GARDEN VALLEY HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
honored residents’ dignity and respect when they failed to provide haircuts according to
resident needs and choices for two out of 26 sampled residents (Residents #95 and #30),
and when staff failed to ensure residents were appropriately covered when in public, which
affected one resident (Resident #66). The facility census was 102.
Review of the un-dated booklet entitled, Resident Rights For Long-Term Care In Missouri,
provided through Missouri’s Long-Term Care Ombudsman (an advocate) Program, showed
residents should e treated with consideration and respect, with full recognition of their
dignity and individuality.
Review of the facility’s policy for routine resident care, last reviewed 4/6/16, showed:
-Routine resident care is care that is not necessarily medically or clinically based, but
necessary for quality of life, promoting dignity and independence, as appropriate.
-It is the policy of this facility to promote resident centered care by attending to the
physical, emotional, social and spiritual needs and honor resident lifestyle preferences
while in the care of this facility.
-Licensed staff are to assess, implement (including appropriate delegation) and evaluate
for personal needs including emotion, social and spiritual needs.
1. During the resident group interview on 1/24/19 at 1:31 P.M. residents said the facility
did not have someone who provides haircuts. There were a couple volunteers around
Christmas but there is not someone who regularly provides haircuts.
2. Review of Resident #95’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/11/19, showed:
-Received Medicaid;
-Cognitively intact.
During an interview on 1/22/19 at 10:53 A.M., the resident said he/she:
-Had not had his/her hair cut in four months;
-Was on Medicaid and had not been offered a hair cut.
-Was working with the administrator to get a licensed hair salon in the facility.
During an interview and observation on 1/28/19 at 9:49 A.M., observation showed, and the
resident said:
-The resident wanted a haircut
-The resident’s hair was over his/her ears;
-Per the administrator, the facility had not had anyone to give hair cuts in awhile.
3. Review of Resident #30’s annual MDS, dated [DATE], showed:
-Sometimes makes self understood;
-[DIAGNOSES REDACTED].>-Received Medicaid.
During an observation and interview on 1/24/19 at 12:04 P.M., the resident indicated to
Certified Nurse Aide (CNA) E that he/she wanted a haircut. CNA E said someone would be
coming to the facility soon to cut his/her hair and CNA E would put him/her on the list.
CNA E said the facility recently replace the beautician. The resident’s hair was, at
least, to his/her ears and hung down the back of his/her neck.
During an interview on 1/25/19, the social services designee (SSD) said:
-Facility staff have done some research related to obtaining a licensed beautician.
-Resident #95 had talked with the administrator about arranging for one.
-The SSD had talked with someone who might be willing to provide haircuts for residents
who received Medicaid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to create an environment
respectful of the right of each resident when staff did not offer an evening snack to each
resident. This affected three out of 26 sampled residents (Residents #22, #20 and #95) and
others who attended the group resident interview. The facility census was 102.
1. Review of Resident #22’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/8/19, showed:
-Cognitively intact;
-Required extensive assistance for transfers;
-Used a wheelchair for mobility;
-Very important to have snacks available between meals.
During an interview on 1/22/19 at 10:33 A.M., the resident said:
-Staff did not offer evening snacks to residents.

Based on observation and interview the facility failed to notify residents of the current
availability and location of the most recent survey results and facility plan of
correction. The facility census was 102.
1. During a resident group interview on 1/24/19 at 1:31 P.M. one resident said the survey
book should have been by the licenses but he/she has not been able to find it lately.
Observations throughout the survey on 1/22/19, 1/23/19, 1/24/19, 1/25/19, and 1/28/19
showed:
– The survey book was not able to be located in the facility;
– The facility did not post a sign indicating the location of the survey result book.
Review of Resident #95’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/11/19, showed:
– Able to make daily decisions without difficulty;
– No mood or behavior problems.
Observation and interview on 1/28/19 at 8:45 A.M., showed the resident maneuvered his/her
electric wheelchair down the hallway to in front of the surveyor. The resident asked if
the facility was responsible to post for the residents to see a copy of the results of the
inspectors survey. The resident said there was a small book in the front of the facility
for a while but a few weeks ago the notebook was moved and never returned. The new people
in the office did not know the whereabouts of the notebook.
