COUNTRY VIEW NURSING FACILITY, INC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide care in
a manner that enhanced resident dignity and ensured full recognition of individuality, for
three additional residents (Residents #151, #16 and #26). The facility census was 47.
During an interview on 2/13/19 at 6:30 P.M., the Administrator said the facility did not
have a policy regarding treating resident’s with dignity and respect.
1. Review of Resident #16’s care plan, dated 8/19/18, showed the following:
-[DIAGNOSES REDACTED].
-Alteration in self-care ability related to stroke. Staff should allow choices to promote
sense of autonomy and control. Assist with elimination needs as he/she requested;
-At risk for skin breakdown and/or urinary tract infections related to occasional urinary
incontinence. Staff should encourage the resident to report need for urinary elimination
in a timely manner to reduce potential for incontinence;
-At risk for exacerbation of depression. Goal was able to report acceptance of life status
without negative emotions/exacerbation of symptoms of depression. Staff should allow
resident to direct his/her care at all possible opportunities (what to wear and eat, rest
and comfort needs/desires, bedtimes, activities) to promote sense of control/autonomy.
Assure basic physical needs were met to reduce physical distress/discomfort as causes of
emotional distress.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 11/10/18, showed the following:
-Cognitively intact;
-Required extensive assistance of two staff members with bed mobility;
-Required total assistance of two staff members with transfers and toileting;
-Frequently incontinent of bowel and bladder.
Observations on 2/7/19, showed the following:
-From 6:58 A.M. until 7:20 A.M., the call light for the resident’s room was on and the
room door was closed;
-At 7:20 A.M., Nurse Aide (NA) G entered the resident’s room and turned off the call
light. The resident said, I need the bedpan, needed it for 15 minutes. I already went. I
don’t intend to do that, it makes it hard to wait. NA G washed his/her hands and put on
gloves;
-At 7:22 A.M., the resident said, I need the bedpan. The pad is wet. I already went. I
told you that. NA G removed his/her gloves and left the room. The resident said, I peed
the bed;
-At 7:25 A.M., NA G returned to the resident’s room with a clean washable incontinence bed
pad;
-At 7:27 A.M., NA G rolled the resident on his/her side, the resident’s incontinence bed
pad was saturated with urine.
During an interview on 2/7/19 at 7:27 A.M., the resident said if there was something
he/she needed to do, he/she asked staff two hours ahead of time. Otherwise, staff would
not assist him/her in time. He/She did not like urinating in the bed. If he/she had the
bed pan quicker, he/she would not urinate in the bed. He/She was unable to hold urine for
very long.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She should assist Resident #16 with the bedpan when he/she asked. It was not dignified
when residents became incontinent, because they were waiting on staff to take them to the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure one

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
Review of the resident’s nurse’s note, dated 1/26/19 and untimed, showed resident
provoking another resident, hit him/her three times then laughed. Staff intervened and
separated the residents. While pushing the resident he/she said, Won’t do nothing about
it. The resident then turned his/her head towards the resident he/she hit and laughed.
Review of a faxed document from the facility to the resident’s physician, dated 1/29/19
(three days after the incident on 1/26/19), showed the following handwritten note authored
by Registered Nurse (RN) H:
-On 11/10/18 the resident slapped another resident;
-On 1/26/19 slapped another resident three times.
During an interview on 2/8/19 at 8:45 A.M. and 2/13/19 at 2:30 P.M., Certified Nurse Aide
(CNA) F said the following:
-He/she was standing at the nurse’s desk on 1/26/19 when he/she heard Resident #12 yelling
and cursing;
-As he/she arrived to the area just outside of the dining room, he/she took hold of
Resident #24’s wheelchair and began to push him/her back to his/her room;
-Registered Nurse (RN) H arrived and began to assess Resident #12;
-He/she was unsure if Resident #12 had any injuries;
-RN H attempted to speak with Resident #24 when the resident struck him/her in the
stomach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to report to the state agency an
allegation of physical abuse involving two residents (Resident #12 and #24), in a review
of 13 sampled residents. The facility census was 47.
Review of the facility policy Abuse Prohibition, dated 8/2017, showed the following:
Purpose: To ensure residents are free from abuse, corporal punishment, and involuntary
seclusion;
Policy:
-It is the policy of this facility that each resident has the right to be free from abuse,
corporal punishment, exploitation, and involuntary seclusion;
-Residents must not be subjected to abuse by anyone, including but not limited to staff,
other residents, consultants, volunteers, staff of other agencies servicing the residents,
family or legal guardians, friends, or other individuals;
-The administrator will be the coordinator of the abuse prevention quality improvement
committee;
Defining Abuse:
ABUSE means the willful infliction of injury, unreasonable confinement, intimidation,
punishment, or the taking or using photographs or recordings resulting in physical harm,
pain, mental anguish, demean or humiliate the resident;
Types of abuse:
-Physical abuse: includes hitting, slapping, pinching and kicking;
Investigation:
-Facility will investigate all types of abuse (physical, mental, sexual, financial,
involuntary seclusion) and report;

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
During an interview on 2/8/19 at 9:08 A.M., Certified Nurse Aide (CNA) E said he/she
observed Resident #24 attempt to hit other residents in the dining room and he/she had
reported it to the charge nurses.
During an interview on 2/13/19 at 2:32 P.M., CNA D said he/she had seen Resident #24 raise
his/her hand to Resident #12 many times in the dining room, but he/she was not aware of
any physical contact.
During an interview on 2/6/19 at 8:10 A.M. and 2/13/19 at 10:15 A.M., Registered Nurse
(RN) H said the following:
-He/She was new to the facility;
-He/She had not known of the allegation of abuse from 11/10/18, until he/she was asked (by
the administrator) to review nurse’s notes for past behaviors for a physician fax;
-He/She was not aware of the resident’s name which Resident #24 allegedly slapped on
11/10/18 and he/she assumed it had been investigated, but did not have knowledge if it had
or had not been reported to state.
During an interview on 2/8/19 at 1:12 P.M., the Director of Nursing (DON) said the
following:
-He/She was new to the facility as of 12/1/18;
-He/She was not aware of an allegation of a resident being slapped by Resident #24 before
now, so it was most likely not reported to the state agency;
-He/She or the administrator were responsible for reporting to the state agency;
-He/She expected to be notified of all allegations of abuse and all allegations should be
investigated.
During an interview on 2/13/19 at 3:15 P.M., the Administrator said the following:
-He/She had only been at the facility since 1/2/19;
-He/She was not aware of the allegation of abuse from 11/10/18;
-Although the incident preceded his/her employment at the facility, the facility should
have reported the allegation of abuse to the state agency;
-He/She searched and could not find an investigation into the incident or that it had been
reported to the state agency.
MO # 152

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to investigate an allegation of

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
During an interview on 2/6/19 at 8:10 A.M. and 2/13/19 at 10:15 A.M., Registered Nurse
(RN) H said the following:
-He/She was new to the facility;
-He/She had not known of the allegation of abuse from 11/10/18 until he/she was asked (by
the administrator) to review nurse’s notes for past behaviors for a physician fax;
-He/She was not aware of the resident’s name which Resident #24 allegedly slapped on
11/10/18 and he/she assumed it had been investigated, but did not have knowledge if it had
or had not been reported to state.
During an interview on 2/8/19 at 1:12 P.M., the Director of Nursing (DON) said the
following:
-He/She was new to the facility as of 12/1/18;
-He/She was not aware of an allegation of a resident being slapped by Resident #24 before
now;
-He/She expected to be notified of all allegations of abuse and all allegations should be
investigated.
During an interview on 2/13/19 at 3:15 P.M., the Administrator said the following:
-He/She had only been at the facility since 1/2/19;
-He/She was not aware of the allegation of abuse from 11/10/18;
-He/She searched and could not find an investigation into the incident.
MO # 152

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to provide a copy of the
transfer notice to a representative of the Office of the State Long-Term Care Ombudsman
for three of 13 sampled residents (Resident #8, #38, and #40) and two of five residents
selected for closed record review (Resident #43 and #44). The facility census was 47.
Review of the policies and procedures provided by the facility showed there was no policy
for providing transfer/discharge notices to a representative of the Office of the State
Long-Term Care Ombudsman.
1. Review of Resident #8’s medical record showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform residents and/or legal
representatives of their bed hold protocol at the time of transfer for three sampled
residents (Resident #8, #38, #40), and for two (Resident #43 and #44) of five residents
selected for closed record review. The facility census was 47.
Review of the facility’s undated Bed Reservation Agreement showed the following:
-If a resident’s care at the facility was being paid for by Medicaid/Medicare, the
facility would reserve the resident’s bed while he/she was on therapeutic leave for any
period that was a covered service under the program for which the resident was eligible;
-If the resident’s absence from the facility exceeded the time period covered or was due
to a hospitalization , the facility would automatically reserve or continue to reserve the
bed only if the resident and/or legal representative signed and agreed to pay the amount

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and staff interview, the facility failed to develop a
plan of care consistent with resident’s specific conditions, needs, and risks for three of
13 sampled residents (Resident #40, #24 and #12). The facility census was 47.
1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User’s
Manual, Version 3.0, Chapter 4, dated (MONTH) 2011, showed the following:
-The care plan is driven not only by identified resident issues and /or conditions but
also by a resident’s unique characteristics, strengths, and needs;
-A well-developed and executed assessment and care plan looks at each resident as a whole
human being with unique characteristics and strengths;
-The care plan should be revised on an ongoing basis to reflect changes in the resident
and the care that the resident is receiving;
-The effectiveness of the care plan must be evaluated from its initiation and modified as
necessary;
-Changes to the care plan should occur as needed in accordance with professional standards
of practice and documentation. The interdisciplinary team members should communicate as
needed about care plan changes;
-Federal statute and regulations require that residents are assessed promptly upon
admission (but no later than Day 14) and the results are used in planning and providing
appropriate care to attain or maintain the highest practicable well-being;
-Facilities have seven days after completing the admission RAI assessment to develop or
revise the resident’s care plan;
-Minimum Data Set (MDS), federally mandated assessment instruments, completed by facility
staff, are not required for minor or temporary variations in resident status – in these
cases, the resident’s condition is expected to return to baseline within two weeks.
However, staff must note these transient changes in the resident’s status in the
resident’s record and implement necessary assessment, care planning, and clinical
interventions, even though an MDS assessment is not required.
2. Review of the facility’s Care Plan Updates for Short Term Problems policy, dated 2/7/17
showed the following:
-Purpose of the policy was to ensure individualized care was delivered to all residents
according to their needs, to ensure all pertinent staff were aware of short term problems
and appropriate interventions that had been put in place, and to provide comprehensive
interventions to help resolve any short term problems the resident developed;
-It was the policy of the facility to provide individualized care to each resident and
continue to update care plans as short term problems arose;
-All residents who had a fall, infection, required isolation, had skin issues, behavioral
changes, suicidal ideation or any other problem that would likely resolve in a short time,
would have a short term care plan reviewed and initiated and placed with their long term
care plan;
-Once a short term problem was identified, the charge nurse was responsible for initiating
a short term care plan;
-The care plans were located in a binder at the nurses’ station;
– Charge nurses were to find the appropriate care plan, review it, and fill in the
resident’s name, date, and sign;
-Charge nurses were to add interventions that were identified but not on the short term
care plan or strike through those interventions that were not indicated, and initial;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow
physician orders [REDACTED].#6 and #38) and for two additional residents (#150, #151).
Staff failed to apply ACE wraps (compression wraps to minimize swelling) to Resident #6’s
lower extremities, failed to monitor weights daily as ordered for Resident #38, failed to
provide wound care as ordered for Resident #150 and failed to ensure Resident #151 had
access to continuous supplemental oxygen while in the dining room. The facility census was
47.
Review of the facility’s policies and procedures provided by the facility showed there was
no policy for following physician orders.
Review of the facility’s undated policy for oxygen administration showed the following:
-Oxygen administration was the responsibility of the licensed nursing staff and certified
medication technicians;
-The purpose of the policy was to administer oxygen to the resident when insufficient

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure facility
staff provided one resident (Resident #40) of 13 sampled residents and three additional
residents (Resident #4, #16, and #30), that were unable to perform their own activities of
daily living (ADL), the necessary care and services to maintain good personal hygiene and
prevent body odor. The facility census was 47.
Review of the facility’s undated policy for showers showed the following:
-Showers were the responsibility of licensed staff and nursing assistants;
-The purpose of showers was to cleanse and refresh the residents, and to observe the
resident’s skin;
-Staff were expected to document how well the resident tolerated the procedure and the
condition of the resident’s scalp and skin;
-The type, frequency of shower, and amount of assistance required should be listed under
the resident’s plan of care for self-care deficits.
Review of the facility’s undated policy for oral hygiene showed the following:
-Oral hygiene was the responsibility of licensed staff and nursing assistants;
-The purpose of oral hygiene was to cleanse the mouth, teeth, and dentures, to prevent
infection and irritation, and to moisten the mucous membranes;
-Residents were to be offered assistance with oral hygiene before breakfast, after each
meal, and at bedtime.
Review of the facility’s undated perineal care policy and procedure showed the following:
-Perineal care was the responsibility of the licensed nurses and nursing assistants;
-The purpose of the policy was to cleanse the perineum and prevent infection and odor;
-Equipment included peri-wipes, gloves, towels, and wash cloths;
-Procedure:
-Staff were instructed to wash their hands, gather equipment, and bring to bedside;
-Explain procedure to the resident and screen for privacy;
-Staff were to wear gloves and using disposable wipes, wipe from front to back and discard
the wipe after each
stroke;
-Towels or wash cloths may be used for perineal care;
-Assist the resident to a comfortable position with call light within reach, wash hands,
and dispose of used wipes in a
plastic bag and remove them from the room;
-The policy did not specify direction for completion of peri care for males and females.
1. Review of Resident #16’s care plan dated 8/19/18 showed the following:
-[DIAGNOSES REDACTED].
-Alteration in self-care ability related to stroke. Goal was physical needs met. Staff
should allow choices to promote sense of autonomy and control. Assist with elimination
needs as he/she requested;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure Cardiopulmonary
Resuscitation (CPR-process of providing rescue ventilation and chest compressions to
maintain circulation of blood) certified staff were scheduled and present in the facility
24 hours a day, seven days a week and failed to develop and implement a policy addressing
CPR requirements for staff. This failure affected 25 residents who were identified as full
code status (CPR required in the event of cardiac or respiratory arrest). The facility
failed to ensure the medical record accurately and consistently indicated residents’ code
status for one resident (Resident #28) in a review of 13 sampled residents, for one
additional resident (Resident #1) and for three closed records (Resident #152, #42 and
#157) and failed to ensure staff were trained and available to provide CPR when
transporting residents who requested to be full code, in the facility van. Ten additional
residents (Resident #26, #33, #153, #25, #30, #150, #155, #154, #151 and #5) who were a
full code, were transported multiple times by the facility transporter who was not
certified to perform CPR. The facility census was 47.
1. During an interview on [DATE] at 1:00 P.M. the Director of Nursing (DON) said the
facility had no policy regarding staff CPR certification requirements, no policy regarding
scheduling CPR certified staff on every shift 24 hours per day, seven days per week and no
policy regarding CPR certified staff transporting residents who were full code.
Review of the facility undated Cardiopulmonary Resuscitation policy showed the following:
-Responsibility: Licensed nurse and any person in the facility with CPR experience;
-Purpose: To ventilate and establish circulation on a resident with absence of
respirations and pulse;
-Procedure: 3. Delegate a specific individual to check resident’s CPR status; have
individual to call paramedics, attending physician and administrative personnel when
appropriate.
Review of the facility policy Advanced Directives, dated (MONTH) (YEAR), showed the
following:
Policy:
-Residents will be informed upon admission by the Social Service Director (SSD) of the
right to have and maintain Advanced Directives, including Do Not Resuscitate (DNR) and
refusal of treatment, care and services. This will be explained in detail and written
documentation of this policy and procedure will be given to each resident and/or resident
representative upon admission;
-Residents will be involved in the initial plan of care and quarterly review of care
outlining their care wishes and informing the physician, charge nurses, Certified Nurse
Aides (CNA) and other providers of services what the specific wishes are regarding the
resident’s Advanced Directives, Do Not Resuscitate, and the right to refuse treatment,
care and services;
-The plan of care will be reviewed and revised at least quarterly and as needed to reflect
the resident’s cognitive decision making abilities as well as their refusal of treatments,
care and services by the Interdisciplinary Team and resident and/or resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
performed safe transfer techniques for two additional residents (Resident #26 and #151).
The facility census was 47.
Review of the facility’s undated policy and procedure for general safety rules showed the
following:
-General safety of the residents was the responsibility of all employees;
-Staff were to report or correct any unsafe conditions that were observed;
-Staff were to report all injuries;
-Staff were to wear gait belts and use caution when lifting or transferring residents;
-Gait belts were to be used during one person and two person transfers.
Review of the facility’s Gait Belt Policy, dated 10/17/13, showed the following:
-The gait belt was a mandatory part of the nursing department’s uniform;
-Nursing staff were expected to use gait belts at all times when ambulating or
transferring a resident for the safety of the resident;
-Gait belts were to be utilized when assisting a resident from the bed, chair, or
commode/toilet;
-An employee who was injured or caused an injury to a resident as a result of failure to
properly apply and use a gait belt was subject to disciplinary action which could include
termination;
-The policy was to be reviewed and signed by the facility’s employees;
-The policy did not instruct staff on proper placement or instruction on how to use the
gait belt.
1. Review of Resident #26’s Annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/21/18, showed the following:
-Limited assist of one for transfers;
-Extensive assist of two to walk in room and for toileting;
-Used a walker and wheelchair;
-Not steady, only able to stabilize with staff assistance.
Review of the resident’s care plan, last revised on 12/15/18 showed:
-Supervision and encouragement with Activities of Daily Living (ADL’s);
-Independent with ambulation without an assistive device, gait slow and steady.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
incontinence care with an indwelling urinary catheter (a sterile tube inserted through the
urethra into the bladder to drain urine) consistent with acceptable standards of practice,
failed to keep the catheter bag off the floor and failed to maintain the catheter bag
below the level of the bladder during mechanical lift transfers for two of 13 sampled
residents (Resident #2 and #38). The facility reported two residents with indwelling
catheters. The facility census was 47.
Review of the facility’s undated policy for catheter care showed the following:
-Catheter care was the responsibility of licensed nurses and nursing assistants;
-The purpose of the policy was to prevent infection, reduce irritation, and monitor and
record urine output;
-Insertion site care included to wash the perineum well with soap and warm water or
peri-wipes, taking care to wash from front to back;
-NOTE: DO NOT CONTAMINATE THE AREA WITH FECES, IF THE RESIDENT HAD AN INVOLUNTARY BOWEL
MOVEMENT, CLEAN THIS AREA FIRST, WASH HANDS, AND OBTAIN CLEAN EQUIPMENT FOR CATHETER CARE;
-Cleanse the area at the catheter insertion site well.
Review of the facility’s undated perineal care policy and procedure showed the following:
-Perineal care was the responsibility of the licensed nurses and nursing assistants;
-The purpose of the policy was to cleanse the perineum and prevent infection and odor;
-Equipment; peri-wipes, gloves, towels, and wash cloths;
-Procedure:
-Staff were instructed to wash their hands, gather equipment, and bring to bedside;
-Explain procedure to the resident and screen for privacy;
-Staff were to place on gloves and using disposable wipes, wipe from front to back and
discard the wipe after each stroke;
-Towels or wash cloths may be used for perineal care;
-Assist the resident to comfortable position with call light within reach, wash hands,
and dispose used wipes in a plastic bag and remove them from the room.
Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, showed the
following:
-The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile
system;
-Drainage tubing/bags must not touch the floor;
-The drainage bag should always be below the level of the bladder;
-If moved above, urine could flow back into the bladder.
Review of the manual also showed the procedure for giving peri care with a catheter

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure physician visits,
including initial comprehensive visits were conducted within the first 30 days after
admission, and then at 30 day intervals up until 90 days after the admitted for four of 13
sampled residents (Resident #3, #9, #22, and #40). The facility census was 47.
1. Review of Resident #40’s medical record on 2/13/19, showed the following:
-He/She admitted to the facility on [DATE];
-He/She was seen by his/her Family Nurse Practitioner (FNP) on 11/16/18;
-There was no documentation to show he/she had been seen by his/her physician since
admission.
2. Review of Resident #22’s medical record on 2/13/19, showed the following:
-He/She admitted to the facility on [DATE];
-He/she was seen by his/her FNP on 10/19/18;
-There was no documentation to show he/she had been seen by his/her physician since
admission.
3. Review of Resident #9’s medical record on 2/13/19, showed the following:
-admitted [DATE];
-He/She was seen by the FNP on 11/16/18;
-There was no documentation the physician or FNP saw the resident from 11/16/18 to
2/13/19;
4. Review of Resident #3’s medical record on 2/13/19, showed the following:
-admitted [DATE];
-The resident was seen by the physician in 10/2018;
-There was no documentation the physician or FNP saw the resident from 10/2018 to
2/13/2019.
During an interview on 2/13/19 at 5:07 P.M., the Director of Nurses (DON) said the
following:
-There were three physicians that came to the facility to see residents once a month;
-There was a FNP who came to the facility every Friday to see residents;
-The FNP did not see all of the residents every Friday;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
sufficient nursing staff to meet residents’ needs for four residents (Residents #2, #3,
#8, and #9), in a review of 13 sampled residents and for six additional residents
(Residents #4, #16, #18, #30, #33, and #39). Staff failed to provide routine showers to
ensure good personal hygiene and prevent body odors, failed to respond timely to call
lights, and failed to provide restorative therapy when the restorative aide (RA) was
pulled to work as a Certified Nurse Aide (CNA) and was unable to complete duties for the
restorative therapy nursing program. The facility census was 47.
1. Review of the facility’s undated policy for call lights showed the following:
-Staff was to respond promptly to a resident’s call for assistance and to assure call
system is in proper working order;
-All nursing personnel were to be aware of call lights at all times;
-Staff was to answer ALL call lights promptly whether or not they were assigned to care
for that particular resident;
-For bedside call lights, a light would appear over the door of the resident’s room and on
the board at the nursing station;
-Staff was to answer all call lights in a prompt, calm, courteous manner, and turn off the
call light as soon as they entered the room;
-Staff was to never make a resident feel they were too busy to give assistance;
-Be sure all call lights were placed on the bed at all times and ensure they were never on
the floor or bedside stand.
2. During the group interview on 2/6/19 at 10:30 A.M., residents in attendance said the
following:
-Resident #30 and #156 said they usually wait 30 minutes for staff to answer call lights.
Staff was busy and there was not enough staff to answer call lights quickly;
-Resident #156, #150, and #30 said staff turn the call lights off and say they will be
back. Staff does not come back, they forget or get busy with someone else;
-Resident #30 said he/she waited on pain medications for a long time;
-Resident #156 said he/she waited on pain medication and for staff to take him/her to the
bathroom for a long time;
-Resident #30 said he/she was supposed to get a shower three times a week. He/She had not
received a shower for over two weeks;
-Resident #150 said he/she had one shower since admission to the facility at the end of
(MONTH) 2019;
-Resident #32 said he/she had waited ten to 12 days for a shower.
3. Review of Resident #4’s care plan, dated 10/31/18, showed the following:

Based on observation, interview and record review, the facility failed to ensure staff had
appropriate competencies and skills sets to provide nursing and related services to assure
resident safety and attain or maintain the highest practicable physical, mental, and
psychosocial well-being of each resident, as determined by resident assessments and
individual plans of care. The facility had six nursing assistants (NAs) who had not
completed the mandatory 16 hours of certified nurse’s aide training (CNA) prior to
providing direct care to residents. The facility census was 47.
Review of the policies and procedures provided by the facility showed there was no policy
directing NAs to have the required 16 hours of CNA training prior to providing direct care
to residents.
1. Review of a list of NAs provided by the facility showed the following NAs were
currently working at the facility:
-NA K was hired on 12/26/18;
-NA N was hired on 1/2/19;
-NA B was hired on 1/7/19;
-NA M was hired on 1/11/19;
-NA G was hired on 1/17/19;
-NA L was hired on 2/1/19.
Observation on 2/7/19 at 7:20 A.M., showed the following:
-NA G entered Resident #16’s room with a washable incontinence bed pad. He/She washed
hands and applied gloves;
-NA G rolled the resident on his/her side, the washable incontinence bed pad was saturated
with urine;
-NA G rolled up the urine soiled incontinence pad under the resident’s left hip and placed
the dry incontinence pad on the bed. NA G placed the bedpan under the resident on top of
the dry incontinence pad and rolled the resident onto the bed pan. The urine soiled
incontinence pad remained rolled up under the resident’s left hip;
-NA G removed gloves, washed hands and left the room.
Observation on 2/7/19 at 8:18 A.M., showed the following:
-NA G and Certified Medication Technician (CMT) R entered Resident #16’s room and without
washing hands or applying gloves, rolled the resident on his/her right side. Two
incontinence pads were noted under the resident. The urine soiled rolled up incontinence
pad remained under the resident’s left hip and a second dry incontinence pad lay flat
under the resident;
-NA G with ungloved hands, pulled out the urine soiled incontinence pad and through the
pad on the floor beside the bed;
-NA G with ungloved soiled hands, adjusted the dry incontinence pad under the resident,

Based on observation, interview, and record review, the facility failed to provide each
resident with a palatable meal served at appetizing temperatures. The facility census was
47.
1. During an interview on 2/05/19 at 10:50 A.M., Resident #27 said the food was cold at
all meals. He/She ate in his/her room. The resident’s spouse confirmed the food was cold.
During an interview on 2/5/19 at 11:59 A.M., Resident #4 said the meals were cold, staff
did not serve food on the menu, and he/she would like more variety.
Observation on 2/6/19 at 8:22 A.M., showed Nurse Aide (NA) N delivered Resident #2’s
breakfast tray of pancakes, bacon, cereal and milk. NA N sat the resident up and in bed
and adjusted the bedside table for the resident. The resident took a bite of bacon and
pancake and said the food was cold. Staff did not reheat the resident’s breakfast.
During an interview on 2/6/19 at 9:43 A.M., the Dietary Manager said she was in the
resident council meeting on 2/5/19 and several residents said the dining room food was
cold. The Dietary Manager said a few months back resident’s had complained about cold
food.
During a group interview on 2/6/19 at 10:30 A.M., residents said the following:
-Resident #30 said staff serve the same foods over and over, there was no variety. He/She
ate in his/her room and the food was cold. He/She voiced food concerns recently to the
administrator and Dietary Supervisor, and there had been no change;
-Resident #150 said he/she ate in the dining room and the food was cold.
During an interview on 2/13/19 at 10:30 A.M., Resident #150 said over the weekend the
chicken was hard and cold. He/She was unable to chew the chicken. This morning the
pancakes were cold. His/Her family brought in food for him/her that was hot and he/she was
able to eat. The facility food was poor.
Review of the lunch menu for 2/6/19, showed residents were to receive roast pork, dressing
with gravy, broccoli, bread and butter, and pineapple cake.
Observation on 2/6/19 showed the following:
-At 12:14 P.M., the Assistant Dietary Manager took the temperatures of the food on the
steam table prior to preparing the hall trays. The temperature of the pork roast was 167
degrees Fahrenheit (F), broccoli was 168 degrees F, gravy was 168 degrees F, and the
dressing was 169 degrees F;
-At 12:24 P.M., staff prepared hall trays and placed them on the hall cart;
-At 12:31 P.M., the Dietary Manager took the cart containing the hall trays to the nurses
station and announced the hall trays were at the nurse’s station and ready for delivery.
He/She returned to the kitchen;
-No nursing staff were in the hallways when the dietary manager delivered the trays to the
nurse’s station and announced they were ready for delivery.
-At 12:37 P.M., the certified nurse assistant (CNA) on the hall passed the first hall
tray;
-At 12:39 P.M., the CNA passed the second hall tray.
-At 12:40 P.M., staff passed the third hall tray. Staff left the doors on both sides of
the hall cart open;
-At 12:45 P.M., staff passed the ninth hall tray. The CNA shut the doors on the hall cart.
The doors remained open on the cart from 12:40 P.M. to 12:45 P.M.;
-At 12:49 P.M., staff passed the last hall tray;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that four
of 13 sampled residents (Resident #3, #9, #10, and #22), and two additional residents
(Resident #16 and #1) with limited mobility received appropriate services and assistance
to maintain or improve mobility with the maximum practicable independence. The facility
census was 47.
Review of the facility’s undated restorative activities of daily living (ADL) program
policy showed the following:
-It was the responsibility of the licensed nurses and restorative aides (RA) to perform
these duties;
-The purpose of this policy was to assess the need of residents to attain, maintain, or
re-train ADLs;
-Equipment required was adaptive devices as assessed per therapist, restorative
documentation log, and a computer;
-RA would perform procedures listed on care plan ADL goals;
-Licensed nurses were to provide restorative therapy to each resident should the RA be
unavailable on any day residents were to receive therapy to ensure orders were being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure nursing
staff washed their hands after each direct resident contact, failed to wear gloves and
change gloves during direct resident personal care and failed to ensure proper handling of
soiled linens when indicated by professional practices during personal care for three