GREGORY RIDGE HEALTH CARE CENTER

Based on record review and interview, the facility failed to obtain authorization to
manage resident funds for four residents (Residents #33, #52, #50 and #85) out of five
residents sampled for the resident fund review process. The facility census was 106
residents.
1. Record review of the resident fund authorizations showed the following:
– One of five residents had a signed authorization form to allow the facility to manage
funds and
– Authorization forms could not be found for four residents (Residents #33, #52, #50 and
#85).
During an interview on 5/14/18 at 2:18 P.M., the Social Worker said the following:
– He/she was not able to find authorization paperwork for Residents #33, #52, #50 and #85,
– He/she contacted guardians to obtain verbal consents but he/she understood that regular
signed paperwork will be needed and
– He/she had only been employed at the facility for about one and half months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain mattresses in three
resident rooms (308, 209, and 206) without rips which rendered the mattresses not easily
cleanable; failed to ensure the overbed lighting over one bed in resident rooms [ROOM
NUMBERS] worked; failed to maintain the floor in the shared restroom of resident rooms
328/327 in good repair; and failed to maintain the shower stall on the second floor shower
room with good lighting, and without rust stains and grime on the tiles. This practice
potentially affected at least 37 residents residing in or using those areas within the
facility. The facility census was 106 residents.
1. Observations with the Maintenance Supervisor and the Housekeeping Supervisor on
5/10/18, showed the following:
– At 9:10 A.M., there as a 60 inch (in.) long by 22 in. wide area of the mattress covering
that was peeling away from a mattress in resident room [ROOM NUMBER];
– At 10:04 A.M., one of the over bed lights in resident room [ROOM NUMBER] did not work
when the switch was turned on and the chain was pulled;
– At 10:32 A.M., a 33 in. long by 48 in. wide area of the floor in poor repair in the
shared restroom of resident rooms 328/327;
– At 11:04 A.M., one of the over bed lights in resident room [ROOM NUMBER] did not work
when the switch was turned on and the chain pulled;
– At 12:26 P.M., rust and grime was present in the shower stall of the second floor shower
room that covered an area of 54 in. wide by 48 in. deep form the back of the stall to the
front. Further observation showed that when the curtain was pulled in front of the shower
stall the lighting was very dim;
– At 12:43 P.M., 10 in. long rips were present in Bed C in resident room [ROOM NUMBER],
and
– At 12:50 P.M., there was a two in. hole in the mattress of bed B in resident room [ROOM
NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure discharge/transfer
documentation was completed to include reasons for the discharge/transfer, discharge plan
and notification of the resident’s responsible party, for one sampled resident (Resident
#104), who was discharged to another facility, out of three sampled closed records and 30
sampled residents. The facility census was 106 residents.
1. Record review of Resident #104’s Facility Transfer Sheet dated 2/21/18, showed he/she
was transferred to the facility on [DATE] at the resident’s legal guardian’s requested.
Record review of the resident’s Nursing Notes showed the last nursing note dated 4/10/18
that the resident was having aggressive behaviors and was not re-directive using
non-medication interventions. It showed the nursing staff notified the resident’s
physician for a medication order to help calm the resident. There were no notes showing
the resident was ever discharged from the facility or that he/she was transferred to
another facility.
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/15/18 to 4/14/18,
showed there were no physician’s orders documented showing the resident’s discharge
orders.
Record review of the resident’s Physician’s Telephone Orders (PTO) showed there were no
physician’s discharge orders for the resident.
Record review of the resident’s Medical Record showed there was no documentation in the
nursing notes showing when or why the resident was discharged . There was no documentation
showing the resident, resident’s responsible party/guardian or Ombudsman were made aware
of the resident’s transfer to another facility, any discharge letters and there was no
documentation of the resident’s discharge plan or aftercare.
During an interview on 5/16/18 at 9:35 A.M., the Administrator said:
-The resident transferred to the facility on [DATE] and was discharged to another facility
on 4/11/18; -Normally, when a resident is discharged from the facility, the nurse on duty
completes the transfer form, obtains the physician’s order for transfer, notifies the
responsible party or guardian, completes the disposition of medications and documents in
the nursing notes when the resident was to be discharged (the date and location), any
follow up care needs or orders, who the resident left with, the time the resident left and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to conduct a Level One Nursing
Facility Pre-Admission Service Screening for Mental Illness/Mental [MEDICAL CONDITION] or
Related Condition (PASRR) for one sampled resident (Resident #54) upon the resident’s
admission to the facility out of 30 sampled residents. The facility census was 106
residents.
Record review of the facility undated PASRR Assessment Policy showed showed the following:
-Purpose: The purpose of this policy is to utilize the PASRR Assessment to develop a plan
of care that shows continuity from previous history of behaviors and placement.
-Procedure: Upon the resident’s admission to the facility and upon the facility receiving
the PASRR, the Admissions Coordinator will make a copy of the PASRR with the clinical
history of previous behaviors and services provided. The Admissions Coordinator will give
a copy of the PASRR to the Director of Nursing, MDS/Care Plan Coordinator/Effective
Practices Community Supervision (EPICS) Case Manager and Social Services Director.
-The PASRR will be utilized as an instrument to assist the facility in maintaining as much
as possible, previous treatment modalities that were effective in the resident’s life
prior to placement at this facility.
1. Record review of Resident #54’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED]. (A mental health disorder characterized by
persistently depressed mood or loss of interest in activities, causing significant
impairment in daily life).
Record review of the resident’s physician’s orders [REDACTED].
-The resident’s physician had approved the overall plan of care for the resident’s needs;
-To have a Psychiatrist and Psychologist consults as needed and
-To have a Behavioral Therapist consult as needed.
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment tool to be completed by facility staff for care planning) dated 4/25/18 showed
he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 13, which describes the resident
was cognitive alert and oriented and
-Had the ability to express ideas and wants to others in a consistent and reasonable
manner.
Record review of the resident’s Care Plan dated on 4/25/18, showed the following:
-Was to record and monitor for patterns of behaviors;
-Had to monitor for changes in condition that may warrant increased supervision/assistance
and notify the resident’s physician related to resident’s Major [MEDICAL CONDITION];
-Was at risk for side effects from antidepressant medication used;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the care
plan was comprehensive and included a nutritional care plan for one sampled resident who
had a history of [REDACTED].#53) out of 30 sampled residents. The facility census was 106
residents.
1. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on
7/25/15, with [DIAGNOSES REDACTED]. strong enough to interfere with one’s daily activities
and diabetes.
Record review of the resident’s Weight Record showed the following monthly weights:
-Dec. (YEAR)-174 lbs.;
-Jan. (YEAR)-168 lbs.;
-Feb. (YEAR)-161 lbs.;
-Mar. (YEAR)-160 lbs.;
-April (YEAR)-162 lbs.; and (MONTH) (YEAR)-155 lbs. (showed a weight loss of 10.92 % in 6
months, 3.13% in 3 months, 4.32% in 30 days).
Record review of the resident’s annual Minimum Data set (MDS-a federally madated
assessment tool completed by facility staff used for care planning) dated 3/22/18, showed
he/she:
-Had a memory problem and was severely cognitively impaired;
-Was independent with ambulation, mobility, bathing, dressing and toileting and
-Did not have any weight loss.
Record review of the resident’s physician’s orders [REDACTED]. It also showed a
physician’s orders [REDACTED].
Record review of the resident’s Care Plan dated 7/25/17 and updated on 6/22/18 did not
show any nutritional problems, goals or interventions addressing the resident’s diet,
intake, weight loss, nutritional interventions or nutritional needs of the resident. It
did not show whether the resident needed assistance or encouragement to eat or or showed
the resident’s preferences.
Observation on 5/9/18 at 12:15 P.M., showed the resident was up in the dining room eating
a regular diet of ham, mashed potatoes, carrots and drinking a choice of beverages
(lemonade or fruit punch). The resident needed no assistive device and no assistance
needed to eat. He was eating without swallowing difficulty. The Resident ate 100% of his
meal. He did not receive a health shake. When he finished eating, he stood up and
ambulated from the table without assistance or assistive device. The resident was alert
and oriented, was clean and dressed for the weather.
During an interview on 5/15/18 at 3:11 P.M., the Director of Nursing said:
-They did not have anyone currently responsible for completing care plans and they were
behind;
-They were trying to hire someone to work on care plans on a permanent basis and
-Care plans should be comprehensive and reflect the current health status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
physician’s nutritional orders were followed which resulted in the resident receiving the
wrong diet for one sampled resident (Resident #42), to ensure the resident’s physician
orders where verified and followed for a narcotic medication, resulting in medication
given by facility nursing staff without a current physician orders for a schedule II
control substance medication and did not accurately document the resident’s narcotic
medication on the resident’s Medication Administration Record (MAR), Individual Patient
Narcotic Record for one sampled resident (Resident #72) out of 30 sampled residents. The
facility census was 106 residents.
Record review of the Facility Medication Administration Policy and Procedure revised
4/6/17 showed:
Medication are to be given per doctor orders. All medication are recorded on the
resident’s MAR and signed immediately after the resident has taken the medications.
-The Nurse or Certified Medication Technician (CMT) should initial a circle the time of
the medication in question not given and document on back of the resident’s MAR why
refused or not available. Notify the Director of Nursing (DON) or Registered Nurse (RN)
designee,
-Narcotics must be counted with the on-coming shift nurse. Remember to label the
medication card as you give the Narcotic, date and initial given. If the count is
incorrect the off-going nurse must stay until it is corrected and the Resident Care
Coordinator (RCC) and DON or designee must be notified.
-The Nurse or the CMT then will go to the progress note and note the documentation of the
medication discrepancy also noting physician notified,
-Each Resident’s drug regimen will be reviewed monthly by a licensed pharmacist,
-The facility will self-report any serious medication errors to the State department,
conduct an appropriate investigation,and issue disciplinary action up to and including
termination for the first offense based on the outcome of the investigation by the
facility and the findings of the state department’s investigation.
1. Record Review of Resident #42’s Face Sheet showed he/she was admitted on [DATE], with
[DIAGNOSES REDACTED]. chronic concurrent diseases and functional impairments).
Record review of the resident’s Minimum Data Set (MDS- a federally mandated assessment
tool to be completed by facility staff for care planning) dated 2/9/18, showed he/she:
-Was cognitively impaired;
-Was ambulatory without an assistive device and could eat independently with supervision;
-Did not have any swallowing problems, but received a therapeutic diet and
-had a history of [REDACTED].
Record review of the resident’s Physician’s Notes dated (MONTH) (YEAR), showed the
resident’s physician completed a physical exam of the resident and reviewed his/her
medications, labs and medical record. The resident’s physician documented the resident had
significant weight loss. The physician did not give any new nutritional orders, but the
physician noted he/she would continue to monitor the resident’s weight. He/she documented
a [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan dated 2/21/18, showed the resident did not have
a care plan that showed his/her nutritional intake, diet, or food preferences. It did not
show if the resident needed any assistance with eating or had any chewing/swallowing
issues or issues with his/her weight. It showed the resident was diabetic and staff was to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a discharge summary
and recapitulation was completed for one sampled resident (Resident #104) who was
discharged to another facility out of three sampled closed records and 30 sampled
residents. The facility census was 106 residents.
1. Record review of Resident #104’s Facility Transfer Sheet dated 2/21/18, showed he/she
was transferred to the facility on [DATE] at the resident’s legal guardian’s requested.
Record review of the resident’s Nursing Notes showed the last nursing note dated 4/10/18,
showed the resident was having aggressive behaviors and was not re-directive using
non-medication interventions. It showed the nursing staff notified the resident’s
physician for a medication order to help calm the resident. There were no notes showing
the resident was ever discharged from the facility or that he/she was transferred to
another facility.
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/15/18 to 4/14/18
showed there were no physician’s orders documented showing the resident’s discharge
orders.
Record review of the resident’s Physician’s Telephone Orders (PTO) showed there were no
physician’s discharge orders for the resident.
Record review of the resident’s Medical Record showed there was no documentation in the
nursing notes showing when or why the resident was discharged . There was no documentation
showing a Discharge Summary was completed to recapitulate his/her stay at the facility,
where the resident was discharged to and any after care services ordered. There was no
documentation showing the disposition of the resident’s medications or belongings.
During an interview on 5/16/18 at 9:35 A.M., the Administrator said:
-The resident transferred to the facility on [DATE] and was discharged to another facility
on 4/11/18.;
-Normally, when a resident is discharged from the facility, the nurse on duty completes
the transfer form, obtains the physician’s order for transfer, notifies the responsible
party or guardian, completes the disposition of medications and documents in the nursing
notes when the resident was to be discharged (the date and location), any follow up care
needs or orders, who the resident left with, the time the resident left and that the
resident was discharged with all of their belongings;
-The nursing staff should also complete the resident’s inventory sheet to show the
resident left with all of their belongings;
-If Social Services was involved, there should be a social service note and especially if
the resident’s responsible party requested a transfer or discharge;
-The interdisciplinary team was supposed to document the recapitulation of the resident’s
stay on the Discharge summary form. After looking in the resident’s electronic record,
he/she said he/she did not see a discharge summary for the resident;
-There should have been a recapitulation of the resident’s stay documented on the
Discharge Summary form and the form should have been filled out to show that the resident
was transferring to another facility. The resident’s discharge should have included
completing the resident’s inventory sheet, physician’s orders to discharge the resident
and documentation of the disposition of the resident’s medications and
-If the documentation was not in the resident’s medical record then it was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
activities that met the resident’s individual needs and preferences were provided for
seven sampled residents (Resident #30, #53, #54, #68, #90, 92 and #203) who reside in the
locked units; to ensure an activity calendar was posted, provided and implemented to 31
resident’s residing on the men’s locked unit and 22 resident’s residing on the women’s
locked unit. This deficient practice potentially affected 106 residents in the facility.
The facility census was 106 residents.
Record review of the facility’s undated Activity policy and procedure showed the purpose
of the policy was to ensure that all residents in the facility are provided an ongoing
program of activities designed to meet, in accordance with comprehensive assessment, their
interests and their physical, mental and psychosocial well- being. The procedure showed:
-The Life Enhancement Director ensures that activities are designed to promote and enhance
the emotional health, self-esteem, pleasure, comfort, education, creativity, success and
independence for all residents, based on interview and assessing the resident’s likes and
dislikes.
-If the resident requires more intensive interventions for activities, one to one
programming that is relevant to the resident’s specific needs, interests, culture and
history/background, than a individualized activities plan of care will be developed to
enhance their psychosocial well-being.
-The activities calendar will be posted on each floor and will include activities that are
appropriate for the general therapeutic milieu population that meets the specific needs,
cognitive impairments, interests, and supports the quality of life while enhancing
self-esteem and dignity.
-Documentation will be completed on each resident’s activity within the facility.
Documentation will note participation in activities and specific resident-centered
individualized programming that will include, but not limited to, the emotional health,
physical, cognition, promotion of self-esteem, pleasure, comfort, education, creativity,
success and independence.
1. Record review of Resident #30’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s undated admission Activity Evaluation showed it was very
important to the resident to have choices, music (Bob Marley), news, things to do with
groups, favorite activities, going outside. It showed the resident liked spades (card
game), exercise, basketball, music, religious activities, trips/shopping, watching
TV/movies, gardening, talking, woodshop, hunting, helping others, parties, and community
outings.
Record review of the resident’s Activity Notes showed an admission note dated 5/25/17, and
a quarterly note dated 8/24/17, showed the resident was up daily and doing well. He/she
was able to arrive and leave activities at will. He/she enjoyed most social events,
snacks, outings such as shopping and going to the YMCA and smoking. Staff was to continue
to encourage his/her participation. There were no additional notes in the record and there
was no documentation showing how many activities the resident participated in weekly,
monthly or quarterly.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
to be completed by facility staff for care planning) dated 5/26/18, showed he/she:
-Had memory loss;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to obtain a
physician’s orders for the monitoring and care of the resident’s [MEDICAL CONDITION]; to
follow physician’s orders for wound care and treatment to the resident’s abdominal wound,
to transcribe the resident’s abdominal wound treatment physician’s orders to the
resident’s Treatment Administration Record (TAR) and to document the assessment and the
description of the resident’s abdominal wound at least weekly for one sampled resident
(Resident #34) out of 30 sampled residents. The facility census was 106 residents.

-The ADON cleaned the wound with normal saline, then pat dried the area, then applied
Triple Antibiotic Ointment and covered the wound with a boarder foam dressing and
-The RCC had contacted the contracted wound specialist company for further orders.
Record review of the resident’s POS and TAR dated 5/11/18, showed; new Telephone
Physician’s Order dated 5/11/18, to change the wound treatment to the resident’s abdomen
for the staff to cleanse the resident’s left abdominal wound with normal saline, then
apply calcium Alginate with silver, cover the wound with a border foam dressing, and to
change the dressing daily and as needed if soiled.
During an interview and record review on 05/14/18 at 9:49 A.M., LPN E, said;
-There should have been a physician’s order for the resident’s [MEDICAL CONDITION] for
care and assessment;
-The resident’s does prefer to provide their own care and he/she thought the resident had
a verbal agreement with the physician for own care;
-He/she thought there should have had a physician’s order for wound care on resident’s TAR
or on the skin assessment book;
-Review of the resident’s TAR/MAR showed no physician’s orders were found for the
resident’s [MEDICAL CONDITION] care or assessment;
-Review of resident’s medical record was unable to find documentation for the nursing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
locked and alarmed doors were secured and in proper working order at all times to prevent
one sampled resident (Resident #53) out of 30 sampled residents, who was at risk for
elopement, from leaving the facility and to update the resident’s care plan to show he/she
was at risk for elopement and initiate interventions to prevent further elopements. The
facility census was 106 residents.
Record review of the facility’s Elopement policy and procedure dated 4/6/17, showed an
elopement will be defined as any time a resident is missing from the facility or there is
a possibility that a resident has left the facility without appropriate supervision and
their whereabouts are unknown. It showed:
-The first person aware of the elopement will call a code white to the area of the
believed elopement, if known;
-If the resident is believed to be still inside of the facility, the first person to be
aware of the missing resident is to page for all units to search room to room for the
resident;
-As soon as the pages have been made, the Administrator is to be called immediately;
-If the resident has in fact left the facility, notify the resident’s family or guardian;
-The charge nurse on duty will initiate the facility grounds search;
-The charge nurse will call the police to report the elopement when the resident is not
found in the building or on grounds;
-The Administrator will initiate the emergency call list and coordinate the search and
-After the resident is located and returned to the facility, facility staff will notify
the family or guardian, notify all persons involved in the search, perform a full body
assessment, obtain vital signs (pulse, temperature, blood pressure and respirations),
notify the physician, initiate the monitoring protocol document all findings and notify
the state agency at the discretion of the Administrator.
1. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]. enough to interfere with one’s daily activities) and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that the
urinary catheter bag for one sampled resident (Resident #90) out of 30 sampled residents
was kept at a level below his/her bladder; and did not prevent the catheter tubing from
touching the floor. The facility census was 106 residents.
Record review of the facility’s urinary catheter policy dated 4/6/17, showed:
-The facility will ensure any resident with a urinary catheter (a tube inserted into the
bladder to drain the urine) will be maintained to prevent infection.
-Catheter care procedures as follows:
–Keep the urinary drainage bag below the level of the bladder to prevent back flow of the
urine and
–Make sure that the urinary bag does not touch the floor.
1. Record review of the Resident’s #90’s Face Sheet showed he/she was admitted to the
facility on [DATE], with the following Diagnoses: [REDACTED].
-Kidney Failure – A condition in which the kidneys lose the ability to remove waste and
balance fluids;
-Arthritics- Inflammation of joints, causing pain and stiffness than can worsen with age;
-[MEDICAL CONDITION] – A high concentration sodium in the blood and
-Paranoid [MEDICAL CONDITION] – Include auditory hallucinations hearing voices.
Record review of the resident’s Annual Minimum Data Set ( MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 6/29/18, showed
he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 14, which describes the resident
was cognitively alert and oriented;
-Had ability to express idea and wants to others in a consistent and reasonable manner and
-Total dependence with two person assist with Activities for Daily Living (ADL’s)
assistance for eating, bathing, dressing, transferring and mobility.
Record review of resident’s Treatment Administration Record (TAR) dated 1/19/18, showed
treatment orders for Foley Catheter for Wound Healing at 7:00 A.M. and 7:00 P.M.
Record review of the resident’s physician’s orders [REDACTED].
-To change the resident’s catheter every month with a #22 French catheter with 30
mililiters (ml) balloon and to change the urinary drainage bag every month;
-Weekly skin assessments to be completed on Wednesdays (7:00 A.M. and 7:00 P.M.) and
-Had Foley Catheter for Wound Healing.
Record review of the resident’s Care Plan dated 6/29/18, showed he/she:
-Had impaired urinary incontinence and occasionally incontinent of bowel;
-Was at risk for urinary infection;
-Had an indwelling catheter;
-Had on-going assessment of color;
-Had on going assessment for symptoms of urinary tract infection [MEDICAL CONDITION];

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure adequate
monitoring of the nutritional status by not following physician’s orders [REDACTED].
status and weight loss for one sampled resident (Resident #53) who had a history of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that nursing staff had
the appropriate competencies and skills sets to provide nursing and related services to
ensure: resident safety, residents attained or maintained the highest practicable

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. The facility census was 106
residents.
1. Record review of the facility’s Facility Assessment Tool dated 5/9/18 showed:
-The facility was licensed for 116 beds;
-The average number of occupied beds during the previous quarter was 104;
-Staff training, education, and competencies will include competency check-offs from
orientation;
-The training time required for newly hired CNAs was 8.25 hours and
-CNAs were required to complete 12 hours of training annually.
Record review of the the facility’s Competency and In-service book showed:
-No competencies were found for the any of the CNAs during the previous 12 months;
-Less than 12 hours of CNA in-service hours were performed during the last 12 months;
-4.25 hours of CNA in-service hours between 7/16/17 – 3/12/18 and
-Six monthly in-service topics list with no documented in-service training hours.
During an interview on 5/15/18 at 8:14 A.M., the Direct of Nursing (DON) said:
-He/She could not locate staff competencies in the Competency and In-service book;
-He/She would look elsewhere for the staff competencies during the last 12 months and
-The Competency and In-service book should include all CNA in-service hours.
During an interview on 5/15/18 at 12:30 P.M., the Administrator said:
-He/She could not locate any staff competencies during the last 12 months and
-The Competency and In-service book should include all the CNA in-service hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary mental and behavioral health treatment and services, consistent with
professional standards of practice, to promote mental health wellness by not providing
social services assessment and providing mental health counseling and therapy services for
one sampled resident ( Resident #92), who had a history of [REDACTED]. The facility census
was 106 residents.
Record review of the resident’s Admission Face Sheet dated 5/18/16, readmitted last on
4/12/18 showed the resident had a public administrator as his/her guardian, and the
following Diagnoses: [REDACTED].
-Anxiety disorder (fear or worry),
-[MEDICAL CONDITION] disorder (mental disorder have hallucinations or delusions),
-[MEDICAL CONDITION] disorder (manic behavior),
-[MEDICAL CONDITION] (feeling sadness, worthiness),
-Board line intellectual function (is a cognitive impairment, below normal -difficulty in
understanding in reasoning, problem solving, planning, and abstract thinking),
-Hepatic failure (liver function), and
-Convulsions ([MEDICAL CONDITION], body muscles contract and relax rapidly and repeatedly,
resulting in an uncontrolled shaking of the body).
Record review of the resident’s Care Plan dated 8/22/17 showed:
-The resident had a long history of attempted and actual self harm;
-He/she has multiple scars on his/her arms where he/she had bitten himself/herself;
-He/she talked of drinking shampoo and soap,
-Hand written notes of the residents attempted or actual self harm showed 11 total
attempts on the following dates 3/3/18, 3/15/18, 3/25/18, 3/27/18 and 4/13/18,
-Interventions include:
–Facility staff were to redirect the resident immediately when behavior of self harm
starts,
–They were to attempt to determine what might trigger this behavior and educate staff,
–Medication and treatment as order, wrap arms, place on 1:1 staffing,
–Notify physician if behavior begins to discus options and ensure that he/she does not
have access to items that can cause him/her harm,
–Psychiatrist consult as needed,
–Encourage participation in activities,
–Encourage him/her to bond with other resident with similar interest
Record review of the resident’s Long term Psych Management Encounter Note dated 12/13/17,
showed:
-The resident was seen by a Psychiatric Nurse Practitioner on 12/13/17,
-The visit was a follow-up visit, for medication review and management,
-Patient was to be encouraged to pursue more positive behaviors such as talking to staff,
-Complexity of his/her mental condition was noted to be severe,
-Psycho-education and support was provide,
-Staff were to monitor mood, behavior and medications for side effects, and
-Gradual dose reductions were not recommended.
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated

Record review of the resident’s medical record found no ongoing mental health or
behavioral health counseling services had been provided for the resident since the last
suicidal attempt. No documentation found related to a pending appointments.
Record review of the resident’s nurses notes form 4/12/18 to 5/12/18 showed no behavior or
mental health concerns expressed by the resident, the nursing staff recommended that the
resident to use his/her coping skills and to journal his/her thought and feeling,
During a follow up interview on 5/14/18 at 1:57 P.M., the resident said he/she would like
to have individual counseling and group counseling related to mental health concerns.
During an interview on 5/15/18 at 12:45 P.M., Licensed Practical Nurse (LPN) C said:
-At this time the facility does not provide any one on one counseling or group counseling
services for the residents, and
-He/she was not aware of any of the residents attending outpatient counseling services.
During an interview on 5/15/18 at 12:45 P.M., Certified Nurses Assistant (CNA) E said:
-He/she was not aware of any counseling serves offered for the resident’s at the
facilities, and
-The only specialized training they receive is for Crisis Alleviation Lessons and Methods
(CALM-a progressive series of de-escalation/crisis intervention techniques) class.
During an interview on 5/15/18 at 2:37 P.M., the Director of Nursing (DON) said:
-For resident with suicidal risk they would placed on one on one staffing, then every four
hours monitoring,
-All resident should be on hourly face to face check for safety reasons,
-He/she would expect staffing to monitor the resident’s room for any sharp objects,
-At this time the facility does not provide one on one counseling or group counseling for
the residents, and
-The SSW director would be responsible for arranging mental heal or behavioral health
counseling services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
medication pass error rate was less than five percent. The facility had three medication
errors out of 41 opportunities for a 7.3% medication error rate. The facility census was
106 residents.
1. Record review of Resident #18’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Telephone Order Sheet (TOS) dated 4/23/18 showed:
-Decrease [MEDICATION NAME] to 250 milligrams (mg) daily for seven days then discontinue;
-Discontinue [MEDICATION NAME] 325 mg and
–There was no physician’s order to discontinue the Multivitamin or the Aspirin 81 mg
daily.
Record review of the resident’s 4/15/18 – 5/14/18 Physician’s Order Sheet (POS) showed:
-Multivitamin, take one tablet daily for supplement dated 6/16/12;
-Aspirin 81 mg, take one tablet daily for [MEDICAL CONDITION] (CAD -narrowing of the
coronary arteries) dated 8/14/12;
-[MEDICATION NAME] 325 mg, take one tablet daily with no [DIAGNOSES REDACTED].
-[MEDICATION NAME] 250 mg by mouth daily in the morning for [MEDICAL CONDITION] dated
4/21/14 and
-[MEDICATION NAME] 500 mg by mouth at bedtime for [MEDICAL CONDITION] dated 6/22/16.
Record review of the resident’s Medication Administration Record [REDACTED]
-[MEDICATION NAME] 500 mg at bedtime for [MEDICAL CONDITION] dated 6/22/16 with a
handwritten notation to discontinue (dc) dated 4/23/18 and
-Multivitamin, Aspirin 81 mg, and [MEDICATION NAME] 325 mg were not on the resident’s MAR.
–The resident did not receive Multivitamin one tablet or Aspirin 81 mg.
Observation on 5/14/18 at 9:01 A.M., showed Certified Medication Technician (CMT) C did
not administer Aspirin 81 mg or Multivitamin one tablet to the resident during the
medication pass.
During an interview on 5/14/18 at 11:48 A.M., CMT C said:
-He/She administered all of the resident’s morning medications during the medication pass
observation;
-Aspirin 81 mg was not listed on the resident’s MAR indicated [REDACTED]
-Multivitamin one tablet was not listed on the resident’s MAR indicated [REDACTED]
-He/She thinks they were discontinued at the same time the resident’s [MEDICATION NAME]
was discontinued on 4/23/18.
2. Record review of Resident #50’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s POS and MAR indicated [REDACTED]
-[MEDICATION NAME] (a corticosteriod used to reduce irritation and swelling in the airways
to improve breathing) 0.5 mg/2 milliliters (ml) suspension, use one vial via nebulizer (a
device used to administer medication to people in the form of a mist inhaled into the
lungs) once daily at 9:00 A.M. dated 1/17/18 for pneumonia and
-Ipratroprium-[MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] that relaxes the
muscles around the airway so they open up and make breathing easier) 0.5 mg/3 ml one vial
via nebulizer every four hours as needed for pneumonia dated 1/17/18.
Observation on 5/15/18 at 8:01 A.M. showed Licensed Practical Nurse (LPN) E:
-Removed Ipratroprium-[MEDICATION NAME] 0.5 mg/3 ml from the medication cart and entered
the resident’s room;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility staff failed to ensure
the safe storage and accountability of the resident’s narcotic medication card resulting
in missing of 60 tabs of Tramodol (pain medication) and failed to have detail written
documentation related to the discrepancy of the missing medication on the 12 hour
Controlled Drug-Count Record Sheet and the resident’s Individual Patient Narcotic Record,
to include what correction had been taken, to have written documentation of the facility’s
findings from the internal audit of the all facility’s narcotic count sheets and auditing
of the all narcotic on the medication carts related to the facility Register Nurse (RN)
Investigation into the missing narcotic medication, for one sampled resident (Resident
#34); to maintain cleanliness of the medication cart, to ensure unidentified medications
were not stored in the medication cart, failed to ensure opened eye drops were labeled
with the date the medication was opened in one Certified Medication Technician’s (CMT)
medication cart on the 3 North (N) unit. The facility further failed to ensure the
medication refrigerator temperatures were maintained within acceptable parameters, failed
to remove expired medications from the medication refrigerator, and to label opened with
the date the medication was opened in the 3 North medication room. The facility also
failed to ensure insulin stored in the 3 North licensed nursing medication cart was
labeled with the date the insulin was opened. The facility has 3 medication rooms and 6
medication carts. The facility census was 106 residents.
Record review of the Facility Medication Administration Policy and Procedure revised

Based on observation and interview, the facility failed to keep scoops out of sugar and
flour bins; to properly date food cans in the dry storage room; to refrigerate open
condiment jugs; to monitor two inner refrigerator thermometers; to keep a kitchen garbage
can lidded when not in use; to prevent grease build-up on range hood baffles; and to
maintain a sanitary manual can opener blade. These practices potentially affected all

Based on record review and interviews, the facility failed to produce an on-site policy
regarding the acceptance, usage, and storage of foods brought into the facility for
residents, by family and other visitors, to ensure the food’s safe and sanitary handling
and consumption. This deficient practice had the potential to affect all residents who ate
food brought in by visitors. The facility census was 106 residents.
1. Record review of available facility kitchen documents, forms, and logs on 5/9/18
between 9:28 A.M. and 10:45 A.M., failed to show the presence of a policy regarding foods
brought in for residents by family and other visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure facility-wide
infection control logs were maintained for a twelve month period to track infections
within the facility, monitor and/or identify infection trends, and to ensure appropriate
interventions related to facility-wide infection trends were identified and implemented.
The facility census was 106 residents.
Record review of the facility Infection Control Program policy dated 11/28/16 showed:
-The facility will identify, monitor, and track infections in the facility utilizing the
Quality Assurance Process.
-The facility will report incidents of communicable diseases or infections according to
state and federal regulations.
1. During an interview with the Director of Nursing (DON) and record review of the
facility’s Infection Control Tracking showed:
-On 5/14/18 at 8:11 A.M. twelve months of tracking was requested from DON;
-On 5/14/18 at 9:00 A.M. the DON provided an Infection Control Tracking book with
information from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-The DON said he/she was still working on the infection control logs from (MONTH) (YEAR)
and (MONTH) (YEAR). He/She would look for the remaining 12 months of tracking and the
information provided to the surveyor was complete for (MONTH) (YEAR), (MONTH) (YEAR), and
(MONTH) (YEAR).
-An Antibiotic Report was printed for the entire facility for the month in (MONTH) (YEAR)
– (MONTH) (YEAR).
-An Infection Control Line Listing for each unit each month directed staff to document the
following:
–The residents name, room number, infection site, date the specimen was collected and the
pathogen identified in the specimen, date the symptoms started, any predisposing factors,
date the treatment started, if the antibiotic was appropriate to the organism, and if the
infection was resolved;
—Staff did not document any specimen collection, identified pathogens, or if the
infection was resolved;
—Staff did not consistently document if the antibiotic was appropriate to treat the
organism.
-An Antibiotic Usage Report for each unit each month directed staff to document the
following:
–The resident’s name, room number, the antibiotic prescribed, the prescribed dosage, the
start and stop dates of the medication, the date the culture was collected, if the
organism identified in the specimen was sensitive to the prescribed antibiotic, if the
resident had clinical signs of an infection, was the infection resolved, the resident’s

Based on interview and record review, the facility failed to establish a facility-wide
infection prevention and control program that included an antibiotic stewardship program
that included antibiotic use protocols and a system to monitor antibiotic usage. The
facility census was 106 residents.
Record review of the facility Infection Control Program policy dated 11/28/16 showed:
-The facility will identify, monitor, and track infections in the facility utilizing the
Quality Assurance Process;
-The facility will report incidents of communicable diseases or infections according to
state and federal regulations and
–The policy did not address antibiotic use protocols.
1. During an interview with the Director of Nursing (DON) and record review of the
facility’s Infection Control Tracking showed:
-On 5/14/18 at 9:00 A.M. the DON provided an Infection Control Tracking book with
information from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-The DON said he/she was still working on the infection control logs from (MONTH) (YEAR)
and (MONTH) (YEAR). The information provided to the surveyor was complete for (MONTH)
(YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-An Antibiotic Report was printed for the entire facility for the month in (MONTH) (YEAR)
– (MONTH) (YEAR).
-An Antibiotic Usage Report for each unit each month directed staff to document the
following:
–The resident’s name, room number, the antibiotic prescribed, the prescribed dosage, the
start and stop dates of the medication, the date the culture was collected, if the
organism identified in the specimen was sensitive to the prescribed antibiotic, if the
resident had clinical signs of an infection, was the infection resolved, the resident’s

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain hand rails in the
following areas in good repair or firmly affixed to the wall: the corridor outside 322,
the bathing room next to resident room [ROOM NUMBER], the shower room next to the third
floor south nurse’s station, and the second floor south shower room. This practice
potentially affected at least 50 residents who reside in or use those areas in the
facility. The facility census was 106 residents.
1. Observations with the Maintenance Supervisor and the Housekeeping Supervisor on
5/10/18, showed the following:
– At 10:26 A.M., the handrail outside resident room [ROOM NUMBER] had missing plastic
covering which exposed the metal parts underneath, of which some were potentially sharp
enough to damage skin;
– At 10:33 A.M., the handrail in the bathing room next to resident room [ROOM NUMBER],
moved back and forth when it was grabbed;
– At 10:41 A.M., the handrail in the third floor south shower room next to the nurse’s
station, moved back and forth when it was grabbed and
– At 12:24 P.M., the handrails in the second floor south shower room moved back and forth
when they were grabbed.
During an interview on 5/10/18 at 10:26 A.M., the Maintenance Supervisor acknowledged that
handrail outside of room [ROOM NUMBER] needed to be repaired.
During an interview on 5/10/18 at 12:25 P.M., the Maintenance Supervisor acknowledged that
the handrail in the second floor shower room was not only loose from the wall but also
loose from brackets which held the hand rail in place.