KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCARE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s
physician’s order sheet (POS) included the resident’s code status (whether or not the
resident wants to be resuscitated during respiratory or [MEDICAL CONDITION]) for two
sampled residents (Residents #4 and #610); and to ensure the code status was completed
timely and added to the POS for two sampled residents (Residents #102 and #610) out of 23
sampled residents. The facility census was 113 residents.
1. Record review of Resident #4’s entry tracking form showed he/she moved into the
facility on [DATE].
Record review of the resident’s census sheet showed he/she was placed on hospice
(end-of-life care) on 3/22/19.
Record review on 4/16/19 8:47 A.M. showed the resident’s Admission Minimum Data Set (MDS-a
federally mandated assessment tool completed by facility staff for care planning) dated
3/27/19 was incomplete.
Record review of the resident’s care plan dated 3/27/19 showed the resident was a full
code (all life-saving measures are taken in order to treat a patient after/during a
respiratory or [MEDICAL CONDITION]).
Record review of the resident’s (MONTH) 2019 and (MONTH) 2019 POS showed the resident’s
code status was left blank.
Record review on 4/12/19 at 10:42 A.M. showed the outside of the resident’s chart did not
have a full code or a Do Not Resuscitate (DNR – an order from a doctor that resuscitation
should not be attempted if a person suffers cardiac or respiratory arrest) sticker.
During an interview on 4/15/19 at 8:00 A.M., the Social Worker said:
-He/she keeps track of the residents’ code status information in an excel file.
-Residents’ code status information should be on the care plans and should be on the POS.
-His/her excel file shows the resident is a full code.
-A form is kept in the chart that shows the residents’ code status information and he/she
collaborates with nursing staff to update the forms as necessary.
During an interview on 4/15/19 at 7:58 A.M., Licensed Practical Nurse (LPN) E said:
-Residents who are a full code have a green sticker on the outside of the chart.
-The resident would be a DNR as there was not a full code sticker on the outside of the
chart.
During an interview on 4/16/19 at 8:31 A.M., the resident said he/she wanted to be full
code and no one talked to him/her about his/her code status.
During an interview on 4/19/19 at 10:56 AM, the Director of Nursing (DON) said:
-The nurses should look at the residents’ POS to determine their code status.
-The admitting nurse should put the resident’s code status on the POS.
2. Record review of Resident #102’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].)
Record review of the resident’s POS dated 3/12/19 showed there was no documentation of the
resident’s code status.
Record review of the resident’s Social Services Notes dated 3/14/19 showed:
-Advanced directives summary.
–The resident had advanced directives and would give these to the social worker and
–The resident wanted to be a DNR.
Record review of the resident’s Care Plan dated 3/16/19 showed the resident was a full

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
furniture in a resident room was in good repair, and the personal refrigerator and items
in it were at a safe temperature for one sampled resident (Resident #70), out of 23
sampled residents. The facility census was 113 residents.
1. Record review of Resident #70’s face sheet showed the resident was admitted to the
facility 2/15/19 and his/her [DIAGNOSES REDACTED].
-[MEDICAL CONDITION] (decline in mental ability caused by an impaired supply of blood to
the brain).
-Type II Diabetes Mellitus (a long-term metabolic disorder characterized by high blood
sugar, insulin resistance, and relative lack of insulin).
-Subarachnoid Hemorrhage (a life-threatening type of stroke caused by bleeding into the
space surrounding the brain).
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
2/21/19 showed the resident was:
-Cognitively impaired.
-Needed limited physical assistance with bed mobility and transfers.
-Needed extensive physical assistance with dressing and toileting.
-Was independent with eating.
Record review of the resident’s care plan initiated 2/25/19 and revised 3/4/19, showed the

-There was a container of left over soup in the refrigerator.
-The resident had chicken that was brought in by the family for his/her lunch that he/she
did not finish and wanted it placed in his/her refrigerator for later.
During an interview on 4/11/19 at 1:20 P.M., the resident’s family member said:
-He/she reported the broken night stand to the facility staff, but did not remember the
exact day.
-He/she did remember reporting the broken furniture to staff prior to the resident going
to the hospital. (*Note: The resident was hospitalized [DATE].)
-The soup in the resident’s refrigerator had been there for about a week.
-He/she would not want the resident to eat it because it was too old.
-He/she tried to check the resident’s refrigerator weekly when he/she came to visit.
Observation on 4/11/19 at 1:36 P.M. showed:
-The Social Worker came and met with the family member.
-Registered Nurse (RN) B joined the Social Worker and the family member in a discussion
about the concerns that the family member had. During the discussion RN B said a new night
stand was brought in.
–The night stand was sitting on the other side of the room, not on the resident’s side of
the room.
–Neither the resident nor the resident’s family member knew the night stand was for the
resident.
–The resident’s personal belongings were not placed in the new night stand.
–The broken night stand was not removed.
During an interview on 4/19/19 at 9:14 A.M., Certified Nurse Assistant (CNA) H said:
-The nurse checks the residents’ refrigerators.
-No one told him/her the resident had a new night stand sitting on the other side of the
room.
-He/She did not know the resident had a new night stand until he/she saw the old one moved
out to the hall and the new one was in place.
-He/She thought whoever moved the resident’s old night stand out into the hall must have
put the new one into place and put the resident’s personal items into his/her new night
stand.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing said:
-There should be thermometers in all refrigerators.
-Maintenance should be checking the refrigerators.
-The night stand should have been replaced when the resident was admitted into the
facility.

Based on interview and record review, the facility failed to ensure the Criminal
Background Checks (CBC) and the Employee Disqualification List (EDL) checks were completed
prior to hire for one newly hired employee (Employee B) out of eight sampled newly hired
employees. The facility census was 113 residents.
Record review of the facility’s policy titled Background Checks updated 6/2018, showed:
-This facility will conduct employment background screening reference checks on
individuals making application for employment with this facility.
-The Human Resources (HR) Director or designee will conduct background checks and
reference checks on persons considered for employment with this facility prior to hire.
1. Record review of Employee #B’s personnel information showed:
-He/she was hired on 3/4/19.
-The EDL check was not completed until 4/13/19.
-The CBC was not completed prior to hire.
During an interview on 4/18/19 at 9:21 A.M., the HR Director said:
-The CBC should have been completed prior to hire.
-He/she ran one after he/she started.
-He/she started working in the building two days prior to the survey start date, 4/9/19.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said:
-He/She would have expected the CBC and EDL check to have been completed by the previous
HR Director.
-CBC and EDL checks should always be completed prior to hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident was
provided with the facility’s Admission Agreement and had opportunities to ask questions
related to the Admission Agreement for two sampled residents (Resident’s #110 and #309)
out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s admission agreement dated 11/20/18 showed:
-The admission agreement contained:
–Financial arrangements.
–Authorizations and assignments from the resident to the facility.
–Temporary absence including the bed hold policy.
–Discharge, transfer, and room changes.
–Personal property.
–Facility security.
–Smoking policy.
–Governing laws and
–General provisions.
1. Record review of Resident #110’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Nurses’ Notes, dated 3/6/19 showed he/she was admitted to
the facility for weakness to receive skilled rehabilitation therapy services (services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide in writing a
transfer/discharge notice for six sampled residents (Residents #33, #54, #70, #83, #92,
and #40); to notify the Ombudsman (a resident advocate who provides support and assistance
with problems and/or complaints regarding the facility) of the resident’s
transfer/discharge for six sampled residents (Residents #33, #54, #70, #83, #92, and #40)
and to assist the resident with submission of his/her appeal of his/her 30-day discharge
for one sampled resident (Resident #54) out of 23 sampled residents. The facility census
was 113 residents.
Record review of the facility’s transfer/discharge process policy dated (MONTH) (YEAR)
showed:
-The resident and/or their representative will receive written notice of the facility’s
intent for transfer/discharge and their appeal rights prior to the time of
transfer/discharge.
1. Record review of the Resident #54’s assessments and tracking forms showed:
-The resident entered the facility on 11/7/18.
-The resident’s admission Minimum Data Set (MDS-a federally mandated assessment tool
completed by facility staff for care planning) dated 11/13/18 showed the staff assessed
the resident as cognitively intact.
-The resident was discharged with return anticipated on 12/19/18 and
-The resident re-entered the facility on 12/22/18.
Record review of the resident’s medical record showed no documentation of the resident’s
notification of transfer/discharge on 12/19/18 or a 30-day discharge notice dated 3/26/19.
Record review of the resident’s notice of discharge (which was not placed in the
resident’s medical record) dated 3/26/19 showed:
-The resident would be discharged [DATE].
-He/she would be discharged to another facility owned by the facility’s current company or
another facility of his/her choosing.
-The letter showed that the resident could appeal to the Missouri Department of Health and
Senior Services or the State Office of Long Term Care Ombudsman but it did not include any

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide the facility’s
bed-hold information and agreement prior to being transferred/discharged to the hospital
for five sampled residents (Residents #33, #92, #70, #83, and #40) out of 23 sampled
residents. The facility census was 113 residents.
Record review of the facility’s bed-holds and returns policy dated (MONTH) 2019 showed the
resident would receive bed hold information and agreement prior to being transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete a
comprehensive assessment within 14 calendar days after the resident’s admission for two
sampled residents (Residents #4 and #358) out of 23 sampled residents. The facility census
was 113 residents.
1. Record review of Resident #4’s assessments and tracking forms showed:
-The resident entered the facility on 12/10/18.
-An admission Minimum Data Set (MDS-a federally mandated assessment tool completed by
facility staff for care planning) was completed on 12/16/18.
-The resident was discharged with return anticipated on 1/7/19.
-The resident re-entered the facility on 1/7/19.
