EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

Based upon observation and interview, the facility failed to treat each resident with
respect and dignity and, care for each resident in a manner and in an environment that
promotes maintenance or enhancement of his or her quality of life while dining by avoiding
daily use of disposable dishware during meals. The facility census was 46 residents.
1. Observations on 1/27/19 at 9:10 A.M. and 5:58 P.M. in the dining room during breakfast
and dinner, showed all of the residents were eating from disposable, styrofoam dishware.
During an interview on 1/27/19 at 9:10 A.M., Resident #18 said the facility staff told
him/her that the dishwasher had broken for over a month and that was why they were eating
on disposable dishware.
During an interview on 1/29/19 at 6:55 A.M., the Dietary Manager said:
-The dishwashing machine had been working on and off for the last month and they had been
having to improvise with disposable plates and cups;
-The maintenance person had requested parts for the machine, but has had a hard time
obtaining them because of the age of the machine.
Observations on 1/31/19 at 8:02 A.M. in the dining room during breakfast, showed all of
the residents were eating with disposable, styrofoam dishware.
During an interview on 1/31/19 at 8:09 A.M., Resident #41 said:
-The facility staff told him/her that they used to use real dishes, but lately it was
styrofoam;
-I’d rather use real dishes.
During an interview on 1/31/19 at 8:25 A.M., Resident #47 said:
-The facility staff told him/her that they were using styrofoam because the dishwasher had
been out of order;
-They have had problems with it for a long time, but he/she didn’t know for sure how long.
During an interview on 1/31/19 at 11:49 A.M., Resident #14 said:
-The facility had been serving meals and drinks on styrofoam plates and cups for about
three weeks and this was ridiculous;
-The facility had plates and cups to use;
-He/She would not eat breakfast because this was not homelike to eat off styrofoam;
-He/She liked to drink hot tea, but did not want it out of a styrofoam cup;
-He/She used his/her own cup in his/her room for hot tea, because there were no regular
cups available.
During an interview on 1/31/19 at 11:59 A.M., Social Services Designee (SSD) said:
-The facility was using styrofoam cups and plates due to the dishwasher not working;
-The dishwasher had not been working for at least a couple of months;
-The styrofoam plates and cups did not enhance the residents homelike environment and
promote dignity.
During an interview on 1/31/19 at 1:01 P.M., Licensed Practical Nurse (LPN) A said:
-The Maintenance Director (MD) had been repairing the dishwasher off and on;
-It would work for a short period of time and then would break down;
-This has been on-going for a couple of months;
-Not a very homelike environment;
-The residents have voiced concerns about the styrofoam plates and cups.
During an interview on 1/31/19 at 1:33 P.M., the MD said:
-The residents had been eating on disposable dishware for over a month since the kitchen
dishwashing machine had been leaking and in need of repair;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident had the necessary equipment available and operating properly, and to keep fully
charged batteries in order to operate a mechanical lift needed to get a resident into and
out of bed for one sampled resident (Resident #47) out of 12 sampled residents. The
facility census was 46 residents.
Record review of the facility policies showed the facility did not have a policy related
to mechanical lifts and battery charging.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Record review of the resident’s Physician order [REDACTED].
-Orders beginning 1/10/19 for Skilled Occupational Therapy (OT – therapy based on
engagement in activities to maintain or improve functional skills related to Activities of
Daily Life (ADLs – dressing, grooming, toileting, and transfers) three times weekly for 30
days for therapeutic exercise, neurological re-education (Neuro re-ed – exercises to
improve balance, coordination and posture), and self-care training;
-Orders beginning 1/10/19 for Physical Therapy (PT -treatment of [REDACTED].
Record review of the resident’s PT Evaluation and Plan of Treatment, dated 1/10/19, and
accompanying Treatment Encounter and PT Progress Notes, also dated 1/10/19 showed:
-The resident was referred for exacerbation of decrease in abilities related to transfers,
functional skills, postural alignment, balance, mobility, strength, and range of motion
(ROM – full movement potential of a joint);
-The resident was evaluated for his/her ability to benefit from a sit to stand lift device
(a standing and raising aid used by caregivers to transfer a resident between two seated
postures such as the edge of the bed to a wheelchair);
-It was determined the resident required a mechanical lift (a device used to transfer
individuals who are unable to stand or whose weight makes it unsafe for other methods of
transfer) for safe transferring.
