REDWOOD OF BLUE RIVER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to promote dignity
with dining for two sampled residents (Residents #74 and #86) and to promote dignity for a
resident who had no clothes on from the waist down and could be viewed from the hallway
for one sampled resident (Resident #327) out of 26 sampled residents. The facility census
was 130 residents.
Record review of the facility’s undated Privacy and Dignity policy showed:
-The facility promotes resident care in a manner and in an environment that maintains or
enhances dignity and respect;
-Staff assist residents in maintaining self-esteem and self-worth;
-The facility promotes independence and dignity in dining; and
-As part of the Admission process residents are informed of their rights.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances; and
-Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent
event or something with an uncertain outcome).
Record review of the resident’s Care Plan revised on 10/18/18 showed he/she:
-Had an Activities of Daily Living (ADLs-dressing grooming, eating) self-care deficit
related to his/her [DIAGNOSES REDACTED].>-Needed one staff member for supervision,
cueing, and assistance with eating as needed.
Record review of the resident’s quarterly Minimum Data Set (a federally mandated
assessment tool required to be completed by the facility staff for care planning) dated
4/24/19 showed the resident:
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating; and
-Needed one staff member’s physical assistance with eating.
Observation on the Secure Care Unit (SCU) dining room on 6/5/19 showed:
-At 12:23 P.M.:
–There was one staff member, Certified Nursing Assistant (CNA) D assisting the residents
with their lunch meals;
–The resident was in his/her wheelchair in the dining room;
–The resident had chicken, rice, green beans, bread, apple juice, water and a health
shake;
–The resident was eating his/her meal with his/her fingers;
–The resident stuck his/her fingers in the apple juice and would suck the juice off
his/her fingers repetitively;
-At 12:36 P.M.:
–CNA D stood over the resident and put his/her apple juice cup in the resident’s hand;
–CNA D stood over the resident and gave the resident a bite of food;
–CNA D pulled a chair up, then sat down and told the resident to use his/her fork and
spoon, then quickly got up to assist another resident to their room;
–The resident ate a few bites of food with his/her fork then started dipping the fork in
the apple juice and sucking it off the fork repetitively;
-At 12:42 P.M.:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to promote
self-determination and choices with morning waking times for two sampled residents

Based on interview and record review, the facility failed to ensure personal mail such as
letters and cards delivered to the facility on Saturdays was dispersed to the residents on
the day of delivery. This has the potential to affect all the residents who receive mail
at the facility. The facility census was 130 residents.
Record review of the facility’s Resident Rights – Mail policy, undated, showed:
-Residents have access to mail delivery and
-Mail is delivered to the premises or to the facility’s post office box, including
Saturday deliveries.
1. During an interview on 6/6/19 at 1:36 P.M. with five residents who normally attend the
Resident Council Meetings, the group members said:
-During the week Activity Staff delivered mail to the residents Monday through Friday;
-Saturday mail was sorted by the Business Office on Monday and
-Nobody from Activities or any other department distributed mail to the residents on
Saturdays.
During an interview on 6/10/19 at 2:53 P.M. Business Office Staff A said:
-He/she separated facility and resident mail Monday through Friday;
-Mail was usually delivered to the facility by 1:00 P.M., although it can be delivered as
late as 3:00 P.M. and
-On Saturdays Activities Staff sorts and passes out mail to the residents.
During an interview on 6/11/19 at 11:35 A.M., Activity Assistant (AA) A and AA B said:
-The Business Office gets the mail and sorts out bills Monday through Friday, and gives
the Activity Staff the residents’ personal mail, such as letters and cards, around 12:00
P.M. to 2:00 P.M.;
-The Business Office sorted Saturday mail on Mondays;
-They (AAs) pass mail to residents around 1:30 P.M. Monday through Friday;
-Both AAs were scheduled to work on Saturdays;
-Neither AA had been given a key to get the mail themselves;
-Every once in a while there was a Front Office Staff working on Saturdays, but they do
not sort the mail and give personal mail to the Activity Staff to disperse or give the
mail to the Activity Staff to sort and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
notification of the resident’s physician when the resident’s blood sugars were greater
than 400 for one sampled resident (Resident #58) and to notify the residents responsible
party of the development of a wound to his/her leg for one sampled resident (Resident #79)
out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Change of Condition Notification policy, undated, showed:
-An Acute Change of Condition is defined as a sudden, clinically important deviation from
a resident’s baseline in physical, cognitive, behavioral or functional domains;
-The facility will promptly inform the resident, consult with the resident’s Attending
Physician and notify the resident’s legal representative when the resident endures a
significant change in condition including and
-The Licensed Nurse will notify the resident’s responsible party or the
family/decision-makers of any changes in the resident’s condition as soon as possible,
documenting the time the family/responsible person was contacted.
1. Record review of Resident #58’s face sheet showed he/she was admitted to the facility
on [DATE], and readmitted on [DATE], with the following Diagnoses: [REDACTED].
-Diabetes.
Record review of the resident’s physician’s orders [REDACTED]. sugar is less than 60 or
greater than 400 before meals and at bedtime for diabetes.
Record review of the resident’s Medication Administration Record [REDACTED]
-On 5/3/19 at 12:00 P.M. the resident’s blood sugar was 440; and
-On 5/6/19 at 12:00 P.M. the resident’s blood sugar was 415.
Record review on the resident’s Nurse’s Notes for (MONTH) showed the staff did not
document that they notified the resident’s physician on 5/3/19 or on 5/6/19 regarding the
resident’s elevated blood sugar over 400.
During an interview on 6/11/19 at 11:00 A.M. Licensed Practical Nurse (LPN) A said:
-Usually, blood sugar parameters were between 60-400, (anything below 60 and above 400 was
out of range);
-Out of range blood sugars were reported to the resident’s physician;
-The nurse who checked the blood sugar, notified the resident’s physician and documented
the physician’s response and/or order; and
-The blood sugar readings were documented on the resident’s MAR.
During an interview on 6/12/19 at 11:14 A.M., the Director of Nursing (DON) said he/she
expected:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to complete
an incident/accident report form per facility policy in a timely manner for a possible
injury of unknown origin to the knee for one sampled resident (Resident #327) out of 26
sampled residents. The facility census was 130 residents.
Record review of the facility’s Incident Investigation policy, undated, showed:
-An incident included, but was not limited to the following:
–Falls;
–Abuse;
–Burns;
–Unusual occurrences;
–Bruises;
–Medication error;
–Missing person;
–Property loss and
–Respiratory arrest;
-Injuries of unknown origin were not listed as an incident requiring investigation;
-In the event of an incident, a Licensed Nurse or the individual who first encounters or
witnesses an incident will complete the Incident/Accident Report Form and document the
following on the Incident Log:
–Resident name, day and shift the incident occurred;
–Indicate the Type, Injury, Location, Severity and Medication/Treatment Error Codes and
-Interviews with staff member and other witnesses will be documented on the Interview
Record;
-Incident information will be reviewed by the Director of Nursing (DON) and the Quality
Assessment and Assurance (QAA – a system to monitor and evaluate aspects of service and
care to ensue standards of quality are being met) Committee on a monthly basis.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19
showed he/she:
-Was severely cognitively impaired and
-Needed the limited assistance of staff for personal hygiene, dressing and transfers.
Record review of the resident’s Nurses Progress Notes dated 5/17/19 at 10:17 A.M. showed:
-The staff reported to the nurse that the resident screamed and yelled when they attempted
to get the resident dressed;
-The resident was assessed and the resident said his/her right upper hip and leg had pain
and
-The resident’s physician was notified and gave orders to obtain an x-ray of the
resident’s right hip and right leg.
Record review of the resident’s Nurses Progress Notes dated 5/17/19 at 4:57 P.M. showed:
-The resident told a Certified Nursing Assistant (CNA) My knee hurts so bad;
-The resident was assessed and had swelling and redness to his/her right knee;
-The resident’s right thigh and hip appear to be intact with no redness or swelling and
-The resident’s physician was notified and gave orders to x-ray the resident’s right knee
due to increased swelling and pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer/discharge to the hospital, including
the reason for the transfer/discharge for one sampled resident (Resident #58) out of 26
sampled residents. The facility census was 130 residents.