-The resident was discharged with return anticipated on 1/20/19.
-The resident re-entered the facility on 1/28/19.
-The resident was discharged with return anticipated on 1/31/19 and
-The resident re-entered the facility on 3/15/19 (after being gone for more than 30 days).
Observation on 4/11/19 2:19 P.M. showed the resident was asleep in bed on a low air loss
mattress (a specialty mattress with a series of air sacs in which the pressure can be
adjusted to provide pressure redistribution and provides a continuous flow of air across
the surface of the mattress which prevents moisture build-up on the skin), was receiving
oxygen, had a nebulizer (a device used to administer medication to people in the form of a
mist inhaled into the lungs) and a [MEDICAL CONDITION] (Continuous Positive Airway
Pressure-a machine that provides pressure during exhalation to decrease work of breathing
and assist with obstructive tissues) on his/her bedside dresser.
During an interview on 4/12/19 at 10:47 A.M., the resident said he/she was in hospital for
pneumonia (lung inflammation caused by infection).
Record review on 4/15/19 at 9:04 A.M. and on 4/16/19 at 8:47 A.M. showed the resident’s
3/27/19 admission MDS for his/her 3/15/19 admission was not completed.
During an interview on 4/18/19 11:26 at A.M., the MDS Coordinator said:
-The resident was gone for over 30 days, so he/she would need a new admission MDS.
-The resident went on hospice during the first week of his/her return to the facility so
they needed to do a significant change MDS.
-The resident’s admission MDS should have been done already and
-He/she just hasn’t done the resident’s MDS.
2. Record review of Resident #358’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s [DIAGNOSES REDACTED].>-Hypertension (HTN – high blood
pressure).
-[MEDICAL CONDITION] (CAD – the buildup of cholesterol and fatty deposits (called plaques)
on the inner walls of the arteries).
-[MEDICAL CONDITION] (increased levels of lipids or fat proteins in their blood).
-[MEDICAL CONDITION] with [MEDICAL CONDITION] (acute or chronic cognitive deterioration
due to diffuse or focal cerebral infarction that is most often related to [MEDICAL
CONDITION] disease) and
-Psychiatric Disorder (a behavioral or mental pattern that causes significant distress or
impairment of personal functioning).
Record review on 4/18/19 of the resident’s Electronic Health Record showed:
-The resident was admitted to the facility on [DATE] and
-The resident’s Admission MDS was completed 4/17/19 (more than 14 days after his/her

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident’s with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required,
for one sampled resident (Resident #102) out of 23 sampled residents. The facility census
was 113 residents.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASARR Desk Reference, dated 3/3/08, showed:
-The PASARR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form). (In this facility, all beds are Medicaid certified).
-A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION], dementia,
[MEDICAL CONDITION], etc., MR or related MR condition to determine the need for
specialized service (completion of the DA124A/B form). The facility responsible for
completing the DA124A/B and/or DA124C forms is also responsible for submitting completed
form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care
Regulation, Central Office Medical Review Unit (COMRU).
-PASARR screening is required: To assure appropriate placement of persons known or
suspected of having a mental impairment,
-To assure that the individual needs of mentally impaired persons can be and are being met
in the appropriate placement environment,
-To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C, and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
baseline care plan within 48 hours for one sampled resident (Resident #92) and to provide
a summary of the baseline care plan for four sampled residents (Residents #92, #70, #40,
and #42) out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s baseline care plan policy dated (MONTH) (YEAR) showed:
-A baseline care plan would be developed within 48 hours of the resident’s admission.
-The resident and their representative will be provided a written summary of the baseline
care plan by the completion of the comprehensive care plan.
1. Record review of Resident #92’s entry tracking form dated 3/9/19 showed he/she entered
the facility on 3/9/19.
Record review of the resident’s medical record showed no baseline care plan for the
resident’s admission on 3/9/19.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 3/12/19 showed he/she
was cognitively intact.
Record review of the resident’s comprehensive care plan dated 3/13/19 showed he/she:
-Was a fall risk.
-Was at risk for declining in his/her abilities to care for himself/herself.
-Was receiving hospice (end of life care) services.
-[MEDICAL CONDITION] and
-Was at risk for pain.
Record review of the resident’s nurse’s note dated 4/1/19 showed he/she had a change in
condition related to a fall.
Record review of the resident’s telephone orders showed a physician’s orders [REDACTED].
Record review of the resident’s entry tracking form showed the resident returned to the
facility on [DATE].
Record review of the resident’s baseline care plan dated 4/8/19 showed no documentation
that a summary of the resident’s baseline care plan was provided to the resident or
his/her responsible party.
Observation on 4/15/19 at 6:45 A.M. showed the resident was asleep in bed.
Observation on 4/16/19 at 8:39 A.M. showed the resident was in his/her room with a
visitor.
During an interview on 4/18/19 8:30 A.M., Regional Nurse B said:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to accurately
document the administration of as needed pain medication for two sampled residents
(Resident #67 and #71), and to follow a physician’s orders [REDACTED].#71), out of 23
sampled residents. The facility census was 113 residents.
Record review of the facility’s medication administration general guidelines policy dated
(MONTH) (YEAR) showed:
-The individual who administers the medication records the administration on the
resident’s Medication Administration Record (MAR) directly after the medication is given
and
-When as needed medications are administered, the following documentation is provided:
date and time of administration, dose, complaints or symptoms for which the medication was
given, results achieved from giving the medication and the time results were noted,
signature or initials of the person recording administration and signature or initials of
the person recording effects, if different from the person administering the medication.
1. Record review of Resident #67’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/20/19 showed
he/she:
-Received scheduled pain medication, as needed pain medication and non-medication
interventions for pain and
-Said he/she was almost constantly in pain and the worst the pain had been in the lookback
period was a nine out of ten with ten being the worst possible pain.
Record review of the resident’s pain care plan dated 2/20/19 showed he/she was at risk for
pain and received scheduled pain medications.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 milligrams (mg) (an opioid pain medication) showed there was no Controlled
Medication Utilization Record for the resident’s [MEDICATION NAME] 7.5/325 mg for 3/1/19
through 3/4/19 at 6:00 A.M.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 mg for 3/4/19 at 6:00 A.M. through 3/31/19 at 5:45 P.M. showed two tablets
were administered 36 times.
Record review of the resident’s (MONTH) 2019 MAR showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 7.5/325 mg, two tablets was documented on the front of the MAR as

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure ongoing
resident centered activities, as well as one on one activities for residents not

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to schedule an
ophthalmologist (a physician who specializes in the treatment of [REDACTED].#67) out of 23
sampled residents. The facility census was 113 residents.
Record review of the facility’s consultation policy dated (MONTH) (YEAR) showed:
-A physician’s orders [REDACTED].
-A licensed nurse obtains a physician order [REDACTED].>1. Record review of Resident
#67’s 2/5/19 vision exam showed the plan was to consult with an ophthalmologist.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/20/19 showed the
following staff assessment of the resident:
-Was cognitively intact.
-Had adequate vision and
-Was not wearing corrective lenses during the assessment.
Record review of the resident’s care plan dated 2/20/19 showed the resident’s vision
impairment and the use of glasses were not included in the care plan.
Record review of the resident’s medical records showed no documentation regarding
following up with an appointment with an ophthalmologist.
Observation and interview on 4/12/19 at 9:22 A.M., showed the resident:
-Was wearing glasses.
-When he/she went to his/her eye appointment, he/she was told he/she needs to see an
ophthalmologist and
-He/she asked about getting an ophthalmologist appointment but no one made an appointment
for him/her.
During an interview on 4/16/19 at 11:53 A.M., the Director of Nursing (DON) said:
-The nurse should call the resident’s primary care physician to request a referral for the
ophthalmologist and
-After a referral for the ophthalmologist from the resident’s primary care physician is
obtained, then the nurse should schedule the ophthalmologist appointment.
During an interview on 4/18/19 at 10:49 A.M., the Social Worker said:
-It used to be Social Services that received the ancillary progress notes for scheduling
follow-up appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to ensure an
alternating pressure reducing mattress was in good repair; to obtain physician’s orders
for the alternating pressure reducing mattress; to maintain the mattress on the correct
settings for one sampled resident (Resident #309) who was admitted with pressure ulcers
(localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure, or pressure in combination with shear and/or friction); and to
ensure the specialty mattress was at the proper weight setting for one sampled resident
(Resident #83) out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s Support Surfaces policy dated 4/2019 showed:
-Redistributing support surfaces were to promote comfort for all bed or chair bound
residents, prevent skin breakdown, promote circulation and provide pressure relief of
reduction.
-All beds (air mattresses) that have adjustable settings, generally based on weight or
firmness overlay that have adjustable settings, generally based on weigh or firmness would
be monitored to ensure the correct setting and
-If settings were represented by a single weigh number, the number closest without going
over would be used.
1. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s Physician’s Orders Sheet (POS) dated 4/4/19 showed:
-There were no physician’s orders for the alternating pressure reducing mattress settings;
and
-There were no physician’s orders showing how often to monitor the resident’s alternating
pressure reducing mattress.
Record review of the resident’s baseline care plan dated 4/4/19 showed:
-The resident was admitted to the facility with wounds; and
-The resident was admitted with the use of a wound vac (a machine used to treat advanced
bed sores. A pump is then attached to this area to draw moisture from the wound itself.
The pump acts as a vacuum to draw the excess fluids from the wound and collect them into a

-Was severely impaired cognitively.
-Required extensive assistance with bed mobility, transfers, and locomotion.
-Was totally dependent on staff with dressing, toilet use, personal hygiene, and bathing.
-Was always incontinent of bowel and bladder.
-Had a condition or chronic disease that may result in a life expectancy of six months or
less.
-Was at risk of developing pressure ulcers.
-Had one unstageable pressure ulcer with suspected deep tissue injury in evolution and
-Had the unstageable pressure ulcer upon re-entry to the facility.
Record review of the resident’s most recent Care Plan showed:
-The resident was receiving hospice care.
-Staff was to monitor the resident’s weight per facility protocol or physician’s order.
-Staff was to administer medications and treatments per the physicians’ orders and
-There was not an update to show the resident’s current interventions related to his/her
wound.
Observation on 4/11/19 at 12:54 P.M. of the resident’s room showed:
-The resident had a Low Air Loss Mattress (LALM – a mattress with tiny laser made air
holes in the top surface that continually blow out air causing the patient to float; a
preferred method of treatment and prevention of skin ulcers) and
-The LALM weight setting was set on 180 pounds.
Record review of the resident’s Weekly Wound Assessment, dated 4/11/19, showed:
-The resident had one wound.
-The wound was located on the resident’s left heel.
-Interventions included repositioning, heels raised while in bed, bony prominences padded,
a specialty mattress, and additional supplements as ordered.
-Staff was to provide the following treatment:
–Cleanse area to the resident’s left heel with wound cleanser.
–Pat dry.
–Apply skin prep and dry dressing daily and as needed.
-The wound was improved.
Observation on 4/15/19 at 7:55 A.M. showed the resident was sitting in his/her Broda Chair
(a high-back tilt-in-space positioning wheelchair) at the dining table. He/she was wearing
protective boots on both feet and legs.
Observation of the resident in his/her bed on 4/16/19 at 11:45 P.M. during wound care
showed the resident’s LALM weight setting was on 180 pounds.
Observation on 4/18/19 at 10:46 A.M. showed the resident’s LALM weight setting was set on
180 pounds.
During an interview on 4/18/19 at 10:47 A.M., CNA J said:
-He/She thought Central Supply was responsible for checking mattresses.
-He/She did not know what the resident’s LALM should be set on and
-He/she would let Central Supply know if there is a problem with mattresses.
During an interview on 4/18/19 at 10:52 A.M. Certified Medication Technician (CMT) D said:

-The bath aides weigh the residents and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
restorative services were provided to maintain, improve, or prevent decline in range of
motion for one sampled resident (Resident #62) out of 23 sampled residents. The facility
census was 113 residents.
Record review of the facility’s Rehabilitative Nursing Care revised 4/2019 showed:
-Rehabilitation nursing care was provided for each resident admitted .
-Nursing personnel were trained in rehabilitative nurses’ care. Our facility has an active
program of rehabilitative nursing which was developed and coordinated through the
residents care plan; and
-Assist residents with their routine range of motion exercises.
1. Record review of Resident #62’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] disease (refers to a group of conditions that can lead to a [MEDICAL
CONDITION] event, such as a stroke. These events affect the blood vessels and blood supply
to the brain. If a blockage, malformation, or hemorrhage prevents the brain cells from
getting enough oxygen, brain damage can result).
Record review of the resident’s Care Plan revised 11/8/18 showed he/she:
-Had a left upper extremity contracture (an abnormal usually permanent condition of a
joint, characterized by flexion and fixation).
-Needed a hand splint applied to his/her left hand contracture; and
-Was on hospice (end of life care) related to a [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
2/21/19 showed he/she:
-Was cognitively intact.
-Had limitations with range of motion on one upper and lower side (arm and leg); and
-Needed the assistance of one staff member with transfers, and bed mobility.
Record review of the resident’s physician progress notes [REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident safety during
a facility van transport due to the seat belt not being fastened properly for one sampled
resident (Resident #78) out of 23 sampled residents. The facility census was 113
residents.
Record review of the facility’s policy titled Facility Provided Transportation dated
3/2019 showed:
-Only approved facility employees designated as facility Transportation Driver will
operate the van.
-The facility Transportation Driver will be approved to drive the van/bus only after
reviewing and signing the Van Driver job description, reviewing this policy, completing
Transportation Driver orientation curriculum, and proving role competency covering van use
and safety performance, verified and signed by the Administrator.
-A Certified Nursing Assistant (CNA) or activity assistant, with the understanding of the
van attendant/safety responsibilities, as laid out in this policy, will accompany
residents and serve as attendant, on medical appointments as indicated.
-The Transportation Driver secures wheelchairs to the transportation van/bus to stabilize
the assisted devices during the trip.
-Ensures that resident/patients are secured with lap belts or seatbelts.
-The Transportation Driver will not move the van/bus until everyone is secured and belted
and ensures that passengers are wearing seat belts at all times, while the van/bus is
being operated.
-The Transportation Driver attends and participates in facility in-service training, and
other continuing education, career and professional development opportunities.
-The attendant will assist the driver to secure the wheelchairs in the van/bus; and
-All residents, attendants, and the driver are to use seat belts while the van is in
motion.
1. Record review of Resident #78’s face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (any abnormal condition of the structure or function of brain
tissues, especially chronic, destructive, or [MEDICAL CONDITION] conditions); and
-[MEDICAL CONDITION] (a medical condition in which excess body fat has accumulated to the
extent that it can result in many serious, potentially life-threatening health problems).
Record review of the resident’s nurses notes dated 3/26/19 at 4:01 P.M. showed:
-Nurses were notified at 10:45 A.M. that resident had slid out of his/her wheelchair while
in the van.
-The resident was taken to the hospital for evaluation, and was on the way back to the
facility.
-The resident had no new orders from the hospital; and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that an
enteral feeding (tube feeding-the delivery of a nutritionally complete food, containing
protein, carbohydrate, fat, water, minerals, and vitamins, directly into the stomach) was
administered as ordered for one sampled resident (Resident #40) out of 23 sampled
residents. The facility census was 113 residents.
Record review of the facility’s policy titled Enteral Nutrition Feedings with a revised
date of (MONTH) 2019 showed:
-To provide enteral nutrition therapy to residents unable to obtain nutrition orally, when
such therapy is ordered by the physician and not clinically contraindicated.
-Intermittent (occurring at irregular intervals, not continuous or steady) enteral feeding

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to change a
Peripherally Inserted Central Catheter (PICC line- a thin, soft, long catheter (tube) that
is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in
a large vein that carries blood into the heart. The PICC line is used for long-term
intravenous (IV) antibiotics, nutrition or medications, and for blood draws) dressing and
to create a baseline care plan for the PICC line for one sampled resident (Resident #309)
out of 23 sampled residents. The facility census was 113 residents.
1. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s baseline care plan dated 4/5/19 showed there was no care
plan for the resident’s PICC line.
Record review of the resident’s skin/wound note dated 4/5/19 showed:
-The resident had non-healing chronic pressure ulcers (localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction); and
-The resident was being treated with intravenous (process of giving medication directly
into a resident’s vein) medication for wound infections.
Record review of the resident’s undated Treatment Administration Record (TAR)showed:
-A physician’s orders [REDACTED].
–There was no documentation that showed the resident’s PICC line dressing had been
changed on 4/5/19 or on 4/12/19.
During an interview and observation on 4/15/19 at 8:17 A.M. showed:
-The resident had a PICC line in his/her left upper, inner arm.
-The PICC line dressing was not dated and had brownish dirt on the edge of the bottom of
the dressing.
-The lower part of the PICC line dressing was lifting up from the resident’s skin; and
-The resident said the last time the PICC line dressing had been changed was before
his/her admission to the facility.
During an interview on 4/15/19 at 8:30 A.M., Licensed Practical Nurse (LPN) A said:
-The resident’s PICC line dressing was soiled and was not dated.
-The dressing should be changed by a Registered Nurse (RN) weekly and as needed; and
-When the dressing was changed, the nurse was supposed to date the PICC line dressing.
During an interview on 4/16/19 at 10:13 A.M. LPN D said:
-He/she thought the electronic medical record generated a baseline care plan.
-He/she was unsure who created/updated the baseline care plans; and
-A baseline care plan had not been created for the resident’s PICC line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure a
[MEDICAL CONDITION] (a surgical incision in the neck to allow a direct airway) was kept
clean; to suction the [MEDICAL CONDITION] as needed and to document suctioning had been
done for one sampled resident (Resident #610) out of 23 sampled residents. The facility
census was 113 residents.
Record review of the facility’s policy titled Oxygen Use dated 3/2017, showed:
-The staff was to make sure nothing was blocking the resident’s air openings.
-The staff was to document the air flow (liters per minute).
-The staff was to document the PSI levels (Oxygen level) and
-The staff was to make sure the air openings were not blocked.
Record review of the facility’s policy titled [MEDICAL CONDITION] care: dated 8/2018,
showed:
-Daily [MEDICAL CONDITION] care included cleaning the stoma (the surgical hole in the
neck).
-Clearing the [MEDICAL CONDITION] of secretions.
-Changing the inner cannula (the inside tube).
-Replacing the neck tie.
-The following information should be recorded in the resident’s medical record:
–The date and time of [MEDICAL CONDITION] care.
–The resident’s response to treatment.
–The amount and consistency of secretion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
communication between the facility and the [MEDICAL TREATMENT] (a mechanical way to filter
the blood from an artery, remove waste, purifying it, adding vital substances and
returning it to a vein when the kidneys stop functioning) treatment center was maintained
and ongoing to ensure the continuum of care; to assess and accurately chart the assessment
of the resident’s [MEDICAL TREATMENT] shunt (an implanted tube to which an artery and vein
is attached to provide a larger than normal volume of blood flow for effective [MEDICAL
TREATMENT]) site for the presence of the bruit (a turbulent blood flow through the blood
vessel heard by auscultation (listening for the sound with a stethoscope) and thrill (a
vibration felt by palpation (feeling with the finger tips) in the blood vessel) for four
sampled residents (Residents #608, #101, #67, and #88) and did not remove a surgical
dressing for weeks after a peritoneal [MEDICAL TREATMENT] shunt was removed for one
sampled resident (Resident #608) out of 23 sampled residents. The facility census was 113
residents.
Record review of the facility’s Hemo (blood) [MEDICAL TREATMENT] care policy dated Oct.
2014 showed:

Based on interview and record review, the facility failed to provide the 12 hours of
Dementia training for the staff as required. There are Dementia residents living in the
facility. The facility census was 113 residents.
1. Record review of the facility’s employees’ educational sheets showed:
-The education did not include any Dementia training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to meet the
behavioral needs for one sampled resident (Resident #102) out of 23 sampled residents by
not monitoring mood and behaviors for a resident with a long psychiatric history and a
psychiatric in-patient hospital stay for potential self-harm during his/her course of stay
at the facility; and to update the care plan to include his/her suicidal ideation and
monitoring of these potential behaviors. The facility census was 113 residents.
Record review of the facilities Behavioral Management policy dated 2/2019 showed:
-It is the policy of this facility to provide an interdisciplinary approach for the care
of the residents who exhibit problem behavioral symptoms which could lead to negative
consequences for themselves or others.
-Behavioral symptoms and approaches shall be placed in the residents-specific plan of care
and communicated to the care staff and other departments, as appropriate; and
-Residents with a history of behavior problems shall be properly monitored.
1. Record review of Resident #102’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION] (a mood disorder that causes a persistent feeling of sadness
and loss of interest).
-Personal history of self-harm.
-Alcohol dependence, in remission; and
-Cocaine abuse.
Record review of the resident’s physician’s orders [REDACTED].
-Trazadone 100 milligrams (mg) daily for depression.
-On 3/16/19:
–[MEDICATION NAME] 0.5 mg twice a day for anxiety (a psychiatric disorder causing
feelings of persistent anxiety); and
–[MEDICATION NAME] 40 mg daily (for depression).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the resident was
provided assistance with identifying community placement options and completing the
application process or in making arrangements for home care services or transfer to
another facility, according to the resident’s needs, to ensure one sampled resident
(Resident #158) out of 23 sampled residents had a safe and appropriate discharge. The
facility census was 113 residents.
1. Record review of Resident #158’s undated Face Sheet showed he/she was admitted to the
facility on [DATE] and was his/her own responsible party. A family member was listed as a
primary contact. The resident had [DIAGNOSES REDACTED].>-Stimulant Abuse (a condition
in which the use of one or more stimulant substances (drugs that raise the levels of
physiological or nervous activity in the body) leads to significant impairment or
physical, mental or social distress).
-[MEDICAL CONDITION] Disorder (a disorder associated with mood swings ranging from
depressive lows to manic (exaggerated excitement) highs); and
-Muscle Weakness.
Record review of the resident’s Baseline Care Plan, dated 12/18/18 showed:
-The resident’s initial discharge goals were to transfer to a Residential Care Facility
(RCF – a facility that provides basic supervision and personal care assistance with
activities such as hygiene and dressing); and
-The resident was receiving Rehabilitation Therapy (services that help a person regain
cognitive (mental) and/or physical abilities that have been lost or impaired as a result
of disease, lack of use or injury).
Record review of the resident’s Social Services note, dated 12/25/18 showed:
-The resident was cognitively intact.
-The resident’s Social Services Assessment had been completed; and
-The note contained no further information about the resident.
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 12/25/18,
showed:
-The resident was cognitively intact; and
-The resident was receiving Therapy services.
Record review of the resident’s Plans to Discharge into the Community Care Plan, dated
1/3/19 showed:
-The resident would be involved in discharge planning and assisted with applications for
community resources.

Based on interview and record review, the facility failed to ensure the narcotics were
counted every shift with accompanying signatures to verify the correct narcotic count, and
to ensure signatures were from an on-coming and off-going staff member. The facility
census was 113 residents
Record review of the Controlled Substances Policy, with a revised date of 2/11/19 showed:
-Nursing staff must count controlled medications at the end of each shift.
-The nurse coming on duty and the nurse going off duty must make the count together; and
-The staff must document and report any discrepancies to the Director of Nursing (DON).
1. Record review of the Eight Hour Verification of Controlled Substance Card Count for
(MONTH) 2019 showed:
-Medication cart one had:
–43 missing signatures out of 186 opportunities, resulting in a 23 percent (%) missing
rate.
–8 times both on-coming and off-going signatures were the same, resulting in a 4%
duplication rate.
-Medication cart two had:
–106 missing signatures out of 186 opportunities, resulting in a 57% missing rate.
–1 time both on-coming and off-going signatures were the same, resulting in a 0.005%
duplication rate.
-Medication cart three had:
–38 missing signatures out of 186 opportunities, resulting in a 20% missing rate; and
–3 times both on-coming and off-going signatures were the same, resulting in a 2%
duplication rate.
During an interview on 4/11/19 at 9:37 A.M., Certified Medication Technician (CMT) A said:
-On-coming and off-going staff count narcotics at the change of shift.
-They would sign the Eight Hour Verification of Controlled Substance Card Count sheet when
finished; and
-Discrepancies were reported to the DON.
During an interview on 4/19/19 at 10:57 A.M. the Director of Nursing (DON) said he/she
expected:
-Narcotics to be signed out immediately after given.
-To see narcotic counts done at every shift change with signatures; and
-Discrepancies to be reported to him/her.
At the time of exit, the facility had still not provided (MONTH) 2019 and (MONTH) 2019
Eight Hour Verification Of Controlled Substance Card Count sheets, after being requested.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide dental
services for one sampled resident (Resident #62) out of 23 sampled residents, who had
teeth in poor repair. The facility census was 113 residents.
Record review of the facility Dental Services policy revised 11/2017 showed routine and
emergency dental services were available to meet the resident’s oral health services in
accordance with the resident’s assessments and plan of care.
1. Record review of Resident #62’s Face Sheet showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to be completed by facility staff for care planning)
dated 5/21/18 showed the resident:
-Was cognitively intact; and
-Had no dental concerns.
Record review of the resident’s Care Plan revised on 11/8/18 showed the resident needed
the assistance of one staff member for Activities of Daily Living (ADLS-dressing, bathing,
and grooming).
During an observation and interview on 4/11/19 at 11:11 A.M., the resident said:
-He/she had broken teeth and missing teeth.

Based on observation and interview, the facility failed to refrigerate an open sauce jug;
to maintain clean floors in the walk-in refrigerator and freezer; and to keep the range
hood’s fire suppression nozzle pipes above the stove free from excessive grease build-up.
These practices potentially affected all residents who ate food from the kitchen. The
skilled nursing facility census was 113 residents with a licensed capacity for 180.
1. Observations during the kitchen inspection on 4/11/19 between 8:44 A.M. and 1:04 P.M.,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to educate all staff as to the
existence, whereabouts, and contents of a written, 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 113 residents with a licensed capacity of 180 residents.
Record review on 4/11/19 at 10:49 A.M. of the policies provided by the Dietary Manager
from the Dietary Manual binder showed three separate pages that were entitled Food Brought
in from Outside the Community with four procedure points, Guidelines for Families Bringing
Food in from Home with five points on food safety, and POLICY: Food From Outside Food
Sources with six points of ‘Policy Interpretation and Implementation, respectively, that
had no facility specific information and were obtained online from the Innovation Services
Diet Manual.
Record review of the policy entitled Food from Outside (Brought by Families) provided by
the Administrator showed a different generic document with seventeen points of Policy
Interpretation and Implementation obtained online that had the corporate logo added to the
upper right corner, but had not been individualized to the facility.
1. During an interview on 4/12/19 at 2:31 P.M., Licensed Practical Nurse (LPN) A said if
food is brought in from the outside:
– It has to match the resident’s diet.
– They confirm that the resident can feed him/herself.
– It’s put in the medication room refrigerator, and
– He/she did not believe the procedure was written down anywhere, they just learned of it
by word of mouth early on.
During an interview on 4/16/19 at 9:17 A.M., LPN D said if food is brought in from the
outside:
– The container is labeled with the resident’s name and dated.
– They will give it to the resident upon request.
– If not eaten, the food is only kept for three days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to establish and
maintain a comprehensive infection prevention and control program designed to help prevent
the development and transmission of water borne pathogens (a bacterium, virus, or other
microorganism that can cause disease) and to provide documented assessments for such an
outbreak. This deficient practice had the potential to affect all residents, visitors, and
staff who reside in, visit, use, or work in the facility; and to ensure [MEDICAL
CONDITION] (TB-a lung infection caused by a bacterium) testing was completed for one
sampled resident (Resident #309); to maintain sterile procedure while doing [MEDICAL
CONDITION] (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions) care (Trach care) for one sampled resident
(Resident #40); to ensure proper hand washing and/or hand sanitizing was completed with
glove changing [MEDICAL CONDITION] for one sampled resident (Resident #93), and to keep
oxygen tubing clean for one sampled resident (Resident #610) out of 23 sampled residents.
The facility census was 113 residents with a licensed capacity for 180.
Record review of the facility’s policy [MEDICAL CONDITION] Screening for Resident’s
updated on 11/2018 showed:
-All residents would receive a two-step TB test upon admission; and
-The policy did not direct the staff what to do if the resident refused the two-step TST
upon admission.
Record review of the facility’s Infection Control Program Policy last updated 2-2018
showed:
-Handwashing continues to be the primary means of preventing the transmission of
infection.
-The staff is educated on proper handwashing technique, when to wash hands and monitored
for compliance.
-Staff involved in direct resident care wear intact disposable gloves that are changed