Record review of the resident’s OT Evaluation and Plan of Treatment, dated 1/10/19 and
accompanying OT Progress Note, dated 1/10/19, showed:
-The resident was referred due to his/her decrease in functional mobility and impaired
balance;
-It was determined the standing lift was not a viable transfer option and a mechanical
lift would be safer for the resident and staff.
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning purposes), dated
1/22/19, showed the resident:
-Was cognitively intact;
-Was totally dependent upon two or more staff for transfers.
Record review of the resident’s comprehensive Care Plan, dated 1/24/19, showed:
-The resident was limited in his/her ability to perform ADLs and transfers due to [MEDICAL

-Maintenance might know what had to be done to fix the lift.
During an interview on 1/31/19 at 9:30 A.M., the Director of Therapy/PTA said:
-The mechanical lift was appropriate for the resident’s weight and three to four staff
were required during a transfer for the resident’s safety;
-Approximately one and a half to two weeks ago, the mechanical lift raised only to a
certain height and staff had to use the manual lever to complete the transfer. The lift
worked smoothly in the manual mode;

Based on interview and record review, the facility failed to ensure residents had the
opportunity to consistently receive mail, magazines and packages that were delivered to
the facility on Saturdays on the day of delivery for residents who receive personal mail.
The facility census was 46 residents.
Record review of the facility policies showed the facility did not have a policy related
to the delivery of mail.
Record review of the Resident Council Meeting minutes for the months of (MONTH) (YEAR),
(MONTH) (YEAR) and (MONTH) (YEAR), showed there were no recent discussions related to
delivering mail to residents on Saturdays.
1. During discussion at the Resident Council Group Meeting on 1/28/19 at 1:30 P.M., the
eight cognitively intact residents in attendance were asked if they received mail on
Saturdays. The residents said:
-The Activity Director gave them their mail on the Saturdays he/she worked, which was
normally every other Saturday;
-The mail came late in the day at approximately 4:00 P.M.;
-If the Activity Director didn’t work on a Saturday they received their mail on the
following Monday.
During an interview on 1/31/19 at 8:34 A.M., the Activity Director said:
-On the Saturdays he/she didn’t work, the Activity Assistant worked at the facility and
was supposed to pass out personal mail such as magazines, cards and letters to the
residents before leaving for the day;
-The Activity Assistant usually left work around 3:30 P.M.;
-The mail came between 3:00 and 4:00 P.M.;
-When he/she was made aware the Activity Assistant left the faciity on a Saturday before
the mail was passed out to residents, he/she called the Certified Medication Technician
(CMT) and asked the CMT to pass out the resident’s mail or came in to work and did so
him/herself.
During an interview on 1/31/19 at 10:34 A.M., the Activity Assistant said:
-He she/worked half of the Saturdays and the Activity Director worked the other half;
-If the mail arrived on Saturday before he/she left for the day, he/she delivered personal
mail to residents;
-Approximately half the Saturdays he/she worked, the mail was delivered before he/she left
for the day;
-He/She usually left the faciity on Saturdays between 3:00 and 4:00;
-If the Saturday mail hadn’t been delivered before he/she left for the day, he/she thought
Nursing held the residents’ personal mail in the Medication Room until the following
Monday;
-When working on Saturday, he/she let the charge nurse know if he/she was leaving before
3:00 P.M. and did not let anyone know if the mail had been delivered to the residents
before he/she left.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nurses (DON) said:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure advanced directives
were in place for one sampled resident (Resident #47) out of 12 sampled residents who
wanted to appoint someone as Durable Power of Attorney (DPOA – a person previously
identified to make decisions for an individual in the event the person becomes unable to
make his/her wishes known should he/she become incapacitated). The facility census was 46
residents.
Record review of the facility’s Advanced Directive policy, revised 9/25/06, showed:
-Upon admission, the nurse and social worker should verify if the resident has an advanced
directive (written instruction such as a Living Will or Durable Power of Attorney for
Health Care) in place;
-Advanced directives recognized the resident’s wishes and should be known and followed by
facility staff;
-Advanced directives must be revised and updated as the resident indicates with the annual
Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility
staff for care planning purposes).
1. Record review of Resident #47’s Face Sheet showed he/she:
-Was originally admitted to the facility on [DATE] and last readmitted on [DATE];
-Was his/her own responsible party;
-Had no person(s) listed as DPOA.
