Every finding on record at Wythe Cnty Community Hosp Ecu

Based on staff interview and clinical record review, the facility staff failed to provide residents and/or resident representatives with a copy of the baseline care plan.The findings included: A review of residents' clinical records failed to reveal evidence of the facility providing a copy of the baseline care plan to the resident and/or resident representative. On 11/25/25 at 12:24 PM, the Director of Clinical Effectiveness Quality and Risk Management stated they were unaware of the need to provide residents with a copy of the baseline care plan, and this was not a facility practice. The facility policy titled Interim Care/Interdisciplinary Care Plans did not address providing the resident and their representative with a summary of the baseline care plan.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on staff interview and clinical record review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 1 of 5 sampled residents, Resident #1. The findings included:Resident #1's diagnoses included but were not limited to congestive heart failure, hypertension, myocardial infarction, and hyponatremia.Resident #1's ECU [extended care unit] admission History dated 11/20/25 indicated the resident had received a pneumococcal vaccine after the age of 65. However, the date and type of pneumococcal vaccine was not documented in Resident #1's clinical record.Registered Nurse (RN) #1 was interviewed on 11/25/25 at approximately 11:45 AM. RN #1 verified Resident #1's admission history form only indicated he had received a pneumococcal vaccine after the age of 65 but did not include the type of pneumococcal vaccine or date received. The facility Infection Preventionist (IP) provided Resident #1's Official Immunization Record from the Virginia Immunization Information System (VIIS) which indicated the resident had not received a pneumococcal vaccine in the past. The facility was unable to provide evidence of Resident #1 being offered a pneumococcal vaccine following admission. On 11/25/25 at 12:15 PM, the survey team met with the administrative team and discussed the concern of staff failing to offer Resident #1 a pneumococcal vaccine.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on staff interview and clinical record review, the facility staff failed to ensure the correct code status was in place for 1 of 6 residents, Resident #1.The findings included:Resident #1's diagnoses included but were not limited to congestive heart failure, hypertension, myocardial infarction, and hyponatremia. Resident #1's ECU [extended care unit] admission History dated 11/20/25 indicated the resident had no advanced directive but code status was DNR (do not resuscitate). A review of Resident #1's clinical record on 11/24/25 revealed a current order dated 11/20/25 for full code resuscitation status. On 11/24/25 at 2:45 PM, during an interview with Registered Nurse (RN) #1, the documentation discrepancy regarding Resident #1's code status was discussed. RN #1 stated she would clarify this with the resident. RN #1 returned and stated the resident's code status was correct on the admission history and should be DNR. Resident #1's code status order was changed to DNR on 11/24/25 at 3:30 PM. On 11/25/25 at 1:15 PM, RN #1 stated the physician entered the code status order and she did not know what happened to cause the error. On 11/25/25 at 1:40 PM, the survey team met with the administrative team and discussed the concern regarding Resident #1's code status.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on observation and staff interview, the facility staff failed to store food and items used to prepare food in a manner to prevent the outbreak of foodborne illness. As evidenced by outdated items in the kitchen area and nesting of wet pans. The findings included: The facility kitchen included 7 containers of out of date water chestnuts, 18-gallon jugs of out of date water, and nesting of wet pans. Two surveyors entered the facility kitchen (dietary department) on [DATE] at approximately 11:00 a.m. The registered dietician (RD) accompanied the surveyors on this observation. Surveyor #1 identified the following issues. Eighteen-gallon jugs of water with a best buy date of [DATE]. The RD verbalized to the surveyor that the jugs of water were not for oral consumption, they knew they were out of date, and they were going to discard them. However, the jugs of water were stored with items that were currently being used in the facility kitchen. This surveyor also observed metal baking pans turned upside down and stacked on top of each other. The surveyor visualized water droplets on the outside of one of these pans. When brought to the attention of the RD, the RD stated they should have been placed on a drying rack and they would have them redone. Surveyor #2 identified 7 cans of water chestnuts labeled best before ,[DATE]. After reviewing the date on the container dietary staff person #1 stated these were expired. When asked who was responsible for discarding expired items the RD verbalized to the surveyors that it was everyone responsibility to identify out of date products and they used the process First in first out. On [DATE] at 9:53 a.m., surveyor #1 made a second observation of the dietary department. The 18-gallon jugs of water remained on the same shelf in the dietary department. On [DATE] at 12:08 p.m., Registered nurse #1 was made aware of the issues in the kitchen area. No further information regarding these issues were provided to the survey team prior to the exit conference on [DATE].

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment for 1 of 7 records, Resident # 7. The findings included: The discharge MDS was coded that Resident #7 was discharged to an acute care hospital when the resident was actually discharged home with home health services. Resident #7's closed electronic clinical record was reviewed on 02/06/2020. The physician's discharge summary listed the resident's [DIAGNOSES REDACTED]. The discharge MDS with an ARD (assessment reference date) of 11/20/19 noted in Section C (Cognitive Patterns) that Resident #7 had a BIMS (brief interview for mental status) score of 6 out of 15. In Section A (Type of Assessment) the resident's discharge was described as planned and return was not anticipated. Also in Section A (Identification Information), the MDS noted Resident #7 was discharged to an Acute Hospital. The clinical record included a nurse's note dated 11/20/19 that indicated Resident #7, with their medical power of attorney, were given discharge instructions, education and prescriptions before being escorted by staff via wheelchair to the facility's front entrance for discharge. The clinical record also included a discharge summary that read within the Hospital Course that Resident #7 would be discharged home with home health. The discharge summary was written and electronically signed by a nurse practitioner and also electronically signed by the attending physician. The facility's administrator was interviewed on 2/06/2020 at 10:40 a.m. regarding the inaccurate MDS concern. The administrator stated that none of the facility's MDS coordinators were available at the time to be interviewed; the MDS coordinator who filled out Resident #7's discharge MDS was out sick. The administrator recalled Resident #7 and remembered the resident leaving the facility with family after being discharged home with home health services. After viewing the MDS, the administrator acknowledged the MDS read that Resident #7 was discharged to an acute hospital. No further information regarding this issue was provided to the survey team prior to exit.

Based on staff interview and clinical record review the facility staff failed to ensure that residents receive treatment and care by following physician's orders [REDACTED].#107). The findings included: The facility staff failed to wait 6 hrs between two doses of [MEDICATION NAME] which was ordered every 6 hrs prn (as needed) and failed to administer [MEDICATION NAME] in the evening as ordered for Resident #107. Resident #107's electronic clinical record was reviewed on 02/05/2020. [DIAGNOSES REDACTED]. Resident #107 was a new admission and therefore no MDS (minimum data set) was reviewed. The resident was alert and oriented on 02/05/2020. Physician orders [REDACTED]. 1. [MEDICATION NAME] Tab ([MEDICATION NAME] Tab) 50mg by mouth every 6 hours as needed for pain (pain scale 4-10). 2. Atorvastatin Tab ([MEDICATION NAME] Tab) 80mg by mouth every night at bedtime. The electronic Medication Administration Record [REDACTED]. The first time at 7:15 a.m. for a pain scale of 4, the second time at 11:36 a.m. for a pain scale of 6, and the third time at 9:20 p.m. for a pain scale of 4. There was 4 hours and 21 minutes between the first and second dose instead of 6 hours that was ordered. The eMAR provided documentation that Resident #107 received [MEDICATION NAME] 40mg by mouth on 01/26/2020 at 9:02 a.m. even though the medication was ordered to be given at bedtime. The facility's administrator was informed of these medication administration concerns on 02/05/2020 at approximately 4:30 p.m. The administrator acknowledged the eMAR showed there was less than 6 hrs between the first two doses of [MEDICATION NAME] on 02/04/2020 and [MEDICATION NAME] was given in the morning of 01/26/2020 (9:02 a.m.) instead of the ordered bedtime (scheduled for 9:00 p.m.). The facility's administrator was interviewed on 02/06/2020 at 11:53 a.m. regarding the medication administration time concerns. The administrator had spoken with the nurse who had administered the medications and there was no more information provided. No further information regarding the medication administration times was provided to the survey team prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store medications on 1 of 1 units the extended care unit. The findings included: The facility failed to store insulin and a sodium chloride flush per their facility policy. On 12/11/18 at 12:19 p.m., the surveyor observed a box labeled [MEDICATION NAME] R insulin on the Residents over the bed table. Inside this box, the surveyor observed an open vial of [MEDICATION NAME] R insulin. Resident #54 stated she had received insulin earlier. On 12/11/18 at 2:07 p.m., the surveyor observed a syringe of sodium chloride used for flushing IV's on the Residents over the bed table. On 12/12/18 10:14 a.m., the surveyor spoke with RN (registered nurse) #1 regarding the insulin and sodium chloride flush at bedside. RN #1 stated the medications should not have been left at the bedside. On 12/12/18, RN #1 provided the surveyor with the facility policy/procedure titled, Medication Administration/Review ECU (extended care unit). This policy/procedure read in part, .To establish guidelines for proper administration of medications in the Extended Care Unit .All resident's medications will be stored in the resident's drawer of the ECU medication cart . The administrative staff were notified of the issues regarding the medications on 12/12/18 at 12:22 p.m. No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on staff interview and employee record review, the facility staff failed to provide dementia training for 5 of 5 aides who worked on the extended care unit. The findings included: The facility did not provide dementia management training. The surveyor requested the facility to provide evidence of training to include dementia management training. On 12/12/18 at 9:45 a.m., during an interview with the HRD (human resource director). The HRD verbalized to the surveyor that they had 5 aides that worked on the ECU (extended care unit) and she did not think they had done anything regarding dementia management training. The administrative staff were notified of the concerns regarding dementia training on 12/12/18 at 12:22 p.m. No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on staff interview the facility staff failed to notify the Ombudsman of Resident transfers or discharges. The findings included: The facility failed to notify the Ombudsman when a Resident was transferred or discharged . On 12/12/18 at 11:15 a.m., during an interview with RN (registered nurse) #1 regarding Resident discharges RN #1 verbalized to the surveyor that that they do not notify the Ombudsman of transfers and/or discharges and she was not aware of the regulation. The administrative staff were notified of the issue regarding the Ombudsman notification on 12/12/18 at 12:22 p.m. No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on observation, staff interview and facility policy review, the facility staff failed to label, date and store food in the refrigerator and failed to ensure facility staff with beards wore beard restraints. The findings included: The surveyor toured the facility kitchen 9/6/17 beginning at 9:40 a.m. with the dietary manager and other #5. During the initial tour of the facility the following items were observed: In the reach in refrigerator, a stainless steel pan held a package of roast beef. The package had a stamp that read 6/21/17. The package itself read Use by or freeze by 8/4/17. The pan containing the roast beef had a layer of roast beef juices; however, the surveyor was unable to observe when the roast beef had been placed in the reach in refrigerator. There was no date found on the package. Other #5 stated the roast beef would be thrown away. I don't know when it was pulled. It must have got missed. In a second reach in refrigerator, the surveyor observed an opened bag of multiple pieces of bread. The bag of multiple pieces of bread was not labeled as to the contents or dated and was not securely tied. Also, the surveyor observed 6 bags of bagels. There was no date or label on the bagels. The dietary manager stated the bags of bagels had been removed from their original boxes that contained all the product information. The dietary manager stated the kitchen will return to leaving in the original packaging. The surveyor also observed an opened bag of vegetable medley that had no date when opened. The bag was not securely tied and the surveyor could easily see the bag's contents. Other #5 stated the bag should have been labeled when opened. The surveyor returned to the kitchen at 9/6/17 at 11:30 a.m. to do the tray line temperatures. The surveyor observed other #3 (the cook) as the tray line temperatures were checked. The surveyor observed other #3 with facial hair and a mustache. Other #3 did not have a beard restraint to cover the facial hair. When asked about the beard restraint, other #3 stated didn't need to wear one because of the length of the beard. Other #3 stated a beard restraint was only worn if the beard was longer than ¼ inch. Other #3 stated it didn't matter to him. I'll wear a beard restraint or shave it. The surveyor informed the chief nursing officer (CNO), administrative registered nurse #1, administrative registered nurse #2, and the interim chief executive officer (CEO) of the above observations on 9/6/17 at 4:30 p.m. The surveyor requested the facility policy on the storage of foods and label and dating food items. Also, information on beard restraints. No further information was provided prior to the exit conference on 9/7/17.

Based on staff interview and facility document review, the facility staff failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly and the designated key members of the committee attended quarterly. The findings included: The facility staff failed to ensure the director of nursing, a physician and three other staff members attended the meetings quarterly and that the QAA meetings were held quarterly. The surveyor met with the Director of Clinical Effectiveness (administrative registered nurse #1) on 9/7/17 at 10:50 a.m. to discuss the Quality Assessment and Assurance program. Administrative registered nurse #1 stated that committee met on the extended care unitand she was not part of that meeting. The current manager for that unit was not available during the survey 9/6/17 through 9/7/17 to interview. The surveyor and the Director of Clinical Effectiveness reviewed the QAA information on 9/7/17. The QAA meeting held 12/14/16 did not include three other staff members. The sign in roster included the medical director, the unit manager of ECU, and two other members. The QAA meeting designated as a quarterly meeting was held 2/22/17. This meeting did not include the unit manager/DON (director of nursing). March 2017 had four weekly meetings; however, none were designated as a QAA meeting and did not include the key members of the committee. The QAA meeting held 4/5/17 did not include the unit manager/DON. Three other weekly meetings were held; however, none had the required key members present. May 2017 had three weekly meetings; however, none were designated as a QAA meeting and had the required key members. A QAA meeting was held 6/28/17. The physician was not present at the meeting. The surveyor interviewed the Director of Clinical Effectiveness on 9/7/17 at 11:10 a.m. The director stated the unit manager tried to coordinate a date to meet when the medical director would be available. The director of clinical effectiveness stated the meetings were held on a day when the medical director had surgery. She also stated the unit manager was clocked in to the area but probably didn't sign the roster. The surveyor informed the chief nursing officer (CNO), the administrative registered nurse #1/Director of Clinical Effectiveness, and administrative registered nurse #2 of the concern with the QAA program during the meeting on 9/7/17 at 11:50 a.m. No further information was provided prior to the exit conference on 9/7/17.

Based on observation and staff interview, the facility staff failed to post information regarding the local ombudsman contact information and failed to post contact information on the local area on aging. The findings included: The facility staff failed to ensure the Resident Rights poster contained information on the local long-term care ombudsman and the local area on aging. During the initial tour of the facility on 9/6/17 at 9:15 a.m., the surveyor observed the Resident Rights poster enclosed in the bulletin board on the wall near the ECU (extended care unit) nurse's station. The surveyor did not observe information on the local long-term care ombudsman and the local area on aging. The surveyor observed the Resident Rights poster again on 9/7/17 at 8:00 a.m. The area where the local ombudsman contact information should have been located was blank. The area where information on the local area on aging was blank. The poster was dated November 21, 2016. The surveyor interviewed registered nurse #1 on 9/7/17 at 8:00 a.m. R.N. #1 stated that information could possibly be found in the ECU admission packet. The surveyor and R.N. #1 reviewed the packet and found no information for the local long term care ombudsman or the local area on aging. The surveyor informed the CNO (chief nursing officer), administrative registered nurse #1, and administrative registered nurse #2 of the missing information from the Resident Rights poster on 9/7/17 at 11:50 a.m. The C.N.O. stated the information on the local ombudsman was incorrect on the local ombudsman website and the facility had called to obtain the name of the current local long term care ombudsman. The C.N.O. stated the information contained a previous ombudsman for the area. All agreed the Resident Rights poster had missing information. No further information regarding the incorrect postings was provided to the surveyor prior to the exit conference on 9/7/17.

Based on observation and staff interview, the facility staff failed to ensure the daily staffing information posted contained the name of the facility, the current census, the total hours worked and the actual hours worked for each nursing discipline. The findings included: The facility staff failed to ensure the daily staffing information posted contained the name of the facility, the census, the actual hours worked and the total hours worked. During the initial tour of the facility on 9/6/17 at 9:15 a.m., the surveyor observed the staffing sheet. The staffing information was written on an erasable board and was enclosed in the bulletin board on the wall near the ECU (extended care unit) nurse's station. The surveyor did not observe the name of the facility, the current census, the total hours worked and the actual hours worked on the erasable board. The surveyor interviewed registered nurse #1 on 9/7/17 at 8:00 a.m. R.N. #1 stated that information was all that was written on the board. The surveyor informed administrative registered nurse #2 of the staffing requirements on 9/7/17 at 9:30 a.m. and administrative R.N. #2 provided the surveyor with the Hospital Staffing Roster dated 9/6/17. The staffing for ECU (extended care unit) contained the names of registered nurse #1 and certified nursing assistant #3. The roster did not contain the name of the facility, census, actual hours worked or total hours worked. The surveyor informed R.N. #2 that the posted staffing information was to be retained for 18 months. The surveyor informed the C.N.O. (chief nursing officer),administrative registered nurse #1, and administrative registered nurse #2 of the above concern on 9/7/17 at 11:50 a.m. No further information regarding the staff postings was provided to the surveyor prior to the exit conference on 9/7/17.

Based on staff interview and facility document review, it was determined that the facility staff failed to develop and implement a policy and procedure to prohibit resident abuse for the 8 bed Extended Care Unit (ECU) of the hospital. Additionally, the facility staff failed to screen potential residents for possible sexual offences prior to admission into the ECU. The Findings included: On October 13, 2015 at 3 p.m. the surveyor entered the 8 bed Extended Care Unit of the hospital. The surveyor met with the Chief Nursing Officer (CNO) and requested the policy and procedure for abuse prevention. The surveyor informed the CNO that the surveyor would need the policy for abuse prevention to include hiring requirements and investigations of suspected abuse. The surveyor notified the CNO that the surveyor would also need to see evidence that the facility was screening potential new residents for a history of sexual offences. On October 14, 2015 at 8 a.m. the Director of Risk Management (DoRM) hand delivered a policy and procedure titled, Suspected Elder Abuse. The policy and procedure read in part . Purpose: Any elderly or incapacitated adult presenting to (name of hospital withheld) for treatment or traumatic injuries will have complete assessment and have identified and suspicious signs or symptoms which may indicate abuse and to have this report to the appropriate authorities. Procedure: . Assessment-- . Alleged violations will be reported to the appropriate state agency with five (5) working days. Abuse/neglect will be reported to the (name of agency withheld) of Social Services at (telephone number withheld) and the Virginia Department of Health via Fax (telephone number withheld), and the District III Ombudsman at (telephone number withheld) and the State Surveyor at (telephone number withheld). (sic) The policy and procedure was reviewed and revised on 2/2014. The surveyor observed that the policy was inaccurate related to the time frame for notification of suspected abuse and neglect to Adult Protective Services (APS). Notification of any allegation of suspected abuse or neglect must be reported immediately to the APS. The facility must initiate an investigation and the findings of the investigation must be reported within 5 days to the appropriate agencies. On October 14, 2015 at 1:30 p.m. the surveyor met with the CNO and DoRM. The surveyor informed the Administrative Team (AT) that the facility policy and procedure for abuse prevention was incorrect as related to the reporting timeline to APS. The surveyor notified the AT that any and all allegations of suspected abuse must be reported immediately to APS. The surveyor also notified the AT that she was still waiting for validation/verification that residents were being screened for possible sexual offenses prior to being admitted into the unit. The DoRM stated that the registration department was checking/doing the screening for sexual offences prior to admission into the unit. The DoRM called the registration department and asked for validation/verification that residents were being screen prior to admission into the ECU for a history of sexual offences. The DoRM hung up the telephone and informed the surveyor that the registration department stated that they were not completing the sexual offender screening prior to admission. The surveyor notified the AT that Residents must be screened prior to admission onto the unit for a history of possible sexual offences. On October 14, 2015 at 2:10 p.m. the Director of the Registration Department (DoRD ) came and met with the CNO, DoRM and surveyor. The DoRD stated that the registration department was supposed to check for sexual offences. The DoRD stated that when patients were admitted into the hospital they did not know if the patient would be admitted to the ECU unit, and therefore the registration department did not know when and who to complete the screening on for sexual offences. No additional information was provided prior to exiting the facility as to why the facility failed to develop and implement a policy and procedure for abuse prevention. Furthermore, no additional information was provided as to why the facility staff were not screening for possible sexual offences prior to residents being admitted into the unit.

Based on a medication pass and pour observation, 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 3 Residents in the sample survey, Resident #3. For Resident #3 the facility staff failed to ensure complete and accurate Physician order [REDACTED]. The Findings Included: Resident #3 was a [AGE] year old male who was admitted into the unit on 10/9/15. Admitting [DIAGNOSES REDACTED]. No Minimum Data Set (MDS) assessments were available due to his recent admission on 10/9/15. On October 14, 2015 at 8:20 a.m. the surveyor observed a Registered Nurse (RN #3) for a medication pass and pour observation. The surveyor observed RN (#3) obtain multiple medications including, but not limited to: [MEDICATION NAME] 5mg. RN (#3) crushed all the medications, including the [MEDICATION NAME] 5 mg and administered the medications through Resident #3's PEG tube. On October 14, 2015 at 8:30 a.m. the surveyor reviewed Resident #3's clinical record. Review of the clinical record produced signed Physician order [REDACTED]. POS ' s included, but were not limited to: [MEDICATION NAME] Tab (tablet) ([MEDICATION NAME] Tab) 5 mg po (by mouth) daily. Nothing By Mouth. (sic) Additional review of the clinical record produced Resident #3's October 2015 Medication Administration Records (MAR 's). Review of the October 2015 MAR's revealed that the facility staff were documenting that the [MEDICATION NAME] 5 mg was being administered by mouth. On October 14, 2015 at 8:35 a.m. the surveyor notified RN (#3) that Resident #3's POS's ordered for Resident #3's [MEDICATION NAME] 5 mg to be administered by mouth. RN (#3) stated that Resident #3 received all of his medications via his PEG tube. The surveyor notified RN (#3) that someone had entered the order in incorrectly of Resident #3's POS's and that the POS's were inaccurate. The surveyor also notified RN (#3) that the facility staff had documented on the October 2015 MAR's that the [MEDICATION NAME] 5 mg was being administered by mouth; with in fact the [MEDICATION NAME] was being administered via the PEG tube. On October 14, 2015 at On October 14, 2015 at 1:30 p.m. the surveyor notified the Chief Nursing Officer CNO) and the Director of Risk Management (DoRM) that the facility staff failed to ensure a complete and accurate clinical record for Resident #3. The surveyor notified the Administrative Team (AT) that Resident #3's POS's ordered for [MEDICATION NAME] 5 mg to be administered by mouth. The surveyor notified the AT that Resident #3 was NPO (nothing by mouth) and that the remainder of his medications were ordered to be administered via the PEG tube. The surveyor also notified the AT that the facility staff were also documenting that the [MEDICATION NAME] was being administered by mouth on the October 2015 MAR ' s, when in fact, the medication was being administered via the PEG tube. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure a complete and accurate clinical record, POS's and MAR's, for Resident #3.

Based on staff interview and clinical record review, it was determined that the facility failed to develop a Comprehensive Care Plan for 1 of 3 Residents in the sample survey, Resident #2. For Resident #2 the facility staff failed to develop a CCP to include an indwelling Foley catheter on a 5 Day Medicare and Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/1/15. The Findings Included: Resident #2 was a [AGE] year old female ho was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS located in the clinical record was a 14 Day Medicare MDS assessment with an ARD of 10/8/15. The facility staff coded that Resident #2 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #2 required extensive assistance (3/3) with Activities of Daily Living (ADL's). In Section H. Bladder and Bowel the facility staff coded that Resident #2 was always continent of her bladder. On October 14, 2015 at 12 noon the surveyor reviewed Resident #2's clinical record. Review of the clinical record produced a 5 Day Medicare and Admission MDS assessment with an ARD of 10/1/15. The facility staff coded that Resident #2 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #2 required extensive assistance (3/3) with ADL's. In Section I. Bladder and Bowel the facility staff coded that Resident #2 had an indwelling catheter and that urinary continence was not rated. In Section V. Care Area Assessment (CAA's) Resident #2 triggered for Urinary Incontinence and Indwelling Catheter. The facility staff coded that they would develop a CCP to address Resident #2 ' s indwelling catheter. Further review of the clinical record produced Resident #2's CCP. Review of the CCP failed to produce a care plan that addressed Resident #2's indwelling Foley catheter. Continued review of the clinical record produced a Nurse's Note dated 10/1/15 that documented that Resident #2's Foley catheter was discontinued. On October 14, 2015 at 12:25 p.m. the surveyor spoke with a Registered Nurse (RN #3), who was assigned to care for Resident #2 for the day. The surveyor notified RN (#3) that Resident #2's 5 Day Medicare and Admission MDS assessment with the ARD of 10/1/15 identified that Resident #2 had an indwelling Foley catheter. The surveyor also notified RN (#3) that Resident #2 triggered for urinary incontinence/indwelling catheter in Section V.CAA's. The surveyor notified RN (#3) that the facility staff had documented that a care plan would be developed to address Resident #2's urinary incontinence/indwelling catheter. The surveyor notified RN (#2) that review of the CCP failed to produce a care plan that addressed Resident #2's urinary incontinence/indwelling catheter. The surveyor reviewed Resident #2's 5 Day Medicare and Admission MDS assessment and the CCP with RN (#2). RN (#2) was unable to locate a care plan that addressed Resident #2's urinary incontinence/indwelling catheter. On October 14, 2015 at 1:30 p.m. the surveyor notified the Chief Nursing Officer CNO) and the Director of Risk Management (DoRM) that Resident #2 was admitted into the unit with a Foley catheter. The surveyor also notified the Administrative Team (AT) that Resident #2 had a 5 Day Medicare and Admission MDS assessment with an ARD of 10/1/15 that coded that Resident #2 had an indwelling Foley catheter. The surveyor notified the AT that Resident #2 triggered for urinary incontinence/indwelling catheter in Section V. CAA's. The surveyor notified the AT that the facility staff had documented that a care plan would be developed to address Resident #2's urinary incontinence/indwelling catheter. The surveyor notified the AT that review of the CCP failed to produce a care plan that addressed Resident #2 ' s urinary incontinence/indwelling catheter. No additional information was provided prior to exiting the facility as to why the facility staff failed to develop a CCP for Resident #2 that included a care plan that addressed Resident #2's indwelling Foley catheter.

Based on a medication pass and pour observation, staff interview, clinical record review and facility document review it was determined that the facility staff failed to follow professional standards of nursing practice in the area of medication administration via a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 3 Residents in the sample survey, Resident #3. For Resident #3 the facility staff crushed all of his physician ordered medications together and administered all of the medications together via the PEG tube. The Findings Included: Resident #3 was a [AGE] year old male who was admitted into the unit on 10/9/15. Admitting [DIAGNOSES REDACTED]. No Minimum Data Set (MDS) assessments were available due to his recent admission on 10/9/15. On October 14, 2015 at 8:20 a.m. the surveyor observed a Registered Nurse (RN #3) for a medication pass and pour observation. The surveyor observed RN (#3) obtain multiple medications including: [MEDICATION NAME] 5mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 4 mg, Aspirin 325mg and [MEDICATION NAME] 500mg. RN (#3) obtained a small plastic clear bag and pour the all the medications into the small plastic bag. RN (#3) then crushed all of the medications together/at the same time. RN (#3) then entered Resident #3's room and administered all of the crushed medications together at one time to Resident #3 via his PEG tube. On October 14, 2015 at 8:30 a.m. the surveyor reviewed Resident #3's clinical record. Review of the clinical record produced signed Physician order [REDACTED]. POS ' s included, but were not limited to: [MEDICATION NAME] 4 mg PEG daily, [MEDICATION NAME] Tab (tablet) ([MEDICATION NAME]) Tab 5 mg PEG daily, ASA (Aspirin Tab) 325 mg PEG daily, [MEDICATION NAME] Tab (tablet) ([MEDICATION NAME] Tab) 5 mg po (by mouth) daily, [MEDICATION NAME] Tab (tablet) [MEDICATION NAME] 500 mg PEG daily. (sic) On October 14, 2015 at 8:25 a.m. the surveyor notified RN (#3) that she had observed that she, RN (#3), had pulled all of Resident#3's medications and then poured together, crushed together and mixed together all of Resident #3's medications. The surveyor notified RN (#3) that the surveyor had observed that RN (#3) had administered all of Resident #3's medications together to Resident #3 during the medication pass and pour observation. The surveyor asked for the facility policy and procedure for medication administration via a PEG tube. On October 14, 2015 at 9:40 a.m. the Director of Risk Management (DoRM) hand delivered a policy and procedure titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy. The policy and procedure read in part . If you are administering medications through the enteral feeding tube, follow these guidelines: Don't mix medications together because of the risk of physical and chemical incompatibilities. (sic) On October 14, 2015 at On October 14, 2015 at 1:30 p.m. the surveyor notified the Chief Nursing Officer CNO) and the DoRM that the facility staff failed to follow professional standards of nursing practice in the area of medication administration via a PEG tube. The surveyor notified the Administrative Team (AT) that during a medication pass and pour observation RN (#3) had pulled, poured, crushed and administered all of Resident #3's medications together. The surveyor notified the AT that that each medication was supposed to be administered separately/individually via the PEG tube. No additional information was provided prior to exiting the facility as to why the facility staff failed to follow professional standards of nursing practice in the area of medication administration through a PEG tube for Resident #3.

Based on staff interview and facility document review it was determined the facility staff failed to produce quarterly QA (Quality Assurance) meeting sign in sheets that included a medical director or physician. Findings: On 1/21//14 at approximately 1:30 p.m., as part of the survey process, the facility's Quality Assessment and Assurance program was reviewed with the quality assurance administrative staff registered nurse. The nurse provided the QA staff sign-in sheets for June 12th 2014 and December 4th 2014 with all the signatures including a physician. The QA nurse was unable to locate the other two sign in sheets. The nurse informed the surveyor that the meetings were held twice a month and provided sign in sheets for the months she could locate. However, she could not locate the sign in sheets for the months of March, April, and May. The QA nurse stated she was sure they were misplaced due to construction of the office during those months. The Chief Nursing Officer and the administrator were informed of the QA issue on 1/12/15 at 2:45 p.m. The QA nurse said she had no additional information on the meetings prior to the surveyors exit.

Based on observation, staff interview, and facility document review, facility staff failed to properly store kitchen equipment in a sanitary manner. The Findings Included: An initial tour of the kitchen was done on 1/22/14 at 11:05 a.m. The surveyor was accompanied by the Chef and Dietitian. The ice chest was observed and the surveyor asked the Chef to open the chest. When opened it was noted that the ice scoop was lying on top of the ice. The surveyor asked the Chef if that was the correct storage. He said no and removed the scoop. Then the surveyor observed a rack containing multiple pans that were stacked. The Dietitian stated that the pans were on a storage rack. The pans were stacked on top of one another. The surveyor asked the dietitian to pick up individual pans from the stack and water ran from inside and off the pans. The dietitian asked the staff to remove the pans from the rack. On 1//23/14 at 9:00 am, the surveyor returned to the kitchen and found the ice scoop stored in a container outside of the ice chest. A dietary aide picked up the pans on the storage rack and all were dry. The surveyor asked if the facility had a policy and procedure for cleaning, drying and storage of cooking equipment. On 1/23/14, at 3:00 PM, the Chief Nursing Officer (CNO), assistant administrator, dietitian and the unit manager were informed of the equipment in the kitchen not stored in a sanitary way. Prior to exiting the facility on 1/23/14 the Dietitian hand delivered a facility policy titled, "Food & Nutrition Services Policies and Procedures." The document read in part: "B. Wash 5. Place pans on drying rack for air dry. 6. Store dry pans in their proper place."