During an interview on 1/28/19 at 3:05 P.M., the Director of Nursing (DON) said:
– She and the Administrator began employment at the facility at the same time and toured
the facility at the same time;
– While on tour, she asked about the survey results notebook and nobody knew where it was.
During an interview on 1/28/19 at 3:15 P.M., the Nursing Staff Scheduler (NSS) told the
Administrator he/she thought the Survey Result Book was sitting on a shelf, locked up back
in the old DON office. The Administrator said he would find the book.
Review on 1/28/19 at 3:55 P.M., showed the Administrator with a thin white notebook with
the previous year survey results inside. The facility’s plan of correction was not
included in the Survey Results Book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to clarify code status upon
admission and failed to document the resident’s code status on the resident’s admission
record in such a way to be readily accessible to staff in the event of an emergency for
one of 26 sampled residents, (Resident #42). The facility census was 102.
1. Review of the facility’s general code status policy, dated, [DATE], showed, in part:
– This policy is applicable to all adult living centers;

1. Observation on 1/22/19, at 10:15 A.M., of room [ROOM NUMBER] showed:
– The right hand side of the closet door had a hole in it;
– The plywood on the back of the bathroom door was busted with jagged edges;
– The wall in the bathroom had three separate holes in it, approximately baseball size;
– Above the baseboard in the bathroom by the toilet, an area had been patched and had a
slit in it;
– The tile around the toilet had grime and dirt around it;
– Several areas of the wall had been patched, was not covered with paint.
2. Observation on 1/22/19 at starting at 12:14 PM in the 500 hall’s (locked unit) common
area showed the following:
– A softball sized half-moon black substance on ceiling.
– A tan recliner used by residents with multiple brown stains in seat, arm rest and back;
– A pink recliner with brown grim on both arm rests;
– Three dining room chair with foam exposed on the seat;
– The window to courtyard with splatters, smears;
– The white door to courtyard with black scuff marks across bottom 12 inches;
– In room [ROOM NUMBER] showed a softball sized dent in the closet door.
– In room [ROOM NUMBER], the hot water was not working at the sink, it only had a slow
drip when the hot water handle was turned to the on position.
During an interview on 01/25/19 at 9:35 AM Housekeeping staff A said he/she had worked
here two months and anytime they see any repairs, they put in a work order kept at the
nurses station or will find the maintenance staff.
In an interview at 4:00 P.M., the maintenance supervisor said staff don’t always fill out
the work orders.

Based on record review and interview the facility staff failed to conduct all required
background checks. Staff did not check the Certified Nurses’ Assistant (CNA) Registry for
all staff to ensure they did not have a Federal Indicator (a marker given by the federal
government to individuals who have committed abuse/neglect). The facility census was 102.
1. Review of the facility policy dated 10/1/00 titled Background checks/EDL Checks Under
Missouri Law did not address checking the CNA Registry.
2. Review of the Director of Nursing (DON) employee file showed:
– Date of hire 1/7/19;
– No CNA Registry check found.
3. Review of Licensed Practical Nurse (LPN) H’s employee file showed:
– Date of hire 10/18/18;
– No CNA Registry check found.
4. Review of LPN I’s employee file showed:
– Date of hire 3/14/18;
– No CNA Registry check found.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure resident
Minimum Data Set (MDS) were completed accurately for three of 21 sampled residents,
(Resident’s #25, #103 and #42). The facility census was 102.
1. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 10/17/18, showed:
– Long and short term memory problems;
– No impairment to the upper and lower extremities;
– [DIAGNOSES REDACTED].
Observation and interview on 1/22/19, at 2:36 P.M., showed:
– The resident lay in bed;
– Family member A was at bedside;
– Family member A said the resident had a stroke and was paralyzed (partly or wholly
incapable if movement) on the right side.
2. Review of Resident #42’s physician order [REDACTED].
– Start date: 9/26/18: an order for [REDACTED].
Review of the resident’s quarterly MDS, dated , 10/30/18, showed:
– Cognitive skills intact;
– In the last five days, the resident did not receive scheduled pain medications, did not
receive any as needed pain medications and did not use any non medication interventions;
– Pain level was not assessed;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– Start date: 9/26/18: an order for [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED]
– The resident received [MEDICATION NAME] 20 times for pain.
3. During an interview on 1/28/19, 11:43 A.M., the Director of Nursing (DON) said:
– If a resident is receiving pain medication, the MDS section for pain should be filled
out;
– If the resident had an impairment on one side of their body or both sides, the MDS
should identify it.

**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 care plan consistent with the resident’s specific conditions, needs and risks
to provide effective person centered care for one of 26 sampled residents, (Resident #102
). The facility census was 102.
1. Review of Resident # 102’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/11/18, showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for transfers;
– Had one stage 3 pressure ulcer (a full thickness of skin is lost, exposing the
subcutaneous tissues) which was present of admission;
– [DIAGNOSES REDACTED].
Review of the resident’s undated care plan, showed:
– The resident had a pressure ulcer on the left buttock;
– The resident had an activities of daily living (ADL) self care performance deficit
related to [MEDICAL CONDITION];
– The resident required physical assistance of two staff with transfers.
– The care plan did not indicate what type of device to use to assist the resident with
transfers.
Observation and interview on 1/24/19, at 10:01 A.M., showed:
– Licensed Practical Nurse (LPN) C provided wound care to the resident and said the wound
was located on the resident’s sacrum (area at the base of the spinal column).
Observation on 1/25/19, at 11:20 A.M., showed:
– Certified Nurse Aide (CNA) E and CNA B transferred the resident with the use of a gait
belt ( a special belt placed around the resident’s waist to provide a handle to hold onto
during a transfer).
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– The care plans should have the correct location of the wounds;
– The care plans should specify how to transfer the resident was to be transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to check placement of
gastrostomy tube (G tube, tube surgically inserted through the abdominal wall into the
stomach for administration of food, fluids and medications), for one of 26 sampled
resident’s, (Resident #72), did not watch (Resident #45) take medications when
administered which the resident then kept at bedside, did not follow the physician’s order
to obtain labs for (Resident #80) and failed to allow Resident #3 and Resident #37’s
fingertip to air dry before obtaining the blood sample. The facility census was 102.
1. Review of the facility’s medication administration by enteral tube (a way to provide
food or medications through a tube placed in the nose, stomach or the small intestine)
policy, revised, 11/23/18, showed, in part:
– This policy addresses guidance for the clinical administration of medications through a
G- tube;
– Check the placement of the tube before administering medication and/or fluids.
2. Review of Resident #72’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/5/18, showed:
– Cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order sheet (POS), dated, January, 2019, showed:
– an order for [REDACTED].>- Check for residual prior to each intermittent feeding; if
greater than or equal to 100 cc., hold tube feeding . Check residual again in two hours.
Notify physician and /or Nurse Practitioner when appropriate;
– The physician’s order did not specify to check for placement prior to administering
medications and/or tube feedings.
Review of the resident’s Medication Administration Record, [REDACTED]
– Enteral feed order every day and evening shift. Check for residual prior to each
intermittent feeding; if greater than or equal to 100 cc., hold tube feeding. Check
residual again in two hours. Notify physician and /or Nurse Practitioner when appropriate;
– Did not specify to check for placement prior to administering medications and/or tube
feedings
Observation on 1/25/19, at 7:45 A.M., showed:
– Licensed Practical Nurse (LPN) B opened the new irrigation tray with piston syringe and
placed the plastic drape over the resident’s lap;
– Attached the syringe with the plunger to the [DEVICE] and drew back approximately 30 ml
of residual and reinserted it;
– LPN B removed the syringe and removed the plunger and re-attached the syringe to the
[DEVICE];
– LPN B flushed with 30 ml. of water and then administered the resident’s medication;
– LPN B did not check for placement before checking for residual.
During an interview on 1/28/19, at 11:09 A.M., LPN B said:
– He/she should have used a stethoscope and checked for placement.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– Staff should use a stethoscope and check for placement before administering medications.
3. Review of the facility’s blood glucose point of care testing policy, revised 5/23/18,
showed, in part:
– The importance of ongoing glucose monitoring is necessary to detect extremes of high or

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to complete a discharge summary
for one of three sampled resident (Resident #108) when the resident was discharged from
the facility. The facility census was 102.
1. Review of the facility policy dated 3/10/17 titled Transfer and Discharge Policy
showed:
– When a resident’s discharge is anticipated, facility will develop and implement a
discharge plan that focuses on the resident’s goals, the preparation of residents to be
active partners and effectively transition them to post-discharge care, and the reduction
of factors leading to preventable readmissions.
– When a discharge is anticipated, the facility will develop a discharge summary that
includes, but is not limited to the following:
1. Summary of Stay;
2. Final Summary Available for Release;
3. Medication Reconciliation;
4. Post-Discharge Plan of Care;
– A copy of the post-discharge plan will be provided to the resident, and with the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide adequate
incontinent care for two residents (Residents #25, #30) out of 26 sampled residents who
required assistance, and failed to provide baths/showers and grooming for dependent
residents. This affected three sampled residents (Residents #9, #22, #43) and Resident’s
#15 and #91. The facility census was 102.
1. Review of the facility’s policy related to bathing and showering, revised 4/25/18,
showed:
-Determine resident preference for shower or bathing;
-Determine resident preference for morning or evening bathing;
-Determine resident preference for number of baths/showers per week;
-Care plan resident preferences and communicate to staff providing personal care;
-Residents have the right to refuse care, including bathing;
-Attempt and document attempts for alternative bathing options
-Provide oral care-brush teeth or clean dentures;
-Brush/comb hair as applicable;
-Men should be shaved during bathing, if applicable.
2. Review of Resident #22’s bathing documentation from 10/28/18 through 1/25/19, showed:
-Nine documented showers, including one refusal;
-Up to seven to twenty eight days between documented showers;
-Only one week that staff documented the resident received two showers in one week.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/8/19, showed:
-Cognitively intact;
-Required extensive assistance for transfers, dressing, toileting and bathing;
-Occasionally incontinent of bladder;
-Continent of bowel;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised on 1/17/19, showed:
-Had bowel and bladder incontinence;
-Bathing per choice. See bath schedule;

In an interview on 1/25/19 at 11:46 A.M. , CNA I said all residents are given showers two
times per week. Shower sheets are turned into the charge nurse.
Observation on 1/25/19 (Friday) at 4:00 P.M. showed Resident’s #15 and #91 in the common
area with uncombed, greasy looking hair.
Observation on 1/28/19 (Monday) at 9:24 A.M. showed Resident #15 and #91 sitting in the
common room with uncombed, greasy looking hair and unkempt clothing.
In an interview on 1/28/19 09:30 A.M. CNA J said when he/she gets residents up in the
morning, staff pick out their clothes, takes them to the toilet, washed their face and
combed their hair.
Review of shower sheets for Resident #15 showed in January, 2019, the resident received
showers on 1/1, 1/8, 1/21, and 1/24.
Review of shower sheets for Resident #91 showed in January, 2019, the resident received
showers on 1/8, 1/16, and 1/21.
6. During an interview on 1/28/19, at 11:43 A.M., the DON said:
– They have shower aides who are assigned to give showers;
– The nurses are responsible to make sure the showers are being done;
– Staff should fill out the shower sheets;
– If there was a blank area on the shower sheet, she would say the resident didn’t get
their showers;
– If a resident wanted a shower twice weekly, that is how it should be scheduled.
7. Review of the facility’s policy and procedure for Perineal Care, revised 9/6/17,
showed:
– To promote a sense of well-being and meets hygiene standards of care;
– Perform after incontinence of bowel, bladder, as needed and at least twice per shift for
residents wearing incontinence products;
– Includes cleansing of the perineum, from the pubis symphysus bone to the coccyx area;
– Begin with the front genital area first and end with the coccyx area;
– Cleanest to dirtiest;
– Manipulate and thoroughly cleanse all perineal skin areas and inner thighs.
8. Review of Resident #30’s care plan, last revised on 12/20/18, showed:
-Had bladder incontinence related to dementia;
-Check every two hours for incontinence;
-Wash, rinse and dry perineum.
Review of the resident’s annual MDS, dated [DATE], showed:
-Required supervision and assistance of one for personal hygiene;
-Always incontinent of bladder.
Observation on 1/24/19 at 12:04 P.M., showed Certified Nurse Aide (CNA) A and CNA E
provided care for the resident in the following manner:
-Both staff washed their hands and put on gloves.
-CNA A unfastened the resident’s brief.
-CNA E handed pre-moistened wipes to CNA A.
-CNA A cleansed the resident’s groin areas, but did not cleanse the resident’s genitals.
-Staff completed cleansing of the resident’s backside, then removed gloves and washed
their hands.
During an interview on 1/24/19 at 4:55 P.M., CNA A said staff should cleanse the

This deficiency is uncorrected. For further examples see Statement of Deficiency dated,
1/19/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, Licensed staff failed to assess the
resident’s change in condition when direct care staff reported they found an open area and
blood on the back of the resident’s left pant leg. This affected one of 26 sampled
residents (Resident #88). The facility census was 102.
1. Review of Resident #88’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/7/18, showed:
– Able to make daily decisions;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide and care
plan for restorative services (RS) to assist residents to attain or maintain their highest
practicable level of functioning for three residents (Residents #30, #43 and #102) out of
26 sampled residents who had limited range of motion (ROM) and/or other physical
limitations. The facility census was 102.
Review of the facility’s restorative program policy, last revised on 7/26/18, showed:
-The purpose of this policy is to provide direction and guidance to the clinical team to
assess and implement a plan of action for resident-specific care to maintain or improve
mobility with maximum practicable independence unless a reduction in mobility is
demonstrably unavoidable.
-Oversight and accountability for the program includes the medical director, director of
nurses (DON) and therapy (occupational and/or physical consults).
-The resident/representative will be included in the development of the restorative care
plan.
-Provision of necessary services, equipment, assistive devices and environmental
adaptations will be based on the assessment/evaluation.
-Care plan will address, but is not limited to, types of treatments, measurable
objectives, goals, interventions required for contractures, provides for increasing and
promotion of independence to the extent clinically possible for range of motion (ROM) and
mobility.
-Staff will be trained and competent in rehabilitative/restorative care.
-There will be sufficient staff to meet the needs of the program and resident care.
-Documentation to include attempts to implement and revise the care plan to address
changing needs, unavoidable decline and/or reduction in ROM and mobility, and addresses
potential complications.
1. Review of Resident #30’s therapy documentation, provided by facility staff, showed:
-Occupational therapy plan of care (evaluation only), dated 2/12/18, for a power
wheelchair safety test, with discharge plans to remain in facility with a functional
maintenance program;
-Occupational therapy plan of care (evaluation only), dated 6/14/18, for a power
wheelchair assessment, with discharge to current facility.
-Staff was unable to provide documentation for any restorative therapy received by the
resident.
Review of the resident’s care plan, last revised on 12/20/18, showed:
-[DIAGNOSES REDACTED].
-Had amputations of both lower extremities;
-Required extensive to total assistance for most care;
-Did not address limited use of his/her right extremity or any interventions to maintain
or improve the status of the right extremity.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview and record review, the facility failed to assure staff
assured residents’ remained free of accident hazards when they failed to follow
manufacturer’s guidelines and facility’s Mechanical Lift policy during a mechanical lift
transfers for two sampled residents (Residents #9 and #70). Staff also did not use proper
techniques to reduce the possibility of accidents and injuries during the use of gait belt
(a safety device and mobility aid used to provide assistance during transfers, ambulation
or repositioning) transfers for Resident #25 and #88. The facility census was 102.
1. Review of the facility’s competency for Proper Use of a Gait Belt, provided by the
facility the facility Gait Belt policy, showed:
– Gait belts are used for safe transfers and ambulation;
– The gait belt should be tightly fastened around the upper chest;
– The gait belt should be applied snuggly to prevent slipping or riding up;
– Grab the gait belt on each side to assist the resident to stand.
2. Review of Resident #88’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/7/18, showed:
– Able to make daily decisions;
– Required assistance of staff for transfers.
Review of the resident’s care plan, revised on 1/14/19, showed:
– Resident is at high risk for falls;
– Required one assist of staff with transfers.
– Limited range of motion with both lower extremities.
Observation and interview on 1/24/19 at 9:46 A.M., showed Certified Nurse Aide (CNA) F and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided peri care and catheter (a sterile tube inserted into the urinary bladder to drain
urine) care in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the
possibility of a UTI which affected Residents #75, #80, #43 and #102. The facility census
was 102.
1. Review of the facility’s policy and procedure for Perineal Care, revised 9/6/17,
showed:
– To promote a sense of well-being and meets hygiene standards of care;
– Perform after incontinence of bowel, bladder, as needed and at least twice per shift for
residents wearing incontinence products;
– Includes cleansing of the perineum, from the pubis symphysus bone to the coccyx area;
Begin with the front genital area first and end with the coccyx area;
– Cleanest to dirtiest;
– Manipulate and thoroughly cleanse all perineal skin areas and inner thighs.
Review of the facility’s policy and procedure for Catheter Care, revised 5/1/17, showed:
– Catheter care is performed at least twice daily;
– Catheter associated urinary tract infections is the most common adverse event associated
with an indwelling catheter;
– For residents with a catheter, perform peri care first and with incontinence of bowels;
– With a clean cloth or wipe, firmly grasp the catheter tubing nearest to the insertion
site to prevent movement or accidental dislodgement and clean around the insertion site;
– With a clean cloth or wipe, wipe down the catheter from the insertion site approximately
six inches;
– Secure the catheter to leg with a device or tape.
2. Review of Resident # 75’s medical record showed a laboratory urinalysis report, dated
11/14/18, showed bacteria consistent with a UTI.
Review of the resident’s care plan, revised on 12/3/18, showed:
– At risk for developing UTI;
– Change drainage bag per policy;
– Check tubing for kinks each shift;
– Empty and record output each shift.
– Provide catheter care daily.
Review of the resident’s Minimum Data Set (MDS|), a federally mandated assessment
instrument completed by facility staff, dated 1/9/19/ showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to assure staff
provided proper respiratory care when staff failed to properly clean oxygen concentrator
filters. This affected Residents #75, #80, #70 and #82. The facility census was 102.
1. Review of the facility’s policy for Oxygen Therapy Using Concentrators, revised
11/9/18, showed filters and machines are to be cleaned once a week.
2. Review of Resident #80’s care plan, revised 5/25/18, did not address and breathing
problems or oxygen use.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/28/18, showed:
– Both short and long term memory problems;
– Required assistance of staff with all activity of daily living.
Staff did not code the MDS with any breathing problems or oxygen therapy.
Review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– Order for continuous oxygen at two liters via nasal canula to keep oxygen saturation
level above 90 %.
Observation at varying times on all days of the survey 1/22/19, 1/23/19, 1/24/19, 1/25/19
and 1/28/19 showed the resident used both a portable oxygen tank and his/her oxygen
concentrator in his/her room. The oxygen concentrator had two places for foam filters. The
empty place for the filter had gray dust covering the area that wiped away with a finger.
The other space held a foam filter that was heavily covered with gray lint and dust that
could be scraped off with a fingernail.
3. Review of Resident #75’s January, 2019, POS, showed:
– [DIAGNOSES REDACTED].
– Order for oxygen at two liters via nasal canula to keep oxygen saturation levels at 92%
or greater.
Review of the resident’s plan of care, revised 1/2/19, showed:
– Check saturation level every shift;
– Monitor symptoms of respiratory distress;
– Promote lung expansion and improve air exchange by positioning with proper body
alignment so that he/she does not slide down in bed.
Review of the resident’s MDS, dated [DATE], showed :
– Ale to make daily decisions without difficulty;
– Dependent on staff for all ADLs;
– Oxygen therapy.
Observation at varying times on all days of the survey 1/22/19, 1/23/19, 1/24/19, 1/25/19
and 1/28/19 showed the resident used his/her oxygen concentrator in his/her room. The
oxygen concentrator had two places for foam filters. The empty place for the filter had
gray dust covering the area that wiped away with a finger. The other space held a foam

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff consistently and
accurately documented pain medication administration and failed to ensure the resident’s
pain medication supply did not run out for one out of 26 sampled residents (Resident #47).
The facility census was 102.
Review of the facility’s policy related to medication administration, last revised on
12/14/17, showed:

Based on observation, interview, and record review, the facility failed to post the nurse
staffing data in a prominent place readily accessible to all residents and visitors on a
daily basis at the beginning of each shift. The facility census was 102.
1. Observations on 1/25/19 and 1/28/19 showed incomplete nurse staffing data forms posted
in a plastic sleeve on a wall to the right of the front entry to the facility. There was
no nurse staffing data posted on the 500 hall locked unit. Staff had not completely filled
out the forms according to staff actually working, rather they listed the amount of staff
scheduled for the entire day (24 hour period) and did not list the census.
