CREVE COEUR MANOR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to maintain
resident dignity by failing to properly cover urinary catheter (tube to drain urine from
the bladder) bag for one resident (Resident #13), failed to sit while assisting three
residents (Resident #48, #81, and #195) with meals, and failed to cover exposed skin in
public areas for one resident (Resident #81). Additionally, facility staff failed to
ensure the availability of undergarments for one resident (Resident #44). The facility
census was 99.
1. Review of the facility’s Resident’s Rights policy, undated, showed staff are directed
to treat residents with consideration, respect and full recognition of his/her dignity and
individuality, including privacy in treatment and in care for his/her personal needs.
Review of the facility’s Indwelling Catheter policy, dated (MONTH) 2001, showed staff are
directed to promote dignity by making sure the catheter bag is covered.
Review of the facility’s Feeding Dependent Residents policy, dated (MONTH) 2001, showed
staff are directed to sit at the same level as the resident when possible and converse
with the resident in an appropriate manner.
Review of the facility’s policy for the duties of the Social Services Director (SSD),
undated, showed he/she is to ensure residents have appropriate and proper fitting
clothing, shoes, socks, and undergarments in good repair, to present a well-groomed
appearance.
2. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/9/18, showed staff assessed the resident with an indwelling catheter.
Review of the resident’s care plan, updated 6/15/18, showed the resident had a Suprapubic
catheter (tube surgically inserted into the abdomen and the bladder to drain urine) and
staff are directed to do the following:
-Change catheter as ordered;
-Drainage bag at proper height;
-Offer fluids frequently.
Observation on 4/24/18 at 8:54 A.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
Observation on 4/25/18 at 9:22 P.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
Observation on 4/25/18 at 10:01 A.M., showed the resident in bed. The resident’s catheter
bag contained urine and staff did not cover the urinary catheter bag. Observation showed
the catheter bag in view from the hallway and residents and staff walked past the
resident’s room. Further observation showed Licensed Practical Nurse (LPN) K provided
catheter care to the resident and did not place the catheter bag in a dignity bag.
Observation on 4/26/18 at 9:18 A.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said
residents’ catheter bags should be kept covered in a dignity bag so the urine is not

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

Based on interview and record review, facility staff failed to ensure residents have
appropriate access to their trust fund account, including on weekends. The facility census
was 99.
1. Review of the facility’s policy on availability of funds, undated, showed staff are
directed:
-All funds maintained in the Trust Fund must be made available to participating residents
during normal business hours;
-The funds must be available to residents no less than 10 hours a week, and no less then 3
days a week;
-Standard policy would dictate that the funds be available during regular business hours
Monday through Friday;
-The residents must be fully informed of the time and days in which funds may be received.
2. During an interview on 4/24/18 at 9:30 A.M., the Bookkeeper said residents are not able
to receive their funds on the weekends as no one is in the facility to access the funds on
Saturday or Sunday. He/She said if the residents need money they need to let him/her know
on Friday before he/she leaves.
3. During a group meeting on 4/24/18 at 10:54 A.M., residents in attendance said they are
not able to get any of their funds on the weekends, they have to either ask for it on
Friday or wait until Monday.
4. During an interview on 4/26/18 at 6:50 P.M. the Administrator said resident funds are
only offered Monday through Friday. He/She said staff check with residents on Friday
evenings to ensure no one needs money for the weekend. He/She was not aware residents
should have access to funds on the weekends.
5. During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said funds
are not offered to residents on the weekends. He/She said residents know they have to
request funds for the weekend by 5:00 P.M. on Friday evenings.

Based on interview and record review, facility staff failed to purchase a surety bond in
an amount sufficient to assure security of all personal funds the facility holds for
residents. The census was 99.
1. Review of the facility’s policy on Surety Bond, undated, showed the following:
-The Surety bond liability amount should always be adequate to cover one and one half
times (1 1/2 times) the highest balance of the Resident Trust Fund, per the bank
statement;
-The monthly balance should be viewed against the amount on the surety bond;

Based on observation, interview and record review the facility failed to ensure fifteen
residents’ (Resident #10, #22, #26, #32, #37, #38, #44, #48, #52, #81, #83, #188, #191,
#195, #197) who live on the 200 hall right to private communication when they failed to
repair the resident phone in a timely manner. The facility census was 99.
1. Review of the facility’s Resident Rights policy, undated, showed staff are directed to
ensure residents are free to communicate freely and privately with persons of their
choice, receive their mail unopened, and be allowed private telephone conversations.
2. Observation on 04/23/18 at 12:12 P.M., showed the 200 hall resident phone plugged in
but without a dial tone.
Observation on 04/24/18 at 9:35 A.M., showed Resident #26 used the phone at the nurse’s
station to speak to family and the ADON interrupted him/her many times during the call.
3. During an interview on 04/23/18 at 11:59 A.M., Resident #44 said he/she is not allowed
to use the phone. He/She has not been able to use the phone in four months. He/She said
he/she complained to the state in Jefferson City and then his/her phone rights were shut
off. He/She said staff took the phone out of the phone room so he/she could not use it.
During an interview on 04/24/18 at 9:44 A.M., Resident #197 said he/she used the phone at
the nurse’s desk one time and got yelled at for using it.
During an interview on 04/24/18 at 9:53 A.M., Resident # 83 said he/she usually uses the
phone at the nurse’s desk but today he/she was told he/she could use the phone in the
phone room. The resident said the phone did not work before. He/She said he/she can not
remember how long the phone was broken.
During an interview on 04/25/18 at 2:17 P.M., Resident #12 said the resident phone has
been down for two or three months because someone cut the phone line.
During an interview on 04/25/18 at 3:54 P.M., CNA H said he/she did not know the resident
phone was broken. He/She said sometimes the residents break the phone but staff usually
replace it the next day.
During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said the
residents on the locked unit broke the phone and it happens often. He/She said he/she is
unsure of how long the phone was broken. He/She said the residents are able to use the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, facility staff failed to ensure residents’ rights to
personal privacy was protected, when they stored 12 boxes of pharmacy records and shower
sheets in an unlocked and unattended location near a public hallway. Additionally, staff
failed to ensure a resident’s right to privacy when they included the resident’s personal
mail communications in his/her medical record for one resident (Resident #44). Facility
census was 99.
1. Observation on 04/23/18 at 2:25 P.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
Observation on 04/24/18 at 10:48 A.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
Observation on 04/25/18 at 9:39 A.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
During an interview on 04/26/18 at 5:57 P.M., LPN J said medical records should be stored
in the locked medical records office. He/She said medical records should be locked up or
out of reach.
During an interview on 04/26/18 at 6:59 P.M., the DON said resident medical records are
kept locked next door in medical records. He/She said there are medical records kept in a
closet across from his/her office. He/She said there should be a lock on the door and
he/she said he/she asked maintenance for a lock in (MONTH) but they have not installed it
yet.
2. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff are directed to provide
assistance with dressing.
Review of the residents’ Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 12/04/17, showed staff assessed the resident as follows:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to complete the Care Area
Assessment (CAA) Section (section V0200) of the Minimum Data Set (MDS), a federally
mandated resident assessment tool, for 15 residents (Residents #10, #13, #20, #26, #31,
#38, #44, #48, #52, #53, #63, #68, #76, #83, and #191) and failed to complete
comprehensive assessments for four residents (Resident #5, #8, #11, and #22). The facility
census was 99.
1. Review of the Centers for Medicare & Medicaid Services (CMS) MDS database showed
Resident #5’s last submitted quarterly assessment with an assessment reference date (ARD)
of 11/02/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/19/18 finalized, not transmitted, and the completion date on Section Z0500B as

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview facility staff failed to complete a Comprehensive
Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool,
for three residents (Resident #26, #32, and #81) out of 20 sampled residents. The facility
census was 99.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, showed
direction for staff as follows:
-Comprehensive Assessments are required comprehensive assessments include the completion
of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as
care planning. Comprehensive assessments are completed upon admission, annually, and when
a significant change in a resident’s status has occurred or a significant correction to a
prior comprehensive assessment is required. They consist of:
-Admission Assessment;
-Annual Assessment;

Based on interview and record review, facility staff failed to transmit required Minimum
Data Set (MDS) assessments for 16 residents (Residents #1, #2, #3, #4, #6, #7, #9, #10,
#12, #13, #14, #15, #16, #17, #18, and #19 ). The facility census was 99.
1. Review of the Resident Assessment Insturment (RAI) Manual, dated 10/1/17, directs
assessments must be sumitted:
-Comprehensive assessments must be transmitted electronically within 14 days of the Care
Plan Completion Date (V0200C2 + 14 days);
-All other MDS assessments must be submitted within 14 days of the MDS Completion Date
(Z0500B + 14 days).
2. Review of the Centers for Medicare & Medicaid Services (CMS) MDS database showed
Resident #1’s last submitted quarterly assessment with an assessment reference date (ARD)
of 11/01/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/17/18 finalized, not transmitted, and the completion date on Section Z0500B is
04/17/18.
Review of the facility’s MDS software showed an annual assessment due on 02/01/18, not
validated, not finalized, not transmitted, and not completed.
3. Review of the CMS MDS database showed Resident #2’s last submitted quarterly assessment
with an ARD of 11/02/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/17/18 finalized, not transmitted, and the completion date on Section Z0500B is
04/17/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to document a complete and
accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did
not accurately code an assistive/mobility device for two residents (Resident #22, and
#48), behaviors for one resident (Resident #44), a psychiatric/mood disorder [DIAGNOSES
REDACTED].#44), injections and antipsychotic medication for one resident (Resident #44), a
fall with injury for one resident (Resident #83), Preadmission Screening and Resident
Review (PASRR) and Antipsychotic medication review for one resident (Resident #191), of 20
sampled residents. The facility census was 99.
1. Review of Resident #22’s quarterly change Minimum Data Set (MDS), dated [DATE], showed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to accurately complete the
Pre-Admission Screening and Resident Review (PASRR) process prior to admission for one
resident (Resident #44). The facility census was 99.
1. Review of the Central Office Medical Review Unit (COMRU) Instructional Guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASRR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to a nursing
facility to ensure the client does not trigger a Level II screening. A level II screening
refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II.
-The triggers for the level II screening are:
-the client has had inpatient psychiatric treatment in the past two years;
-the client was suicidal or homicidal (includes Dementia clients);
-the client has very aggressive behavior (includes Dementia clients);
-the client has a [DIAGNOSES REDACTED].
2. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
to the facility on [DATE].
Review of the resident’s PASRR Level I, dated 11/21/17, showed the resident did not have a
major mental illness diagnosis, did not display signs or symptoms of a mental illness, and
did not have serious problems in level of functioning in the last six months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review facility staff failed to complete the Pre-Admission
Screening and Resident Review (PASRR) process prior to admission, and failed to notify the
appropriate mental health authority for a referral/screening, after an acute inpatient
Psychiatric hospital stay for one sampled resident (Resident #32). The facility census was
99.
1. Review of the facility’s records showed it did not contain a policy to address the
PASRR screening and referral process.
2. Review of the Central Office Medical Review Unit (COMRU) Instructional Guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASRR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening;
-The DA-124 C (form for the screening) must be completed prior to admitting the client to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to update the plan
of care with changes in the resident’s needs for nine residents (Resident #22, #26, #32,
#44, #48, #52, #81, #191, and #195) out of 20 sampled residents. The facility census was
99.
1. Review of the facility’s records showed it did not contain a policy to address
resident’s care plans.
2. Review of Resident #22’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 1/03/18, showed staff assessed the resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice.
Review of the resident’s care plan, dated 10/24/16, showed staff did not update the care
plan when the resident could no longer ambulate on his/her own and began to use a
wheelchair.
Observation on 4/24/18 at 4:03 P.M., showed the resident in the dining room in his/her

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to meet
professional standards when they failed to follow the physician’s order regarding oxygen
administration for one resident (Resident #68). Additionally staff failed to obtain x-ray
results in a timely manner and follow physician’s orders to administer PRN (as needed)
pain medication for one resident (#195). The facility census was 99.
1. Review of the facility’s Oxygen Administration policy, dated (MONTH) 2001, showed
facility staff are directed to check the physician’s order for liter flow and method of
administration.
2. Review of Resident #68’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/16/18, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Required extensive assist of two or more staff for bed mobility and bathing;
-Required total assistance of one staff for locomotion, dressing, and personal hygiene;
-Required total assistance of two or more staff for transfers, and toilet use;
-Had shortness of breath with exertion, rest, and lying flat;
-No oxygen therapy.
Review of the resident’s care plan, undated showed the resident was on oxygen as needed
and the resident is very confused when the resident needs his/her oxygen.
Review of the resident’s Physician Order Sheet (POS), dated (MONTH) (YEAR), showed a
telephone order, dated 2/21/18, directed staff to discontinue oxygen of two liters
continuously and start two liters via nasal cannula as need to keep saturation above 90
percent (%).
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Observation on 4/24/18 at 9:03 A.M. showed the resident in his/her room in bed. The
resident had his/her oxygen on and set at six liters per nasal cannula.
Observation on 4/24/18 at 2:58 P.M. showed the resident in his/her room in bed. The
resident had his/her oxygen on and set at six liters per nasal cannula.
Observation on 4/25/18 at 9:57 A.M. showed the resident in his/her room in bed. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to provide an
ongoing program of activities designed to meet the residents’ interest during the weekend
for 10 sampled residents (Residents #10, #13, #22, #26, #38, #44, #48, #63, #68, and #83).
The facility census was 99.
1. Review of the facility’s policy for the Director of Activity (AD), undated, showed the
AD is to assure that an ongoing program of activities is designed to meet, in accordance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure
residents’ environment remained free from accident hazards, when they propelled two
residents (Resident #29 and #48) without foot pedals, failed to properly transfer one
resident (Resident #81), and failed to put fall prevention measures in place for one
resident (Resident #195) of 20 sampled residents in a manner to prevent accidents.
Facility staff also failed to ensure the residents’ environment remained free of accident
hazards when they failed to ensure razors and chemicals were not accessible to residents.
The facility census was 99.
1. Review of the facility’s policy on Wheelchair use, updated 11/2001, showed staff are
directed:
-The purpose is to provide mobility for the non-ambulatory resident with safety and
comfort;
-Fold foot rests up out of the resident’s way for safety, and do not remove foot rests
unless the resident uses feet on floor to enable mobility;
-Lower foot rests and place resident’s feet on foot rest if used. Position feet and legs
in good body alignment. Elevate legs as ordered;
-Encourage and instruct resident in proper procedures for safely propelling the
wheelchair.
2. Review of Resident #48’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 5/13/17, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Limited assistance of one person with bed mobility, and transfer;
-Extensive assist of one person with ambulation, locomotion on/off unit, dressing, toilet
use, and personal hygiene;
-Did not use any mobility devices.
Review of the resident’s care plan for fall intervention, last updated 6/15/17, showed
staff are documented the resident has impaired ambulation, and directed staff:
-Use wheelchair for mobility as a result of Dementia;
-Resident uses high back wheelchair with two foot rests;
-Resident needs assistance.
Review of the resident’s comprehensive MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-Extensive assistance of one person with ambulation, locomotion on and off unit, dressing,
toilet use, and personal hygiene;
-Did not use any mobility devices.
Observation on 4/26/18 at 10:45 A.M., showed Certified Nursing Assistant (CNA) E propelled
the resident in his/her high back wheelchair without foot pedals from the dining room to
his/her room, while his/her feet slid along the floor.
Observation and interview on 4/26/18 at 10:54 A.M., showed CNA D and CNA E transferred the
resident from the chair to the bed, provided perineal care, and transferred the resident
back to the wheelchair. CNA D began to propel the resident back to the dining room. CNA D
said the resident does have foot rests for his/her wheelchair, but staff did not know
where to find them at the moment. The CNA said staff are expected to push the resident in
his/her wheelchair with the foot pedals to prevent an accident from his/her feet jamming
on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review facility staff failed to complete
required assessments and maintain proper documentation for the use of side rails for three
residents (Resident’s #13, #63, and #68). The facility census was 99.
1. Review of the facility’s Restraints and Enabler policy and procedure, reviewed (YEAR),
showed staff are directed to do the following:
-Complete the Device Decision Guide to determine if it is appropriate to place the
resident in a restraint or enabler;
-Any resident that is identified to have a need for a enabler is to be referred to therapy
department;
-If it is determined there is a need for a enabler the resident and/or responsible party
will meet for a care plan meeting to allow for informed consent regarding the type of
device to be used, when the device will be used, what medical symptom is being treated,
and what way the device will improve the resident’s quality of life;
-A physician order [REDACTED]. of life;
-On a quarterly basis, the care plan team will meet to determine if a restraint reduction
and elimination is appropriate. The Device Decision Guide will be repeated during this
time;
-Any trial reductions will be addressed in the care plan and the nursing department will
document the resident’s response to the reduction a minimum of daily until the care plan
team determines the success or failure of the reduction attempt.
2. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/9/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of one staff for locomotion and dressing;
-Required total assistance of two or more staff for transfer, toilet use, and personal

Based on interview and record review, facility staff failed to provide the services of a
Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week.
The facility census was 99.
Review of the facility’s Staffing Pattern, reviewed (MONTH) (YEAR), showed for a census of
96 residents, provisions will be made for:
-Director of Nursing (DON): 40 hours per week;
-Assistant DON: 40 hours per week;
-Program Manager (PM): 40 hours per week;
-Two Licensed Practical Nurse/RN: total of 16 hours each shift (day, evening, and night).
Review of the facility’s Licensed Nurses staffing schedule, dated (MONTH) (YEAR), showed
staff did not document an RN was scheduled to work for the month of April.
Review of the facility’s RN staff time sheets, dated 4/1/18 through 4/25/18, showed the
total hours worked between the only two staffed RNs (the DON and the PM), on the following

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures to address the appropriate timeframes for the different steps in
the Medication Regimen Review (MRR) process to identify irregularities and minimize or
prevent adverse consequences for two residents (Resident #48 and #68), of five sampled
residents selected for medication management. The facility census was 99.
1. Review of the facility’s records showed it did not contain a policy to address
appropriate timeframes for the different steps in the MRR process.
2. Review of Resident #48’s medical records, showed staff documented the resident was
admitted to the facility on [DATE], with [DIAGNOSES REDACTED].
Review of the resident’s Care Plan for [MEDICAL CONDITION], last updated 8/8/16, showed
staff documented the resident had [DIAGNOSES REDACTED].
-Administer [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] and [MEDICAL
CONDITION] disorder), [MEDICATION NAME] (medication to treat depression), and Quetiapine
(medication to treat [MEDICAL CONDITIONS] disorder and depression);
-Document behaviors as they occur;
-Abnormal Involuntary Movement Scale (AIMS) assessment on admission, quarterly and with
significant changes;
-Pharmacist and Physician will evaluate and document continued use of medications, and
taper medications monthly as indicated.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 11/14/17, showed staff assessed the resident as follows:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to obtain an appropriate
[DIAGNOSES REDACTED].#44). Additionally facility staff failed to obtain stop dates of 14
days or less on as needed (PRN) [MEDICAL CONDITION] medications (chemical substance that
changes brain function and results in alterations in perception, mood, consciousness or
behavior), for two residents (Resident #22 and #44). The facility census was 99.
1. Review of the facility’s Rights of Medication Administration policy, undated, showed
staff are directed to:
-Identify the resident;
-Check the medication;
-Check the dose;
-Check the route of administration;
-Check the time the medication is supposed to be given;
-Document administration immediately;
-Confirm the reason for use;
-Ensure a proper response to the medication.
2. Review of the facility’s Physical and Chemical Restraint policy, (YEAR), showed staff
are directed to ensure residents remain free from chemical restraints by:
-Ensuring restraints are used to treat a medical symptom;
-Reviewing the resident’s condition, circumstances, and environment along with their
medical symptom;
-Documenting any trial reductions in the resident’s care plan and charting the resident’s
response to the reduction daily.
3. Review of Resident #22’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 01/03/18, showed staff assessed the resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice.
Review of the resident’s physician’s orders [REDACTED]. Further review showed staff did
not document information in the resident’s medical record to support extending the
medication beyond 14 days.
During an interview on 04/26/28 at 5:57 P.M., Licensed Practical Nurse (LPN) J said all
medication, especially [MEDICAL CONDITION] medications, should include a corresponding
[DIAGNOSES REDACTED]. He/She said PRN [MEDICAL CONDITION] medication orders should include
a stop date within 14 days.
During an interview on 04/26/18 at 6:59 P.M., the Director of Nursing (DON) said nursing
staff should make sure all [MEDICAL CONDITION] medications include a [DIAGNOSES REDACTED].
4. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff did not provide direction
or interventions to address the resident taking [MEDICAL CONDITION] medication.
Review of the residents’ MDS, dated [DATE], showed staff assessed the resident as follows:

Based on observation, interview, and record review facility staff failed to store food and
maintain kitchen surfaces in a sanitary manner to prevent potential cross-contamination.
The facility census was 99.
Review of the facility’s policy on Food Storage, (YEAR), showed staff are directed to:
-Store food on clean dry shelves, clean from contaminants;
-Store food at appropriate temperatures and using appropriate methods;
-Label all food items with the name and the date by which it should be sold, consumed, or
discarded;
-Rotate products so the oldest are used first;
-Discard food past the expiration date;
-Store deliveries as soon as they have been inspected;
-Store leftovers in covered, labeled and dated containers;
-Store poisonous materials and chemicals separate from food;
-Never leave any food item uncovered and not labeled.
1. Observation on 04/23/18 at 10:57 A.M., showed the following:
-Coffee stains on the two lower shelves of the coffee station;
-Soiled plastic drip mats on the shelves of two beverage service carts;
-Four large Tupperware like containers of cereal unsealed, unlabeled, and not dated;
-Four small Tupperware like containers of cereal unlabeled and not dated;
-One opened sliced cheese in the refrigerator unsealed, unlabeled, and not dated;
-One loaf of bread unsealed, unlabeled, and not dated;
-Debris on refrigerator shelves;
-One large bag of instant mashed potatoes unsealed;
-Three bags of crab Rangoon open, unsealed, unlabeled, and not dated;
-One bag of large brats open, unsealed, unlabeled, and not dated;
-One bag of chicken patties open, unsealed, unlabeled, and not dated;
-One bag of French fries open, unsealed, unlabeled, and not dated;
-One bag of hamburger patties open, unsealed, unlabeled, and not dated;
-20 large bottles of seasoning open and unsealed,;
-One large bowl of seasoning open, unsealed, unlabeled, and not dated stored on the bottom
shelve next to kitchen sink;
-Four pitchers of drinks in colored pitchers on the beverage cart, undated;
-Two five-gallon buckets of dish cleaning chemicals stored in dry storage.
During an interview on 05/02/18 at 2:07 P.M., dietary staff Q said staff should wipe off
any noticeable debris as soon as possible. He/She said open food should be sealed and

Based on observation, interview, and record review, facility staff failed to appropriately
sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after
use for five residents (Resident #12, #32, #188, #205, and #237), to prevent the spread of
infection causing contaminants. Facility staff also failed to wear gloves or wash/sanitize
hands during meal assistance for six residents (Resident #26, #29, #44, #48, #79, #188) to
prevent the spread of infection causing contaminants. The facility census was 99.
1. Review of the facility’s policy on Blood Sugar Monitoring, undated, showed staff are
directed:
-Observe (standard) universal precautions;
-Wash hands before and after all procedures;
-Clean and dry skin well before procedure;
-Dispose of disposable equipment appropriately;
-Thoroughly clean all equipment used with super Sani Cloth and return to appropriate
storage area;
-Follow the manufacturer’s directions for the type of equipment used in the facility.
2. Observation on 4/23/18 at 12:26 P.M., showed Certified Medication Technician (CMT) A
removed a glucometer from the top drawer of the medication cart, applied gloves, checked
Resident #12’s blood glucose level, laid the unsanitized multi-use glucometer on top of
the Medication Administration Record [REDACTED]. The CMT did not sanitize the multi-use
glucometer before or after use.
3. Observation on 4/23/18 at 12:40 P.M., showed CMT A sanitized hands, applied gloves,
removed the unsanitized multi-use glucometer from the top drawer of the cart, checked
Resident #32’s blood glucose level, placed the unsanitized multi-use glucometer on top of
the MAR, and sanitized hands. The CMT did not sanitize the multi-use glucometer before or
after use.
4. Observation on 4/23/18 at 12:42 P.M., showed CMT A applied gloves, picked up the
unsanitized glucometer from on top of the MAR, checked Resident #188’s blood glucose
level, and placed the unsanitized multi-use glucometer on top of the cart. The CMT did not
sanitize the multi-use glucometer before or after use.
5. Observation on 4/23/18 at 3:51 P.M., showed CMT U removed a glucometer from the top