PARKWAY HEALTH CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the advanced directive
were correct and according to the choices of two sampled residents (Resident #92 and #91)
out of 44 sampled residents. The facility census was 93 residents.
1. Record review of Resident #92’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].), [MEDICAL CONDITIONS] ([MEDICAL CONDITION]- a
progressive disease that is characterized by shortness of breath and difficulty
breathing), [MEDICAL CONDITION] (abnormal heart rhythm), kidney failure (a medical
condition in which the kidneys no longer function), abdominal pain, high blood pressure
and malnutrition.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
to be completed by facility staff for care planning) dated [DATE] showed he/she:
-Was alert and oriented with minimal confusion and
-Needed limited assistance with bathing, dressing, transferring, and continence.
Record review of the resident’s Social Service Notes dated [DATE], showed he/she was
admitted to the facility and was oriented to person and place but was not oriented to the
month or day of the year. The note showed the resident was a Full Code (if a patient has a
cardiac or respiratory arrest, the healthcare provider is ethically and legally obliged to
perform life-saving measures).
Record review of the resident’s Code Status form, signed by the resident, and Social
Service Worker on [DATE], and by the resident’s physician on [DATE], showed the resident
was a Full Code.
Record review of the resident’s Physician Order Sheet (POS) showed:
-On 10 /,[DATE], the resident’s code status was Do Not Resuscitate (DNR-a medical order
written by a doctor. It instructs health care providers not to do cardiopulmonary
resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops
beating) and
-[DATE] to [DATE] showed the resident’s code status was DNR.
During an interview on [DATE] at 10:22 A.M., the Director of Nursing (DON) said:
– When the resident is admitted to the facility, if they come with physician’s orders the
code status will be on the orders;
-Then the resident or responsible party will meet with the Social Worker and if the code
status is changed at that time, the Social Worker will document that in the notes and it
will be changed on the resident’s POS;
-This morning before he/she sent the resident out to the hospital, he/she noticed that the
resident’s POS showed the resident’s code status was DNR and the resident is not a DNR;
-The resident’s signed code status form showed that he/she is a Full Code and the
resident’s physician signed it on [DATE], so it should have been changed on the POS to
show the resident was a Full Code and
-He/She changed the resident’s code status on the resident’s POS this morning.
2. Record review of the Resident’s #91 Face Sheet showed he/she was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Bacteremia – The presence of bacteria in the blood;
-Dysphagia – Is the medical term used to describe difficulty swallowing;
-Disorder of Brain – A broad term for any brain disease that alters brain function or
structure;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain the fans in resident
rooms 203, 206, 204, free of a heavy dust buildup; failed to maintain the mattress in
resident room [ROOM NUMBER] in good repair; failed to maintain the restroom ceiling vents
in resident rooms 102, 105, 303, and the 40 Hall shower room, free of a heavy dust buildup
inside the vents; failed to maintain the floors of resident rooms 201, 206, 205, 306, 32,
36, 37, 30, 404, 412, free of dust and grime; failed to maintain resident rooms 105, 36,
free of a buildup of cobwebs (tangles of the silken threads of a spider web usually
covered with accumulated dirt and dust); failed to maintain one stand up lift free of a
buildup of dust and food debris; failed to ensure the minimum square footage required (80
square feet) in residents rooms was maintained for three residents who shared room [ROOM
NUMBER]; and failed to ensure room [ROOM NUMBER] was free of excessive clutter
(wheelchairs, Hoyer lifts and Sit to Stand equipment were stored on one half of the room,
one of the closet’s door was broken, one high walker chair and one oxygen tank were also
stored in that room). This practice potentially affected at least 70 residents throughout
the facility. The facility census was 93 residents.
1. Observations with the Maintenance Director, the Administrator, and the Housekeeping
Supervisor on 11/20/18, showed:
– At 9:03 A.M., a buildup of dust was present in the restroom ceiling vent of resident
room [ROOM NUMBER],
– At 9:06 A.M., a buildup of dust was present in the ceiling vent of the shower room next
to resident room [ROOM NUMBER],
– At 9:16 A.M., there were two cracks that measured 28 inches (in.) and 22 in. in length

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview the facility failed to ensure the
Initial and Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or
Condition (PASARR) Disorder was completed and obtained upon admission for one sample
resident (Resident #81) out of 44 sampled residents. The facility census was 93 residents.
Record review of the Missouri Department of Health and Senior Services Division of
Regulation and Licensure regarding Pre-Admission Screening for Mental [MEDICAL CONDITION]
or Related Condition (PASARR) Disorders Policy showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to to contact or
notify the resident’s physician when the resident’s blood sugar was above 300 parameters
during the late evening/ and night hours for over a period of four days for one sample
resident (Resident #7) and failed to follow a physician’s orders [REDACTED].#75) out of 44
sampled residents. The facility census was 93 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to provide
oversight for one resident (Resident #35) to protect himself/herself and at least 10 other
residents who resided in that area from the risk of fire, because that resident smoked in
his/her room. The facility census was 93 residents.
Record review of the facility’s policy regarding Smoking Safety dated 4/6/17, showed:
– No smoking in resident rooms,
– The facility will ensure that all designated smoking areas will utilize a
non-combustible, self-closing container for the resident’s smoking to ensure cigarette and
ashes are disposed of properly,
– The facility will provide direct supervision for smoking by patients classified as not
responsible, and
– The facility metal containers will have self-closing cover devices into which the ash
trays can be emptied are readily available to all areas where smoking is permitted.
1. Record review of the Resident’s Care Plan dated 12/14/17, showed facility staff were to
monitor the resident’s room daily for signs of smoking in his/her room, document, and
report behavior to the nurse.
Record review of the resident’s smoking assessment dated [DATE], 6/24/18 and 9/4/18,
showed Resident #35 was:
-Alert and oriented times,
-Able to hold cigarettes, lighter/matches without assistance,
-Had been educated on the risks of smoking,
-Was not physically able to extinguish a lit cigarette/ash that has fallen on themselves
or others,
-had a history of [REDACTED].>-Was not compliant with facility rules.
Record review of the Resident quarterly Minimum Data Set (MDS- a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
9/12/18, showed the resident scored a 15 on his/her BIMS assessment indicating that he/she
was alert and oriented, and understood others.
Observation with the Maintenance Director, the Housekeeping Supervisor and the
Administrator, on 11/20/18 at 9:48 A.M., showed:
– The presence of cigarette ashes on the floor,
– Numerous burn marks on the left side of the drawer and the television set, and
– No self-closing ash trays in the room.
During an interviews on 11/21/18 at 11:15 A.M., the Care Plan Coordinator said:
– He/she noticed smoking in the resident’s room about year and half ago,
The facility tried to place the resident on supervised smoking with a staff member
watching,
– That was only done for a couple of weeks, and
– As far as he/she knew, the Resident was doing well.
During an interviews on 11/21/18 at 11:17 A.M., Licensed Practical Nurse (LPN) A said:
– No one reported to him/her that the resident had smoked in his/her room,
– He/she had never heard from anyone that the resident smoked in his/her room,
– He/she had done one-hour checks and had never smelled smoke in the resident’s room, and
– He/she knew the resident went to his/her smoke break.
During an interviews on 11/21/18 at 11:23 A.M., Housekeeper B said the following after

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain a
physician’s order for the resident to provide his/her own [MEDICAL CONDITION] care and the
self monitoring of the [MEDICAL CONDITION] site, failed to have detail documentation of
the skin assessment including [MEDICAL CONDITION] site and ongoing monitoring of the
resident’s [MEDICAL CONDITION], and failed to have documentation of the resident’s ability
to provide [MEDICAL CONDITION] care, return demonstrations had been monitored for one
sampled residents (Resident #90) out of 44 sampled residents. The facility census was 93
residents.
1. Record review of Resident # 90 Admission Face Sheet showed the resident was admitted to
the facility on [DATE] with the following [DIAGNOSES REDACTED].>- [MEDICAL CONDITION]
([MEDICAL CONDITION], is a chronic disease involving the airways in the lungs), -[MEDICAL
CONDITION] (is an opening — called a stoma — that connects the colon to the surface of
the abdomen),
-Noncompliance with other medical treatment and regimen.
Record review of the resident’s [MEDICAL CONDITION] Care Plan dated 5/1/18 showed the
resident:
-Was content of bladder and toilets by self,
-Had a [MEDICAL CONDITION] bag on his/her left side of his/her abdomen,
-Able to care for himself/herself and for his/her [MEDICAL CONDITION] himself/herself
-Supplies are kept in his/her room,
-Had aerosol air fresheners in his/her room to control odors,
-At risk for altered skin related to [DIAGNOSES REDACTED].
-Goal include:
-Will be free of infection related to his/her [MEDICAL CONDITION],
-Will Maintain current ADL function and abilities
-Will shower at least once a week,
Intervention include;
–Encourage proper hand hygiene before and after [MEDICAL CONDITION] care,

-[MEDICAL CONDITION] care to be done by he staff every shift and was documented by the
nurse’s initial.
Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed
physician’s orders for:
-[MEDICAL CONDITION] Care was to done by facility staff on each shift,
-[MEDICAL CONDITION] bag was to be change by nursing staff every three days and as needed,
-Did not have a physician’s order for the resident to provide his/her own [MEDICAL
CONDITION],
-Did not have a physician’s order for the licensed nursing staff to assess the resident’s
knowledge and ability to care for his/her [MEDICAL CONDITION].
During an interview on 11/19/18 at 1:00 P.M., the resident’s Physician A said;
-The resident had been providing his/her own ostomy care for several years,
-He/she would expect to have a physician’s order for the facility nursing staff to assess
the resident’s ability provide his/her own ostomy cares on an annual bases
-The resident may have had a physician’s order in the past to provide his/her own [MEDICAL
CONDITION] care,
-Would expect the resident to have an ongoing physician’s order for the resident to
provide his/her own [MEDICAL CONDITION] care,
-The facility nursing staff are to monitor the resident ostomy site and stoma during the
weekly and monthly skin assessment.
During an interview on 11/21/18 at 6:30 A.M., Certified Nurse’s Assistant (CNA) E said:
-The CNAs do not have a CNA care card that shows how to care for the residents,
-Would talk with the charge nurse on how to care for the resident’s or if any changes in
the resident’s care,
-The resident’s ADL cares provided by the CNA staff are documented in the ADL cares book
and was not aware of a CNA care plan book,
-The resident had been providing his/her own [MEDICAL CONDITION] care,
-The CNA’s only obtain the resident’s ostomy bags, and other ostomy supplies when
requested by the resident,
-He/she would only assist the resident if asked,
-The charge nurses assess the resident’s skin and the resident [MEDICAL CONDITION] site.
Review of the resident’s CNA Skin assessment Sheet dated 11/23/18 showed;
-The resident had [MEDICAL CONDITION] on the right lower abdomen and there were no areas
of concerns documented.
During an interview on 11/27/18 at 2:20 P.M., the resident said:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure one
sampled resident remained on continuous tube feeding, failed to ensure the physician’s
orders included parameters for holding the resident’s tube feeding (a medical device used
to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow
safely, or need nutritional supplementation. The state of being fed by a feeding tube is
called enteral feeding or tube feeding), failed to ensure certified nursing staff
performed duties within their professional limitations for one sampled resident (Resident
#82) and failed to follow physician’s enteral feeding orders to ensure the resident was
recieving his/her caloric and water intake as recommended by the Registered Dietician (RD)
to prevent the resident from a gradual weight loss for the last three weeks and failed to
notify the RD of new physician order to change the continuous enteral feeding to 22 hours
of enteral feeding as this good affect the caloric and water intake the resident is
required to recieve in a 24 hour period as recommended by the RD for one sample resident
(Resident #91) out of 44 sampled residents. The facility census was 93 residents.
Record review of the facility’s policy according to Centers for Disease Control (CDC)
guidelines – New Regulations for Nutrition, Weight Loss, Adaptation and Tube Feeding.
-Enteral tube feeding should not be given to people unless they are malnourished or at
risk of malnutrition and have, inadequate or unsafe oral intake and functional, accessible
gastrointestinal tract or they are taking part in a clincial trial.
-Nutrition support intervention in patients identified by screening and assessment at risk
for malnutrition or malnourished may improve clinical outcomes for patients.
-At – risk patients should have a nutrition screen followed up by dietitian assessment,
care plan and follow-up.
-Nutritional assessment tools are generally comprised by the following sections, history,
physical examination, laboratory tests, calculations of calorie necessities; and
indication for nutritional therapy.
-Acutely ill patients under [MEDICATION NAME] nutrition receive infusions continuously,

Record review of the resident’s Dietary Notes dated 11/22/18 at 9:00 A.M., showed the
resident:
-Was to continue on Medicare Part A services.
-[DEVICE] was patent and running at 70 cc hour and had water flushes.
Record review of the resident’s Dietary Notes 11/22/18 at 9:57 A.M. showed the resident:
-Was to remain NPO.
-Continued to receive Glucerna 1.2 at 70 cc per hour with the same water flushes.
-Had a new physician’s on 11/8/18 to hold the tube feeding for two hours for ADL’s and
therapy.
-Continued to receive Glucerna 1.2 at 70 cc per hour for 22 hours providing 1848 caloric
intake per day.
-100 % estimated caloric intake needs, and 92 grams of protein (126% estimated protein
needs per day)
-No new labs noted.
-Resident height is 68′
-Resident’s weight for (MONTH) (YEAR) is 179 pounds.
-Resident was up one pound in one month.
-Resident was down 25 pounds in three months, a 12.3 % weight loss, down 23 pounds in five
months since initial admitted .
-Continue to follow and be available as needed according to the Registered Dietician.
Record review of the resident’s Nurse’s Noted dated 11/26/18 at 3:40 P.M. showed the
resident :
-[DEVICE]s cares are provided every shift.
-Was reminded not to touch the [DEVICE]; the resident has Dementia and sometimes he/she is
forgetful and must be redirected by staff for total care.
During an interview on 11/28/18 at 10:00 A.M., the CNA C said he/she:
-The Restorative Aides (RA) were respo

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

Record review of the resident’s Quarterly MDS dated [DATE] showed:
-Was mildly cognitively (slight mental impairment of perception and reasoning) impaired;
-Was able of performing activities of daily living with occasional cueing; and
-Needed prompting and cueing to perform personal hygiene.
Record review of the resident’s Physician’s Order Sheet (POS) dated 10/12/18 to 10/26/18
showed the resident was to have his/her [MEDICAL TREATMENT] right upper extremity
(RUE)shunt fistula assessed for bruit and thrill every shift.
Record review of the resident’s Treatment Administration Record (TAR) for 10/15/18 to
11/14/2018 had a physician’s order for assessment of the resident’s [MEDICAL TREATMENT]
shunt fistula in the right upper extremity to be completed once per shift by the nursing
staff which showed:
-Assessment was completed on the TAR until night of 10/26/18;
-Had been transported to local hospital on [DATE]; and
-Was admitted to the hospital for evaluation and treatment on 10/26/18.
Record review of the resident’s nursing notes dated 10/26/18 written by Licensed Practical
Nurse (LPN) C showed:
-The resident’s Physician was notified of the resident’s low red blood cell count;
-Physician gave orders to send the resident to a local hospital for evaluation and
treatment; and
-Transportation was by ambulance to the local hospital.
Record review of the resident’s nurse notes of 11/8/18 showed:
-The resident returned from the hospital to the facility at 5:00 P.M.;
-All medications had been reviewed and verified by the resident’s physician;
-A head to toe assessment had been done; and
-A physician’s order to assess the [MEDICAL TREATMENT] shunt fistula was not obtained from
the resident’s physician.
Record review of the resident’s (MONTH) TAR showed the staff did not have a physician’s
order to assess the [MEDICAL TREATMENT] shunt from 11/8/18 to 11/ 28/18.
Observation on 11/21/18 at 9:45 A.M. the Assistant Director of Nursing (ADON) assessed the
resident’s bruit by auscultation (listening with a stethoscope) and felt the vibrations of
the thrill.
During interview on 11/21/18 at 9:48 A.M. the ADON said she would document her assessment
of the [MEDICAL TREATMENT] shunt in the nurse notes for the resident.
During an interview on 11/28/18 at 9:45 A.M. Licensed Practical Nurse (LPN) D said:
-The resident had gone to the hospital on [DATE];
-Returned to the facility on [DATE];
-Upon returning to the facility no order had been obtain for assessing the [MEDICAL
TREATMENT] shunt fistula;
-A physician’s order had been requested on 11/28/18;
-Assessment of the [MEDICAL TREATMENT]’s shunt fistula on the RUE was to be done by Bruit
and thrill; and
-Documentation would be on the TAR.
During an interview on 11/28/18 at 10:01 A.M. LPN C said:
-Assessing the Bruit and thrill is fast assessment; and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
medications were administered with an error rate of less than 5 percent (%). Three
medication errors were detected out of 50 observed medication opportunities resulting in
an error rate of 6.0%,including failure to use correct technique when administering
insulin pen for one sampled resident (Resident #31) and eye drops for one sampled resident
(Resident #21). The facility census was 93 residents.
Review of the [MEDICATION NAME] Pen Manufactures Prescribing Guide information Sheet dated
(YEAR) showed to Perform Safety Test on the insulin pen by:
– Dial a test dose of 2 units.
-Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air
bubbles rise to the top of the needle. This will help you get the most accurate dose.
-Press the injection button all the way in and check to see that insulin comes out of the
needle. The dial will automatically go back to zero after you perform the test.
– If no insulin comes out, repeat the test 2 more times. If there is still no insulin
coming out, use a new needle and do the safety test again.
-Always perform the safety test before each injection
Review of Humalog (is a registered trademark of(NAME)Lilly and Company) Insulin Pen
Instructions for Use revised: (MONTH) 13, (YEAR) showed Prime Insulin Pen before each
injection:
-Priming your Pen means removing the air from the Needle and Cartridge that may collect
during normal use and ensures that the Pen is working correctly.
-If you do not prime before each injection, you may get too much or too little insulin.
-To prime your Pen, turn the Dose Knob to select 2 units.
Record review of the State Operations Manual dated (YEAR) showed eye drops should be
placed into the conjunctiva (under eye portion if the eye lid) sac, and the tear duct
should be pressed for one minute or the eye closed for 3 to five minutes for optimal eye
drop absorption
1. Record review of Resident #31’s Face Sheet showed:
-He/she was admitted to the facility on [DATE] and
-He/she had [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) dated 8/30/18 showed he/she
was moderately cognitively impaired.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]
Physician order [REDACTED].>-To receive [MEDICATION NAME]Pen U-100 to be given

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to prevent a
significant medication error during insulin administration by not priming the insulin pen
prior to dialing the intended dose for one sampled resident’s (Resident #31) out of 44
sampled residents. The facility census was 93 residents.
Review of the [MEDICATION NAME] Pen Manufactures Prescribing Guide information Sheet dated
(YEAR) showed to Perform Safety Test on the insulin pen by:
– Dial a test dose of 2 units.
-Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air
bubbles rise to the top of the needle. This will help you get the most accurate dose.
-Press the injection button all the way in and check to see that insulin comes out of the
needle. The dial will automatically go back to zero after you perform the test.
– If no insulin comes out, repeat the test 2 more times. If there is still no insulin
coming out, use a new needle and do the safety test again.
-Always perform the safety test before each injection
Review of Humalog (is a registered trademark of(NAME)Lilly and Company) Insulin Pen
Instructions for Use revised: (MONTH) 13, (YEAR) showed Prime Insulin Pen before each
injection:
-Priming your Pen means removing the air from the Needle and Cartridge that may collect
during normal use and ensures that the Pen is working correctly.
-If you do not prime before each injection, you may get too much or too little insulin.
-To prime your Pen, turn the Dose Knob to select 2 units.
1. Record review of Resident #31’s Face Sheet showed:
-He/she was admitted to the facility on [DATE] and
-He/she had [DIAGNOSES REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to identify and
provide timely dental services for replacement of dentures for one sampled resident
(Resident #75) out of 44 sampled residents. The facility census was 93 residents.
1. Record review of Resident #75’s Facility admission sheet date showed the resident was
admitted on [DATE] with the following Diagnoses: [REDACTED].
-Symbolic dysfunction (A communization disorder that affects an individual’s ability to
comprehend, or apply language and speech to effectively communicate with others) .
-Chronic [MEDICAL CONDITION] (A long [MEDICATION NAME] liver infection).
-Urinary Tract Infection (An infection of the kidney, ureter, bladder, or urethra).
-[MEDICAL CONDITION] (a benign overgrowth of prostate tissue that surrounds the urethra
constricting urine flow).
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 7/18/18 showed the
residents had no dental issues noted in section [MI] Oral/Dental Status.
Record review of the resident’s physician’s orders [REDACTED].
-The resident had standing physician’s orders [REDACTED].
Observation on 11/27/18 at 12:02 P.M. of the resident showed he/she had no teeth visible
in his/her mouth.
During interview on 11/27/18 at 12:05 P.M. with the resident said:
-Have not seen a Dentist.
-Lost my dentures when I was at the local hospital.
-Would like new dentures.
During a interview on 11/28/18 at 8:55 A.M., the Social Service Designee (SSD) said:
-The Dentist has been here much since September.
-The Dentist was busy in (MONTH) with people getting dentures.
-The Resident had not mention needing dentures to him/her.
-Have called the dentist, and have left a message to try to get a dental appointment at a
hospital.
-Is responsible for putting new residents on the dentist list, and the resident had not
been on the list to see the dentist.
During an interview on 11/28/18 at 10:32 A.M. the SSD said:
-The visiting dentist had returned his/her call.
-The dentist had made an appointed to see the resident later the same afternoon.
During an interview on 11/28/18 at 12:48 P.M. the Director of Nursing (DON) said my
expectations are that:
-The nursing staff should have done a head to toe assessment for a newly admitted
resident.
-The head to toe assessment should have included an oral/dental assessment.
-The oral/dental assessment should have included, documenting missing, broken, decayed or
chipped teeth.
-If a resident had no teeth and/or needed dentures that assessment should have been
documented.
-Staff should have scheduled the initial dental appointment for the resident within 24 to
48 hours after admission.

Based on observation, interview and record review, the facility failed to maintain the
temperature of cheesy broccoli and baked chicken at or above 135 ºF (degrees Fahrenheit)
throughout the meal service on Applegate Lane. This practice potentially affected eight
residents who may have selected the alternate that day. The facility census was 93
residents.
1. Observation on 11/19/18 at 2:26 P.M., showed the temperature of the baked chicken was
122 ºF and at 2:31 P.M., the temperature of the cheesy broccoli was 125 ºF on the steam
table.
During an interview on 11/19/18 at 2:32 P.M., Dietary Aide (DA) A said he/she was not able
to monitor the temperatures because he/she did not have a thermometer with him/her at the
steam table.
Record review of the 2013 FDA Food Code
– Chapter 501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.
(A) Except during preparation, cooking, or cooling, or when time is used as the public
health control as specified under section 3-501.19, and except as specified under
paragraphs B) and C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be
maintained:
(1) At 135 ºF or above, except that roasts cooked to a temperature and for a time
specified in 3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at
a temperature of 130 ºF above.

Based on observation, record review and interview, the facility failed to have enough
dietary staff on the schedule on 11/19/18 to ensure that food that was delivered to the
facility was put away in a timely manner after delivery; and to ensure the lunch meal was
served to the Cherry Lane, Applegate and Memory Lane Units within a timely manner of the
listed times for lunch service. This practice potentially affected at least 85 residents.
The facility census was 93 residents.
1. Observations and interviews during meal preperation and service on 11/19/18 showed:
– At 9:06 A.M., two dietary staff (the Dietary Manager (DM) and one aide Dietary Aide (DA)
A) were on duty,
– At 9:06 A.M., the DM said there was just him/her and one DA on duty and there will be a
prep cook coming in around 10:00 A.M., maybe a little earlier,
– At 9:36 A.M., there were numerous items in the stock room which needed to be
refrigerated which were not put away yet, which included:
– Items that should be frozen include the following: one 30 pounds (lbs.) box of
margarine, one 50 lbs. box of frozen egg product, one 40 lbs. box of pollock fillets, one

Based on observation and interview, the facility failed to ensure the carrots on a test
tray in the Cherry Lane area was maintained at or close to 120 ºF (degrees Fahrenheit).
This practice potentially affected at least seven residents who received their trays
closer to the end of the lunch meal. The facility census was 93 residents.
1. Observation on 11/19/18 at 2:02 P.M., of the test tray with Certified Nurse’s Assistant
(CNA) D, showed the temperature of the carrots was 106 ºF, 14 degrees below the
recommended serving temperature.
During an interview on 11/19/18 at 2:03 P.M., CNA D said he/she has not seen anyone from
the dietary department at the unit measuring temperatures of room trays.
During an interview on 11/21/18 at 8:40 A.M, Dietary Aide (DA) C said he/she checked the
food temperatures in the kitchen but does not check temperatures in the serving areas.

Based on observation, interview and record review, the facility failed to prevent or
maintain the following: a buildup of debris in the knife holder; maintain the oven mits
without rips, maintain the floor under the dishwasher area and the six burner stove free
of dishes and food debris, maintain the top of the six burner stove free from burnt on
grease, maintain the ice machine free from grime inside the machine, maintain Refrigerator
three free from a ripped gasket (a piece of rubber or some other material that is used to
make a tight seal between two parts that are joined together), maintain four cutting
boards free from numerous nicks which rendered those cutting boards as not easily
cleanable. This practice potentially affected all residents. The facility census was 93
residents.
1. Observations on 11/19/18 from 9:08 A.M. through 1:40 P.M., showed:
– At 9:08 A.M., there was a buildup of debris inside the knife holder,
– At 9:11 A.M., the oven mit that was used by the Dietary Manager (DM) while cooking, had

Based on record review, observation and interview, the facility failed to ensure that food
stored in the resident use refrigerator in Memory Lane, was labeled with someone’s name
and a date it was stored. This practice potentially affected at least 20 residents in the

Based on observation, interview and record review, the facility failed to keep the lid of
the outdoor dumpster closed over two days. The facility census was 93 residents.
1. Observations on 11/21/18 at 5:59 A.M., 7:41 A.M., 10:14 A.M, and 11:56 A.M, showed the
dumpster lid open continually.
2. Observations on 11/27/18 at 8:16 A.M., 9:18 A.M., 1:27 P.M. and 3:28 P.M., showed the
dumpster lid open continually.
During an interview on 11/27/18 at 3:28 P.M., the Dietary Manager said he/she had stressed
keeping the lid closed to his/her people and employees throughout the facility time and
time again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure infection
control practices to prevent cross contamination were implemented by failing to properly
store oxygen supplies for one sampled resident (Resident 92) , failed to ensure proper
placement of the resident’s catheter bag during cares and transfer for one sampled

-While CNA’s or nursing staff providing personal care, he/she would expect staff ensure
infection control preventin guidlines. If the CNA’s or nursing staff gloves soilded should
have changed his/her gloves and not to wipe them off with resident personal wipes,
-Would expect CNAs/and Nursing staf should not continuee resident care with soiled
clothes,
-When CNA’s and nursing staff should have changed their gloves and wash their hands with
soap and water, or use foam hand sanitizer wash during peri care,
-The staff should always wash thier hands with soap and water before leaving the resident
room.
-The facility had recently had in-serviced the staff on the proper way to wash their hands
and on the proper glove use prior to the survey.
Record review of the federally policy statement dated 12/3/18, showed the facility will
ensure any resident with a urinary catheter will be maintained to prevent infection and to
follow the Catheter Care procedures as follows:
-To make sure the urinary catheter bag tubing does not touch the floor to avoid or prevent
the spreading of communicable diseases to the resident.
3. Record review of the Resident’s Face Sheet #86 showed he/she was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Pain
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
assessment too to be completed by facility staff for care planning ) dated 10/20/18 showed
he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 10, which describes the resident
was cognitive alert and oriented.
-Was able to express ideas and wants to others in a consistent and reason manner.
-Was a one person assist with Activities of Daily Living (ADL) for eating , bathing,
dressing , transferring, personal hygiene and mobility needs.
-Was able to eat independently with set up help only and needed some assistance with
clothing items after daily toilet use.
Record review of the resident’s Care Plan dated, 10/20/18 showed the resident:
-Had a #16 french Foley Catheter.
-The resident was sent to the hospital after a mental status change.
-admitted to the hospital with [REDACTED].
-Had returned to the facility with a Foley Catheter to assist with monitoring of the
Hemiuria,
-Was to be free of infection related to his/her Catheter bag through the next review date
1/21/18.
-Was to provide catheter care every shift.
-Was to ensure his/her dignity is kept intact at all times by keeping the catheter bag
covered at all times.
-Was to empty his/her Catheter bag routinely.
-Was to wash his/her hands before and after providing catheter care.
-Was to monitor for changes in the resident’s urine such as color, smell, consistency and
report any changes to the resident’sdoctor.
Record review of the resident’s Care Plan dated on 10/20/18 showed he went to the hospital
due to breaking the catheter off into bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain a pipe next to the
automated dishwasher in the kitchen free of a leak which contributed to standing water and
failed to notify the maintenance department about that leak, maintain the floor in
resident room [ROOM NUMBER] free of a large damaged area and failed to maintain the pipe
under the sink in the Memory Lane Men’s Unit. This practice potentially affected at least
three residents who resided in resident room [ROOM NUMBER].
1. Observation on 11/19/18 at 9:01 A.M., and 10:40 A.M., showed the presence of standing
water on the floor next to where there food trays were stored on the shelf.
During an interview on 11/19/18 at 10:40 A.M., the Dietary Manager said the water came
from a leak on a pipe that was close to the automated dishwasher
During an interview on 11/20/18 at 8:38 A.M., the Maintenance Director said that time was
his/her first time he/she saw the leak under the sink.
2. Observation on 11/19/18 at 9:49 A.M., showed:
– A damaged section of floor in resident room [ROOM NUMBER] that was 15 inches (in.) long
by 12 in. wide,
– A a piece of the floor tile that exposed the floor base that was oblong and about the
size of a medium sized box,
– A resident who happened to be in the room at the time which said that he/she sometimes
tripped over the area when walking due to the uneven surface and that area was not
cleanable,
– The resident said the floor had been that way for almost a year, and
– He/She said he/she spoke to the maintenance personnel some time ago about that issue.

Based on observation, interview and record review, the facility failed to maintain the
kitchen free of gnats (small flies) and failed to maintain the window sill of the Memory
lane clean utility room free of a heavy buildup of dead insects. The facility census was
93 residents.
1. Observations on 11/19/18 at 8:52 A.M., 9:23 A.M., and 12:45 P.M., showed gnats flying
around in kitchen, four gnats on a napkin, and several gnats on the ceiling above the
dishwasher area.
During interviews on 11/19/18, the following was said:
– At 3:14 P.M., Preparation Cook (PC) A said he/she noticed the gnats, and
– At 3:15 P.M, the Dietary Manager (DM) said he/she had noticed the gnats as well and had
contacted maintenance.
2. Observation with the Maintenance Director and the Administrator on 11/20/18 at 11:25
A.M, showed a heavy buildup of dead insects in the window sill of the Memory Lane clean
utility room.
During an interview on 11/20/18 at 11:26 A.M., the Maintenance Director noticed the dead
insects.
3. Observation with the Maintenance Director on 11/21/18 at 6:39 .M, showed two openings
in the window in the attic area above Cherry Lane.
Record review of the following chapters of the 2013 Food and Drug Administration (FDA),
showed:
6-202.15 Outer Openings, Protected.
(A) Except as specified in paragraphs B, C, and E, and under paragraph D of this section,
outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and
rodents by:
(1) Filling or closing holes and other gaps along floors, walls, and ceilings;
(2 Closed, tight-fitting windows;
6-501.111 Controlling Pests.
The PREMISES shall be maintained free of insects, rodents, and other pests. The presence
of insects, rodents, and other pests shall be controlled to eliminate their presence on
the PREMISES by: