The surveyor discussed the form with the attending physician other #1 on 4/22/15 at 5:05 p.m. The attending physician stated not checking the boxes was an oversight on his part. He stated he called Resident #3's responsible party and confirmed she still wanted the DNR status for Resident #3. He provided the surveyor an addended DNR. No further information was provided prior to the exit conference on 4/22/15. 2. The facility staff failed to ensure the facility staff maintained a complete and accurate March 2015 treatment administration records and failed to document when the responsible party was notified of an abrasion that occurred 2/21/15 for Resident #4. The clinical record of Resident #4 was reviewed 4/21/15 and 4/22/15. Resident #4 was admitted to the facility 3/27/14 with [DIAGNOSES REDACTED]. Resident #4's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/2/15 assessed the resident with a cognitive summary score of 2 out of 15. He was not interviewable. (a). The March 2015 Medication Reconciliation Transfer Profile (physician orders) was reviewed 4/21/15 and 4/22/15. The order read Coal Tar Shampoo 0.5% 1 applicator use as shampoo every Mon (Monday), Thu (Thursday), Sat (Saturday): 1500 (3:00p.m.) *Hazardous Drug* Toxic *Ignitable**PPE (personal protective equipment): Gown*; dandruff. The surveyor reviewed the March 2015 treatment administration records. There were blanks for 3/2/15 (Monday), 3/7/15 (Saturday), 3/9/15 (Monday), 3/14/15 (Saturday), 3/23/15 (Monday), and 3/26/15 (Thursday). The surveyor observed the bath area and found the bottle of tar shampoo in Resident #4's box. The bottle was ¼ full. (b). The interdisciplinary notes were reviewed and the ID note dated 2/21/15 0000 (midnight) read Pt (patient) has a new abrasion on (R) (right) forearm. Dressing was applied d/t (due to) scant bleeding. Pt (patient) removed dressing stating It was too much on my own. When pt (patient) was asked how the abrasion occurred, he stated I hit it on something, I don't know what. Presently no dressing on R arm-bleeding has ceased. MOD (medical on duty) notified. LAR (legal representative) to be notified in a.m. (morning). A (assessment): New abrasion P (plan): Monitor. The next entry in the ID notes was dated 2/25/15 at 0805 (8:05 a.m.) and did not include evidence the LAR was informed of the abrasion that occurred 2/21/15. The surveyor did a family interview with Resident #4's son (responsible party) on 4/22/15 at 12:58 p.m. Resident #4's RP stated They call me about everything. The surveyor informed the administrator and the unit nurse coordinator of the above findings on 4/22/15 at 4:15 p.m. The unit nurse coordinator stated she was unable to locate the incident report for 2/21/15 and would expect staff to document when families are informed of falls, skin issues, medication changes, etc. The administrator stated the FIRS (incident reports) were locked up at this hour and he couldn't confirm the RP had been informed. No further information was provided prior to the exit conference on 4/22/15.