HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to treat each
resident 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, for
one of five residents observed during personal care who was left exposed (Resident #114).
The census was 148.
Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required assessment
instrument completed by facility staff, dated 9/22/18, showed:
-Clear speech, distinct intelligible words;
-Makes self-understood;
-Able to understand others;
-Extensive assistance required for bed mobility, dressing and toilet use;
-Total dependence for personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Activity of daily living (ADL) care deficit related to [MEDICAL CONDITION] and
limited mobility;
-Goal: To be clean, odor free and well groomed on a daily basis;
-Approach: Assist with choosing simple comfortable clothing that enhances ability to dress
self.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A entered
the resident’s room and gathered supplies. He/she uncovered the resident, unsecured the
resident’s brief and provided care to the resident. CNA A said he/she needed to get more
towels. He/she exited the resident’s room, closing the door behind him/herself and left
the resident uncovered and exposed. CNA A returned to the resident’s room and continued to
provide care to the resident. There was a knock on the resident’s door. CNA A said come
in. He/she did not cover the resident or verify the identity of the person at the door.
The person at the door entered the room as he/she said nursing, looked in the room, turned
around and exited the room, closing the door behind him/her. CNA A continued to provide
care to the resident.
During an interview on 11/13/18 at 9:0 A.M., the Director of Nursing (DON) said if staff
need to step away during incontinence care, she would expect staff to assure the resident
was covered. If a resident is exposed and someone knocked on the door, she would expect
staff to pull the privacy curtain if in a shared room. In private rooms, staff should ask
the person at the door to wait a minute and cover the resident up. It is not acceptable
for staff to tell someone to come in before knowing who was at the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview the facility failed to promote the resident’s
self-determination though support of resident choices when staff failed allow residents to
eat in their room, failed to turn a resident’s television on, and failed to allow a
resident telephone usage. (Resident #114, #11, and #47). The facility census was 148.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
residents had appropriate access to their trust account, including weekends. The facility
also failed to ensure each resident was afforded the right to withdraw funds from the
amount of their choosing (Resident #50). This deficient practice affected all the
residents who had a resident trust account. The census was 148.
Review of the facility’s undated daily banking procedure, received on 11/9/18, showed:
-Bank request sheets are to be available for requesting funds Monday through Friday,
excluding holidays until 3:00 P.M.;
-The bank request sheets are picked up from every station by the social service designee
(SSD) and delivered to the business office before 4:00 P.M. for processing into RFMS. All
requested funds, if available, are delivered the following morning;
-Beneficiary’s requesting funds on the daily bank request should write their name, the
amount, and the intent for the requested funds. A current balance or trust account
statement can also be requested on the bank request sheet by writing balance next to their
name or on the same line as their name;
-All binders should be revised by SSD before returning to the business office manager
(BOM). Anyone passing money is responsible for the following:
-Obtaining resident’s signature;
-Resident signature, or witness signature if unable to sign;
-Staff signature;
-CIRCLE the resident’s intention for using the funds;
-Any funds not passed will be returned at the time but can request for the following day;
-If self-responsible: The daily cash withdrawal limit is $50.00;
-If request is more than $50.00, funds will be disbursed two business days after the
request is written in the binder or on the bank request sheet;
-Receipts are requested, but not required to be returned to the business office;
-Their authorization and signature is required for all transactions;
-Power of Attorney (POA) not active unless deemed incapacitated;
-Healthcare POA not authorized to handle financial matters;
-Facility is Representative Payee: Daily cash withdrawal limits depend on the individual,
balance availability, and their location;
-Substantial withdrawal requests are reviewed on a case by case basis;
-Daily withdrawal limits are also case by case, but generally anyone that gives their
money away, throws it in the trash, or frequently misplaces it, will be limited to receive

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain furniture and
equipment in good repair for two of 29 sampled residents whose wheelchair locks and foot
pedals did not lock (Resident #114) and whose safety helmet was torn (Resident #126). The
census was 148.
1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 9/22/18, showed:
-Extensive assistance required for bed mobility, dressing and toilet use;
-Mobility devices: Wheelchair.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nurse Aide (CNA) A provided care to
the resident and transferred the resident to his/her wheelchair. The back rest of the
wheelchair was torn. CNA A assisted the resident to sit on the edge of his/her bed. CNA A
placed the resident’s wheelchair against the wall and said the resident’s wheelchair
didn’t lock so he/she has to prop it against the wall. CNA A said he/she put in a request
for maintenance to fix it yesterday, but it had been broken for one or two weeks. CNA A
transferred the resident to his/her wheelchair. He/she then placed the left foot rest on
the resident’s wheelchair, placed his/her left foot on the foot rest and then placed the
right foot on top of the left foot. CNA A said the wheelchair was broken and the right
foot rest no longer connected to the wheelchair. CNA A propelled the resident out of the
room and into the hall.
Observation on 11/8/18 at 8:43 A.M., showed the resident sat in his/her room in his/her
wheelchair. The left foot pedal was on and both feet rested on the one pedal. The right
foot rest sat on a table in the resident’s room.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) and
administrator said if a resident’s wheelchair was broken, they should report it to
maintenance. Staff should remove the resident from the broken wheelchair and provide the
resident with another wheelchair while their wheelchair is getting fixed. Staff should
report a wheelchair with broken foot rest and that will not lock immediately or as soon as
it is observed to be broken. It is not safe for a resident to be transferred to a
wheelchair that does not lock and it is not safe for a resident to be propelled in a
wheelchair that only has one foot rest.
2. Review of Resident #126’s quarterly MDS, dated [DATE], showed:
-BIMS score of 9 out of 15, showed the resident is cognitively impaired;
-[DIAGNOSES REDACTED].
Observation on 11/6/18 at 1:52 P.M., showed the resident wore a safety helmet as he/she
sat in the dining room.
Observation and interview on 11/6/18 at 2:14 P.M., showed the resident wore a safety
helmet. The safety helmet was torn on both sides that fit around the resident’s ears. The
inside of the helmet that several rips, approximately 1/2 inch in length in the front of
the helmet. The resident said he/she had the helmet for several years, and the facility
would not give him/her a new one. The resident said he/she had to wear the safety helmet
because he/she falls a lot.

Based on interview and record review, the facility failed to establish a grievance policy
that identified the grievance official, included the right to file a grievance anonymously
and that required the facility to maintain evidence demonstrating the result of all
grievances for a period of no less than three years from the issuance of the grievance
decision. The census was 148.
Review of the facility’s Grievance policy, dated 1/10/10, showed:
-The purpose of this policy is to provide a mechanism by which, residents, their families,
friends, significant others, or staff can lodge grievances with the facility as well as
providing for a means for grievance resolution;
-Following notification of the grievant, the form will be filed in the Grievance Binder
for one year;
-The policy failed to identify the grievance official;
-The policy failed to include the right to file a grievance anonymously;
-The policy failed to maintain evidence demonstrating the result of all grievances for a
period of no less than three years from the issuance of the grievance decision.
During an interview on 11/13/18 at 9:00 A.M., the administrator said social services is
the grievance official. She would not necessarily believe the facility grievance policy
should identify the grievance official. Residents and visitors have the right to file a
grievance anonymously, this should be included in the grievance policy. She would expect
the grievance policy identify that grievance be maintained for 3 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
right to be free from abuse was not violated when residents were abused by other
resident’s (Resident #126, #47, #12, 143, #39, and #89) for 29 sampled residents. The
facility census was 148 residents.
Review of the facility’s abuse and neglect policies, showed:
-External Reporting of Abuse, Neglect, theft and Crimes policy, dated 1/2012: It is the
policy of this facility to establish external reporting guidelines for facility staff in

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
policy as well as state and federal regulations by not notifying the Department of Health
and Senior Services (DHSS) about an allegation of physical abuse, immediately, but not
later than two hours for seven or 29 sampled residents identified has having been involved
in resident to resident abuse or having an allegation of abuse (Resident #126, #47, #12,
#143, #50, #89, and #39). The census was 148.
Review of the facility’s abuse and neglect policies, showed:
-External Reporting of Abuse, Neglect, theft and Crimes policy, dated 1/2012: It is the
policy of this facility to establish external reporting guidelines for facility staff in
the event they become aware or formulate a reasonable suspicion that abuse, neglect, theft
or a crime has been committed against a resident of the facility:
-Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred
against a resident the facility Administrator or his/her designee will initiate external
reports to the department;

Review of DHSS records, showed the facility did not report the 11/6/18 allegation of
abuse.
Observation on 11/7/18 at 8:40 A.M., 12:41 P.M., and 1:17 P.M., showed LPN Y at the
nursing station in the 3 South unit.
During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident
reported abuse, it would be the facility’s policy to investigate, find out which staff
member and if the person was there, they would be suspended, pending the investigation.
They would do a skin assessment to check for injury. Staff did not report the incident to
the administrator. She would expect CNA W to report it to the nurse manager and it would
be reported to the administrator. She would expect them to follow the facility’s policy.
If abuse occurred, they would contact the department within two hours. They would send LPN
Y home pending investigation.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/4/18, showed the resident has potential to be
physically aggressive related/to anger, history of harm to others, and poor impulse
control. On 10/19/18, struck peer when he/she touched him/her.
Review of the resident’s progress notes, dated 10/19/18 at 7:07 A.M., showed therapy
reported to nurse that the resident hit another resident, unwitnessed by staff, when asked
what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident
separated, physical assessment performed, no bruising, or discoloration noted. Denies
pain.
Review of DHSS records, showed the facility did not report the 10/19/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed
altercation, he/she would expect there to be an investigation. If resident said someone
hit him/her, they would investigate to make sure it really happen. The DON was not aware
of the altercation that involved the resident. She would have expected staff to report all
altercations to her.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Has hallucinations.
Review of the resident’s care plan, dated 10/24/18, showed:
-Focus: Resident had been struck by peer on 10/21/18;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed follow their policy
to conduct a complete and thorough investigation for allegations of abuse, and failed to
submit their investigation in the required time frame to the Department of Health and
Senior Services (DHSS). In addition, the facility failed to prevent further potential
abuse while the investigation is in progress, for seven or 29 sampled residents identified
has having been involved in resident to resident abuse or having an allegation of abuse
(Resident #126, #47, #12, #143, #50, #89, and #39). The census was 148.
Review of the facility’s Resident Protection During Abuse Investigations policy, dated
1/2012, the facility desires to establish a resident secure environment and will take
steps to protect residents from exposure to additional acts of mistreatment following an
allegation or reported instance of abuse, neglect, theft or criminal action committed
against the residents while an investigation is conducted:
-Resident to resident events: Residents who allegedly abuse another resident should be
removed from contact with other residents until such time that reasonable clinical
judgement determines that their behavior no longer poses a significant risk to other
residents or until the investigation is concluded;
-Abuse, Neglect, Theft, Crimes Investigations: The facility will initiate and complete an

Observation on 11/7/18 at 8:40 A.M., 12:41 P.M., and 1:17 P.M., showed LPN Y at the
nursing station in the 3 South unit.
During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident
reported abuse, it would be the facility’s policy to investigate, find out which staff
member and if the person was here, they would be suspended the staff member pending the
investigation. They would do a skin assessment to check for injury. Staff did not report
the incident to the administrator. She would expect CNA W to report it to the nurse
manager and it would be reported to the administrator. She would expect them to follow the
facility’s policy. They would send LPN Y home pending investigation.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/4/18, showed the resident has potential to be
physically aggressive related/to anger, history of harm to others, and poor impulse
control. On 10/19/18, struck peer when he/she touched him/her.
Review of the resident’s progress notes, dated 10/19/18 at 7:07 A.M., showed therapy
reported to nurse that the resident hit another resident, unwitnessed by staff, when asked
what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident
separated, physical assessment performed, no bruising, or discoloration noted. Denies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 29 sampled residents, six had been recently

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for six of 29 sampled residents who were recently transferred to a hospital for
various medical reasons (Residents #124, #112, #57, #84, #143 and #150). The census was
148.
1. Review of Resident #124’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer.
2. Review of Resident #112’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer.
During an interview on 11/6/18 at 10:48 A.M., the resident said he/she was in the hospital
recently and does not remember receiving any bed hold policy from the facility.
3. Review of Resident #57’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 5/31/18 or 8/12/18.
During an interview on 11/6/18 at 12:30 P.M., the resident said he/she had been admitted
to the hospital several times recently and does not remember receiving any bed hold policy
from the facility.
4. Review of Resident #84’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 9/1/18 or 10/17/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that each resident
receives an accurate assessment, reflective of the resident’s status at the time of the
assessment, by staff qualified to assess relevant care areas and are knowledgeable about
the resident’s status, needs, strengths, and areas of decline for four residents
identified as having behaviors (Resident #126, #47, #12 and #143) of 29 sampled
resident’s. The census was 148.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing): Behavior not exhibited;
-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming
at others, cursing at others): Behavior not exhibited;
-Other behavioral symptoms not directed towards others (e.g., physical symptoms such as
hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds):
Behavior not exhibited;
-Rejection of care: Behavior not exhibited;
-Wandering: Behavior not exhibited;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure coordination for
residents admitted to the facility had a DA-124 level I screen (used to evauluate for the
presence of psychiatric conditions to determine if a preadmission screening/resident
review (PASARR) level II screen is required) as required, for four of 29 sampled residents
(Resident #1, #78, #124 and #150). The census was 148.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASSAR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to the a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disabilities had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASSAR) level II screen is required) as required,
for six of 29 sampled residents (Resident #1, #78, #124, #150, #32 and #109). The census
was 148.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASSAR process:

**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 baseline care plan consistent with the resident’s specific conditions, needs,
and risks within 48 hours of admission to properly care for one resident (Resident #452)
out of one newly admitted resident sampled. The facility census was 148.
Record review of Resident #452’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 11/1/18, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s electronic and paper medical record, showed no baseline
care plan found.
Observation on 11/7/18 at 6:59 A.M., showed the resident sat on the edge of his/her bed,
awake, call light in reach. The resident could not hear this surveyor ask him/her
questions. The resident shook his/her head at this surveyor and declined to interact.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said:
-Base line care plans should be completed with the admission paperwork within 24 hours;
-The admitting nurse is responsible for creating baseline care plans for new admits;
-The current post admission audits do not include a process to ensure the baseline care
plans were completed timely;
-Staff is expected to access baseline care plans in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had complete, accurate and individualized care plans, to address the specific needs of the
residents, for six of 29 sampled residents (Residents #1, #114, #139, #150, #39 and #102).
The census was 148.
1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff dated 10/21/18, showed:
-Total dependence on two person physical assist for transfers;
-Functional limitations in range of motion:
-Upper extremity: impairment on one side;
-Lower extremity: impairment on both sides;
-Mobility devices: Wheelchair;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Physical therapy end date, 9/20/18.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident is at risk for falls due to [DIAGNOSES REDACTED].>-Goal: Resident
will not sustain serious injury through the review date;
-Approach: Educate staff to use gait belt during transfers and assist of 2 person for all

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
comprehensive care plan in seven days after completion of the comprehensive assessment and
no more than 21 days after admission to properly care for one resident (Resident #452) out
29 sampled residents. The facility census was 148.
1. Record review of Resident #452’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 11/1/18, showed
the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Section V: Care Area Assessment Summary triggered the following areas to be care planned
for the resident:
-Cognitive Loss/Dementia;

Based on interview and record review, the facility staff failed to complete a
comprehensive discharge summary for one of one closed record sampled resident (Resident
#152). The census was 148.
Review of Resident #152’s closed medical record, showed the resident discharged to another
long term care facility on 8/16/18. Staff did not complete a discharge summary, which
would include a final summary of the resident’s status, a reconciliation of all pre and
post discharge medications and a post-discharge plan of care.
During an interview on 11/13/18 at 6:48 A.M., the Administrator said the Social Worker is
responsible for completing the discharge summary. The new Social Worker had only been at
the facility since 10/17/18, and the two Social Workers, who left on 10/3/18, had not been
completing any discharge summaries on the discharged residents.
During an interview on 11/13/18 at 8:07 A.M., the Social Worker said she is responsible
for completing the discharge summary on discharged residents, but had not done any as of
this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who is unable to carry out activities of daily living receives the necessary
services to maintain good grooming and personal hygiene, for three residents (Resident #1,
#139 and #89) of 29 sampled residents. Two resident were left soiled after incontinent
episodes and one resident was not provided with proper grooming for facial hair. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to implement an
ongoing resident centered activity program that incorporates the resident’s interests to
maintain and/or improve a resident’s physical, mental and psychosocial well-being, for one
of one resident investigated for activities (Resident #139) of 29 sampled residents. The
census was 148.
Review of Resident #139’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff, dated 10/13/18, showed:

Review of the resident’s Pre-Admission Screening and Resident Review (PASRR, used to
determine the most appropriate care setting and services for a resident with mental
illness) Mental Illness (MI) Level II Evaluation, dated (MONTH) 26, (YEAR), showed:
-[DIAGNOSES REDACTED].
-History of symptoms: Crying out for several hours, throwing self onto the floor and
climbing out of bed;
-Communication ability: Communicates with difficulty. Non-verbal, yelling out, dancing in
wheelchair to music in the day room;
-Staff responses to maladaptive behaviors: One on one to communicate with the resident;
-Noted to move body to music when taken to community area by staff.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident is nonverbal and is provided socialization by staff and family to
provide socialization and conversations. He/she calms down when talked to by others.
He/she screams and yells a lot when he/she does not have attention provided or is
attempting to communicate with others:
-Goal: Psychosocial needs will be met and anticipated by staff and family;
-Approach: Talk with the resident while providing care;
-Activities not care planned.
Review of the resident’s Preference for Customary Routine and Activities assessment, dated
10/18/18, showed staff assessment of daily and activity preferences:
-Receiving showers;
-Snacks between meals;
-Staying up past 8:00 P.M.;
-Family or significant other involvement in care discussions;
-Listening to music and television;
-Spending time outdoors;
-Participating in religious activities or practices.
Review of the facility’s (MONTH) (YEAR) activity calendar, showed:
-Religious activities scheduled (MONTH) 6th, 7th, 13th, 14th, 20th, 21st, 27th and 28th
with no time specified and the 13th at 2:00 P.M.;
-Music and/or television activities scheduled (MONTH) 2nd, 4th, 9th, 11th, 18th, 23rd,
25th and 30th at 2:15 P.M.;
-Food/Snack activities scheduled (MONTH) 1st through 5th, 8th through 12th, 15th, 17th
through 19th, 22nd through 26th and 29th through 31st at 8:30 A.M., and the 2nd, 4th, 9th,
11th, 12th, 18th, 23rd, 25th and 30th at 2:15 P.M.;
-No late night activities scheduled past 8:00 P.M.
Review of the resident’s (MONTH) (YEAR) activity participation documentation, showed the
following activities:
-Socials/ice-cream: 10/3, 10/12 and 10/19/18;
-Coffee/news: 10/5 and 10/22/2018;
-One on ones: 10/29/18;
-Own agenda/television: Daily from 10/1 through 10/31/18;
-No documentation if the resident’s participation was active or passive.

**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 remained as free of accident hazards as possible and each resident
received adequate supervision and assistance devices to prevent accidents by failing to
assure staff transferred residents safely based on facility policy and acceptable
standards of practice for two of three residents observed during transfers (Residents #139
and #114), failing to monitor a resident during smoking, per their plan of care (Resident
#1), failing to properly investigate falls and set interventions in place to prevent
future falls for three residents (Residents #1, #123 and #12) and failing to ensure
medications and/or razors were not left unattended and accessible to residents. The sample
size was 29. The census was 148.
1. Review of Resident #139’s annual Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 10/13/18, showed:

-The resident had an unwitnessed fall on 9/10/18;
-The resident was found in a sitting position leaning back on bed on pad. The bed was in
the lowest position;
-The resident was unable to state what occurred;
-Neuro checks, vital signs and ROM were performed;
-No injuries were observed at the time of the incident;
-The resident’s consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Blank;
-No injuries noted post incident;
-The resident’s consciousness and mobility post incident: Blank;
-Predisposing environmental factors: None;
-Predisposing physiological factors: None;
-Predisposing situation factors: Other;
-Other information: Trying to get out of bed without assistance;
-Witnesses: No witnesses;
-No cause determination, and no interventions taken at the time of the incident and/or
post incident noted.
Review of the resident’s fall risk assessment, dated 10/5/18, showed high risk for falls.
Further review of the resident’s current care plan, in use at time of the survey, showed
no updated interventions after the 7/3, 7/15 and 9/10/18 falls.
Review of the medical record, showed no neurological flow sheets completed for the
resident’s unwitnessed falls on 7/3, 7/15 and 9/10/18.
Observation on 11/06/18 at 12:38 P.M., showed the resident sat in his/her wheelchair in
the dining room and fed himself/herself meatloaf, mixed vegetables and mashed potato
without difficulty. On 11/7/18 at 10:18 A.M., the resident sat in his/her wheelchair in
his/her room
During an interview on 11/13/18 at 7:48 A.M., Registered Nurse (RN) BB said staff know how
to care for residents by looking at the care plan and any day to day report. When a
resident falls, the nurse is responsible to assess the resident, complete the fall report,
notify management/family/physician, and complete neuro checks if the resident hit their
head or the fall was unwitnessed.
During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation,
including neuro checks that had been provided was the only fall documentation the facility
had for this resident.
7. Review of Resident #12’s electronic face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE] showed:
-BIMS score of 8 out of 15, indicates moderate cognitive impairment;
-Independent with all ADLs.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes;
-Goal: The resident will not harm self or others through the review date;
-Interventions: Staff will encourage and redirect the resident out of other resident’s
rooms/personal space as needed.
Review of the facility’s incident list for last 6 months, showed the following for the
resident. Un-witnessed falls on 7/31/18 and 8/11/18.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, on-going monitoring and communication with the [MEDICAL TREATMENT] center.
The facility identified four residents who received [MEDICAL TREATMENT]. Of those four,
two were chosen for the sample and issues were found with both residents (Residents #57
and #142). The sample was 29. The census was 148.
1. Review of Resident #57’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 8/24/18, showed:
-[DIAGNOSES REDACTED].
-Special treatment for [REDACTED].
Review of the resident’s electronic Physician order [REDACTED].
-An order, dated 8/23/18, to send the resident to [MEDICAL TREATMENT];
-No order the frequency of the [MEDICAL TREATMENT];
-No order to check the arteriovenous (AV) fistula (connection or passageway between an
artery and a vein, surgically created for [MEDICAL TREATMENT] treatments) for bruit/thrill
(the thrill is the vibration you feel as blood flows through the fistula. The bruit is the
sound you hear, heard with a stethoscope);
-No order to check the AV fistula for signs/symptoms of infection and bleeding.
Review of the resident’s care plan, in use during the survey, showed staff did not care
plan the resident for [MEDICAL TREATMENT].
Review of the resident’s progress notes, showed:
-No documentation of assessment and/or monitoring of the fistula;
-No documentation of assessing the fistula for bruit and thrill;
-No documentation of assessing for signs and symptoms of infection and bleeding;
-No documentation of assessing the resident for pain before and after [MEDICAL TREATMENT];
-No documentation of communication between the [MEDICAL TREATMENT] center and facility.
Observation on 11/6/18 at 12:31 P.M., and on 11/8/18 at 7:29 A.M., showed the resident had
an AV fistula in his/her left arm.
2. Review of Resident #142’s electronic face sheet, showed he/she was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s POS, in use during the survey, showed:
-[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday. Pickup at 10:30 A.M.;
-Assess and document thrill and bruit to left AV shunt every shift;
-Renal diet, mechanical soft texture, regular consistency.
Review of the resident’s care plan, in use during the survey, showed:
-Focus: The resident has a [DIAGNOSES REDACTED].>-The resident receives [MEDICAL
TREATMENT] treatments at a [MEDICAL TREATMENT] center on Tuesdays, Thursdays and
Saturdays;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure that all
nursing staff possessed the competencies and skill sets necessary to provide nursing and
related services to meet the residents’ needs safely and in a manner that promotes each
resident’s rights, physical, mental and psychosocial well-being by failing to assure staff
were competent in safe transfer techniques and the ability to assess a residents ability
to safely transfer. In addition, the facility failed to assure staff were competent in the
facility abuse protocols related to resident to resident abuse and resident behaviors.