During interviews on 1/28/19 at 2:45 P.M.,Licensed Practical Nurse (LPN) F said the nurse
staffing sheet was always kept at Center Court. At 2:55 P.M., LPN G said the only posted
staffing he/she knew about at Center Court as the notebook where staff looked to find
their assigned work areas. At 3:05 P.M., the Director of Nurses said the Nursing Staff
Scheduler (NSS) took care of posting the nurse staffing form but she did not know where if
was posted. At 3:46 P.M., the NSS said he/she filled out the form each day how many of
each staff were scheduled for each shift. He/She had not entered the census information on
the form. The form was not filled out at the beginning of each shift with the number of
nursing staff that showed up to work each shift. He/she said there was only one staffing
sheet for the entire building. There was not a nurse staffing form posted on the 500 hall
locked unit.

Based on observations, interviews and record review, the facility failed to ensure the
intravenous (IV) emergency medication and supplies kit (E-Kit) was locked, current and not
expired. The facility census was 102.
1. Review of the facility’s storage and expiration of medications, biologicals, syringes
and needles policy, revised, on 10/31/16, showed, in part:
– The facility should ensure that infusion therapy products and supplies are stored
separately from other medications and biologicals;
– Facility should request that Pharmacy perform a routine nursing unit inspection for each
nursing station in facility to assist facility in complying with its obligations pursuant
to Applicable Law relating to the proper storage, labeling, security and accountability of
medications and biologicals.
2. Observation on 1/28/19, at 10:40 A.M., of the medication room for the 100, 200, and 300
halls, showed:
– In the cabinet underneath sink an opened toolbox used as IV E-kit and had no locks on
it;
– It expired 3/2018 and had several 1000 milliliters of various types of IV fluids which
were expired.
Review of the facility’s consultant pharmacist summary, dated, January, 2019, showed, in
part:
– Medications in the emergency supply are in date, ordered/re-ordered appropriately, and
sealed (if applicable); evaluation showed no irregularities observed.
During an interview on 1/28/19, at 11:43 A.M., the Assistant Director of Nursing (ADON)
said:
– The pharmacist consultant checked the medication rooms and medication carts for expired
medications;
– She destroys the expired medications with another Certified Medication Technician (CMT)
and if it’s a narcotic, destroyed it with another nurse;
– She had not destroyed any medications in five weeks;
– She was not aware of an IV E-kit that was opened and expired 3/18;
– The pharmacist was in the facility last week;
– She was not for sure if the pharmacist checked the medication rooms or medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record reviews, the facility failed to provide
documentation that the consultant pharmacist (PharmD) performed monthly medication regimen
recommendations (MRR) for the month of (MONTH) (YEAR). The facility failed to provide

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with an error rate of less than five percent. Facility staff made
seven errors out of 25 opportunities for error, resulting in an error rate of 28%. This
affected six residents (Residents #22, #100, #72, #3). The facility census was 102.
1. Review of the facility’s policy related to administering nasal sprays, revised 7/24/18,
showed:
-Ask resident to clear nasal passages by gently blowing nose prior to administration;
-Assist resident to tilt head slightly upwards;
-Using a gloved finger, or direct the resident to occlude the opposite nostril, administer
the spray into the nostril.
-Direct tip of the sprayer toward midline of nose so mist will flow to the back of the
nasal cavity rather than dripping down the throat.
-Ask resident to inhale, breathing in through the nose, and squeeze the atomizer (device
for emitting a fine spray) quickly and firmly while releasing the occluded nostril.
-Repeat procedure in other nostril, if indicated.
-Instruct resident to keep head tilted back several minutes until medication is dispersed.
2. Review of Resident #22’s current electronic physician order [REDACTED].
Observation on 1/24/19 at 10:14 A.M., showed Certified Medication Technician (CMT) A
administered the resident’s [MEDICATION NAME] nasal spray (a steroid used to treat
allergies and inflammation) in the following manner:
-Shook the medication bottle and handed it to the resident;
-The resident administered two consecutive sprays into the right nostril, without
occluding the left nostril or waiting between sprays;
-The resident repeated the same procedure to the left nostril;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure that
one out of 26 sampled residents, (Resident # 72) were free from significant medication
errors. The facility census was 102.
