OAKWOOD ESTATES NURSING & REHAB

**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 by
posting resident’s personal information on signs, not providing visual privacy, not
speaking to resident’s in a dignified manner, and by not covering residents during
incontinence care, for four residents (Resident #169, #216, #20, #320). The sample was 20.
The census was 96.
1. Review of Resident #169’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/1/19, showed:
-Focus: The resident has limited physical mobility related to weakness;
-Interventions:
-The resident is weight bearing;
-Provide gentle range of motion as tolerated with daily care;
-Provide supportive care and assistance with mobility as needed. Document assistance as
needed;
-Physical therapy (PT), occupational therapy (OT) as ordered as needed (PRN).
Review of the resident’s progress notes, dated 3/19/19, showed he/she had a fall on the
weekend of 3/9/19 through 3/10/19 when ambulating at night by him/herelf to bathroom.
Resident reported that his/her knee gave out.
Observation and interview of the resident on 3/21/19, showed the following:
-At 10:00 A.M., he/she sat in his/her room with the door open. He/she sat on the commode
next to his/her bed. The resident had a towel over his/her lap and, he/she was visible
from the hallway. Staff walked by the resident’s room, but did not look in the resident’s
direction. The Assistant Director of Nursing (ADON) walked by, but did not go into the
resident’s room;
-At 10:15 A.M., Certified Medication Technician (CMT) J arrived to the resident’s room and
placed the medication cart in front of the resident’s door. The resident continued to sit
on the commode in his/her room. The CMT entered the resident’s room, prepared and
administered the resident’s oral medication;
-At 10:21 A.M., CMT J was in the resident’s room while the door remained open. The
medication cart no longer sat in front of the resident’s door. The resident sat on the
commode. The towel no longer lay on the resident’s lap. The resident’s thigh and buttock
was exposed to the hallway as he/she sat on the commode;
-At 10:33 A.M., CMT J left the resident’s room and went to the next room. The resident
continued to sit on the commode, visible to the hall. The resident placed the towel over
his/her lap. Staff and visitors continued to walk by the resident’s room;
-At 11:00 A.M., the resident sat on the commode with a towel over his/her legs. The
resident said he/she waited for PT to assist him/her off the bedside commode, but they
never came back. The resident’s call light lay on his/her bed, out of reach. Two staff
entered the room with the resident’s roommate. The resident asked for assistance.
During an interview on 3/21/19 at 1:21 P.M., the resident said the incident today was not
the first time he/she was left on the commode. It happened during the night shift, and
he/she did not receive assistance until the next shift. The door was also left open. The
staff are rude and often ignore him/her when he/she needed help. The resident said the
room is located on a hall that has a lot of traffic. Staff and visitors have to walk on
his/her hall to get to the other halls in the facility, so they are able to look into

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to promote the
resident’s self-determination through support of resident choices when staff failed ensure
a system to accommodate a resident’s choice for being in an intimate relationship
(Resident #63). The sample was 20. The facility census was 97.
Review of Resident #63’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/26/18, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have written authorization
for management of personal funds for eight out of a sample of 10 resident reviewed for
funds authorization (Resident #122, #272, #47, #18, #66, #38, #15, and #67). The census
was 97.

Based on interview and record review, the facility failed to provide quarterly resident
fund statements within 30 days after the end of the quarter and failed to provide bank
statement for four out of 12 months. In addition, the facility failed to ensure resident
trust fund (RTF) accounts were not overdrawn for 13 additional residents reviewed for
accounting of funds (Resident #316, #170, #171, #124, #12, #30, #215, #43, #65, #35, #50,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to return money in a timely
manner for six sampled residents who were discharged from the facility (Resident #173,
#174, #66, #6, #176, and #175). The census was 97.
1. Review of Resident #173’s medical record, showed the resident discharged on [DATE].
Review of the resident trust fund (RTF) statement, dated [DATE], showed a balance of
$30.00.
2. Review of Resident #174’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $28.22.
3. Review of Resident #66’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $2,423.24.
4. Review of Resident #6’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $9.01.
5. Review of Resident #176’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $1,267.02.
6. Review of Resident #175’s medical record, showed the resident discharged on [DATE].

Based on interview and record review, the facility failed to maintain an approved surety
bond to ensure the protection of resident funds. The census was 96.
Review of the Department of Health and Senior Services approved bond list, showed the
facility did not have an approved surety bond.
1. Review of the resident trust fund account, for (MONTH) (YEAR) through (MONTH) 2019,
showed an average monthly balance of $33,000.00 which would required a surety bond of
$49,500.00.
2. Review of the facility’s yearly bond renewal, showed:
-September 2014 through (MONTH) (YEAR), the facility’s bond was $70,000;
-September (YEAR) through (MONTH) (YEAR), the facility’s bond was $50,000;
-September (YEAR) through (MONTH) 2019, the facility’s bond was $60,000.
3. During an interview on 3/26/19 at 12:00 P.M., the Business Office Manager said the
current surety bond was $60,000. He/she did not have documentation to show that the surety
bond was approved by Department of Health and Senior Services. He/she had been at the
facility for one month and was not aware that the surety bond was not approved.
4. During an interview on 3/26/19 at 12:35 P.M., the administrator said he would expect
the facility to have an approved surety bond. He received documentation from their
corporate office that DHSS approved their bond.
Review of the facility’s surety bond letter, dated 3/26/19, showed DHSS approved the
surety bond for $60,000.
5. During an interview on 3/26/19 at 1:00 P.M., the administrator and Business Office
Manager confirmed the surety bond was approved on 3/26/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident’s right to
request, refuse, and/or discontinue treatment by failing to obtain physician orders

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a
comfortable homelike environment and ensure resident room temperatures remained between a
temperature range of 71 degrees to 81 degrees Fahrenheit (F) for one of 20 sampled
residents (Residents #18). The census was 96.
Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/25/18, showed the following:
-Cognitively intact;
-Independent with all activities of daily living (ADLs);
-Ambulatory;
-No behaviors;
-[DIAGNOSES REDACTED].
During an observation and interview on 3/22/19 12:42 P.M., showed the resident sat in
his/her bed beside his/her window. The window raised approximately 5 inches, a small fan
sat on a bedside table beside the window. The resident said his/her room was always hot
and he/she just sits in his/her room and sweats. It was so hot and he/she had difficulty
sleeping due to the heat. He/she wanted to sleep naked to help stay cool, but was fearful
someone would walk in. He/she complained about his/her room being so hot, and the social
worker gave him/her the fan to use to help cool the room. The residents have a designated
smoking area outside his/her room and the fan pulls the smoke inside his/her room, and the
smoke burned his/her eyes. He/she would open his/her door to help cool the room down, but
the resident’s walk by and stare at him/her like someone looking at an animal in a zoo,
which made him/her feel uncomfortable. He/she complained to staff all the time about the
heat, but nothing was done about it. Observation at this time, showed the surveyor used a
calibrated digital thermometer to take the temperature of the resident’s room and the
temperature gauge, showed 89.1 degrees F.
During an interview on 3/22/19 at 12:45 P.M., the social worker said he was not aware the
resident had complained about his/her room being too warm and could not remember if he/she
gave the resident a fan to use.
During an interview on 3/22/19 at 12:51 P.M., the maintenance director said the previous
maintenance director had been terminated recently and he had just taken over the position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their abuse, neglect,
misappropriation policy for lost or stolen money for one resident who reported an
allegation of missing money (Resident #272). The census was 96.
Review of the facility’s Abuse, Neglect, Mistreatment and Misappropriation of Resident
Property policy, dated (MONTH) 17, (YEAR), showed:
-Investigation procedures:
-The appointed investigator will, at minimum, attempt to interview the person who reported
the incident, anyone who likely to have knowledge of the incident and the resident if
interviewable;
-Any written statements that have been submitted will be reviewed, along with any
pertinent medical records or other documents.
Review of Resident #272’s care plan, in use during the survey, showed:
-Focus: Problems with keeping track of my money related to [MEDICAL CONDITION]. On (MONTH)
16, 2019, the resident was unable to locate $10 that was in his/her wallet;
-Goal: Keep money locked in the lock box in the reception office;
-Interventions included: Assist to the reception office to get a few dollars for snacks.
Inform of the amount and denomination of money given.
Review of the facility’s investigation showed:
-The resident resided on the 300 hall;
-No staff interviews conducted regarding the resident’s missing money;
-No review of the video footage, of the camera on 300 hall during the investigation.
During an interview on 3/26/19 at 9:00 A.M., the administrator said the data on the video
(on the resident’s hall) was gone.
During an interview on 3/27/19 at 10:35 A.M., the Director of Nursing (DON) said if items
are reported lost or stolen, she completes a self-report. The facility staff would search
to find the items or money that was reported missing. Residents and the staff that work on
that unit are to be interviewed. The facility should have interviewed the staff on that
unit before now and should have attempted to review the camera/video.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written Emergency
Transfer notices to residents and/or representatives as soon as practicable when a
resident is temporarily transferred on an emergency basis to an acute care facility and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide written notice to the
resident or their legal representative of the facility bed hold policy at the time of
transfer to the hospital, for seven of 20 sampled residents, who were recently transferred
to the hospital for various medical reasons (Residents #64, #47, #56, #320, #62, #116 and
#267). The census was 96.
1. Review of Resident #64’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];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
2. Review of Resident #47’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
3. Review of Resident #56’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfer.
4. Review of Resident #320’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
5. Review of Resident #62’s medical record, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a comprehensive
assessment of a resident’s needs, strengths, goals, life history and preferences, using
the resident assessment instrument (RAI) specified by the Centers for Medicare and
Medicaid Service (CMS) within 14 calendar days after admission and not less than once
every 12 months, for three of 24 residents reviewed for resident assessments (Resident
#62, #17 and #122). The census was 96.
1. During an interview on 3/26/19 at 11:16 A.M., the Director of Nursing (DON) said,
currently the facility does not have a Minimum Data Set (MDS, a federally mandated
assessment instrument completed by facility staff) coordinator and MDS assessments are not
being completed.
2. Review of Resident #62’s medical record, showed:
-admitted on [DATE];

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to assess residents using the
quarterly review instrument specified by the State and approved by the Centers for
Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 17
of 24 residents reviewed for resident assessments (Resident #22, #16, #5, #10, #21, #7,
#9, #18, #12, #38, #13, #19, #15, #4, #11, #10, and #116). The census was 96.
1. During an interview on 3/26/19 at 11:16 A.M., the Director of Nursing (DON) said,
currently the facility does not have a Minimum Data Set (MDS, a federally mandated
assessment instrument completed by facility staff) coordinator and MDS assessments are not
being completed.
2. Review of Resident #22’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
3. Review of Resident #16’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
4. Review of Resident #5’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
5. Review of Resident #20’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
6. Review of Resident #21’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
7. Review of Resident #7’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
8. Review of Resident #9’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
9. Review of Resident #18’s medical record, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to encode and be capable of
transmitting the resident assessment instrument within 7 days after completing a
resident’s assessment, to include a subset of items upon a resident’s transfer, reentry,
discharge, and death, for eight of 24 residents reviewed for resident assessments
(Resident #21, #8, #19, #4, #6, #63, #122 and #267). In addition, the facility failed to
electronically transmit encoded, accurate, and complete Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) data to the Centers for
Medicare and Medicaid Services (CMS) system within 14 days after a facility completes a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure the
resident’s Minimum Data Set (MDS, a federally mandated assessment instrument completed by
facility staff) accurately reflect the resident’s status for three of 20 sampled residents
(Resident #38, #33 and #7). The census was 96.
1. Review of Resident #38’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Stroke not documented as a diagnoses.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Issues communicating due to stroke;
-Goal: The resident will maintain current level of communication function by being able to
verbalize needs;
-Interventions: Discuss with resident/family concerns or feelings regarding communication
difficulty. Encourage resident to continue stating thoughts even if resident is having
difficulty. Focus on a word or phrase that makes sense, or responds to the feeling
resident is trying to express. Monitor/document for physical/nonverbal indicators of
discomfort or distress, and follow-up as needed.
2. Review of Resident #33’s significant change MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].>-Special services received while a resident: Hospice Care;
-Does the resident have a condition or chronic disease that may result in life expectancy
less than six months: No;
-Staff failed to accurately document the resident’s condition resulted in a life
expectancy of less than six months necessitating hospice services.
Review of the resident’s physician order [REDACTED].>Review of the resident’s care
plan, updated on [DATE], and in use during the survey, showed:
-Problem: Resident has a terminal prognosis related to late effects stroke. Hospice care;
-Goal: Comfort will be maintained;
-Interventions included: Consult with physician and social services to have Hospice care
in the facility.
3. Review of Resident #7’s quarterly MDS, dated [DATE], showed the following:
-Cognitively impaired;
-Ambulatory;
-Vision adequate, can see fine detail, no corrective lenses;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed:
-Problem: At risk for falls due to confusion, gait/balance problems, psychoactive drug
use, unaware of safety needs, and vision/hearing problems due to dementia;
-Approach: Anticipate the resident’s needs. Educate the resident/family/caregivers about
safety reminders and what to do if a fall occurs.
During an observation on [DATE] at 12:36 P.M., Certified Nursing Assistant (CNA) BB
assisted the resident to the small dining room inside the secured unit. As the resident
leaned onto CNA BB’s right side, CNA BB wrapped his/her right arm around the resident’s

**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 (PASARR) level II screen is required) as required,
for two of 20 sampled residents (Resident #216 and #116). The census was 96.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASARR 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 a nursing
facility to ensure the client does not trigger a Level II screening. A Level II screening
refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II;
-The triggers for the Level II screening are:
-The client has had inpatient psychiatric treatment in the past two years;
-The client was suicidal or homicidal (includes dementia clients);
-The client has very aggressive behavior (includes dementia clients);
-The client has a [DIAGNOSES REDACTED].
1. Review of Resident #216’s medical record, showed:
-admitted to the facility on [DATE];
-Resided in a Medicaid certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen or PASARR Level II screen found.
2. Review of Resident #116’s medical record, showed:
-admitted to the facility on [DATE];
-Resided in a Medicaid certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen or PASARR Level II screen found.
3. During an interview on 3/27/19 at 8:05 A.M., the Social Service Designee (SSD) said
they were unable to locate any DA 124 Level I or PASARR Level II screen for either
resident and would need to request a copy.

**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 for each resident that includes the instructions needed to
provide effective and person-centered care of the resident that meet professional
standards of quality, by not including the minimum healthcare information for one out of
four newly admitted sampled residents (Resident #320). The census was 96.
Review of Resident #320’s medical record, reviewed on 3/22/19 at 2:05 P.M., showed:
-admitted [DATE];
-Medical [DIAGNOSES REDACTED].
-A health status progress note dated 3/5/19 at 5:03 P.M., showed incontinent of bowel and
bladder. Oxygen at 2 or 3 liters per minute;
-A social service progress note dated 3/6/19 at 12:35 P.M., showed the resident:
-Alert and oriented times two (able to recall person and place), with some confusion and
forgetfulness;
-Required limited assistance of one to two staff for transfers and assistance of one
staff for activities of daily living (ADL’s bathing, toileting, dressing, etc.);
-Propelled self by wheelchair.
Review of the resident’s baseline care plan, dated 3/7/19 and reviewed on 3/25/19 at 3:34
P.M., showed:
-No documented [DIAGNOSES REDACTED].
-No documentation of incontinence of bowel and bladder or assistance required with ADLs
with the corresponding goals and person centered interventions.
Observation on 3/21/19 at 12:48 P.M., showed the Assistant Director of Nursing (ADON) and
the Director of Nursing (DON) transfer the resident from his/her wheelchair with use of a
gait belt. The resident was soaked with urine
Observations on 3/22/19 at 6:50 A.M., showed the resident lay naked in his/her urine
soaked bed, an oxygen nasal cannula was wrapped around the handle bar on the back of the
resident’s wheelchair, there was no oxygen tubing connected to the concentrator located at
the bedside.
During an interview on 3/26/19 at 2:19 P.M., the DON said:
-Base line care plans should include information from the transfer forms and assessments
from the admitting nurses, pertinent medical diagnoses, oxygen therapy, and ADL needs;
-The admitting nurse is responsible for creating the base line care plan;
-The ADON is responsible for checking the base line care plans for accuracy.

**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 ensure a
resident who is unable to carry out activities of daily living (ADLs) receives the
necessary services to maintain good nutrition, grooming, and personal hygiene, for four of
four observations of incontinence care (Residents #42, #37, #20 and #320). The sample was
20. The census was 96.
Review of the facility’s perineal (the surface area between the thighs, extending from

Assistant (CNA) Q washed hands, put on gloves and provided the resident with care. CNA Q
removed a half full with urine plastic urinal from between the resident’s legs, wet a wash
cloth with water, applied body wash and shampoo to a cloth, cleaned the central area of
the genitals, from back to front with one swipe of the wash cloth, dried the area, covered
the resident, removed gloves and left the resident’s room. At 7:45 A.M., CNA Q returned to
the room with CNA F. Both CNAs washed hands and put on gloves. CNA F turned the resident
onto his/her right side, washed and dried the resident’s left hip, buttocks and rectal
area and turned the resident onto his/her left side. They washed and dried the resident’s
right hip and buttocks, placed a clean incontinence pad underneath the resident, turned
the resident onto his/her back, placed an empty urinal between his/her legs and covered
the resident. Both CNAs removed their soiled gloves, washed their hands and left the
resident’s room. Neither CNA washed the resident’s entire genital area, or rinsed the soap
off of the resident’s skin prior to leaving the room.
Review of the bottle of Soothe and Cool body wash and shampoo, showed to rinse the skin
thoroughly.
2. Review of Resident #37’s annual MDS, dated [DATE], showed:
-Cognitive status not assessed;
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 3/25/19 at 6:15 A.M., showed the resident lay in bed awake. CNA Z washed
hands, put on gloves and provided the resident with care. CNA Z filled a wash basin with
water, placed Smooth and Cool soap into the wash basin, causing the water to become
visibly soapy. CNA Z removed the resident’s urine and stool soiled adult incontinence
brief, turned the resident onto his/her left side, washed and dried the right hip and
rectal area, placed a clean incontinence brief on the resident, dressed and transferred
the resident into his/her wheelchair. He/she removed his/her soiled gloves, washed hands
and left the resident’s room. CNA Z did not wash the resident’s entire genital area, hips
or buttocks to ensure all of the urine and stool had been removed from the resident’s
skin, nor did he/she rinse the soap from the skin prior to dressing and transferring
him/her into the wheelchair.
3. Review of Resident #20’s annual MDS, dated [DATE], showed:
-Brief interview for mental status (BIMS) score of 6 out of 15, indicating severe
cognitive impairment;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with pressure ulcers receive necessary treatment and services, consistent with
professional standards of practice, to promote healing, prevent infection and prevent new
ulcers from developing. This resulted in one resident with a history of pressure ulcers
developing new stage III pressure ulcers and worsening of two stage II pressure ulcers
into an unstageable pressure ulcer when the facility failed to monitor the resident’s
skin, accurately assess and document wound observations, and obtain treatment orders
timely after staff reported to the nurse the resident had new open areas (Resident #267).
In addition, issues were identified with three additional residents who developed new
and/or worsening pressure ulcers when the facility failed to follow physician orders,
accurately assess and document wound observations, report new and deteriorating pressure
ulcers to the physician and use proper technique when treating wounds to prevent infection
(Residents #59, #33 and #116). The facility identified seven residents with pressure
ulcers and all seven were included in the sample of 20. The census was 96.
Review of the facility’s undated Measurement, Assessment of Pressure Ulcers, Wounds and
Other Skin Problems policy, showed:
-At first observation of any skin condition, the charge nurse or treatment nurse is
responsible to measure and describe skin condition in the clinical record;
-All measurements will be recorded in centimeters. All ulcers will be measured weekly and
results recorded;
-Identify the type of ulcer. The medical record should clearly support the clinical basis
for the determination of etiology (cause) of the ulcer;
-Identify the stage or extend of tissue destruction involved;
-Ulcer assessment:
-Obtain length, width and depth;
-Assess wound/skin condition for drainage and record type and amount;
-Assess for presence of necrotic (dead) tissue;
-Assess for presence of granulation tissue (new tissue growth);
-Assess the periwound (skin surrounding the wound) and wound edges;
-Assess odor and pain;
-Describe any problems with adherence to treatment of [REDACTED]. Example: Refuses
treatment or to relieve pressure.
1. Review of Resident #267’s medical record, showed:
-[DIAGNOSES REDACTED].
-A Braden assessment (used for predicting pressure ulcer (injury to the skin and/or
underlying tissue, as a result of pressure or friction) risk), dated 3/4/19, showed a
score of 17, which indicated the resident at risk for pressure ulcers;
-A Braden assessment dated [DATE], showed a score of 14, which indicated the resident at

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with an indwelling urinary catheter (a tube inserted into the bladder for the purpose of
continual urine drainage), received the appropriate care and services to prevent urinary
tract infections to the extent possible by failing to maintain proper placement of
indwelling urinary catheter tubing and obtain orders for catheter use. The facility
identified four residents as having indwelling urinary catheters. Three of those were
chosen for the sample. Of those three, problems were found with one (Resident #10). The
sample was 20. The census was 96.
Review of the Resident #10’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/13/19, showed:
-Focus: Resident has suprapubic catheter (a sterile tube inserted into the bladder through
the abdominal wall to drain urine), and [MEDICAL CONDITION] bladder (the bladder does not
empty properly due to a neurological condition);
-Approach:
-Monthly and as needed (PRN), urologist comes to the facility to change catheter;
-Check tubing for kinks each shift;
-Monitor for signs and symptoms of discomfort on urination and frequency;
-Monitor/record/report to MD for signs and symptoms of urinary tract infection: pain,
burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased
pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills,
altered mental status, change in behavior, change in eating patterns;
-Focus: Resident has a urinary tract infection [MEDICAL CONDITION] related suprapubic
catheter and recurrent UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary respiratory care and services consistent with professional standards of practice
by not following physician orders for oxygen therapy, failing to provide ongoing
assessment and documentation of the resident’s respiratory status and response to oxygen
therapy and failing to care plan interventions for oxygen therapy. As a result, the
resident experienced acute on chronic [MEDICAL CONDITION] (inability to breathe) which
required re-hospitalization , for one resident (Resident #320). In addition, the facility
failed to obtain orders for oxygen usage for one resident (Resident #63). The sample was
20. The census was 96.
1. Review of the Resident #320’s hospital records, dated 3/5/19, showed:
-Hospital admitted [DATE];
-Resident was wheelchair bound and oxygen dependent and was found by nursing home staff
unresponsive, lying on the floor without supplemental oxygen. The resident’s blood oxygen
saturation rate was 77% on room air. Emergency personnel were called for transport to
emergency room ;
-On arrival at emergency room , the resident was intubated (insertion of a tube through
the mouth into the airway) and placed on mechanical ventilation (a machine that helps a
person breathe when they cannot breathe on their own).
Review of the resident’s hospital discharge orders, dated 3/5/19, showed:
-Discharge [DIAGNOSES REDACTED].>-Oxygen Saturation (percentage of oxygen in the
blood), check as needed for respiratory distress (difficulty breathing) or change in
condition per nurse assessment;
-Oxygen instructions: Oxygen at 3 Liters (L) per minute by nasal cannula (a devise for
delivering oxygen by way of two small tubes that are inserted into the nares)
continuously.
Review of the resident’s facility medical record, showed:
-Readmission date of [DATE];

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that
residents who require [MEDICAL TREATMENT] (the process of filtering toxins from the blood
in individuals with kidney failure) receive such services, consistent with professional
standards of practice, by failing to obtain physician orders [REDACTED]. The facility
identified two residents who received [MEDICAL TREATMENT]. Of those two, one was selected
for the sample and issues were identified for this resident (Residents #122). In addition,
the facility failed to provide a [MEDICAL TREATMENT] policy. The sample size was 20. The
census was 96.
Review of Resident 122’s care plan, in use during the survey, showed:
-Check and change [MEDICAL TREATMENT] dressing daily at access site;
-Encourage resident to go for scheduled [MEDICAL TREATMENT] appointments;
-Monitor vital signs. Notify physician of significant abnormalities;
-Monitor/document report to physician as needed any signs or symptoms of infection to
access site: Redness, swelling, warmth, or drainage;
-Monitor/document for [MEDICAL CONDITION] (swelling);
-Monitor/document report as needed for signs or symptoms of renal (kidney) insufficiency:
changes in levels of consciousness, changes in skin turgor, oral mucosa, changes in heart
and lung sounds;
-Monitor/document report as needed any signs or symptoms of the following: bleeding,
hemorrhage (bleed) bacteremia (blood infection), septic shock.
Review of the resident’s physician order [REDACTED].
-No order for the resident to receive [MEDICAL TREATMENT], where or how often;
-No order to check the thrill and bruit (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 monitor [MEDICAL TREATMENT] site for bleeding.
Review of the resident’s Medication Administration Record [REDACTED]
-No documentation of the [MEDICAL TREATMENT] site monitored for bleeding;
-No documentation staff checked for bruit and thrill.
During interviews on 3/26/19 at 5:43 P.M. and 3/27/19 at 10:30 A.M., the Director of
Nursing (DON) said the facility does not have a [MEDICAL TREATMENT] policy. She would
expect there to be an order for [REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff had
the appropriate competencies and skills sets to provide nursing and related services to
assure resident safety and attain or maintain the highest practicable physical, mental,
and psychosocial well-being for each resident when they failed to demonstrate competency
in symptoms of [MEDICAL CONDITION] (lack of oxygen in the body), oxygen settings and use
when a resident with a history of [MEDICAL CONDITION] and pneumonia had an empty oxygen
tank (Resident #320), failed to demonstrate competency in resident self-determination and
choice (Resident #63) and failed to demonstrate competency on the facility [MEDICAL
CONDITION] (TB) screening policy by not assuring staff had no contact with residents until
after their first step Purified Protein Derivative (PPD). In addition, the facility failed
to ensure each nurse aide had no less than 12 hours of in-service education per year to
address resident care needs and/or deficient areas, as observed during the annual survey,
for five of five certified nursing assistants (CNAs) sampled. The census was 96.
1. Review of the Resident #320’s medical record, on 3/22/19 at 2:05 P.M., showed:
-admitted [DATE];
-Medical [DIAGNOSES REDACTED].
Review of the resident’s hospital discharge orders, dated 3/5/19, showed:
-Discharge [DIAGNOSES REDACTED].>-Oxygen Saturation (O2 sat, amount of oxygen in blood)
– Check as needed for respiratory distress (difficulty breathing) or change in patient’s
condition per nurse assessment;
-Oxygen instructions – Oxygen at 3 Liters (L) per minute by nasal cannula (a devise for
delivering oxygen by way of two small tubes that are inserted into the nares)
continuously.
Review of the physician order [REDACTED].
-No orders for oxygen therapy;
-No orders for oxygen saturation tests.
Observations on 3/21/19, showed:
-At 10:45 A.M., the resident sat in his/her wheelchair in his/her bedroom with his/her
chin to his/her chest and his/her body slumped over the right side of the wheelchair.
His/her right arm dangled down to the wheelbase. An oxygen condenser unit alongside the
resident’s bed, not in use. An empty oxygen tank attached to the back of his/her wheel
chair and the resident wore a nasal cannula connected to the empty oxygen tank. At 11:53
A.M., Certified Nurse Assistant (CNA) M entered the resident’s room and immediately exited
the room and said he/she needed clean supplies. CNA M did not recognize the resident’s
symptoms of possible [MEDICAL CONDITION] and/or offer to assist the resident;
-At 12:43 P.M., the resident propelled him/herself down the hall, with the empty oxygen
tank attached to the back of his/her wheel chair. He/she shouting Help me, please help me!
Clinical Support N was located in the hall and passed water and ice to residents and
responded, Yep and walked away. A nurse in the hall passed medication from a medication
cart. He/she failed to respond to the resident’s pleas for help. The resident continued to
propel him/herself down the hall towards the nurse’s station, by pulling on the handrails,
grunting, cursing and calling for help. There were several nursing staff members at the
nurse’s station within ear shot and view of the resident. No one responded to his/her
shouts for help. No staff recognized the resident’s symptoms of distress;
-At 12:47 P.M., The Assistant Director of Nursing (ADON) saw the resident at the nurse’s

Based on observation, interview and record review, the facility failed to ensure each
nurse aide had no less than twelve hours of in-service education per year based on their
individual performance review, calculated by their employment date rather than the
calendar year, for five of five certified nursing assistants (CNAs) employed at the
facility for more than one year. In addition, the facility failed to provide in-service
training on topics identified as deficient during the current annual survey. The census
was 96.
Observation on 3/26/19 at approximately 12:00 P.M., showed a stack of in-service sign in
sheets for a variety of topics provided by the Director of Nursing (DON). Review of the
sign in sheets, showed no indication of how many minutes/hours each in-service included or
a tracking of CNA in-service training hours. On 3/26/19 at 4:57 P.M., the nurse educator
provided additional documentation of CNA in-service training hours tracked since she took
over the position in (MONTH) (YEAR).
1. Review of CNA Q’s employee filed, showed date of hire (DOH) 1/1/99.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 2 hours of in-service training provided;
-An in-service tracking log, dated 2019, showed 2 hours and 30 minutes of in-service
training provided;
-No in-service training provided on emergency protocol, Health Insurance Portability and
Accountability Act (HIPAA)/privacy, dementia care, transfers, activity of daily living
(ADL) care, accidents/safety, range of motion (ROM), turning/repositioning, pressure ulcer
prevention, and oxygen use.

Based on observation and interview, the facility failed to post the number of licensed and
non-licensed nursing staff for each shift that were directly responsible for resident
care, for four of five days of the survey and failed to post the facility census, the
total hours for the licensed and non-licensed nursing staff for each shift and failed to
maintain the daily nurse staffing data for a minimum of 18 months as required. The census
was 96.
Observation on 3/21/19 at 9:50 A.M., showed the facility’s nursing staff information
posted, which contained the name of the facility, date, total number of licensed and
non-licensed nursing staff for the day, evening and night shift, but contained no census
or number of hours worked for licensed and non-licensed nursing staff for each shift
responsible for resident care.
Observation on 3/22/19 at 8:00 A.M., on 3/25/19 at 6:00 A.M., 7:44 A.M., and 3:45 P.M., on
3/26/19 at 6:24 A.M. and at 4:23 P.M., and on 3/27/19 at 8:39 A.M., showed the facility’s
nursing staff information posted, dated 3/21/19, remained posted and had not been changed.
During an interview on 3/27/19 at 11:39 A.M., the staffing coordinator said he/she is
responsible for posting the nursing hours, and had just posted the nursing hours for
3/27/19. He/she started working as the staff coordinator in (MONTH) (YEAR) and is pulled
to work the floor frequently and does not get the hours posted on those days.
During an interview on 3/27/19 at 12:08 P.M., the staffing coordinator said he/she was
unaware he/she had to maintain the posted daily nursing hours for 18 months and had not
been keeping them and was not aware the posted information needed to include the census,
the number of licensed and non-licensed nursing staff as well as the total hours for the
licensed and non-licensed nursing staff responsible for resident care.

**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 displays or is diagnosed with [REDACTED]. In addition, the facility failed to
develop a personalized plan of care to ensure services to promote the resident’s highest
level of functioning and psychosocial needs, for one out of 20 sampled residents (Resident
#63). The facility census was 97.
Review of Resident #63’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/11/18, showed:
-Focus: He/she is verbally aggressive related to ineffective coping skills and poor
impulse control. Resident has a history of using profanity towards staff, residents, and
roommates. He/she had several roommates. He/she does not have a roommate long due to
conflict with the roommate and/or their visitor. He/she is not willing to compromise areas
of the room with others. He/she also has a history of making false allegations against
roommates;
-Interventions: Administer medications as ordered. Monitor/document for side effects and

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation when the controlled substance shift change count check sheets were
missing documentation for six of the six facility medication carts. The facility census
was 96.
Review of the facility’s undated Controlled Substance Storage and Handling policy, showed:
-Policy: Controlled substances (medication in Schedule II, III, IV, V) have high abuse
potential and may be subjected to special handling, storage, and record keeping;
-All Class II controlled substances will be counted each shift or whenever there is an
exchange of keys between off-going and on-coming licensed nurses. The two nurses will:
-Both nurses will count the number of packages of controlled substances that are being
reconciled during the shift/shift count and document on the shift controlled substance
count sheet;
-Two nurses will sign the shift/shift controlled substance count sheets acknowledging
that the actual count of controlled substances and count sheet matches the quantity
documented;
-Any discrepancy in the count of controlled substances shall be reported in writing to
the responsible supervisor and a signed entry shall be recorded on the page where the
discrepancy is found;
-The supervisor shall institute an investigation to determine the reason for the
discrepancy. The record shall then be updated;
-The consultant pharmacist shall make regular checks of the handling, storage, and
recording of controlled substances.
1. Review on 3/25/19 at 6:10 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the nurse’s cart for the 100 hall, showed:
-12 out of 73 shifts with one nurse documented count of narcotics;
-8 out of 73 shifts count of narcotics without nurses documented;
-18 out of 73 shifts without count of narcotics.
2. Review on 3/25/19 at 6:20 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the certified medical technician’s (CMT) cart
for the 100 hall, showed:
-27 out of 73 shifts with one nurse documented count of narcotics;
-13 out of 73 shifts count of narcotics without nurses documented;
-26 out of 73 shifts without count of narcotics count of narcotics.
3. Review on 3/25/19 at 6:30 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the CMT cart for the 300 hall, showed:
-29 out of 73 shifts with one nurse documented count of narcotics;
-12 out of 73 shifts count of narcotics without nurses documented;
-29 out of 73 shifts without count of narcotics.
4. Observation on 3/25/19 at 6:30 A.M., showed Nurse BB pre-signed his/her initials in the
off-going nurse column on the facility’s controlled substance shift change count check
sheet, dated (MONTH) 2019, for the CMT’s cart for the 300 hall.
5. Review on 3/25/19 at 7:45 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the medication cart for the 400/500 hall,
showed:

**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 received hypnotic medications had regularly scheduled evaluations and
assessments. The facility also failed to document a clinical rationale for the use of
hypnotics and failed to ensure staff documented a need or reason that supported the use
for one of 20 sampled residents (Resident #10). The census was 96.
Review of Resident #10’s significant change Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/15/18, showed the following:
-Brief Interview for Mental Status (BIMS) score of 15 out of 15, showed the resident
cognitively intact;
-[DIAGNOSES REDACTED].
-Total dependence for transfers, dressing, eating, and hygiene;
-Antidepressants and opioids administered in the last seven days;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure as needed (PRN) orders
for [MEDICAL CONDITION] drugs are limited to 14 day unless the attending physician or
prescribing practitioner believes that it is appropriate for the PRN order to be extended
beyond 14 days, document their rationale in the resident’s medical record and indicate the
duration for the PRN order, for two out of 20 sampled residents (Residents #59 and #47).
The census was 96.
1. Review of Resident #59’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/19/18, showed:
-Short term and long term memory problems;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s physician orders, dated (MONTH) 2019 and reviewed on 3/22/19,
showed and order dated 3/1/19, for [MEDICATION NAME] (antipsychotic medication used to
treat mental illness, behavior problems, and agitation) 2 milligram (mg), give every 2
hours PRN for agitation or anxiety.
Review of the resident’s medical record, showed no documentation the resident’s physician
evaluated the need for the continued order for the [MEDICATION NAME].
2. Review of Resident # 47’s quarterly MDS, dated [DATE], showed:
-Short term and long term memory problems;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s physician orders, dated (MONTH) 2019 and reviewed on 3/25/19,
showed an order dated 2/25/19, for [MEDICATION NAME] ([MEDICAL CONDITION] medication used
to treat anxiety) 2 mg per milliliter (ml), take 0.5 ml three times a day as needed.
Review of the resident’s medical record, showed no documentation the resident’s physician
evaluated the need for the continued order for the [MEDICATION NAME].
3. During an interview on 3/26/19 at 2:19 P.M., the Director of Nursing (DON) said PRN
[MEDICAL CONDITION] medications should get renewed every 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 34 opportunities observed, three errors
occurred resulting in an 8.82% medication error rate (Residents #124, #42 and #17). The
census was 96.
1. Review of Resident #124’s physician order [REDACTED].
-Diagnoses included [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease);
-An order dated 3/13/19, to administer [MEDICATION NAME] (used for treatment of
[REDACTED].
Observation on 3/22/19 at 8:58 A.M., showed Certified Medication Tech (CMT) J administered
1 puff of the [MEDICATION NAME] to the resident, waited 30 seconds and administered the
second puff of the inhaler.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure drugs and
biologicals were labeled and stored in accordance with currently accepted professional
standards in two of two medication storage rooms. The census was 96.
Review of the facility’s undated medication storage policy, showed:
-Policy: Medications and biological are stored safely, securely, and properly following

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide or obtain laboratory
services to meet the needs of its residents for one of 20 sampled residents (Resident
#167). The census was 96.
Review of Resident #167’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 3/20/19, for [MEDICATION NAME] trough (monitor levels of the antibiotic
[MEDICATION NAME] in the blood) twice a week;
-An order, dated 3/20/19, for complete blood count (CBC, screening test to determine
general health status) lab;
-An order, dated 3/20/19, for comprehensive metabolic count, (CMP, a test that provides
information of the body’s chemical balance and metabolism) lab;
-An order, dated 3/20/19, for [MEDICATION NAME] 1250 milligram (mg) /250 milliliter (ml)
infuse 250 ml (1,250 total) intravenous every 12 hours at 9:00 A.M. and 9:00 P.M.
Review of the resident’s lab results, showed the following:
-A lab result, dated 3/21/19, for [MEDICATION NAME] trough, showed normal range;
-No lab result for CMP or CBC.
During an interview on 3/26/19 at 3:13 P.M., the Director of Nursing (DON) said the charge
nurse was responsible for ensuring the labs are completed as ordered. The DON confirmed
that the resident was admitted on [DATE]. She would expect to see a completed CMP, CBC,
and one more [MEDICATION NAME] trough level by this time. The lab for CBC and CMP were not
completed. It is important for the resident’s labs to be completed as ordered to determine
if there are toxic levels or normal levels in the blood.