CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ right to self-administer medications had been determined as clinically
appropriate for one of 26 sampled residents (Resident #114). The census was 130.
Review of Resident #114’s medical record, showed:
-An admission Minimum Data Set (MDS), a federally mandated assessment instrument completed
by facility staff, dated 12/25/18, showed [DIAGNOSES REDACTED].
-No assessment for the ability to self-administer medications.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s care plan, dated 12/25/18, showed no documentation for the
ability to self-administer medication.
Observation and interviews on 3/18/19 at 11:55 A.M. and at 1:30 P.M., showed a medicine
cup on the resident’s bedside table with nine pills inside the cup. The resident appeared
to be asleep and startled when the surveyor called out his/her name a few times. He/she
looked at the medicine cup and said, Oh, I need to take my pills. He/she was very groggy
and said he/she did not sleep much the night before. The nurse would leave his/her
medication sometimes because it was hard to wake him/her. During an interview at 1:30
P.M., the resident said staff sometimes left his/her medication on the table. The staff
had not educated him/her on self administration. Staff would know he/she took it because
he/she would use his/her call light if he/she did not have all his/her medication. He/she
liked staff to leave the medication so he/she would not have to wake up to take it so
early.
During an interview on 3/18/19 at 12:35 P.M., Licensed Practical Nurse (LPN) W said he/she
administered the resident’s medication at 9:00 A.M. He/she did not realize the resident
did not swallow the medication because he/she put the cup up to his/her mouth. The
resident had not been assessed to administer his/her own medications. He/she probably
should not have left the medication in the resident’s room.
During an interview on 3/20/19 at 5:20 P.M., the corporate nurse said the staff member
should not have left medication with the resident without an order from the physician to
self-administer.
Review of facility’s resident self administration of medications policy dated 8/1/16,
showed:
-Policy – It is the policy of the facility to provide resident centered care that
safeguards the residents right for self-administration of their own medication that
supports resident dignity and self-determination;
-The facility will not require or compel any resident to administer their own medication
if they do not desire to do so or cannot safely do so. The facility will not knowingly
permit an unsafe act for self-administration of medications. Self-administration of
medications still requires nurse observations and monitoring for effects and side-effects;
-The facility will periodically review the ability to self-administer medication based
upon change in status;
-On admission, the facility will assess the resident for safety through an IDT
(interdisciplinary team) care planning team prior to the resident exercising their right
of self-administration of drugs within 7 days after the comprehensive assessment is
completed as required by regulations;
-Procedure:
-Determine if the resident desires to self-administer medication;
*Physician/provider order is required for residents to self-administer medication;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
resident has a right to make choices about aspects of his or her life in the facility that
are significant to the resident by not providing coffee in the morning prior to the
service of breakfast for one resident (Resident #86) and not providing residents access to
the dining room outside of meal service hours. This had the potential to affect all
residents who would choose to utilize the dining room during times outside of meal service
and/or drink coffee at times dietary staff are not available. The census was 130.
1. Review of Resident #86’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/8/19, showed:
-Brief Interview for Mental Status (BIMS) score of 13 out of 15;
-A BIMS score of 13-15, showed the resident cognitively intact;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed no
documentation the resident had been assessed as unsafe to drink hot liquids.
During an interview on 3/15/19 at 7:31 A.M., the resident said there was a group of 10 to
12 residents who used to go in the dining room before breakfast and drink coffee together.
Now staff will not serve coffee until breakfast is served, never before 7:30 A.M. This was
an activity that he/she really enjoyed and it was taken away. Staff keep the door to the
dining room closed and resident’s cannot even go in until breakfast time. This change
occurred when kitchen management changed.
Observation on 3/15/19 at 7:30 A.M., showed the doors to the kitchen closed and several
residents waited in the hall. Dietary staff opened the doors at 7:31 A.M. and residents
entered the dining room. Water and juice available to residents. No coffee available. At
approximately 7:40 A.M., staff started to bring cups of coffee from the kitchen to
residents who sat in the dining room.
2. Review of the list of meal times, provided by the facility, showed the following dining
room times:
-Breakfast: 7:30 A.M. through 8:30 A.M.;
-Lunch: 12:00 P.M. through 1:00 P.M.;
-Dinner: 5:30 P.M. through 6:30 P.M.
Observation on 3/14/19, 3/15/19 and 3/18/19 through 3/20/19, showed the doors to the
dining room closed when meal service not in progress.
3. During an interview on 3/20/19 at 1:48 P.M., the dietary manager said when floors are
being cleaned after a meal, doors are closed and residents cannot be in the dining room
because the floors are wet. She does not want residents in the dining room unattended. She
could see why residents believed they were not allowed in the dining room since the doors
are kept closed, but they could open the doors and come in. She did not know why the doors

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility the facility failed to ensure resident
mattresses were were in good repair, control strong urine odors that did not dissipate
throughout the survey process and ensure bathroom vents had covers and were clean and in
good repair (Resident #95). The census was 130.
1. Review of Resident #95’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/17/19, showed:
-Rarely/never understood;
-Rarely/never understands;
-Extensive assistance of two (+) staff required for bed mobility and transfers;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-[DIAGNOSES REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ rights to be free from abuse were not violated as evidenced by resident to
resident physical altercations involving six of 26 sampled residents (Residents #85, #51,
#52, #127, #106 and #90). The census was 130.
1. Review of Resident #85’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility, dated 2/8/19, showed:
-Brief interview for mental status (BIMS, a screen for cognitive impairment) score of 15
out of 15 (a score of 13-15 indicates intact cognition);
-Trouble concentrating on things such as watching television and reading a newspaper;
-No behaviors;
-Extensive assistance from one staff for bed mobility, transfers, dressing and bathing;
-Mobility device, wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/24/19 and revision dated 3/4/19, showed:
-Problem: Potential to demonstrate verbally abusive behaviors related to mental and
emotional illness and poor impulse control, staff witnessed resident pulling and
scratching another resident;
-Goal: Resident with staff assistance will have fewer episodes of yelling out/verbal
behavior, will not harm self or others, will seek out staff/caregiver when agitation
occurs and will verbalize understanding of need to control physically aggressive behavior
through next review;
-Interventions: Analyze key times, places, circumstances, triggers and what de-escalates
behavior, assess/anticipate resident’s needs, assess resident’s coping skills/support,
contact the resident’s family when resident becomes agitated, provide physical/verbal cues
to alleviate anxiety, give positive feedback, assist to set goals for more pleasant
behavior, encourage resident to seek out staff members when agitated, monitor and document
observed behaviors and attempted interventions in the behavior log, resident was
immediately removed away from the resident (roommate) and taken out of the room on 3/3/19.
Review of the resident’s progress note dated 3/3/19 at 12:30 P.M., showed the resident was
found in his/her room, scratching and hitting his/her roommate. The incident was heard by
two nurses. They separated the resident and his/her roommate. The resident said his/her
roommate called him/her a b***h and w***e. The resident said he/she began hitting and
scratching his/her roommate. The resident’s physician was contacted.

Based on interview and record review, the facility failed to ensure newly hired employees
were screened to rule out the presence of a Federal Indicator, with the Certified Nurse
Aide (CNA) Registry, and the Employee Disqualification List (EDL). This affected two of 10
sampled employees hired since the last survey. The facility hired at least 100 new
employees since the last survey. The census was 130.
According to Missouri Department of Health and Senior Services (DHSS): Section for
Long-term Care LTC Bulletin, Volume 3 Issue 1, Fall 2004, if a CNA had or currently has
had their name on the EDL, they receive a federal marker. Those CNAs who have a federal
marker may not be employed at any time in a facility that receives Medicaid or Medicare
benefits.
According to Missouri Department of Health and Senior Services (DHSS): Section for
Long-term Care LTC Bulletin, Volume 6 Issue 1, Winter 2008, providers are required to
check the registry before hiring any individual and may not continue to employ a person
whose name appears on the registry with a federal indicator. Providers must seek registry
verification from all states believed to have information on an individual.
1. Review of the Admission Director’s employee file, showed:
-Hire date: 11/5/18;
-EDL and CNA registry check performed on 3/15/19.

Based on interview and record review, the facility failed to develop and implement written
policies and procedures that address prevention of resident to resident altercations
through identification and monitoring of residents with behaviors. In addition, the policy
failed to address the investigation of incidents and protection of residents if the abuser
is a visitor and/or volunteer. The census was 130.
Review of the facility’s Abuse, Neglect and Misappropriation policy, revised 10/12/18,
showed:
-It is the intent of this facility to prevent the abuse, mistreatment or neglect of
residents or the misappropriation of their property, corporal punishment and/or
involuntary seclusion and to provide guidance to direct staff to manage any concerns or
allegations of abuse, neglect or misappropriation of property;
-Prevention: The physical environment has been designed to prevent seclusion of residents,
staff members are identified by name badges, staffing is established based on census;
-The policy failed to identify prevention through an ongoing assessment, care planning for
appropriate interventions and monitoring of residents with needs and behaviors which might
lead to conflict;
-Investigation of incidents:
-In the event the alleged perpetrator is a staff member, that staff member will be
removed from areas of resident living and interviewed by nurse on duty;
-In the event the alleged abuse involved a resident-to-resident altercation, the
residents will be placed in separate areas by the staff and the appropriate physical
assessments will be completed on each resident;
-Protection from abuse:
-In the event a staff member has been accused, they will be interviewed by the executive
director or designee and be immediately escorted from the facility;
-When the alleged abuse involves a resident to resident altercation, the residents will
be separated by the staff and the appropriate physical assessments will be completed on
each resident;
-The policy failed to address the investigation of incidents and protection of residents
if the abuser is a visitor and/or volunteer.
During an interview on 3/20/19 at 4:56 P.M., the corporate nurse and administrator said
they would expect the abuse and neglect policy address the protocol for abuse prevention
for resident to resident altercations as well as investigation of incidents and protection
of residents if the abuser is a visitor and/or volunteer.

**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 one resident, when the resident’s care needs changed (Resident
#86). The sample was 26. The census was 130.
1. Review of Resident #86’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 2/8/19, showed:
-Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicated the resident
cognitively intact;
-Wandering: Behavior not exhibited;
-Independent with mobility and locomotion.
Review of the resident’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-At risk for communication problems. Delayed response to questions. Ensure/provide a safe
environment;
-Activity of daily living self-care performance deficit. Activity intolerance, impaired
balance/limited mobility/limited range of motion. Poor coordination. Requires staff
supervision while at the facility;
-The care plan failed to address the resident’s ability to leave independently on leave of
absence (LOA).
During an interview on 3/18/19 at 6:57 A.M., the resident said he used to live at an
apartment complex nearby and provided the name of the complex. He/she walked there over
the weekend. Staff eventually called his/her cell phone when they realized he/she was
gone. He/she went there to eat corned beef and cabbage with his/her old roommate. At 11:21
A.M., the resident said he/she left the facility Saturday (3/16/19) morning. It was
approximately six to seven hours before staff called to find out where he/she was. The
nurse who called said he/she should have signed out at the nurse’s desk. He/she knew that
he/she was supposed to do that, but just he/she did not. No one at the facility knew
he/she left the campus and/or that he/she was not coming back that night, until they
called. He/she returned before dinner the following day, 3/17/19.
Review of the facility’s LOA binder, located at the front desk, reviewed on 3/19/19,
showed:
-The resident signed out on 3/16/19 at 10:00 A.M. and returned on 3/17/19 at 4:20 P.M.;
-No documentation to show where the resident went or how long the resident’s leave was
anticipated.
Review of the resident’s LOA sign out log, located in the resident’s hard chart at the
nurse’s station, reviewed on 3/19/19, showed no documentation the resident went on LOA on
3/16/19.
During an interview on 3/19/19 at 7:01 A.M., Licensed Practical Nurse (LPN) C said he/she
was the nurse responsible for the resident on Saturday morning (3/16/19) from
approximately 6:00 A.M. to noon. He/she was not aware the resident left the facility. At
lunch he/she noticed the resident was not there eating, but did not know where he/she was
at that time.
During an interview on 3/19/19 at 9:50 A.M., with the administrator and Director of
Nursing (DON), they said they would expect staff follow their LOA policy. In the
resident’s chart, each resident has a LOA sheet. There is also a binder at the front desk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify physicians when
residents’ blood glucose levels exceeded parameters as ordered by those physicians. The
facility identified 23 residents that received routine blood glucose checks. Review of
their blood glucose levels, showed three exceeded parameters without the physician being
notified consistently, and one had high blood glucose levels with no parameters to notify
the physician (Residents #13, #68, #23 and #106). In addition, the facility failed to
ensure one resident’s pacemaker was monitored. (Resident #10). The census was 130.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents received the
minimum of two showers weekly and were kept clean and dry. Of the 26 residents sampled,
seven were reviewed for routine showers and problems were found with all seven (Residents
#18, #50, #75, #79, #95, #104 and #108). The census was 130.
1. Review of Resident #18’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/19/18, showed:
-No cognitive impairment;
-No behaviors;
-Extensive assistance with personal hygiene, dressing and bed mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 12/19/18, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure cardiopulmonary
resuscitation (CPR, initiation of life sustaining measures in the event the heart stops
beating) certified staff accompanied all residents with a full code (initiate CPR in the
event the heart stops beating) status, when transported to and from appointments in the
facility van. The census was 130.
Review of Employee S’s employee file, showed:
-Hire date: [DATE];
-No documentation of CPR certification.
During an interview on [DATE], the administrator said she should ensure all transportation
drivers including Employee S has a CPR certification. Some of the resident’s transported
are full code residents. The issue must have been overlooked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided consistent monitoring, assessments, documentation and physician updates for two
full code residents that experienced changes in their conditions. One was found lifeless
and unable to be revived and the other was found unresponsive and transferred to the
hospital (Residents #278 and #104). The census was 130.
Review of the facility’s policy regarding Skilled Documentation Guidelines, updated
[DATE], showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to adequately
assess, monitor and treat one resident’s pressure ulcer. The facility identified eight
residents with pressure ulcers. All eight were sampled with one additional sampled
resident to equal nine. Problems were found with the addition resident (Resident #227).
The census was 130.
Review of the facility’s policy on Skin Care and Wound Management, dated 7/1/2016, showed:
-Policy: The facility staff strives to prevent resident skin impairment and to promote
healing of existing wounds. The interdisciplinary team works with resident and
family/responsible party to identify and implement interventions to prevent and treat
potential skin integrity issues. The interdisciplinary team evaluates and documents
identified skin impairments and pre-existing signs to determine the type of impairment,
underlying condition contributing to it and description of impairment to determine
appropriate treatment;
-Each resident is evaluated upon admission and weekly thereafter for changes in skin
condition. The resident’s skin condition is also re evaluated with change in clinical
condition, prior to transfer to the hospital and upon return from the hospital;
-Prevention: Complete the Braden Scale (screening tool to determine risk of pressure
ulcers) on admission, weekly times three weeks, quarterly and change of clinical condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
that qualified for restorative therapy services received those services. The facility
identified 20 residents with current restorative therapy orders, six were sampled and none
of them were receiving restorative therapy as ordered (Residents #75, #102, #104, #52, #14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provided 24 hour
protective oversight and supervision for one resident when facility staff failed to
implement the facility resident leave of absence policy regarding the process to inquire
of the estimated length of absence from the facility and failed to develop a procedure to
inquire of the resident’s whereabouts while on voluntary leave for one resident (Resident
#86) who signed out to go outside the front of the building on 3/16/19 at 10:00 A.M.
Without informing staff of his/her departure, the resident walked approximately 6.7 miles
through a heavily populated area and across four lane roads with an estimated 2 hour and
17 minute walking distance. The resident did not receive his/her medications during the
time out of the facility and did not return to the facility until 3/17/19 at 4:20 P.M. The
census was 130.
Review of the facility’s Elopement Management policy, dated 7/1/16, showed:
-Elopement: The Centers for Medicare and Medicaid Services (CMS) defines elopement as when
a resident leaves the premises or a safe area without authorization and/or necessary
supervision. Each state may define elopement by a set of criteria for self-reporting
purposes;
-The facility is to immediately initiate procedures to locate any resident that is
unaccounted for. Notification of appropriate parties will comply with state and federal
regulations. Following location of the involved resident, the facility leadership will
review prevention systems to identify performance opportunities;
-Residents who are their own person and choose to leave the premises without staff
knowledge will be considered an Unauthorized Leave of Absence (LOA) and not elopement.
Review of the facility’s Resident Leave of Absence policy, dated 7/1/16, showed:
-A resident who is cognitively intact with independent decision making with a physician’s
orders [REDACTED]. In the event the resident exits the facility without signing out on the
log, the facility will initiate an investigation in an attempt to locate the resident.
Upon the resident return to the facility, appropriate reeducation for the LOA procedure
will be completed;
-For residents that sign out for a LOA, the resident or family/responsible party will
indicate the anticipated time of return at the time they sign out;
-Procedure:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow
physician’s orders for weight loss prevention and nutritional needs and ensure acceptable
parameters for nutritional status were maintained to prevent severe weight loss for one
resident, who experienced a 12.01% weight loss within a three month period and another
sampled resident who experienced weight loss. The facility identified 10 residents who
received tube feedings. Of those 10, four were chosen for the sample of 26 and problems
were found with two (Residents #5 and #102). The census was 130.
1. Review of Resident #5’s Admission Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/3/18, showed:
-Entry date of 11/26/18;
-Severely impaired cognitive skills for daily decision making;
-Altered level of consciousness;
-Required total assistance of one staff for eating;
-[DIAGNOSES REDACTED].
-Required a feeding tube (gastrostomy tube ([DEVICE]) a tube inserted through the abdomen
that delivers nutrition directly to the stomach);
-Proportion of calories received while tube feeding was 26 to 50%;
-Height and weight: Blank.
Review of the resident’s weight summary sheet, showed the resident weighed 143.2 pounds
(lbs) on 12/10/18.
Review of the resident’s undated care plan, showed:
-Focus: Initiated on 12/4/18, the resident had a nutritional problem and required eternal
nutrition and hydration via feeding tube to meet his/her needs;
-Goal: Maintain adequate nutritional and hydration status as evidenced by maintaining
weight within 5% for one month and 10% within six months, no signs and symptoms of
malnutrition (lack of proper nutrition caused by not having enough to eat) or dehydration
to meet estimated needs through the next review date;
-Focus: Initiated on 12/28/18, the resident had impaired mobility and no means of verbal

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed physician orders [REDACTED]. The facility identified ten residents who received
tube feedings. Of those ten, five were chosen for the sample of 26 and problems were found
with two (Residents #79 and #95). The census was 130.
1. Review of Resident #79’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/5/19, showed:
-Severe impaired cognition;
-Total assistance from one staff with bed mobility, transfers, dressing, eating, hygiene
and bathing;
-Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach to provide
nutrition, hydration and medication) with tube feedings;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident with a continuous positive airway pressure ([MEDICAL CONDITION], a machine used
for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts))
received the treatment as ordered (Resident #10). The census was 130.
Review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/9/18, showed:
-[DIAGNOSES REDACTED].
-No short/long term memory loss;
-Required staff supervision for bed mobility, transfers, dressing, toileting, personal
hygiene and bathing;
-Incontinent of bowel and bladder;
-No special treatments.
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED].
-No documentation regarding a [MEDICAL CONDITION].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, monitoring and ongoing communication with the [MEDICAL TREATMENT] (process
for removing toxins from the blood for individuals with kidney failure) center for
residents on [MEDICAL TREATMENT]. In addition, the facility failed to have signed [MEDICAL
TREATMENT] agreements/contracts for residents who received [MEDICAL TREATMENT]. The
facility identified seven residents who received [MEDICAL TREATMENT]. Of those seven, five
were selected for the sample of 26 and issues were found with three (Residents #51, #108

Review of the resident’s POS, dated 1/20/19 through 3/20/19, and in use during the survey,
showed:
-An order dated 3/14/19, to check shunt for pain, redness, bleeding, swelling or
non-functioning access site after [MEDICAL TREATMENT] every Monday, Wednesday and Friday;
-An order dated 3/14/19, to complete pre and post [MEDICAL TREATMENT] assessments every
Monday, Wednesday and Friday;
-An order dated 3/14/19, for [MEDICAL TREATMENT] at named location, Monday, Wednesday and
Friday;
-An order dated 3/14/19, to obtain vital signs and weight on [MEDICAL TREATMENT] days
(weight should be post [MEDICAL TREATMENT] dry weight) every Monday, Wednesday and Friday;
-No orders for checking the [MEDICAL TREATMENT] shunt/port, pre/post [MEDICAL TREATMENT]
assessments and/or obtaining vital signs/weights or location of the [MEDICAL TREATMENT]
center until 3/14/19.
Review of the resident’s nurse’s notes dated 2/6/19 through 3/11/19, showed no continual
thorough assessments of the resident’s condition before/after [MEDICAL TREATMENT],
assessment of the resident’s [MEDICAL TREATMENT] port/catheter for signs of infection,
bleeding, redness or swelling and no on-going communication between the [MEDICAL
TREATMENT] center and facility.
Review of the resident’s MAR dated 1/1/19 though 3/14/19, showed no orders or
documentation for checking the [MEDICAL TREATMENT] shunt/port, pre/post [MEDICAL
TREATMENT] assessments and/or obtaining vital signs/weights or location of the [MEDICAL
TREATMENT] center until 3/14/19.
Review of the resident’s weights in the computer, MAR and TAR, showed no post [MEDICAL
TREATMENT] weights.
4. Review of the facility’s signed/dated [MEDICAL TREATMENT] contracts/agreements provided
by the facility, showed:
-A [MEDICAL TREATMENT] contract/agreement signed/dated 2/13/18, but not signed by the
[MEDICAL TREATMENT] center;
-A [MEDICAL TREATMENT] contract/agreement signed/dated 3/14/19 by the [MEDICAL TREATMENT]
center, but not the facility;
-A [MEDICAL TREATMENT] contract/agreement signed/dated 3/15/19 by the facility and
[MEDICAL TREATMENT] center;
-No other signed/dated [MEDICAL TREATMENT] contracts/agreements were provided.
5. During an interview on 3/20/19 at 8:15 A.M., the administrator said the facility should
have contracts/agreements with each [MEDICAL TREATMENT] center that residents go to for
treatments. She verified the facility only had the three [MEDICAL TREATMENT]
contracts/agreements and two of the contracts were dated 3/14/19 and 3/15/19.
6. During an interview on 3/20/19 at 5:30 P.M., the regional director of clinical
operations said she expected nursing staff to assess and monitor the resident’s condition
before/after [MEDICAL TREATMENT] and monitor the resident’s [MEDICAL TREATMENT] for signs
of redness, bleeding and/or infection. She expected the nursing staff to complete the pre

Based on interview and record review, the facility failed to ensure each nurse aide had no
less than twelve hours of in-service education per year based on their individual
performance review, calculated by their employment date rather than the calendar year, for
eight of eight sampled certified nursing assistance (CNAs) employed at the facility for
more than a year. The census was 130.
1. Review of CNA F’s employee file and training records, showed:
-Date of hire 3/17/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
2. Review of CNA G’s employee file and training records, showed:
-Date of hire 1/15/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
3. Review of CNA H’s employee file and training records, showed:
-Date of hire 11/8/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
4. Review of CNA I’s employee file and training records, showed:
-Date of hire 8/3/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
5. Review of CNA J’s employee file and training records, showed:
-Date of hire 3/24/15;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
6. Review of CNA K’s employee file and training records, showed:
-Date of hire 1/6/12;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to allow one of 26
sampled residents to make a choice regarding his/her code status (Resident #227). The
census was 130.
Review of Resident #227’s entry Minimum Data Set (DS), a federally mandated assessment
instrument completed by facility staff, showed an admission date of [DATE].
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED].
-[DATE]: Hospice evaluation and treatment;
-[DATE]: Do not resuscitate (DNR).
Review of the resident’s Baseline Care Plan, dated [DATE], showed:
-admitted : [DATE];
-Code status: blank;
-Alert and cognitively intact;
-Social services: Resident recognized the need to be in long term care.
Review of the resident’s Outside the Hospital Do Not Resuscitate Order, dated [DATE],
showed:
-Agree to the Outside the Hospital Do not Resuscitate Order;
-May revoke this order at anytime;
-Signed by the resident’s family member;
-Signed by the hospice physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure hot foods
were at least 120 degrees Fahrenheit (F) when served and cold foods were at 41 degrees F
or less when served. This potentially could effect all residents who ate in the facility.
The census was 130.
1. Observation of the Serenity hall trays on 3/18/19 at 8:11 A.M., showed:
-Eggs: 112 degrees F;
-Cinnamon roll cold to touch with a temperature of 100 degrees F;
-Orange juice: 60 degrees F.
2. Observation of the [MEDICATION NAME] hall trays on 3/18/19 at 8:10 A.M., showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
used acceptable infection control procedures during two blood glucose tests (BGT) and two
of three observations of incontinence care (Residents #38, #56, #15 and #227). The census
was 130.
1. Review of Resident #38’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 3/15/19 at 6:25 A.M., showed Nurse HH sanitized his/her hands, applied
gloves and cleaned the glucometer (machine used to test blood sugar levels) prior to use
with hand gel alcohol sanitizer. The nurse obtained the resident’s BGT, removed his/her
gloves, sanitized his/her hands and cleaned the glucometer machine after use with hand gel
alcohol sanitizer. Further observation, showed no disinfecting agent and/or bleach wipes
available on the medication cart.
2. Review of Resident #56’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 3/15/19 at 6:35 A,M., showed Nurse HH sanitized his/her hands, applied
gloves and obtained the resident’s BGT. Nurse HH removed his/her gloves, sanitized his/her
hands and cleaned the glucometer machine after use with hand gel alcohol sanitizer.
3. Review of Resident #15’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/12/18, showed:
-Severe impaired cognition;
-[DIAGNOSES REDACTED].>-Incontinent of bowel and bladder.
Observation on 3/15/19 at 5:20 A.M., showed the resident lay on a wet incontinence pad.
Certified Nurse Aide (CNA) GG did not wash his/her hands, applied gloves and provided
perineal care (washing the front and back of the hips, genitals, anal area and buttocks).
The CNA did not remove his/her gloves, turned the resident from side to side, washed the
resident’s buttocks and applied a clean incontinence brief. With the same gloves, CNA
picked up the resident’s clothes and dressed the resident before removing his/her gloves.
4. Review of Resident #227’s entry MDS, showed an admission date of [DATE].
Review of the resident’s Baseline Care Plan, dated 3/4/19, showed:
-Alert and cognitively intact;
-Required one person assistance for bed mobility, toileting, eating, grooming, hygiene and
bathing;
-Incontinent of bowel and bladder.
Observation on 3/20/19 at 11:42 A.M., showed the resident lay in bed. CNA LL washed
his/her hands, applied gloves and provided perineal care. He/she turned the resident onto
his/her right side, washed the resident’s buttocks, applied a clean brief, straightened
the covers and touched other clean items before removing his/her gloves.
During an interview on 3/20/19 at 12:05 P.M., CNA LL said he/she should have removed