1. Review of the facility’s medication administration policy, revised 12/14/17, showed, in
part:
– The purpose of this policy is to provide guidelines for general medication
administration to be provided by personnel recognized as legally able to administer;
– Observe the five rights in giving each medication: the right resident, the right time,
the right medicine, the right dose, and the right route;
– Read medication label three times before administering medication, first, when comparing
label to Medication Administration Record [REDACTED].
2. Review of Resident #72’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/5/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].
Observation and interview on 1/25/19, at 8:46 A.M., showed:
– Licensed Practical Nurse (LPN) B removed three vials of [MEDICATION NAME], 20%, 4 ml.
vial, (200 mg. /ml.) from the drawer and placed them on the surface of the medication

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview, ad record review, the facility failed to ensure staff
properly stored and discarded resident medications and stock medications. Staff failed to
date medications when opened and failed to discard expired medications. This had the
potential to affect all residents in the facility. The facility census was 102.
1. Review of the facility’s storage and expiration of medications, biologicals, syringes
and needles policy, revised, 10/31/16, showed, in part:
– Facility should ensure that medications and biologicals that have an expired date on the
label, have been retained longer than recommended by manufacturer or supplier guidelines,
have been contaminated or deteriorated, are stored separate from other medications until
destroyed or returned to the pharmacy or supplier;
– Once any medication biological package is opened, the facility should follow
manufacturer/supplier guidelines with respect to expiration dates for opened medications;
– Facility staff should record the date opened on the he medication container when the
medication has a shortened expiration date once opened;
– Facility should destroy and reorder medications and biologicals with soiled, illegible,
worn, makeshift, incomplete, damaged or missing labels or cautionary instructions;
– Facility should destroy or return all discontinued, outdated/expired, or deteriorated
medications or biologicals;
– Facility should request that pharmacy perform a routine nursing unit inspection for each
nursing station in the facility to assist facility in complying with its obligations.
2. Observation and interview on 1/28/19, at 9:19 A.M., of the medication room for the 400
and 600 halls showed:
– One unopened bottle of Vitamin E (supplement), expired, 8/18;
– One opened bottle of [MEDICATION NAME] Q ([MEDICATION NAME]);
– One unopened bottle of Nephro-Aid, dietary supplement, expired 9/2018;
– One opened vial of [MEDICATION NAME] insulin, no date when opened, the vial stated
filled 8/8/18 and the brown bottle it was kept in had a label that stated filled 9/14/18;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed protocols to prevent the spread of infection related to hand hygiene during
residents’ personal and wound care This affected four out of 26 sampled residents
(Residents #43, #75, #70, #102). Additionally, staff failed to clean the port of the
insulin pens and failed to properly clean the glucometer between use, which affected,
Resident’s #3 and #37, and failed to clean the port of the drainage bag and use a barrier
when emptying the drainage bag for Resident #103. Staff did not clean a soiled mattress
before applying clean linens for Resident #78. The facility census was 102.
1. Review of the facility’s policy related to standard precautions, revised 4/1/17,
showed:
-The facility will adhere to the CDC (Centers for Disease Control and Prevention)
guidelines and recommendations for hand hygiene unless otherwise explicitly stated.
-[MEDICATION NAME] hand hygiene is a simple but effective way to prevent the spread of
infections, by breaking the chain of infection.
-When hands are not visibly soiled, alcohol-based hand sanitizers are the preferred method
for cleaning hands in this healthcare setting.
-Use soap and water for cleaning hands when hands are visibly dirty or soiled.
-Perform hand hygiene when hands move from a contaminated body site to a clean body site
during patient care, before and after contact with a resident’s intact skin, and after
contact with body fluids or excretions, non-intact skin or wound dressings, and after
glove removal.
2. Review of Resident #43’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/5/18, showed:
-Required extensive assistance for bed mobility and personal hygiene;
-Presence of a urinary catheter (sterile tube inserted into the bladder to drain urine);
-Had a stage 4 (full thickness skin loss) pressure ulcer.
Review of the resident’s care plan, last revised 1/13/19, showed:
-Received wound care for a pressure ulcer to the sacrum (area below the spinal column and
between the hip bones);
-Had a urinary catheter with a recent urinary tract infection [MEDICAL CONDITION];
-Required extensive assistance for personal hygiene and two staff to turn or re-position
him/her.
Observation and interview on 1/24/19 at 9:22 A.M. showed Licensed Practical Nurse (LPN) C
provided wound care in the following manner, and said: