BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
could safely administer their own medications for three of three residents observed with
medications left at the dining room table during mealtime (Resident #36, #10 and #66). The
census was 142.
1. Review of Resident #36’s annual, Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff,dated 10/17/18, showed the following:
-Mild cognitive impairment;
-Required limited assistance from staff for most activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed Registered Nurse
(RN) E placed a small clear plastic cup containing at least four pills on the table where
the resident sat and walked away. Nurse E did not observe the resident consume the
medications.
Further observation of the resident on 1/10/19 at 8:12 A.M., showed him/her sitting at the
dining room table with a clear plastic cup which contained a red pill, small yellow pill,
pink pill and two white pills. RN E stood at the medication cart and dispensed medications
for other residents.
2. Review of Resident #10’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed the resident sat
at the dining room table with a small plastic clear cup containing at least three pills.
RN E stood at the medication cart across the dining room dispensing medication into other
cups.
3. Review of Resident #66’s admission MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Required limited staff assistance with activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed the resident sat
at the dining room table with a small plastic clear cup containing at least three pills.
RN E stood at the medication cart across the dining room dispensing medication into other
cups.
4. During an interview on 1/10/19 the Director of Nursing said she expected staff to
observe residents take medication at the time of administration. Only residents with
physical orders to self administer medications could take medication without supervision.
5. Review of a list of residents with physician orders [REDACTED].#36, Resident #10 or
Resident #66.

Based on observation, interview and record review, the facility failed to maintain survey
reports with respect to all surveys and complaint investigations, including any plan of

Based on interview and record review, the facility’s abuse and neglect policies and
procedures failed to identify when, how and by whom determinations of capacity to consent
to sexual contact will be made and where this documentation will be recorded. Furthermore,
the facility failed to complete criminal background checks (CBC), check the employee
disqualification list (EDL, a list maintained by DHSS, of individuals who have been
determined to have: abused or neglected a resident, patient, client, or consumer;
misappropriated funds or property belonging to a resident) and ensure newly hired
employees were screened to rule out the presence of a Federal Indicator, with the
Certified Nurse Aide (CNA) Registry prior to the start of work. The facility also did not
include reporting all alleged violations to the Administrator, state agency, adult
protective services and to all other required agencies within the required two-hour
timeframe. The deficient practices affected five of 10 sampled employees hired since the
last survey. The facility hired at least 110 new employees since the last survey. The
census was 142.
Review of the facility’s Abuse Prevention Program Overview, revised (MONTH) (YEAR), showed
the following:
-Policy: This facility affirms the right of our residents to be free from abuse, neglect,
misappropriation of resident property, corporal punishment and involuntary seclusion. The
facility desires to establish a resident sensitive and resident secure environment;
-The purpose of this policy is to develop a mechanism to reduce the risk of abuse,
neglect, misappropriation of resident property and/or crimes from being committed against
the residents of this facility;
-Screening: The facility will develop and implement policies and procedures to screen
potential employees and residents in an attempt to obtain information that would assist in
making hiring or admissions decisions;
-Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or
sexual assault;
-The policy did not identify when, how and by whom determinations of capacity to consent
to sexual contact will be made and where this documentation will be recorded.
-Policy: External Reporting:
-Upon receipt of an allegation or upon the formulation of a reasonable suspicion that
abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, theft or

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required
for two of 28 sampled residents (Residents #20 and #61). The census was 142.
1. Review of Resident #20’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
During an interview on 1/16/19 at 9:25 A.M., the social worker said the resident had been
admitted from another facility and it is always difficult to receive the information
regarding a DA-124 and/or PASARR.
2. Review of Resident #61’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed the following:
-DA-124 level I screen completed on 11/4/16 and recommended a level II screening be
conducted for serious mental illness;
-No PASARR level II screen found.
During an interview on 1/16/19 at 9:35 A.M., the administrator said the resident had been
admitted from a different facility and the DA-124 had been sent from that former facility.
She did not know the DA-124 screening recommended further screening for serious mental
illness. She could not produce the recommended follow up mental health screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a comprehensive person-centered care plan for each resident that includes
measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and
psychosocial needs, for two of 28 sampled residents (Residents #11 and #33). The census
was 142.
1. Review of Resident #111’s annual Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/6/18, showed the following:
-Moderate cognitive impairment;
-Tired or little energy several days;
-Poor appetite or overeating nearly every day;
-Extensive assistance required for activities of daily living (ADL’s);
-Upper and lower extremity impairment on one side;
-Incontinent of bowel and bladder;
-Received antidepressant medications the previous 7 days;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure resident
care plans reflected their current needs, goals and interventions, by not updating them
regarding a specific bladder device used by one resident (Resident #48), risk for
elopement for one resident (Resident # 131) and one on one activities for one resident
(Resident #47). The census was 142.
1. Review of Resident #48’s quarterly Minimum Data Set (MDS), a facility mandated
assessment instrument completed by facility staff, dated 11/1/18, showed the following:
-No cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
-[DIAGNOSES REDACTED]. A [MEDICATION NAME] is permanent and does not require a catheter).
Review of the resident’s care plan, dated 10/13/17 and last updated on 10/24/18, showed

2. Review of Resident #131’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Wandering: Behavior not exhibited;
-Required limited assistance from staff for personal hygiene, dressing and bed mobility;
-Occasional urinary incontinence;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 1/7/19, showed the following:
-Focus: Resident is an elopement risk/wanderer related to confusion at times;
-Goals included: Resident will not leave facility unattended through the review date;
-Approaches included: Assess for fall risk, provide structured activities such as
toileting and walking inside and outside.
Review of the resident’s medical record, showed no elopement assessments.
During an interview on 1/15/19 at 9:35 A.M., the facility Nurse Practitioner said the
resident is no longer an elopement risk due to decreased mobility and support from staff.
The care plan should updated to reflect the resident’s current status.
3. Review of Resident #47’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Total dependence on staff for all care;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 11/1/18, showed the following:
-Preferred to spend most of the time in his/her room watching tv, has been getting up out
of bed daily and watching television in the quiet room for a couple hours a day;
-Will participate in one on one activities with activity aid three times per week.
Review of the facility’s list of residents who received one on one activities, did not
show the resident listed.
Observations of the resident, showed:
-On 1/8/19 at 2:50 P.M., the resident sat in a wheelchair in the small TV room by the
nurses station, with no other residents in the room and yelled continuously. No activity
was being conducted. A certified nurse aide said when he/she can’t find the remote
control, or something is wrong, that is what he/she does;
-On 1/9/19 at 11:04 A.M., the resident sat in a wheelchair in the TV room and watched TV
alone, with no activity being conducted;
-On 1/10/19 at 9:56 A.M., the resident sat in a wheelchair in the TV room while another
resident sat in a chair at the back of the room, with eyes closed and no activity being

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

Based on observation, interview and record review, the facility failed to ensure and
clarify physician orders [REDACTED]. This affected three of 28 sampled residents (Resident
#293, #67 and #103). The census was 142.
1. Review of Resident #293’s admission Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 12/31/18, showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].
-An order dated 1/8/19, to insert hyperdermoclysis (subcutaneous (under the skin) infusion
of fluids) and monitor the site for redness, swelling and/or leaking;
-An order dated 1/8/19, to administer D5 (sugar water) NaCL (Normal saline) via
hyperdermoclysis at 60 cubic centimeters (cc)’s every shift for two days.
Review of the Medication Administration Record [REDACTED]. The night shift on 1/8/19 had
no initials.
Observation on 1/10/19 at 9:55 A.M., showed the resident seated in a wheelchair at the
dining room table on the first floor. An IV pole (pole to hold intravenous fluids) stood
next to him/her with a pillowcase over the bag of IV fluids and the tubing stretched to
his/her abdomen.
Observation on 1/10/19 at 10:32 A.M., showed the resident sat in his/her room, the
hyperdermoclysis tubing remained connected to his/her abdomen, the dial-a-flow (device
placed on IV tubing to control the flow rate) set to OPEN and the IV bag hung empty on the
IV pole.
Observation on 1/11/19 at 4:44 A.M., showed the resident lay in bed and D5 NaCL infused
via hyperdermoclysis. The dial-a-flow showed 150 cc/hr and approximately 400 cc remained
in the D5 NaCL bag.
Observation on 1/11/19 at 8:36 A.M., showed the resident in bed with D5 NaCL infusing via
hyperdermoclysis into his/her abdomen and the dial-a-flow set at 150 cc/hour.
Further Review of the POS [REDACTED].
Further review of the MAR, dated 1/1 through 1/31/19, showed no documentation regarding D5
NaCL infusions for 1/10 or 1/1/19.

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

Based on observation, interview and record review, the facility failed to provide and
ensure adequate perineal care (peri-care, cleansing from the front of the hips, in between
the legs and the buttocks) and failed to provide expected personal hygiene needs,
including nail trimming, bathing, showers, shaving of facial hair for male and female
residents. This affected nine of 28 sampled residents (Residents #103, #140, #49, #20,
#87, #293, #73, #61 and #48). The census was 142.
1. Review of Resident #103’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 11/29/18, showed:
-Severe cognitive impairment;
-Needed extensive assistance of two staff for all care needs;
-[DIAGNOSES REDACTED].>-Always incontinent of bowel and bladder;
-Received treatment for [REDACTED].
Review of the resident’s care plan, updated on 11/29/18, showed:
-Activities of Daily Living (ADL, dependence of self care tasks), incontinent of bowel and
bladder. Needs staff assistance to complete care needs;
-Approach: Staff to assist with incontinence care as needed (PRN). Keep clean and dry.
Change and provide toileting every two hours and PRN. Report changes in skin to the nurse.

During an observation and interview on 1/11/19 at 4:25 A.M., the resident lay in the bed
on his/her left side, on top of two bed pads with a dark brown circular ring noted on the
bed pad under him/her. Certified Nurse Aide (CNA) C entered the room, placed a wash cloth
into the room sink, turned on the warm water and applied gloves. He/she removed the sheet
from the resident. A large rolled up bath towel lie in between the resident’s legs at the
groin and was saturated with dark colored urine. CNA C said I don’t know who did this, it
must have been the other aide, I don’t know why they do this. He/she said the resident had
been assigned to him/her for care during his/her shift. He/she removed the soiled bed pads
and placed a clean pad under the resident. CNA C obtained the wash cloth from the sink and
applied soap. He/she assisted the resident onto his/her right side and used the soapy wash
cloth to wipe off the resident’s left hip. He/she applied a clean brief under the resident
and fastened the brief into place. CNA C did not provide any peri-care or cleaning of the
back or lower thighs. CNA C said the residents get checked on every two hours and he/she
does not know how the rolled towel got placed in between the legs of the resident. He/she
could not remember the last time he/she checked on the resident for incontinence care and
did not communicate with the other night shift aide to see if the resident had received
care.
2. Review of Resident #140’s admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;

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

Based on observation, interview and record review, the facility failed to follow their
activity schedule, assist dependent residents to activities, provide one-to-one activities
to those residents who required individual attention and document each individual’s needs
on their care plans for four of 28 sampled residents (Residents #22, #73, #11 and #31).
The census was 142.
1. Review of the activity calendar for 1/8 through 1/11/19 and 1/14/19, showed the
following scheduled activities;
-On 1/8/19, Spa Time at 9:30 A.M. and 11:30 A.M. and You’re Pulling My Leg at 2:00 P.M.;
-On 1/9/19, Bible Study at 10:00 A.M., Current Events at 11:00 A.M., Mark Mane at 2:00
P.M. and Room Visits at 3:00 P.M.;
-On 1/10/19, Book Mobile at 9:25 A.M., Mass at 10:00 A.M., Bingo at 2:00 P.M. and Social
Hour at 3:00 P.M.;
-On 1/11/19, Twist and Shout at 10:00 A.M., Hydration at 11:00 A.M., Puzzle Making Fun at
2:00 P.M. and Room Visits at 3:00 P.M.;
-On 1/14/19, Sing and Praise at 10:00 A.M., Move and Groove at 11:00 A.M. and All About Me
Posters at 2:00 P.M.
Review of a list of canceled activities from 1/8/19 through 1/14/19, provided by the
activity director, showed the following:
-On 1/8/19 the 2:00 P.M. You’re Pulling My Leg activity did not occur;
-On 1/9/19 the 10:00 A.M. Bible Study activity did not occur;
-On 1/11/19 the 10:00 A.M. Twist and Shout and Puzzle Making Fun activities did not occur;
-On 1/12/19 the 10:30 A.M. Chapel Service did not occur;
-On 1/14/19 the 11:00 A.M. Move and Grove activity and All About Me Poster activity did
not occur.

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Based on observation, interview and record review, the facility failed to obtain physician
ordered treatments for a facility acquired pressure ulcer (injury to skin and underlying
tissue resulting from prolonged pressure on the skin), failed to monitor, document and
ensure appropriate treatments remained intact and in place. This deficient practice

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
restorative nursing therapy as ordered for three of 28 sampled residents (Residents #121,
#36 and #11). The census was 142.
1. Review of Resident #121’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/13/18, showed the following:
-Cognitively intact;
-Required total assistance from staff for transfers, dressing and toileting;
-Functional limitation in range of motion (ROM): Impaired on one side of upper and lower
extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Special treatments offered: staff provided restorative therapy (RT) zero minutes in seven
of seven days assessed.
Review of the residents (MONTH) 2019 physician order [REDACTED].
Review of the resident’s care plan, last revised 1/7/19 and in use during the survey,
showed staff did not address the resident’s participation in RT or interventions to be
provided by staff.
During an interview on 1/08/19 at 3:10 P.M., the resident said he/she sometimes gets RT,
but it has been awhile.
Review of the resident’s RT documentation on 1/14/19, showed the following:
-Goal: Order on 10/30/18, to continue from August, 3-5 times per week;
-Plan of Care: Maintain bilateral lower extremity ROM, strength and maintain bed mobility;
-Approach: Perform up to 20 repetitions of supine heel slides, AP’s, hip abductor and
adductor and/or hip flex/LAQ’s. Perform rolling right and left maximum/dependent times
two, right and left with rail assist;
-Staff documented providing RT a total of six times in (MONTH) (YEAR) on 12/10, 12/11,
12/12, 12/17, 12/18 and 12/19/18;
-No documentation staff provided RT in (MONTH) 2019.
During an interview on 1/14/19 at approximately 1:00 P.M., RT aide/CNA D said he/she
wasn’t sure what the RT orders for Resident #121 meant. He/she just did ROM exercises with
the resident. He/she has not completed any RT for (MONTH) and only 6 times in (MONTH) due
to being pulled to work on the floor. When he/she is working on the floor, he/she cannot
perform RT on his/her residents. He/she is responsible for the 400 Hall RT program, but
has been working on 300 Hall.
2. Review of Resident #36’s annual MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Required limited assistance from staff for most activities of daily living;

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Based on observation, interview and record review, the facility failed to provide
supervision for one resident (Resident #132) who had a physician’s order for nothing by
mouth (NPO, a medical instruction meaning to withhold food and fluids) when a family
member provided the resident liquids on two observed occasions. The census was 142.
Review of the facility’s Census and Conditions Report, provided on 1/9/19, showed 14
residents who received nutrition via [DEVICE] ([DEVICE], a tube surgically inserted into
the stomach to provide hydration, nutrition and medications).
Review of Resident #132’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/12/18, showed the following:
-Severe cognitive impairment;
-Long and short term memory problems;
-Required total assistance from staff for eating, mobility and personal hygiene;
-Signs and symptoms of possible swallowing disorder: Loss of liquids/solids from mouth
when eating and drinking;
-Nutrition approach: feeding tube ([DEVICE]);
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 physician order sheet, showed an order dated
12/16/18 for NPO.
Review of the resident’s care plan, dated 1/7/19 and in use during the survey, showed the
following:
-Focus: Resident requires tube feeding related to dysphasia (difficulty with swallowing);
-Goal: Resident will be free of aspiration and maintain adequate nutritional and hydration
status;
-Approaches included: discuss with resident/family/caregivers any concerns about tube
feeding; monitor/document/report as needed any signs or symptoms of aspiration, the
resident does not like food related activities as it is upsetting to see others eating,
the resident is dependent with tube feeding and water flushes. See physician orders for
current feeding orders.
Further review of the resident’s medical record, showed no documentation the facility had
addressed any alternative nutrition approaches or exceptions with the resident and/or
his/her family.
Observation of the resident on 1/9/19 from 1:36 P.M. to 1:40 P.M., showed the resident sat
up in a geri chair (reclining wheeled chair) in the hall by the nurse’s station with a

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Based on observation, interview and record review, the facility failed to ensure
residents’ urinary catheter (a sterile tube inserted into the bladder to drain urine)
drainage bags and tubing were maintained to prevent possible contamination and orders were
obtained for catheter usage and care. This affected three of six facility identified
residents with catheters (Residents #16, #48 and #140). The census was 142.
Review of the facility’s Catheter care policy, dated 4/2013, showed:
-Purpose: To minimize the risk of infection and complications associated with the use of
indwelling urinary catheters;
-Policy: Catheter care will be completed each shift, following incontinent episodes and
where contamination occurred;
-General Guidelines:
-The drainage bag must be positioned lower than the bladder to prevent the urine in the
tubing and drainage bag from flowing back into the bladder;
-Check the resident often and make sure he/she is not lying on the catheter or tubing;
-Be sure the catheter tubing and drainage bag are kept off the floor.
1. Review of Resident #16’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 10/4/18, showed the
following:
-No cognitive impairment;
-Total dependence on staff for care;
-Indwelling urinary catheter;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 10/4/18, showed the following:
-Has indwelling catheter and will remain free from catheter-related trauma and show no
signs or symptoms of urinary infection, through next review date;

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Based on observation, interview and record review, the facility failed to maintain
acceptable parameters of nutritional status by not ensuring one resident (Resident #67)
was regularly assessed by a registered dietician (RD). The resident experienced
significant weight loss of 16.89% in six months and was not included in seven residents
identified by the facility with unplanned significant weight loss. The census was 142.
Review of the facility’s Policies, Standards, Protocols, and Procedures Manual regarding
nutritional assessments, dated 7/12/13, showed the following:
-Each resident shall undergo a formal nutrition assessment to determine nutrition care
needs and the type of nutrition care to be provided. The formal nutrition assessment shall
be documented within the dietary section of the record and shall be completed by the
facility’s RD;
-Formal nutrition assessments shall be repeated at least every 12 months or in response to
a change in the resident’s condition such as, but not limited to, weight loss, pressure
ulcer development, decreased appetite, etc ;
-During monthly dietician visits, residents with pressure ulcers, tube fed residents,
residents with significant weight loss and residents receiving [MEDICAL TREATMENT] will be
assessed. Other residents can be added to the referral list at the discretion of the
dietary manager, director of nursing, or interdisciplinary care plan team.
1. Review of Resident #67’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 12/31/18, showed the
following:

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Based on observation, interview and record review, the facility failed to have adequate
indications for resident’s medications to support their use for three out of 28 sampled
residents (Residents #131, #38 and #4). The census was 142.
1. Review of Resident #131’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/19/18, showed the following:
-Moderately impaired cognition;
-No behaviors;
-Required limited assistance from staff for personal hygiene, dressing and bed mobility;
-Occasional urinary incontinence;
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-An order, dated 12/12/17, for [MEDICATION NAME] (antidepressant medication), give 30
milligrams (mg) at bedtime for depression;
-An order dated 1/3/18, for Busipirone (antianxiety medication), give 10 mg twice a day
for anxiety;
-An order, dated 3/20/18, for [MEDICATION NAME] (narcotic used to treat severe pain), give
30 mg twice a day for pain;
-An order, dated 9/21/18, for [MEDICATION NAME] (antianxiety medication), give 0.5 mg
every morning for generalized anxiety.
Review of the resident’s care plan, last revised on 1/7/19, showed the following:
-Focus: Resident has a [DIAGNOSES REDACTED].
-Goal: Resident will exhibit indicators of depression, anxiety or sad mood less than daily
by review date;
-Approaches included: Administer medications as ordered and observe for signs/symptoms of
side effects and effectiveness, introduce resident to others with similar interests,
encourage eating in the dining room and conversing with tablemates,
monitor/document/report as needed of any signs/symptoms of depression, including
hopelessness, anxiety, sadness, [MEDICAL CONDITION], negative statements, repetitive
anxious or health-related complaints or fearfulness;
-Staff did not address any triggers for the resident’s anxiety or appropriate
non-pharmacological interventions to attempt when the resident was feeling increased
anxiety.
Review of the resident’s progress notes, showed the following:
-On 9/28/18 at 3:59 P.M., a social services note showed the resident is alert and oriented
to person, place and time with some confusion and is able to make his/her needs known. The

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Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 25 opportunities observed, two errors
occurred resulting in a 6.45 % error rate (Resident #61). The census was 142.
Review of the facility’s medication administration policy, dated 12/19/2013, showed:
-Policy: Medications will be administered in a safe, efficient and accurate manner to
residents for whom they are prescribed and in accordance with current acceptable nursing
practice;
-Guidelines: If a drug is withheld, refused or given at a time other than the scheduled
time, the individual administering the medication will initial and circle the Medication
Administration Record [REDACTED] 1. Review of Resident #61’s medical record, showed:
-[DIAGNOSES REDACTED].

Based on observation and interview, the facility failed to label and store medications in
a safe and effective manner when a nurse predispensed medications into cups and then
stored them in the medication cart to administer at a later time. The facility census was
142.
Review of the facility’s Medication Administration Policy, dated 12/2015, showed the
following:
-Policy: Medications will be administered in a safe, efficient and accurate manner to
residents for whom they are prescribed and in accordance with current acceptable nursing
practice;
-Medications may not be prepared in advance and must be administered within one hour of
their prescribed time, unless otherwise specified.
Observation of the mansion dining room on 1/10/19 from 8:22 A.M. to 8:35 A.M., showed
during breakfast service, Registered Nurse (RN) E dispensed pills from a packet into a
cup, wrote on the cup, and then placed the cup inside a drawer of the medication cart.
This occurred 7 times.

Based on observation, record review and interview, the facility failed to consult with the
registered dietitian before making substitutions to the planned menu to ensure the
substitutions were nutritionally adequate. This practice affected all residents who
received food from the facility’s kitchen. The census was 142.
During an interview on 1/8/19 at 5:20 P.M., Resident # 1 said he/she had been at the
facility for two weeks. He/she had lived there before and just moved back in. He/she said
the food is not as good as it used to be. He/she said they get the same thing fro
breakfast every day: eggs, bacon or sausage, toast and cereal. He/she would like it if
other options were offered, such as biscuits and gravy.
Review of the facility’s approved breakfast menu, showed the following breakfasts
scheduled during the survey:
-1/9/19: choice of juice and cereal, scrambled eggs with bacon and toast;
-1/10/19: choice of juice and cereal, breakfast pot pie;
-1/11/19: choice of juice and cereal, sausage gravy, biscuit and eggs.
Observations of breakfast services in the main dining room, showed the following:
-On 1/9/19 at 8:00 A.M.: cereal, scrambled eggs, bacon, sausage and toast;
-On 1/10/19 at 810 A.M.: cereal, scrambled eggs, bacon, sausage and toast;
-The facility did not serve the approved breakfast;
-On 1/11/19 at 8:37 A.M.: cereal, scrambled eggs, bacon, sausage and biscuit;
-The facility did not serve the approved breakfast.
During an interview on 1/11/19 at 8:37 A.M., Resident #1 said he/she was disappointed
there wasn’t any gravy with the biscuits.
During an interview on 1/11/19 at 8:45 A.M., the dietary manager said the sausage gravy
was not served today because he did not receive their shipment of gravy on Tuesday. He did
not get here early enough this morning to make sausage gravy. They did not serve the
breakfast pot pie because the residents complaint about the vegetables in it. They prefer
omelets. Omelets were only served if a resident specifically asked for one. He was not
aware the substitutions needed to be approved by the dietician.
During an interview on 1/11/19 at 9:00 A.M., the administrator said the dietary manager is
new and has not received all the training necessary with regards to systems. She would
expect the scheduled menu to be served or the dietary manager could go to the store to get

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure pureed
food items were prepared properly to the meet the needs of residents with physician’s
orders [REDACTED]. The facility census was 142.
1. During an interview on 1/8/19 at 11:00 A.M., the dietary manager said they had eight
residents with orders for a pureed diet.
Observation on 1/9/19 at 10:47 A.M., showed Cook Q placed seven pieces of cooked chicken
cordon bleu in the blender, added 2 cups of chicken broth and blended. Cook Q said he/she
was making enough for 10 residents to ensure there was enough. Cook Q blended to a smooth
and thin texture and then placed in a metal pan. Cook Q said the pureed chicken was
completed. Cook Q did not add three additional pieces of chicken cordon bleu to make a
total of 10 servings.
Review of the facility’s recipe for pureed chicken cordon bleu for 10 servings, showed the
following:
-10 servings of prepared chicken cordon bleu;
-10 fluid ounces (oz) of hot chicken broth;
-Measure the number of pureed portions required from the regular recipe;
-Add to food processor and process to fine consistency;
-Gradually add hot broth to meat while processing. All liquid may not be required;
-May add commercial thickener if needed to obtain smooth pudding like consistency.
2. Observation on 1/10/19 at 10:44 A.M., showed Cook Q placed three 4 oz scoops of
spaghetti noodles and sauce in the blender, added one cup of hot water and blended. The
texture was smooth and thin. Cook Q said it was enough spaghetti. The surveyor questioned
how it could be enough for 10 servings. Cook Q added three more 4 oz scoops of noodles
plus one cup of hot water into the blender and blended. He/she then added it to the pan of
previously pureed noodles and sauce. Cook Q did not follow the recipe.
Review of the facility’s recipe for pureed spaghetti with meat sauce for 10 servings,
showed the following:
-10 servings of prepared spaghetti with meat sauce;
-10 fluid oz of hot beef broth;
-Measure the number of pureed portions required from the regular recipe;
-Add to food processor and process to fine consistency;
-Add hot broth to meat mixture and process until smooth.
3. Observation of the breakfast service on 1/15/19 at 7:53 A.M., showed a pan of pureed
sausage on the steam table in the kitchen. A dietary aide took a slotted scoop and placed
a scoop of pureed sausage on a plate. Liquid strained from the slotted spoon of pureed
sausage into the pan on the steam table. The sausage in the pan appeared very grainy and a
pool of liquid formed around it.
During an interview at 7:53 A.M., Cook Q said he/she did not add any bread or thickener to
the sausage. He/she used broth and blended.
Review of the facility recipe, showed commercial thickener could be added if needed to
obtain smooth pudding like consistency.

Based on observation and interview, the facility failed to have a process in place to
check the sanitizer levels in sanitizer buckets, have a process in place to track thawed
health shakes and ensure staff did not use wet dishes during meal service for one meal
observed. These deficient practices had the potential to affect all residents who ate at
the facility. The census was 142.
1. During an interview on 1/10/19 11:06 A.M. the dietary manager (DM) was asked to test
the sanitizer in the sanitizer bucket at the work table by the stove. The DM said he
doesn’t test sanitizer buckets. After looking in his office, he was able to locate the
correct type of strips to test the sanitizer level. He placed the strip in the bucket for
approximately 10 seconds. The test strip showed a dark green color in the 400 parts per
million (ppm) range. After looking at the information on the sanitizer bottle, it was
determined the amount of sanitizer was within range. The DM said he was new, but that
wasn’t an excuse. He was not trained on the need to test sanitizer buckets. He agreed he
should know if the amount of sanitizer being used to clean was at the appropriate level
for sanitation purposes.
2. Observation of the walk in cooler on 1/11/19 at 8:45 A.M., showed a box full of thawed
health shakes without dates. A date on the outside of the box showed 12/21/18. Dietary
Aide (DA) R said the date on the outside of the box is the date they received the box from
the vendor. He/she did not know when the box was placed in the cooler. He/she added more
shakes to the box as it got low.
During an interview at 8:47 A.M., the DM said the date on the outside of the box is when
it was received. He did not know when the shakes were thawed or how long they could be
thawed. He said there were approximately 50 shakes in the box, which he would toss out.
During an interview at 9:00 A.M., the administrator said the DM is new and has not
received all the training necessary with regards to systems.
During an interview at 9:07 A.M., the DM said he spoke with the vendor and the shakes
could be thawed for 14 days and would then need to be thrown away.
3. Observation of the lunch service on 1/08/19 at 11:57 A.M. in the main dining room,
showed staff served lunch from a steam table. At 12:05 P.M., the staff who dished out food
stopped to wait for more plates. At 12:08 P.M., more plates arrived and staff continued to
dish out food for residents. Observation showed water droplets pooled on the plates being
used. Staff used at least six plates with water droplets to serve food to residents.
During an interview on 1/15/19 at 9:00 A.M., with the administrator and the DM, the DM
said staff should never use wet plates. They ran out of plates and had to wash more, which
is why they were wet. They have ordered more plates. The administrator agreed wet plates
should not be used.

Based on interview and record review, the facility failed to produce an on-site policy
regarding the acceptance, usage and storage of foods brought into the facility for
residents by family and other visitors, to ensure the food’s safe and sanitary handling
and consumption. This deficient practice had the potential to affect all residents who ate
food brought in by visitors. The facility census was 142.
Review of the facility’s policies provided, showed no documentation of a policy regarding
foods brought in for residents by family and other visitors.
During an interview on 1/15/19 at 9:14 A.M., the administrator said they did not have a
policy for food brought in by family or visitors.
During an interview on 1/15/19 at 9:14 A.M., the dietary manager confirmed that the
facility did not have a policy regarding outside food brought in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to collaborate with hospice in
the development of a coordinated plan of care for three residents receiving hospice care.
The facility identified eight residents on hospice care and three of those residents were
selected for the sample of 28. Problems were found with all three of those residents
(Residents #242, #22 and #67). The census was 142.
1. Review of Resident #242’s (MONTH) physician order [REDACTED].
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
-Current treatment orders for open wounds to both heels;
-An order, dated 1/3/19, to admit to hospice.
Review of the resident’s hospice binder, showed the following:
-Resident assessed and admitted to hospice on 1/3/19 for terminal [DIAGNOSES REDACTED].
-Hospice nurse to visit two times as week and as needed, hospice certified nurse aide
(CNA) to visit three times a week, hospice social worker and chaplain to visit once a
month and as needed;
-Hospice plan of care reviewed and coordinated with facility;
-No documentation of hospice visits, services provided or communication with facility.
Review of the resident’s care plan, last reviewed on 1/14/19 and in use during the survey,
showed the following:
-Staff did not document the resident’s use of hospice services on the care plan until
1/14/19;
-Focus: Due to terminal prognosis, resident elected to utilize hospice services;
-Goal: Resident’s dignity, autonomy and comfort will be maintained to the highest level
through next review date;
-Interventions: Consult with physician and Social Services to have hospice care for
resident in the facility, work cooperatively with hospice team to ensure the resident’s
spiritual, emotional, intellectual, physical and social needs are met.
During an interview on 1/15/19 at 7:15 A.M., the social service director said she has