Record review of the resident’s Care Plan Conference Summary, dated 10/29/18, showed Care
Plan discussion that the resident’s wishes were to have two of his/her family members
acting as DPOAs.
Record review of the resident’s Physicians Orders Sheet (POS), dated (MONTH) 2019, showed
the resident had the following Diagnoses: [REDACTED]. A person is considered morbidly
obsess if 100 pounds or more over their ideal weight or has a Body Mass Index (BMI – A
measurement of body fat based on height and weight of 40 or more);
-History of [MEDICAL CONDITION] ([MEDICAL CONDITION] – a blood clot in a deep vein).
Record review of the resident’s quarterly MDS, dated [DATE], showed he/she was cognitively
intact.
Record review of the resident’s Care Plan, updated 1/24/19, showed:
-The resident had advanced directives for Do Not Resuscitate status should he/she be found
unresponsive without breath or heartbeat;
-The resident’s wishes related to his/her choice for DPOA were not mentioned.
Record review of the resident’s medical record on 1/29/19, showed no advanced directives
related to DPOA.
During an interview on 1/30/19 at 8:13 A.M., the Social Services Designee (SSD) said:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer or discharge to the hospital,
including the reason for the transfer/discharge for three sampled residents (Resident #
22, #43, and #7) out of 12 sampled residents. The facility census was 46 residents.
Record review of the facility’s Policies showed:
-Acute Care Transfer Policy dated 9/26/06, revised 10/1/12;
-Discharging a Resident Policy dated 5/6/05, revised 10/1/12;
–Neither policy included notifying the resident and resident’s representative in writing
of a resident’s transfer/discharge.
Record review of the facility’s Notice of Transfer or Discharge sheet showed:
-Date; Resident Name; Reason of Discharge; Date Resident Family notified; Verbal Review
Completed; Resident’s family contact, including Name, Relationship and Phone number of
said person;
-The facility must notify the resident and the resident’s representative(s) of the reasons
for the move in writing.
1. Record review of Resident #22’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/9/19 with the following Diagnoses:
[REDACTED].
-Tracheotomy (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions).
Record review of the resident’s nurse’s notes dated:
-11/20/18 at 11:25 P.M., showed the resident was transferred to the hospital with labored
breathing and audible congestion;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and
resident representative of the facility’s Bed Hold Policy in writing at the time of
transfer/discharge for two sampled resident (Resident #22 and #43) out of 12 sampled
residents. The facility census was 46 residents.
Record review of the facility’s Bed Hold Policy showed:
-Policy was undated and unsigned;
-A copy of the facility’s bed hold policy will accompany this notice;
-Any questions regarding the bed hold policy should be addressed with the facility
administrator.
1. Record review of Resident #22’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/9/19 with the following Diagnoses:
[REDACTED].
-Tracheotomy (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions).
Record review of the resident’s nurse’s notes dated, (MONTH) (YEAR) through (MONTH) 2019,
showed staff documented:
-11/20/18 at 11:25 P.M., showed the resident was transferred to the hospital with labored
breathing and audible congestion;
-1/1/19 at 8:00 A.M., showed the resident was transferred to the hospital with labored
breathing and congestion.
Record review of the Discharge Minimum Data Set (MDS – a required, federally mandated
assessment tool completed by facility staff for care planning) showed discharge of the
resident from the facility on:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative(s) in writing of the facility’s bed
hold policy at time of transfer/discharge:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed the resident returned to the
facility on :
-12/20/18; and
-1/9/19.
2. Record review of Resident #43’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/4/19 with the following Diagnoses:
[REDACTED].
-Altered level of consciousness.
Record review of the resident’s nurse’s notes, dated 10/31/18 at 8:30 A.M., showed
resident was transferred to the hospital with chest pain and increased confusion.
Record review of the resident’s nurse’s notes, dated 12/29/18, showed no documentation the
resident was transferred to the hospital.
Record review of the Resident Transfer Form, dated 12/29/18, showed the resident was
transferred to the hospital for altered level of consciousness and weakness.
Record review of the Discharge MDS showed discharge of the resident from the facility on:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a Bed
Rail Care Plan was developed for three sampled resident’s (Resident #47, #7, and #25) out
of 12 sampled residents. The facility census was 46 residents.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Record review of the resident’s Bed Rail/Assist Bar Evaluations, completed 3/7/18 and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to update a care plan to reflect
the resident’s current status for two sampled residents (Residents #8 and #20) out of 12
sampled residents. The facility census was 46 residents.
1. Record review of Resident #8’s face sheet showed he/she re-admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Significant Change Minimum Data Set (MDS a federally
mandated assessment tool to be completed by the facility staff for care planning), dated
11/9/18, showed the resident:
-Had a Brief Interview of Mental Status (BIMS) score of 13 that indicated he/she was
cognitively intact;
-Was totally dependent on one staff member for toileting;
-Had an indwelling catheter (a tube inserted into the bladder to remove urine).
Record review of the resident’s indwelling catheter care plan, dated 11/14/18, showed the
resident had an indwelling catheter in place for [MEDICAL CONDITION]. Further review of
the resident’s care plan showed it had not been updated.
Record review of the resident’s Physician order [REDACTED].
2. Record review of Resident #20’s face sheet showed he/she admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[MEDICATION NAME] (inflammation of the urinary
bladder);
-[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection).
Record review of the resident’s Admission MDS, dated [DATE], showed the resident:
-Had a BIMS score of 13 indicating he/she was cognitively intact;
-Had an indwelling catheter in place.
Record review of the resident’s indwelling catheter care plan, dated 7/6/18, showed:
-The resident had an indwelling catheter in place;
-The care plan had not been updated.
Record review of the resident’s quarterly MDS, dated [DATE], showed the resident:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure heel
float boots (an air cavity for zero pressure while providing air circulation to aid
healing of existing ulcers) were placed on one sampled resident (Resident #36) out of 12
sampled residents, who had existing pressure ulcers (localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction) to his/her heels. The facility census was 46
residents.
Record review of the facility’s Wound and Skin Care Policy, revised 2/1/2011, showed:
-The purpose was to prevent pressure ulcer formation and to develop appropriate
interventions;
-To promote a systematic approach and monitoring process for the care of residents with
existing pressure ulcers and those who are at risk for pressure ulcers;
–The policy did not have specific interventions listed to aid in the healing of pressure
ulcers.
1. Record review of Resident #36’s Face Sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Muscle weakness.
Record review of the resident’s care plan, dated 11/5/18, showed the resident:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
resident environment was free of accident hazards by not maintaining water temperatures
between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and
community bathhouses, which put the residents at increased risk [MEDICAL CONDITION] by
scalding; failed to respond to reports of out of range/fluctuating water temperatures and
investigate the causes; and failed to have a policy in place for maintaining safe water
temperatures. This had the potential to affect the residents residing on the 100, 500 and
600 halls. The facility also failed to transfer one sampled resident (Resident #36) out of
12 sampled residents in a safe manner. The facility census was 46.
Record review of the Burn Foundation website, www.burnfoundation.org, showed the
following:
-Hot Water Causes Third [MEDICAL CONDITION](full [MEDICAL CONDITION] go through the skin
and affect deeper tissue resulting in white or blackened, charred skin) .
— .in 1 second at 156 degrees F;
— .in 2 seconds at 149 degrees F;
— .in 5 seconds at 140 degrees F;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure complete
physician’s orders for [MEDICAL TREATMENT] (process of cleansing the blood by passing it
through a special machine – necessary when the kidneys are not able to filter the blood)
and failed to ensure an effective communication system between the [MEDICAL TREATMENT]
clinic and the facility for one sampled resident (Resident #46) out of 12 sampled
residents. The facility census was 46 residents.
Record review of the facility’s [MEDICAL TREATMENT] policy, revised 2/1/11, showed:
-The policy did not include information related to the [MEDICAL TREATMENT] Communication
Sheet or how often to monitor the resident.
1. Record review of Resident #46’s Face Sheet showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s Physician’s Orders Sheet (POS), dated 1/14/19, showed the
following physician’s orders:
-[MEDICAL TREATMENT]: Tuesday, Thursday, and Saturday at 10:45 A.M.;
-There were no physician’s orders that showed how often to monitor the resident’s fistula
(a creation of a vascular communication by suturing a vein directly to an artery) or how
often to check the resident’s bruit (turbulent blood flow through the blood vessel) and
thrill (a vibration felt in the blood vessel).
Record review of the resident’s admission care plan, dated 1/14/19, showed:
-The resident required [MEDICAL TREATMENT] three times per week;
-The staff were to check the resident’s bruit and thrill at the fistula site each shift
and as needed;
-Observe the fistula site upon return from [MEDICAL TREATMENT] for bleeding;
-Observe and report signs of localized infections at the fistula site;
-Report any adverse signs to the physician.
Record review of the resident’s Treatment Administration Record (TAR), dated 1/14/19,
showed there was no record the resident’s fistula was being monitored.
Record review of the resident’s [MEDICAL TREATMENT] Communication Sheets showed:
-On 1/15/19, 1/20/19 and 1/22/19, there was no documentation from the facility nurse that
showed the resident’s fistula was checked for signs of bleeding upon return from [MEDICAL
TREATMENT];
-There were no [MEDICAL TREATMENT] Communication Sheets for 1/17/19, 1/24/19, and 1/27/19.
Observation on 1/29/19 at 8:52 A.M., showed the resident had a fistula in the right upper,
inner arm with no redness.
During an interview on 1/29/19 at 9:24 A.M., Licensed Practical Nurse (LPN) C said:
-There were no physician’s order for bruit and thrill or how often to monitor the fistula
site;
-He/She would check the bruit and thrill then would document it in the nurses notes when
he/she was working;
-The nurses were responsible for obtaining physician’s orders so all nurses know to check
the thrill, bruit and monitor the fistula site.
During an interview on 1/31/19 at 9:04 A.M., the Assistant Director of Nursing (ADON)
said:
-The nurses were responsible for sending the [MEDICAL TREATMENT] Communication Sheet with
the resident to [MEDICAL TREATMENT];
-The resident brought it back from [MEDICAL TREATMENT] and the nurse was responsible for
reviewing the information and weights;

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–The resident did not use bed rails for positioning or support or to rise from a supine
(lying) to a sitting position;
–One-half bed rails were to be used on the right and left sides of the resident’s bed;
–The form did not show specific risks for entrapment and alternates attempted prior to
the use of the bed rails. Additionally, there was no documentation showing the resident or
his/her Durable Power of Attorney (a person established prior to incapacitation that acts
on behalf of the resident should the resident become unable to make decisions) was made
aware of the risks and benefits of using a one-half side rail and appropriate alternates
attempted prior to use.
Record review of the resident’s Significant Change MDS, dated [DATE], showed the resident:
-Was moderately cognitively impaired;
-Required one person extensive assistance for transfers and one person limited assistance
with bed mobility.
Record review of the resident’s comprehensive Care Plan, revised 11/13/18 showed there was
no Bed Rail Care Plan showing why the resident needed the rails and any risks associated
with having bed rails.
Record review of the resident’s POS for (MONTH) 2019, showed no orders related to bed
rails.
Observations of the resident lying in his/her bed showed the resident had side rails in
use on both sides of his/her bed on the following dates and times:
-1/27/19 at 11:07 A.M.;
-1/27/19 at 1:03 P.M.;
-1/27/19 at 2:29 P.M.
-1/30/19 at 11:04 A.M.; and
-1/31/19 at 9:29 A.M.
During an interview on 1/31/19 at 9:40 A.M., the Director of Therapy/PTA said:
-The resident leaned to the left;
-Therapy was working on passive (the therapist moves the joint) Range of Motion (ROM) on
the right side and active (the resident moves his/her own joints) ROM on the left, trunk
strength and hand therapy;
-Therapy had not assessed the resident for alternatives to side rails.
During an interview on 2/1/19 at 9:42 A.M., the MDS Coordinator said:
-Nursing verbally communicates needs such as bed rails in morning meetings and at other

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a system in place to
ensure Certified Nurse Assistant (CNA’s) received the required 12 hours in-service
education and based on performance reviews annually including abuse and neglect training
and dementia care training. This had the potential to affect all residents at the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
medication refrigerator’s temperatures were monitored daily and maintained within
acceptable parameters for two out of two medication rooms, failed to ensure stock
medications and supplies were disposed of prior to the expiration date for one out of two
medication rooms; and failed to ensure the narcotic count sheet was signed by both
oncoming and off going nurses/Certified Medication Technicians (CMT) to verify the correct
count of narcotics for two out of three medication carts. The facility census was 46
residents.
Record review of the facility’s policies showed there was no policy for:
-Monitoring the medication refrigerator temperatures;
-Expired Medications and supplies;
-Counting narcotics.
1. Record review on 1/30/19 of the facility’s Refrigerator Thermometer Readings log sheet
for (MONTH) (YEAR) and (MONTH) 2019 for the 100 and 300 hall medication room showed:
-Staff are expected to document nightly between 1:00 A.M. and 2:00 A.M., by the night
shift charge nurse;
-December (YEAR) was missing 16 times out of 31 opportunities for 51.6% of the time;
-January 2019 was missing 15 times out of 29 opportunities for 51.7% of the time.
Observation on 1/30/19 at 12:15 P.M., of the 100 and 300 hall medication room showed:
-77 [MEDICATION NAME] (medication which helps prevent the blood from clotting) prefilled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain a governing body, or
designated persons functioning as a governing body, that was legally responsible for
establishing and implementing policies regarding the management and operation of the
facility. This had the potential to affect all residents in the facility. The facility
census was 46 residents.
Record review of the Facility assessment dated [DATE] showed:
-The facility reviewed the following policies during the annual facility assessment:
–Abuse and neglect;
–Fire alarm system;
-There were no other documented policies listed that had been reviewed by the facility
administration to meet the current standards of practice.
Record review of the facility’s list of policies needed for the survey and requested of
the facility showed:
-The facility did not maintain and/or develop current policies including;
–[MEDICAL TREATMENT], last revised 2/1/11;
–Bed hold, not dated and no documented procedure for the staff;
–Wound care and skin policy, revised 2/1/11, no current practices for wounds and

Based on interview and record review, the facility failed to ensure a facility-wide
Infection Prevention, Control Program (IPCP) was established, and failed to ensure
surveillance logs were maintained for 12 consecutive months, to monitor, track, and
identify trends of infections in the facility. This had the potential to affect all
residents who had infections. The facility’s census was 46.
Record review of the facility’s policy’s showed the facility did not have an Infection
Prevention, Control Program Policy.
1. Record review of the facility’s Resident Census and Conditions of Residents (CMS 672)
worksheet completed by the Minimum Data Set (MDS a required, federally mandated assessment
tool completed by facility staff for care planning) Coordinator on 1/28/19 showed there
were nine residents receiving antibiotics when the survey team entered the facility on
1/27/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program (ASP) that included antibiotic use protocols and a system to monitor
antibiotic use and failed to have a policy for the ASP. The deficient practice had the
potential to affect all residents in the facility who had infections. The facility census

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete an
inspection of bed frames, mattresses, and bed rails as part of a regular maintenance
program to identify risk of possible entrapment for three sampled residents (Residents
#47, #7, and #25) out of 12 sampled residents. The facility census was 46 residents.
Record review of the facility’s, undated, Bed Rail Safety Check Guide showed:
-Several potential areas of entrapment to include within and under the rails; between two
rails; between the end of the rail and the side edge of the head and foot board; and
between the mattress edge and the rails, headboard and footboard;
-Side rail bars should be spaced to prevent the head from passing through the opening;
-There should not be extra space between the mattress edge and the rails, headboard and
footboard;
-Compression of the mattress sides should be checked to prevent a person from suffocation
(death from lack of air or inability to breath);
-Latches securing the bed ails should be stable; and
-Maintenance and monitoring of the mattresses, beds and bedside items should be ongoing.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Observations of the resident lying in his/her bed showed the resident had one-half side
rail in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 10:15 A.M.;
-1/27/19 at 12:28 P.M.;
-1/29/19 at 12:42 P.M.;
-1/30/19 at 11:35 A.M.; and
-1/31/19 at 9:59 A.M.
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use on 3/7/18 and 1/21/19 and
-The form did not comprehensively show specific risks for entrapment, the number and type
of bed rails or assist bars recommended and alternates attempted prior to the use of the
bed rails or assist bars. Additionally, there was no documentation that risks and benefits
of side rail use and appropriate alternates were discussed with the resident.
2. Record review of Resident #7’s Face Sheet showed he/she was admitted to the facility on
[DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED].
Observations of the resident lying in his/her bed showed the resident had a Low Air Loss
(LAL) Mattress (mattress comprised of multiple inflatable air tubes that alternately
inflate and deflate, taking pressure off of prominent bony body surfaces such as the heels
and end of the spine) and had side rails in use on both sides of his/her bed on the
following dates and times: