JONESBURG NURSING & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interviews, facility failed to insure staff treated residents in
a manner that maintained their dignity when staff failed to knock before entering
resident’s room, failed to label residents’ belongings out of sight, and hung signs
instructing staff how to care for residents for eight (#22, #30, #31, #33, #44, #162, #164
and #165) of 16 sampled residents. The census was 79.
1. Review of the facility’s Resident Rights Dignity Issues policy, undated, showed the
following:
-All staff members shall knock on the resident’s room door prior to entering, announce
their intention, and whenever possible obtain permission prior to entering the room;
-Cubicle curtains, window coverings, room and bathroom doors shall be pulled during
resident care and treatment to provide privacy to the resident.
2. Observation on 3/3/19 at 5:30 P.M., showed Resident #22 in the dining room with his/her
name written on his/her socks. The resident’s name could be seen by other residents, staff
and visitors.
Observation on 3/4/19 at 11:05 A.M., showed Resident #22 in the dining room with liquid
dripping out of his/her nose onto his/her arm. Further observation showed staff did not
assist the resident.
Observation on 3/5/19 at 10:04 A.M., showed Resident #22 and Resident #164 in the dining
room with their name written on their socks. The residents’ name could be seen by other
residents, staff and visitors.
3. Review of of Resident #30’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/23/18, showed the following:
– Required total physical assistance of two persons for transfers and bathing;
– Required total physical assistance of one person for bed mobility, locomotion,
toileting, and personal hygiene;
– Required extensive assistance of one person for dressing and eating;
– Has limited range of motion of bilateral upper and lower extremities;
– Received pain medication as needed for occasional pain rated at a four on a scale of
0-10;
– At increased risk for pressure ulcers with one unstageable pressure ulcer;
– Received antipsychotic medication, anxiolytic medication, and antidepressant medication
on seven out of the last seven days.
Review of the resident’s care plan, dated 7/23/19, showed it did not provide direction for
staff regarding application of the splints the resident wears bilaterally on his/her upper
and lower extremities.
Observation on 3/3/19 at ****, showed the resident in his/her room with a splint on
his/her right arm and both legs. Additional observation showed an arm splint on the
resident’s lap. The resident said the splint is for his/her right arm and he/she takes it
off sometimes. The resident said the Certified Nursing Assistants (CNAs) apply the splints
and remove them as directed by the hand written signs taped to the bottom of the
resident’s television shelf. Further observation showed the care signs could be observed
by anyone entering the resident’s room.
Observation on 3/7/19 at 10:38 AM, showed the resident in his/her wheelchair watching
television. Additional observation showed the handwritten signs taped below the television
shelf, visible to any visitor to the resident’s room.
During an interview on 3/6/19 at 12:00 P.M., the facility’s physical therapy director said

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to notify and conduct
residents and/or family/representative of care plan meetings for 12 out of 18 sampled
resident (Resident #7, #10, #22, #23, #31, #33, #36, #44, #51, #58, #162, #214). This had
the potential to affect all residents in the facility. The census was 79.
1. Review of the facility’s Resident Assessment Instrument (RAI) Guidelines, not dated,
showed the following:
– The care plan is to be completed no later than the 21st day of the resident’s stay;
– The Minimum Data Set (MDS) Coordinator and/or Social Services Director will coordinate
planning and invitations to care plan meetings with residents and families/legal
guardians;
– The resident and his/her family are an integral part of the care plan process;
– Significant effort to include the resident in the process will occur;

Based on interviews and record reviews, the facility failed to provide a free basic
haircut for Medicaid residents. This had the potential to affect all Medicaid residents.
The census was 79.
Review of the Resident Council Minutes, dated 2/28/19 at 2:35 P.M., showed six residents
and one staff member in attendance. Residents asked when a new hairdresser would be hired
because they were in need of the services of a hairdresser, such as haircuts.
Review of the facility’s admission packet, not dated, showed a Permission for Staff to
Perform Simple Haircuts form. The form said the facility prefers that a licensed
beautician perform beauty/barber services. However, Medicare and Medicaid reimbursement
does include simple haircuts. This will be performed free of charge by a non-licensed
staff member
During a group interview on 3/4/19 at 1:10 P.M., with eleven residents identified by the
facility as alert and oriented, the residents said the facility does not currently have a
hairdresser and does not offer free haircuts. The residents said they did not know exactly
how long the facility has been without a hairdresser but many people need the services,
especially haircuts.
During an interview on 3/7/19 at 4:15 P.M., the administrator and the Director of Nursing
(DON) said the facility has not had a hairdresser since (MONTH) 31, 2019. The facility

Based on observation and interview, facility staff failed to ensure the residents’ right
to personal privacy was protected when they left the Medication Administration Record
[REDACTED]. The facility was 79.
1. Observation on 3/3/19 at 4:16 P.M., showed the MAR indicated [REDACTED]. Further
observation showed staff and residents walked by the cart.
Observation on 3/4/19 at 10:10 A.M. showed staff left the computer open and unattended in
the hallway. Further observation showed staff and residents walked past the computer.
Observation on 3/5/19 at 10:04 A.M., showed the staff left the computer open and
unattended in the hallway. Further observation showed staff and residents walked past the
computer.
2. Observation on 3/5/19 at 10:53 A.M., showed Registered Nurse (RN) A did not close the
door or pull the curtain when he/she changed Resident #165’s wound dressing.
3. During an interview on 3/7/19 at 9:55 A.M., Certified Nurse Assistant (CNA) said the
staff computers should not be open unless facility staff is working on them. When facility
staff are finished, the staff should log out and turn it off. Staff should pull the
curtain or shut the door when they provide care.
4. During an interview on 3/7/19 at 10:08 A.M., Registered Nurse (RN) said the MAR
indicated [REDACTED]. Staff should sign out of the computers when they walk away. The RN
said staff should close the door and pull the curtain when providing care to the
residents.
5. During an interview on 3/7/19 at 12:44 A.M., the administrator and Director of Nursing
(DON) said facility staff should close the door and pull the curtain during resident care.
Additionally, staff should make sure the MAR book is closed or covered when they are away
from the medication cart and the computers should be closed before leaving them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure the admission policy
did not require the resident and/or responsible party to waive potential facility
liability for loss or damage to personal belongings for 18 out of 18 sampled residents
(Residents #3, #7, #10, #13, #22, #23, #24, #30, #31, #33, #34, #36, #44, #51, #57, #58,
#162, #214). This had the potential to affect all residents admitted to the facility. The
census was 79.
1. Review of the facility’s Consent and Authorization forms, showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete initial and periodic
comprehensive assessments of each resident’s functional capacity using the resident

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

Based on interview and record review, facility staff failed to assess residents using the
quarterly review instrument not less frequently than once every three months, for 15 of 18
sampled residents (Resident #3, #7, #10, #13, #23, #24, #30, #33, #34, #36, #44, #51, #57,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to electronically transmit
encoded, accurate, and complete Minimum Data Set (MDS), a federally required resident
assessment completed by facility staff, data to the Centers for Medicare and Medicaid
(CMS) System within 14 days after staff complete a resident’s assessment. This had the

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

Based on observation, interview, and record review the facility staff failed to develop
comprehensive care plans to direct the staff in the care of 13 out of 18 sampled residents
(Resident #3, #7, #13, #22, #23, #30, #31, #34, #36, #57, #58, #162, #214). The census was
79.
1. Review of the facility’s care plan policy, dated (MONTH) (YEAR), showed the following:
– The comprehensive care plan will be based on a thorough assessment that includes, but is
not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff;
– Assessment of each resident is an ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
– A well developed care plan will be oriented to:
– Preventing avoidable declines in functioning or functional levels or otherwise
clarifying why another goal takes precedence;
– Managing risk factors to the extent possible or indicating the limits of such
interventions;
– Addressing ways to try to preserve and build upon resident strengths;
– Applying current standards of practice in the care planning process;
– Evaluating treatment of [REDACTED].
– Using an appropriate interdisciplinary approach to care plan development to improve the
resident’s functional abilities;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to update the
plan of care with changes in the resident’s needs for 12 out of 18 sampled residents
(Resident #3, #7, #10, #13, #22, #23, #30, #31, #34, #36, #57, #162). The facility census
was 79.
1. Review of the facility’s Care Plan Comprehensive Policy, dated (MONTH) (YEAR), showed
staff are directed to provide each resident with:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental, and
psychosocial well-being;
-The interdisciplinary care plan team, with input from the resident, family, and/or legal
representative will develop and maintain a comprehensive care plan for each resident that

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, facility staff failed to maintain
professional standards when they failed to secure a physician’s order for splint
application for two residents (Resident #3 and #30), failed to secure a physician’s order
for two residents (Resident #24 and Resident #30) [MEDICAL CONDITION] (a surgical opening
in the abdominal wall to drain feces) and [MEDICATION NAME] (a surgical opening in the

During an interview on 3/7/19 at 10:15 A.M., LPN J said physician orders for oxygen at
bedtime means the resident should receive oxygen when they go to bed at night, it does not
mean anytime the resident is in bed. He/She said the CNAs put the nasal cannula on the
residents when they are in bed and the nurses set the oxygen at the correct setting and
let the CNAs know when to put it on the residents.
During an interview on 3/7/19 at 10:40 A.M., CNA O said he/she is responsible for putting
the nasal cannula on the resident when they lay down in bed. Hr/She said the CNAs get the
instructions from the charge nurse. The CNA said when the physician’s orders say the
residents oxygen at bedtime, that means when the resident goes to bed at night, not every
time they lay down in bed.
During an interview on 3/7/19 at 12:45 P.M., the administrator and the DON said physician
orders which read oxygen at bedtime means at night time. They said the orders should
actually read at bedtime and as needed (PRN); however, if the order just says bedtime then
that means at night. A resident with those orders should not be given oxygen every time
they are in bed. They said the CNAs are the ones who put the nasal cannula on the resident
and the CNAs know when to put the oxygen on the resident because the charge nurse will
instruct them.
4. Review of Resident #44’s admission MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
– The hard chart had a red sticker on the binding;
– Red do not resuscitate (DNR) sheet;
– A DNR form, dated 9/5/18, and signed by the resident and the physician;
– POS, dated 3/1/19 – 3/31/19, showed an order, dated 9/5/18, for full code;
– The order, dated 9/5/18, for full code was on all POSs since admission.
During an interview on 3/7/19 at 9:34 A.M., CNA N said a resident’s code status is marked
on the hard chart. He/She said a red sticker on the binding means DNR and a green sticker
on the binding means full code.
During an interview on 3/7/19 at 10:15 A.M., LPN J said facility staff can find a
resident’s code status in several ways. There is a color coded sticker on the binding of
the hard chart at the nurse’s station. A red sticker means the resident is DNR and a green
sticker means full code and there is also a red or green sheet inside the chart which
shows the same information. The LPN said the code status should match across all resident
documents and if the codes do not match then the DON should be notified so she can verify
it with the physician.
During an interview on 3/7/19 at 12:45 P.M., the administrator and the DON said the
residents’ hard chart is color coded. They said red means a DNR code and green means a
full code and the code status is also found on the POS. The administrator and the DON said
the code status should be congruent across all resident documents. If staff observe the

Based on observation and interview the facility failed to provide necessary services to
maintain good oral hygiene and grooming for 14 residents (Resident #21, #22, #23, #25,
#36, #58, #162, #163, #164, #166, #170, #172, #173 and #174) who were unable to carry out
their own Activities of Daily Living (ADLs). The facility census was 47.
1. Review of the facility’s Activities of Daily Living (ADL), dated (MONTH) (YEAR), showed
it did not address oral hygiene and grooming.
2. Review of Resident #21’s care plan, dated 12/07/17, showed staff are directed to
provide a comb/brush and cues for grooming hair daily and as needed (PRN).
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/06/19 at 08:57 A.M., showed the resident sat in the dining room with
uncombed hair.
3. Review of Resident #22’s Monthly Summary, dated 02/09/19, showed the resident is
totally dependent upon staff for grooming and personal hygiene.
Observation on 03/03/19 at 05:30 P.M., showed the resident sat in the dining room with

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
services to prevent a decline of activities of daily living (ADL), improve ADLs, decrease
existing limited range of motion (ROM) or contractures (tightening of muscles that

Based on observation and interview, facility staff failed to ensure residents’ environment
remained free of accidents or hazards when staff propelled four residents of 16 sampled
residents (#16, #22, #59 and #163) in wheelchairs without footrests. The facility census
was 79.
1. The facility did not have a policy to instruct staff on the proper use of footrests on
wheelchairs.
2. Observation on 3/4/19 at 4:03 P.M., showed Registered Nurse (RN) A propelled Resident
#163 in his/her wheelchair down the hall without footrests. Further observation showed the
resident’s feet slid on the floor.
Observation on 3/4/19 at 4:14 P.M., showed certified nurse assistant (CNA) D propelled
Resident #22 in his/her wheelchair down the hall without footrests. Further observation
showed the resident’s feet slid on the floor.
Observation on 3/5/19 at 5:00 P.M., showed Licensed Practical Nurse (LPN) H propelled
Resident #16 in his/her wheelchair down the hall without footrests. Further observation
showed the resident’s feet slid on the floor.
Observation on 3/6/19 at 12:45 P.M., showed CNA I propelled Resident #59 in his/her
wheelchair without footrests. Further observation showed the resident’s feet slid on the
floor.
3. During an interview on 3/7/19 at 9:55 A.M., CNA B said when staff propel a resident in

Based on interview and record review, facility staff failed to provide the services of a
Registered Nurse (RN), for at least eight (8) consecutive hours per day, seven days a
week. The facility failed to follow the Facility Assessment Staffing Plan which says the
Director of Nursing (DON) may be a charge nurse if the census is below 60. The facility
census was 79.
Review of the Facility Assessment, dated 11/13/18, showed the DON may be a charge nurse if
the census is below 60.
Review of the facility’s Daily Assignments schedule, dated 12/2/18 – 3/3/19, showed the
facility did not have an RN for eight (8) consecutive hours on the following days:
– 12/1/18 RN A: 5 hours;
– 12/2/18 RN A: 5 hours;
– 12/8/18 DON (census 78);
– 12/9/18 DON (census 77);
– 12/28/18 DON (census 77);
– 1/1/19 DON: 6 hours (census 79);
– 1/14/19 No RN on the Daily Assignment Sheet (census 76);
– 1/15/19 No RN on the Daily Assignment Sheet (census 76);
– 1/19/19 DON (census 76);
– 1/30/19 No RN on the Daily Assignment Sheet (census 75);
– 2/4/19 RN called in. DON (census 76);
– 2/16/19 DON (census 80);
– 2/17/19 DON (census 80);
– 2/22/19 No RN on the Daily Assignment Sheet (census 80);
– 2/25/19 No RN on the Daily Assignment Sheet (census 79);
– 2/27/19 RN A went home sick at 8:00 A.M. (census 79);
– 3/2/19 RN A: 6 hours;
– 3/3/19 RN A: 6 hours.
Review of the facility’s Daily Assignments schedule, dated 12/2/18 – 3/3/19, showed the
facility allowed the Director of Nursing (DON) to work as a charge nurse when the census
was above 59.
– 12/4/18 Evening shift (census 78);

Based on observation, interview, and record review, licensed staff failed to ensure the
Controlled Substance Shift Change Count – Check Sheet for the North 7-3 medication cart
was signed by both the on-coming and off-going staff and did not record the number of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure the medication
regimen was free from unnecessary medications when the facility failed to provide a proper
[DIAGNOSES REDACTED].#4, #7, #13, #58) sampled residents. The facility census was 79.
1. Review of the facility’s Antipsychotic Medication Use policy, dated (MONTH) (YEAR),
showed antipsychotic medications therapy shall be used only when it is necessary to treat
a specific condition. Antipsychotic medications shall only be used for the following
conditions/[DIAGNOSES REDACTED].
2. Review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/25/18, showed the following:
– Cognitively impaired;
– [DIAGNOSES REDACTED].
– Received antipsychotic medication and antidepressant medications in seven out of the
last seven days.
Review of the physician order [REDACTED]. Additional review showed the order did not
contain a 14 day stop date. Additionally the POS did not contain an appropriate [DIAGNOSES
REDACTED].
3. Review of Resident # 7’s annual MDS, dated [DATE], showed [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed an order for [REDACTED].
4. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact;
– [DIAGNOSES REDACTED].
– Received antidepressant medication seven out of the last seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility’s licensed staff failed
to ensure medications were monitored and stored in a safe and effective manner. Licensed
staff failed to remove and discard discontinued medication and improperly labeled
medication from the medication room refrigerator and two medication carts. The facility
census was 79.
1. Review of the facility’s Labeling Drugs and Medications policy, dated (MONTH) (YEAR),
showed all drugs and biologicals must be properly labeled and legible at all times. The
policy does not show direction for staff to date vials of medication when opened, such as
insulin.
2. Review of the manufacturer’s recommendations for [MEDICATION NAME] Insulin (a
rapid-acting human insulin analog used to lower blood glucose), showed the medication must
be discarded 28 days after staff open the vial.
Review of the manufacturer’s recommendations for [MEDICATION NAME] (a long-acting insulin
used for the control of high blood sugar), showed the medication must be discarded 28 days
after the vial is opened.
Review of the manufacturer’s recommendations for Basaglar (a long-acting basal insulin
used to control high blood sugar), showed the medication is not to be used for more than
28 days after opening.
Review of the guidelines provided by the Food and Drug Administration (FDA) for the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to remove soiled
gloves and/or properly wash hands to prevent the spread of bacteria and other infection
causing contaminants during the provision of care and medication administration for six
out of 16 sampled residents (#7, #22, #23, #36, #162 and #165). In addition, the facility
failed to administer the Two-step [MEDICATION NAME] (TB) testing appropriately for five
out of 16 sampled residents (#7, #22, #23, #36 and #162). The facility also failed to
follow infection control protocols for cleaning/disinfecting the glucometer (device to
measure blood sugar levels) during Accu-checks (testing of blood sugar). The census was
79.
1. Review of the facility’s Blood Glucometer Disinfecting Policy, dated (MONTH) (YEAR),
showed staff is directed to clean the blood glucose meter prior to using with approved
wipes with 10% bleach or comparable product, placed on clean field and let air dry
according to manufacturer’s directions.
Observation on 3/4/19 at 10:57 A.M., showed Registered Nurse (RN) A did not clean the