DUTCHTOWN CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to treat each
resident in a dignified manner by leaving a resident’s chest exposed (Resident #85) and
allowing a resident to eat lunch with wet soiled pants (Resident #84). The sample was 18.
The census was 84.
1. Review of Resident #85’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 10/1/18, showed:
-Brief interview for mental status (BIMS) of 7 (a score of 0 to 7 shows severe cognitive
impairment);
-No hallucinations, delusions, behaviors, or wandering;
-One person physical assist required for bed mobility, toilet use, bathing, transfers,
walking in room and corridor, locomotion on and off unit, dressing, and personal hygiene;
-[DIAGNOSES REDACTED].
Observation of the resident on 10/22/18, showed:
-At 12:22 P.M., the resident lay in bed, on his/her back, with his/her hospital gown
pulled down to his/her waist, leaving his/her breasts exposed;
-The doorway to the resident’s room visible from the dining room, where residents ate
lunch at time of observation;
-The door to the resident’s room left open;
-At 12:28 P.M., Social Worker (SW) F delivered a food tray to the resident’s room and left
without speaking to the resident or covering him/her;
-At 12:30 P.M., certified nursing assistant (CNA) I entered the resident’s room, left the
door open, and assisted the resident with putting on his/her hospital gown.
During an interview on 10/25/18 at 1:37 P.M., the administrator said staff are expected to
cover residents when they are exposed. It is not appropriate for staff to deliver a meal
tray to a resident’s room and then leave without covering the resident.
2. Review of Resident #84’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of 8 to 12 shows
moderate cognitive impairment);
-No behaviors;
-Incontinent of bowel and bladder;
-Required maximum assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 10/22/18 at 11:14 A.M., showed the resident sat in his/her wheelchair,
propelling him/herself to the division dining room. The front of his/her gray colored
pants were wet in the groin area on both sides. The wet area extended from the resident’s
crotch area down the legs approximately 10 inches and across the legs approximately 6
inches. At 12:22 P.M., the resident sat in his/her wheelchair in the dining room dressed
in the same wet, gray colored pants. Staff served the resident lunch without changing
his/her wet pants, and the resident had eaten all of his/her lunch. At 12:27 P.M., the
resident propelled him/herself out of the dining room.
During an interview on 10/25/18 at 1:37 P.M., the Administrator said it would never be
appropriate for a resident to be served a meal and allowed to eat that meal in wet
clothing due to dignity issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have signed authorization for
management of personal funds for six out of 18 sampled residents (Resident #24, #45, #39,
#53, #4, and #16). The facility also failed to keep resident trust fund (RTF) accounts
from being overdrawn for five residents (Residents #67, #7, #340, #25, and #341). The
facility held funds for 75 residents. The census was 84.
1. Review of Resident #24’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
2. Review of Resident #45’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
3. Review of Resident #39’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
4. Review of Resident #53’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
5. Review of Resident #4’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
6. Review of Resident #16’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
7. Review of Resident #67’s facility RTF statement, dated 7/31/18, showed a negative
balance of $35.00.
8. Review of Resident #7’s facility RTF statement, dated 7/31/18, showed a negative
balance of $10.00.
9. Review of Resident’s #340 facility RTF statement, dated 8/31/18 and 9/30/18, showed:
-On 8/31/18: A negative balance of $19.92;
-On 9/30/18: A negative balance of $19.92.
10. Review of Resident’s #25’s facility RTF statement, dated 6/30/18, showed a negative
balance of $4.57.
11. Review of Resident #341’s facility RTF statement, dated 6/30/18, showed a negative
balance of $42.87.
12. During an interview on 10/26/18 at 8:34 A.M., the corporate administrator said Social
services is responsible for obtaining the consent forms for the authorization for the
facility to hold resident funds. The authorization form is expected to have the resident’s
name and responsible party documented. She would expect social services to ensure the
resident has a consent form when they start a trust account. An audit is completed yearly,
so it is the perfect time to check the agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide spend down letters
when the balance of the Medicaid residents’ trust fund accounts exceeded $2,799.99. In
addition, the facility failed to have a system in place to show any communication was
provided inform the Medicaid residents of their account balances. This deficient practice
affected 10 sampled residents that received Medicaid assistance (Residents #24, #342, #19,
#49, #71, #59, #343, #75, #66 and #80). In addition, the facility failed to return money
in a timely manner for six residents who were discharged from the facility (Residents
#349, #351, #352, #89, #355 and #356). The facility held funds for 75 residents. The
census was 84.
1. Review of Resident #24’s resident trust fund (RTF) showed the following:
-As of [DATE], the resident had $2,976.92 in his/her account;
-As of [DATE], the resident had $2,893.40 in his/her account.
2. Review of Resident #342’s RTF showed the following:
-As of [DATE], the resident had $3,973.91 in his/her account;
-As of [DATE], the resident had $8,689.89 in his/her account;
-As of [DATE], the resident had $9,678.22 in his/her account.
3. Review of Resident #19’s RTF showed the following:
-As of [DATE], the resident had $9,382.74 in his/her account;
-As of [DATE], the resident had $9,484.37 in his/her account;
-As of [DATE], the resident had $9,485.94 in his/her account.
4. Review of Resident #49’s RTF showed, on [DATE], the resident had $3,326.47 in his/her
account.
5. Review of Resident #71’s RTF showed the following:
-On [DATE], the resident had $2,968.58 in his/her account;
-On [DATE], the resident had $2,847.05 in his/her account.
6. Review of Resident #59’s RTF showed the following:
-On [DATE], the resident had $3,293.66 in his/her account;
-On [DATE], the resident had $2,940.73 in his/her account;
-On [DATE], the resident had $4,194.68 in his/her account;
-On [DATE], the resident had $5,468.74 in his/her account.
7. Review of Resident #343’s RTF showed the following:
-On [DATE], the resident had $3,776.46 in his/her account;
-On [DATE], the resident had $3,176.58 in his/her account;
-On [DATE], the resident had $4,341.36 in his/her account;
-On [DATE], the resident had $4,342.08 in his/her account.
8. Review of Resident #75’s RTF showed the following:
-On [DATE], the resident had $4,558.90 in his/her account;
-On [DATE], the resident had $5,771.76 in his/her account;
-On [DATE], the resident had $7,203.04 in his/her account.
9. Review of Resident #66’s RTF showed the following:
-On [DATE], the resident had $19,702.44 in his/her account;
-On [DATE], the resident had $16,427.90 in his/her account;
-On [DATE], the resident had $17,245.33 in his/her account.
10. Resident of Resident #80’s RTF showed the following:

Based on record review and interview, the facility failed to maintain an approved surety
bond to ensure protection of resident funds. The facility held funds for 75 residents. The
census was 84.
1. Record review of the facility’s Resident Trust General Ledger (Cash Sheet) for the
period of (MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of
$48,000.00, which would require a bond of $72,000.
Review of the Department of Health and Senior Services (DHSS) approved bond list, showed
the facility did not have an approved bond.
Review of a bond provided by the facility showed:
-A bond issued for $157,000.00;
-No documentation of approval from DHSS.
2. During an interview on 10/24/18 at 3:14 P.M., the controller said he/she was
responsible for ensuring the facility had an active bond. He/she increased the bond amount
from $120,000 to $157,000, but did not send the information to DHSS. He/she did not know
if the bond company submitted the information.
3. During an interview on 10/26/18 at 8:34 A.M., the administrator said she was
responsible for ensuring the facility had an approved bond, but she was not aware the
facility did not have one. The corporate administrator said the facility’s controller
increased the bond amount, but never received the letter from DHSS. The insurance company
usually sent the bond information to DHSS, but it fell through the cracks.

Based on interview and record review, facility staff failed to provide a free basic
haircut for all Medicaid residents. In addition, the facility failed to inform the
residents of a free haircut. This had the potential to affect all Medicaid residents. The
census was 84.
1. Review of the facility’s current admission packet, showed the following information:
-Private Pay: Services and supplies covered by Basic Daily Rate: Personal services
required for health, safety, and personal grooming, including basic hair cut;
-Barber and beauty shop services;
-Services and supplied available, but NOT covered by the basic daily rate: Haircuts,
permanents and coloring, barber and beauty shop services.
-Medicaid: Services and supplies available, but NOT covered by Medicaid: Barber and beauty
shop services, except for basic hair care.
Review of the facility’s barber shop price list, showed the cost for a basic hair cut is
$20.
2. Review of Resident #7’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop.
3. Review of Resident #19’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop.
4. Review of Resident #21’s transaction history, showed he/she was charged $20 for beauty

12. Review of the hospice haircut list, showed there were 12 residents on the list,
including:
-Resident #19;
-Resident #59;
-Resident #53.
13. During an interview on 10/25/18 at 9:15 A.M., Resident #19 said he/she went to the
stylist for his/her haircut. He/she never heard of getting a free cut. There used to be a
volunteer that would only cut the men’s hair, but not anymore. He/she confirmed the hair
cut was $20 earlier this month.
14. During an interview on 10/25/18 at 9:32 A.M., Resident #53 said it had been months
since he/she received a hair cut due to the current treatment and bandages on top of
his/her head.
15. During an interview on 10/26/18 at 7:57 A.M., social worker F confirmed that the list
was recent that the residents received a free cut hair from the hospice company within the
last month.
16. During an interview on 10/26/18 at 8:05 A.M., the activity director and social
services said the list of residents received a free hair cut by the hospice company at
some point, not necessary recently. The hospice company had not been to the facility to
give free hair cuts in two in the half months.
17. During an interview on 10/26/18 at 8:34 A.M., the corporate administrator said all
residents were aware of the free haircuts provided by the hospice company volunteers. They
are supposed to come every month, but had not been at the facility for two months. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to obtain a physician’s order
for code status per their policy for two of 18 sampled residents (Residents #389 and
#339). The census was 84.
1. Review of the facility’s undated Advanced Directives policy showed:
-Prior to or upon admission of a resident, the Social Services Director or designee will
inquire of the resident, his/her family members and/or his or her legal representative,
about the existence of any written advance directives;
-Information about whether or not the resident has executed an advance directive shall be
displayed prominently in the medical record;
-The Director of Nursing Services or designee will notify the attending physician of
advance directives so that appropriate orders can be documented in the resident’s medical
record and plan of care.
2. Review of Resident #389’s medical record, showed:
-admission date of [DATE];
-A code status form, signed by the resident on 10/19/18, for full code status (all
lifesaving methods are performed). Further review of the code status form showed signed by
the physician on 10/22/18;
-A Physician Order Sheet (POS), dated 10/15/18 through 10/26/18, showed no physician order
for [REDACTED].>3. Review of Resident #339’s medical record, showed:
-admission date of [DATE];
-A code status form, signed by the resident on 10/16/18, for do not resuscitate (DNR, no
life saving methods are performed) status.
-A POS, dated 10/15/18 through 10/26/18, showed no physician order for
[REDACTED].>During an interview on 10/23/18 at 5:07 P.M., Nurse J said the were no
physician’s orders for the code status. The admitting nurse would be responsible for
entering the resident’s code status and obtaining the order for the POS.
4. During an interview on 10/26/18 at 8:35 A.M., the administrator said it is the Social
Services Director’s responsibility to obtain a resident’s code status. It is expected that
a resident’s code status be reflected on their POS.

Based on interview and record review, the facility failed to ensure their abuse and
neglect policy identified when, how and by whom determination of capacity to consent to
sexual contact will be made and where this documentation will be maintained. The census
was 84.
Review of the facility’s undated Abuse Prevention Plan policy, showed:
-Objective: The facility has a zero tolerance of physical, verbal, sexual and mental
abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident
property and misuse of physical or chemical restraints not required to treat a resident’s
medical symptom by: employees, family member, visitors or other residents;
-The policy failed to identify when, how and by whom determination of capacity to consent
to sexual contact will be made and where this documentation will be maintained.
During an interview on 10/23/18 at 2:42 P.M., the administrator said the facility policy
should identify when, how and by whom determination of capacity to consent to sexual
contact will be made and where this documentation will be maintained. At 3:47 P.M., the
administrator verified the facility does not have a policy to address these issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 18 residents sampled, four had been recently
discharged to a hospital for various medical reasons, all were expected to return, and
none of those four had been issued a written transfer notice upon leaving the facility
(Residents #41, #38, #29 and #20). The census was 84.
1. Review of Resident #41’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from on the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident was provided
a notice upon discharge.
2. Review of Resident #38’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation of discharge notices provided to the resident by the facility for the
2/23/18 and 10/24/18 discharges.
3. Review of Resident #29’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for four of 18 sampled residents (Resident #41,, #38, #29 and #20). The census
was 84.
1. Review of Resident #41’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from on the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 6/9/18 or 6/30/18.
2. Review of Resident #38’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Further review of the resident’s medical record, showed no documentation the resident or
the resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 2/23/18 or 9/20/18.
3. Review of Resident #29’s medical record, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete and electronically
transmit discharge Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, for four random sampled residents (Residents #1, #2, #3 and
#6). The sample was 18. The census was 84.
1. Review of Resident #1’s medical record, showed:
-admitted to the facility on [DATE];
-Admission MDS done on 3/31/18;
-discharged on [DATE];
-No discharge MDS found.
2. Review of Resident #2’s medical record, showed:
-admitted to the facility on [DATE];
-Admission MDS done on 5/11/18;
-discharged to the hospital on [DATE];
-Did not return from the hospital;
-No discharge MDS found.
3. Review of Resident #3’s medical record, showed;
-admitted to the facility on [DATE];
-Admission MDS done on 4/24/18;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had complete, accurate and individualized care plans to address the specific needs of the
residents for three residents by not addressing falls, [MEDICAL CONDITION] and indwelling
urinary catheters (a tube inserted into the bladder for the continual drainage of urine)
(Residents #61, #90 and #20). The sample was 18. The census was 84.
1. Review of Resident #61’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 7/5/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS) score of 13 out of a possible score of 15;
-A BIMS score of 8-15, showed the resident understands and able to make self-understood;
-Supervision required for transfers;
-No falls since prior assessment.
Review of the facility’s Incidents by Incident type report, showed the following for the
resident:
-Date range: 8/1/18 through 8/31/18;
-Unwitnessed fall incident: 8/25/18 at 2:27 A.M.
Review of the resident’s progress notes, showed:
-On 8/25/18 at 2:11 A.M., the resident remains on follow up, denied complaint of pain,
reeducated about calling for assistance;
-No documentation regarding the circumstances that surrounded the fall.
Review of the facility’s Fall Protocol, dated 7/1/18, showed all incidents and accidents
must be called to the Director of Nursing (DON) or designee. Please assure the following
interventions are in place:
-The certified nursing assistant (CNA) and nurse for the resident must come together to
come up with a safe and workable intervention specific to each resident;
-Care plan to be updated by the charge nurse.
During an interview on 9/20/18 at 8:35 A.M., the administrator said the facility changed
to a new electronic medical record company in (MONTH) (YEAR) and not all of the residents’

Based on interview and record review, the facility failed to complete a comprehensive
discharge summary for one of two closed record sampled residents (Resident #89). The
census was 84.
Review of Resident #89’s closed medical record, showed the resident discharged to the
community on 6/29/18. Staff did not complete a discharge summary, which would include a
final summary of the resident’s status, a reconciliation of all pre and post discharge

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assess, monitor
and provide treatment after a [MEDICAL CONDITION] resulting in a fall, provide oral care,
and provide treatment to a foot wound (Resident #90, #24 and #4). The sample was 18. The
census was 84.
1. Review of Resident #90’s admission Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 12/26/17, showed:
-[DIAGNOSES REDACTED].
-BIMS score of 15 out of a possible score of 15;
-Extensive assistance required for transfers.
Review of the resident’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-admitted : 12/19/17;
-An order dated 12/20/17 with an end date of 2/5/18, for levetiracetam ([MEDICATION NAME],
medication used to treat [MEDICAL CONDITION]), 250 milligram (mg) twice a day;
-An order dated 1/8/18, for neurology consult related to [DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no documentation a neurology consult
completed.
Review of the facility’s [MEDICAL CONDITION] Policy, dated 7/2018, showed:
-Preface: This policy/protocol serves as a guideline to staff and it is not deemed to be
all inclusive of care and treatment of [REDACTED].
-After [MEDICAL CONDITION] care: Take vital signs and neurological (neuro) checks. Monitor
for [MEDICAL CONDITION] (inability/difficulty with swallow/talking), headache and altered
level of consciousness. Monitor for paralysis, weakness and pupillary changes;
-[MEDICAL CONDITION] documentation: Location of [MEDICAL CONDITION] activity. Type of
[MEDICAL CONDITION] activity. Duration of [MEDICAL CONDITION] activity. Level of
conscience. Any incontinent episodes. Sleeping or dazed post ictal (post [MEDICAL
CONDITION]) state after [MEDICAL CONDITION] activity. This should be documented in the
nurse’s notes. Notification of physician and family representative should also be noted.
Review of the resident’s progress notes, showed:
-On 2/5/18 at 9:18 A.M., resident found on the floor in room laying on his/her right side.
Resident stated I had a [MEDICAL CONDITION], I didn’t know where I was for a minute, I
fell Resident has old raised area on his/her forehead which resident stated he/she bumped

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of indwelling urinary catheters (a tube inserted into the bladder for the
purpose of continual urine drainage.) The facility identified nine residents as having
indwelling urinary catheters. Of those nine, five were chosen for the sample. Of those
five, problems were found with one resident (Resident #83). The sample was 18. The census
was 84.
Review of the facility Indwelling Urinary Catheter Care Policy and Procedure, dated
10/24/18, showed:
-Caring for the catheter;
-Maintain a sterile, closed, gravity-drainage system and avoid breaking the system;
-Secure catheters to the upper thigh or lower abdomen to avoid bladder and urethral

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
humidified oxygen therapy in an acceptable nursing manner for one of one sampled resident
who received continuous oxygen (Resident #41). The sample size was 18. The census was 84.
Review of the facility’s Oxygen Administration Policy and Procedure, dated (MONTH) 2010,
showed the following:
-Check the tubing connected to the oxygen cylinder to assure that it is free of kinks;
-Turn on the oxygen;
-Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal
catheter);
-Check the mask, tank, humidifying jar, etc., to be sure they are in good working order
and are securely fastened. Be sure there is water in the humidifying jar and that the
water level is high enough that the water bubbles as oxygen flows through;
-Periodically re-check water level in humidifying jar.
Review of Resident #41’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/31/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 15 out of 15 (a score of 12 to 15
indicates cognitively intact);
-No behaviors;
-Oxygen usage;
-Required minimal assistance from staff for dressing, eating and hygiene. Required maximum
assistance from staff for bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 11/20/17, to administer oxygen at 3 to 5 liters to keep oxygen saturation
(amount of oxygen in the blood) above 90%;
-No orders found to change the oxygen tubing or the humidifying bottle or how often.
Observation on 10/22/18 at 10:00 A.M., on 10/23/18 at 1:36 P.M., showed the resident lay
in bed with oxygen administered at 3 liters a minute by nasal cannula. The humidifying

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 26 opportunities observed, two errors
occurred resulting in a 7.69% error rate (Residents #86 and #72). The census was 84.
1. Record review of Resident #86’s electronic physician order [REDACTED].
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME] (short acting) insulin [MEDICATION NAME], inject subcutaneously (SQ,
under the skin) before meals three times daily per sliding scale. For a blood sugar of 351
– 400, administer 10 units.
During an observation on 10/22/18 at 12:45 P.M., Nurse A performed the blood glucose test
with a result of 359. He/she removed the [MEDICATION NAME] from drawer, dialed up 2 units
of [MEDICATION NAME] and pressed the plunger to prime the pen prior to placing the needle
on the [MEDICATION NAME]. He/she placed the needle on the pen and dialed 8 units of
[MEDICATION NAME] and injected the insulin. At 13:05 P.M., he/she started to chart the
insulin administration and said he/she realized the resident was supposed to get 10 units
sliding scale insulin. Nurse A retrieved the resident from the dining room again, pulled
the [MEDICATION NAME] out of the drawer, primed it with 2 units of insulin, placed the
needle on after priming the pen, drew up 2 units insulin, and injected the insulin.
During an interview on 10/24/18 at 1:57 P.M., the Assistant Director of Nursing (ADON)
said it is not appropriate to prime the [MEDICATION NAME] with 2 units before placing the
needle on. Staff should place the needle on first so the resident gets the full dose.
2. Review of Resident #72’s electronic POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME], inject SQ before meals three times daily per sliding scale as follows:
–150 – 200 = 2 units;
–201 – 250 = 4 units;
–251 – 300 = 6 units;
–301 – 350 = 8 units;
–351 – 400 = 10 units;
–401 and up = 12 units;
–If less than 60 or over 400 call the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure drugs and biologicals
used in the facility were labeled in accordance with currently accepted professional
principles, and include the appropriate accessory and cautionary instructions, and the
expiration date when applicable. In addition, the facility failed to store all drugs and
biologicals under proper temperature controls, for one of six medication carts and one of
two medication storage rooms. The census was 84.
1. Observation of the 2nd floor west hall medication cart on 10/23/18 at 11:30 A.M.,
showed:
-One open bottle of Moxifloxacin (antibiotic) eye drops with no open date on the bottle;
-One open bottle of [MEDICATION NAME] (anti-[MEDICAL CONDITION]) eye drops with no open
date on the bottle;
-One open bottle of [MEDICATION NAME] acetate (steroid) eye drops with no open date on the
bottle;
-One open bottle of [MEDICATION NAME] (antibiotic) eye drops with no open date on the
bottle;
-One open bottle of Ketotifen (treats itchy eyes) eye drops with no open date on the
bottle;
-25 Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce packet with
expiration date of 8/1/18;
-One Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce with expiration date
7/1/18;
-Two Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce with expiration date
5/1/18;
-Four Juven therapeutic nutrition powder orange flavor 0.85 ounce with expiration date of
4/1/18;
-One Ready Care (nutritional supplement) 2.0 butter pecan flavor with open date of
10/21/18, opened in the bottom drawer, unrefrigerated.
2. Observation of the 2nd floor medication room on 10/23/18 at 11:56 A.M., showed:
-Three vials of Influenza Vaccine [MEDICATION NAME] Quadrivalent (influenza vaccination
that immunizes against both A and B influenza) (YEAR)-2018 formula, in the medication
refrigerator with an expiration date of 6/30/18;
-The medication refrigerator which contained resident medications, measured 48 degrees

-During an interview at this time, Nurse A said night shift is responsible for monitoring
refrigerator temps;
-The medication rerigerator contained three influenza vaccine vials, eight [MEDICATION
NAME] (insulin) [MEDICATION NAME], two Basaglar (insulin) [MEDICATION NAME], two
[MEDICATION NAME] (non-insulin treatment for [REDACTED].) 23 injection 25/0.5, nine
[MEDICATION NAME] (laxative) 10 milligram (mg) suppositories, and 12 [MEDICATION NAME]
(Tylenol) 650 mg suppositories;
-The freezer covered in ice.
Review of the Centers for Disease Control website, showed:
-The ultimate goal of temperature monitoring is to ensure the preservation of save and
effective medications;
-Refrigerate vaccines between 36 degrees F and 46 degrees F;
-The vaccine refrigeration guidelines can be applied to all medication in refrigerated
storage.
During an interview on 10/24/18 at 1:57 P.M., the Assistant Director of Nursing (ADON)
said she would expect staff to label eye drops, insulin, supplements and inhalers with the
date opened. Night shift typically check for expired medications and dispose of them.
Expired medications should not be stored in the medication cart. Night shift should check
refrigerator temperatures. It is not appropriate for expired influenza medications to be
stored in the refrigerator. Staff should monitor the medication refrigerator temperatures.

Based on observation, interview, and record review, the facility failed to follow three
out of three pureed recipes for three residents on a pureed diet. The census was 84.
1. Observation on 10/24/18, of the pureed breaded pork chop preparation, showed the
following:
-At 10:02 A.M., the Dietary Manager (DM) chopped an unknown amount of breaded pork chop in
the blender, then scooped the chopped meat into a metal container;
-The DM told Dietary Aide (DA) H to prepare three servings of the pureed breaded pork
chops and to use half a slice of bread for each serving;
-DA H added three, 1/2 cup scoops of chopped meat, four, 1/2 cups of pork broth, and two
whole slices of bread to the blender and pureed the ingredients;
-DA H added another 1/2 cup scoop of chopped meat;
-The DM told DA H to add the remaining slice of bread to the blender instead of cutting it
in half because it was the end piece of the loaf;
-DA H added the slice of bread to the blender and pureed the ingredients for approximately
20 seconds;
-The pureed breaded pork chop appeared slightly runny;
-DA H did not use a recipe for the breaded pork chop puree.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure beverages were not
served after the expiration date. This deficient practice had the potential to affect all
residents who ate at the facility. The facility census was 84.
1. Observation on [DATE] at 9:16 A.M., during the initial tour of the facility kitchen,
showed 40 individual cartons of fat free milk, expired (MONTH) 16, (YEAR) and 19 fat free
milk, expired (MONTH) 19, (YEAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain medical records on
each resident that are complete, accurately documented and readily accessible, for one
resident (Resident #61) who had a fall and the circumstance surrounding the fall not
documented in the medical record. In addition, the resident was sent to the hospital and
the circumstances surrounding the transfer was not documented in the medical record. The
census was 84.
Review of Resident #61’s quarterly Minimum Data Set (MDS) a federally required assessment
instrument completed by facility staff, dated 7/5/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS) score of 13 out of a possible score of 15;
-A BIMS score of 8-15, showed the resident understands and able to make self-understood;
-Supervision required for transfers;
-No falls since prior assessment.
Review of the facility’s Incidents by Incident type report, showed the following for the
resident:
-Date range: 8/1/18 through 8/31/18;
-Unwitnessed fall incident: 8/25/18 at 2:27 A.M.
Review of the facility’s Fall Protocol, dated 7/1/18, showed all incidents and accidents
must be called to the Director of Nursing (DON) or designee. Please assure the following
interventions are in place:
-Call to physician;
-Call to responsible part and update resident on new interventions;
-Add fall risk residents to report.
Review of the resident’s progress notes, showed:
-On 8/25/18 at 2:11 A.M., the resident remains on follow up, denied complaint of pain,
reeducated about calling for assistance;
-No documentation regarding a fall that occurred on 8/25/18 at 2:27 A.M., the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure infection
control standards were maintained during blood glucose testing for six residents’ observed
during blood glucose testing (Residents #28, #86, #52, #72, #16 and #7). The facility
census was 84.
Review of the front of the bleach wipes box, showed:
-Bactericidal, fungicidal, tuberculocidal, virucidal in 4 minutes;
-Disinfects in 4 minutes.
1. Review of Resident #28’s electronic physician order [REDACTED].
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME] (fast acting insulin) [MEDICATION NAME], Inject 7 units subcutaneously
(SQ, under the skin) three times daily.
During an observation on 10/22/18 at 12:22 P.M., showed Nurse A did the following:
-Cleansed the cart top with bleach wipes;
-Placed a clean barrier on top of the cart;
-Tried to open the electronic chart (echart) on the laptop attached to the cart. The
electronic Medication Administration Record [REDACTED]
-Went to another cart (cart #2) to use the laptop. The insulin remained on the first cart
(cart #1);
-Cleaned the top of the second cart with bleach wipes and said he/she had to let it dry
for 4 minutes before using;
-Then placed a clean barrier on the cart top without waiting for it to dry;
-Removed the tubs of alcohol prep pads, lancets and gauze 2x’s and placed them on the
clean barrier, leaving a small section to gather supplies on.
-Closed the door, after the resident entered the room, donned gloves, and placed the
glucometer (machine used to check blood sugar levels) on the barrier;
-Performed the blood glucose test;
-Cleansed the glucometer with bleach wipe for approximately 5 seconds, then wrapped the