Record review of the facility’s undated and unsigned policy titled Change of Condition
Policy, showed:
-The facility will promptly inform the resident, consult with the resident’s attending

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative of the facility’s bed-hold policy in writing before transferring
or discharging the resident to the hospital for two sampled residents (Resident #118 and
#58) out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Bed Hold policy dated 10/24/18 showed:
-The purpose of the policy was to ensure that the resident and/or their representative was
aware of the bed hold policy and
-Any time a resident was transferred to an acute care hospital for care the facility was
to notify the resident or his/her representative, in writing, of the bed hold policy.
1. Record review of Resident #118’s Durable Power of Attorney (DPOA) for Healthcare
Decisions showed the resident appointed a relative as his/her representative to make
healthcare decisions when he/she could not make or communicate decisions for
himself/herself on 11/22/17.
Record review of the resident’s Face Sheet showed:
-He/she was admitted to the facility on [DATE];
-He/she had [DIAGNOSES REDACTED].
-His/her DPOA’s name and telephone number was listed as his/her first emergency contact
person.
Record review of the resident’s admission Minimum Data Set (MDS a federally mandated
assessment tool to be completed by facility staff for care planning) dated 5/19/19 showed
he/she had moderate cognitive impairment (difficulty remembering, learning new things,
concentrating, or making decisions that affect everyday life).
Record review of the resident’s facility Hospital Transfer form dated 5/27/19 showed the
resident:
-Was transferred to the hospital due to the resident fell ;
-Had facial and shoulder pain;
-Was usually alert and disoriented but could follow simple instructions;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure activity care plans
contained the activity preferences and individualized activity plan for two sampled
residents (Resident #74 and #86) out of 26 sampled residents. The facility census was 130
residents.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s significant change Minimum Data Set ( MDS-a federally
mandated assessment tool required to be completed by facility staff used for care
planning) dated 10/22/18 showed he/she:
-Was severely cognitively impaired and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a Low Air
Loss (LAL) mattress (air holes in the mattress top surface continually blow out air
causing the patient to float) was maintained at the correct settings and to obtain
complete physician’s orders [REDACTED].#327) out of 26 sampled residents who was at risk
for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged
pressure on the skin). The facility census was 130 residents.
Record review of the facility’s Support Surface Guidelines policy, undated, showed:
-A Pressure Redistribution Support Surface is designed to prevent or promote healing of
pressure ulcers by distributing pressure over a larger surface area of the body and
reducing or eliminating tissue pressure in a concentrated area;
-The facility will identify residents at risk for pressure ulcers and provide care and
services to promote prevention of pressure ulcer development;
-Prevention of pressure ulcers includes support surfaces such as static surfaces (air,
foam, gel and water overlay mattresses) and dynamic surfaces requiring electricity to
operate;
-Dynamic surfaces include:
–Alternating air mattresses which have air cells that alternately inflate and deflate by
a pump, thus shifting supportive pressure from site to site;
–Low Air Loss mattresses which have very large air-filled pillows that continuously
inflate with air and
-Any individual at risk for developing pressure ulcers will be placed on a
pressure-reducing mattress.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19,
showed the resident:
-Was severely cognitively impaired and
-Was at risk of pressure ulcers and used a pressure reducing mattress.
Record review of the resident’s Braden Scale for Predicting Pressure Ulcer Risk dated
6/5/19 showed the resident was at high risk for developing pressure ulcers.
Record review of the resident’s physician’s orders [REDACTED]. (The staff did not document
they notified the resident’s physician to receive further specific physician’s orders
[REDACTED]. weight).
Record review of the resident’s weight dated 5/30/19 showed he/she weighed 97 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
Activity of Daily Living (ADL-eating, dressing, bathing) assistance for two sampled
residents (Resident #74 and #86) with dining; and to assist one supplemental resident
(Resident #40) with opening a snack out of 26 sampled residents. The facility census was
130 residents.
Record review of the facility’s undated Dining Service Standards policy showed:
-The residents are provided a positive meal experience;
-Services provided are based on the needs of the resident population; and
-Adaptive devices are provided, food and beverages are set up to promote independence and
residents are properly positioned, encouraged, cued and assisted as needed.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s Care Plan revised on 10/18/18 showed he/she:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
meaningful activities to meet the interests of and support the physical, mental, and
psychosocial well-being of two sampled residents (Resident #74 and #86) out of 26 sampled
residents; and to provide activities for the 700 and 800 Secure Care Units (SCU). The
facility census was 130 residents.
Record review of the facility’s activity schedules for the 700 and 800 SCUs for 3/2019,
4/2019, 5/2019, and 6/2019 showed there were seven to eight activities scheduled daily
Monday through Saturday including: readings, church, puzzles, trivia, board games, movies
and snacks, nail care, hand massages, card games, exercises, cooking groups, Wii games
(video games), balloon volleyball, arts and crafts, sing-a-longs and sensory stimulations.

Record review of the facility’s Daily Census report dated 6/5/19 showed:
-There were 15 residents residing on the 700 hall SCU and
-There were 15 residents residing on the 800 hall SCU.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to be completed by facility staff used for care
planning) dated, 10/22/18 showed he/she:
-Was severely cognitively impaired and
-Felt that it was very important to have books, newspapers, and magazines to read, to
listen to music, to be around pets, to keep up with the news, to do things with groups of
people, to do his/her favorite activities, and participate in religious services.
Record review of the resident’s Daily Activity Attendance dated 2/2019 showed the
resident:
-Watched television 28 out of 28 days;
-Went to a music/entertainment activity two times that month;
-Went to an educational/reading activity two times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Daily Activity Attendance dated 3/2019 showed the
resident:
-Watched television 31 out of 31 days;
-Went to a music/entertainment activity four times that month;
-Went to an educational/reading activity three times that month;
-Had sensory stimulation group five times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Care Plan revised on 3/25/19 showed he/she:
-Was at risk of harm to self and others related to pushing, grabbing, abusive language,
pinching, scratching and spitting and
-Needed the staff to provide a program of activities that was of interest to the resident
and accommodated his/her needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident was transferred in a safe manner using a gait belt and to transfer the resident
according to the most recent Minimum Data Set (MDS-a federally mandated assessment
instrument completed by facility staff for care planning) for one sampled resident
(Resident #86) out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Transfer policy, undated, showed:
-A transfer is a safe movement of a resident from one surface to another;
-Safe and efficient transfers are a combination of the resident’s physical abilities and
perceptional capacity, proper equipment, appropriate techniques and good planning;
-Transfers may be independent or assisted by one or more caregivers;
-Transfers may involve a mechanical lift or one of several assistive devices;
-General guidelines include monitoring the resident’s tolerance of the procedure and
knowing the resident’s abilities and limitations;
-During gait belt (a device placed around the waist of a resident with mobility issues to
aid the caregiver in safely moving a resident) transfers staff were to:
–Apply the gait belt around the resident’s waist and place the resident’s wheelchair (if
applicable) at a slight angle, locking the brakes;
–Hold the gait belt and instruct the resident to bend forward, placing the stronger foot
slightly behind the weaker foot and directing the resident to push off on the count of
three;
–Provide necessary assistance to help the resident stand and pivot;
–Instruct the resident to reach back with one or both hands and to feel the edge of the
seat against the back of the legs before sitting and
–Remove the gait belt once the resident is safely seated.
1. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) with behavioral
disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Annual MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Needed the extensive assistance of two staff members for transferring.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Had an Activities of Daily Living (ADL – dressing, grooming, bathing, eating, and
toileting) self-care deficit and
-Needed the extensive assistance of staff with transfers.
Record review of the resident’s Physical Therapy Evaluation dated 4/29/19 showed:
-The resident was evaluated for transfers;
-The resident was unable to stand and
-Was totally dependent on the staff with transfers.
Observation on 6/05/19 at 12:49 P.M. showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assist the
resident at meals with his/her beverages to ensure the resident drank his/her allotted
fluids and to offer snacks and beverages for one cognitively impaired sampled resident who
was on pureed foods and thickened liquids (Resident #86) out of 26 sampled residents. The
facility census was 130 residents.
1. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that an
enteral feeding (the delivery of a nutritionally complete feed, containing protein,
carbohydrate, fat, water, vitamins, and minerals directly into the stomach) was
administered as ordered and to ensure the intermittent water flush/intake was administered
as ordered for one sampled resident (Resident #126) out of 26 sampled residents. The
facility census was 130 residents.
Record review of the facility’s Tube Feeding (a procedure used for placing food, fluids
and medications directly into the stomach through a tube inserted through the abdomen)
policy, unsigned and undated, showed:
-The facility will meet the guidelines and resident’s nutritional requirements according
to physician orders;
-A physician order [REDACTED].
-The physician’s orders [REDACTED].
-Upon receipt of the Diet Order and Communication Form the Dietary Manager should contact
the Dietician to review the nutritional order; and
-The physician order [REDACTED].>–The type of formula;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure communication between
the facility and [MEDICAL TREATMENT] (process of cleansing the blood by passing it through
a special machine – necessary when the kidneys are not able to filter the blood) center,
for every [MEDICAL TREATMENT] treatment, for one sampled resident (Resident #126) out of
26 sampled residents. The facility census was 130 residents.
Record review of the facility’s [MEDICAL TREATMENT] Care Policy, not signed and not dated
showed:
-The Facility will be responsible for the overall care delivered to the resident,
monitoring of the resident prior to and after the completion of each [MEDICAL TREATMENT]
treatment, and providing for all non-[MEDICAL TREATMENT] needs of the resident including
during the time period when the resident is receiving [MEDICAL TREATMENT];
-The Facility maintains a contract with a [MEDICAL TREATMENT] service provider which
addresses communications between the Facility and Provider;
-Nursing staff will communicate pertinent information in writing to the [MEDICAL
TREATMENT] Staff which may include:
–Any medication changes;
–Any recent changes in condition;
–The resident’s tolerance of [MEDICAL TREATMENT] procedures.
-The [MEDICAL TREATMENT] Provider will communicate in writing to the facility:
–The resident’s current vital signs;
–Pre and post [MEDICAL TREATMENT] weights; and
–Any problems encountered while the resident was at the [MEDICAL TREATMENT] provider.
-Nursing staff may use the Nurse [MEDICAL TREATMENT] Communication Record to convey
information to the [MEDICAL TREATMENT] Provider;
-All documentation concerning [MEDICAL TREATMENT] services and care of the [MEDICAL
TREATMENT] resident will be maintained in the resident’s medical record; and
-Documentation may include the:
–Nurse [MEDICAL TREATMENT] Communication Record;
–[MEDICAL TREATMENT] Flow Sheet-Return Assessment and
–[MEDICAL TREATMENT] Medical Intake Sheet.
1. Record review of Resident #126’s face sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess
appropriateness of side rail use for residents on a quarterly basis to include showing
alternates attempted that failed to meet resident needs prior to the use of side rails for
one sampled resident (Residents #327) out of 26 sampled residents. The facility census was
130 residents.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19,
showed he/she:
-Was severely cognitively impaired and
-Needed the limited assistance of staff for bed mobility and transfers.
Record review of the resident’s Care Plan revised on 5/24/19 showed he/she:
-Had a self-care performance deficit and
-Was totally dependent on staff for dressing, personal hygiene and transfers.
Record review of the resident’s physician’s orders [REDACTED].¼ side rails on the bed.
Observation on 6/5/19 at 9:15 A.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.
Observation on 6/5/19 at 1:45 P.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.
Observation on 6/6/19 at 1:25 P.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
sufficient nursing staffing for the 700 Secure Care Unit and the 800 SCU to meet the
safety and attain or maintain the highest practicable physical, mental, and psychosocial
well-being of each resident. There were a total of 30 residents that reside on the 700 and
800 SCUs. The facility census was 130 residents.
Record review of the facility’s Nursing Department – Staffing, Scheduling and Postings
policy, undated, showed:
-The facility will employ sufficient nursing staff as determined by resident assessments
and individual plans of care, taking into account the number, acuity (cognitive levels),
and [DIAGNOSES REDACTED].
-Scheduling will be done as needed to meet resident needs and will account for the number,
acuity and [DIAGNOSES REDACTED].
1. Record review of the facility’s staffing sheets for the night shift (from 10:30 P.M.
through 6:30 A.M.) dated 4/1/19 through 5/31/19 showed:
-There was one Licensed Practical Nurse (LPN) or one Certified Medication Technician (CMT)
on the night shift for both the 700 and 800 SCUs;
-There was one Certified Nursing Assistant (CNA) on the night shift for both the 700 and
800 SCUs and
-This was a total of two staff members to care for 30 cognitively impaired residents.
Observation on 6/7/19 of the 700 and 800 SCUs showed:
-At 5:35 A.M. LPN D and CNA H were on the 800 SCU. There were two residents up in
wheelchairs on the 800 SCU. There were no staff members on the 700 SCU;
-At 5:39 A.M., LPN D went into the nurses’ station that connected the 700 SCU and 800 SCU.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to conduct federally required
annual training regarding care for residents with dementia (dementia is the name of a
group of symptoms caused by disorders that affect the brain – people with dementia may not
be able to think well enough to do normal activities, such as getting dressed or eating,

Based on observation, interview and record review, the facility failed to ensure the
controlled medications (narcotics – medications with a potential for abusive use and
dependence upon the medication) were counted and documented at the beginning of each shift
and at the end of each shift for the 700-800 hall and the 300-400 halls to ensure the
accuracy of the distribution and use of the controlled medications. This had the potential
to affect all residents who used controlled medications on the 700, 800, 300 and 400
halls. The facility census was 130 residents.
Record review of the facility Clinical Competency Validation Management of Controlled
Medication, undated, showed:
-The controlled medication inventory is verified between each shift in the process of
handing off the keys to the oncoming nurse from the off-going nurse;
-The off-going nurse and the oncoming nurse together validate that inventory counts of
controlled medications are correct and
-Once all controlled medication counts are verified, the off-going nurse and the oncoming
nurse sign the shift to shift controlled medication reconciliation sheet for the date and
shift of the count.
1. Observation of the 700-800 Licensed Nurse Medication Cart on 6/10/19 at 10:39 A.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure Pro Re
Nata (PRN – prescribed as needed) [MEDICAL CONDITION] medications (drugs that affect brain
activities associated with mental processes and behavior) were limited to a duration of 14
days and that the resident’s physician indicated the duration of extended PRN anxiolytic
(anti-anxiety – drugs used to inhibit anxiety) medications for two sampled residents
(Resident #18 and Resident #109) out of 26 sampled residents. The facility census was 130
residents.
Record review of the facility’s Psychotherapeutic Drug Management policy, undated and
unsigned showed:
-[MEDICAL CONDITION] medications are drugs that affect brain activities associated with
mental processes and behavior;
-Residents should not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless
that medication is necessary to treat a diagnosed specific condition that is documented in
the clinical record;
-PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days;
-Except in the case of anti-psychotic drugs (medications used to treat severe mental
disorders that cause abnormal thinking and beliefs and/or perceptions which are not in

-When not in use the urine graduate should be in a bag or covered.
During an interview on 6/11/19 at 10:35 A.M., CMT A said he/she thought urine graduates
were:
-Changed every one to two days by the CNA’s, especially if dirty;
-Kept in a bag or covered in the resident’s bathroom and
-Labeled with resident’s name, room and bed number and date.
During an interview on 6/11/19 at 11:00 A.M. LPN A said:
– CNA’s, CMT’s or nurses change the urine graduates weekly;
-The graduates were to be labeled with the date, resident’s name, room and bed number and
-The graduate was stored in a bag or with a cover over the top.
During an interview on 6/12/19 11:14 A.M., the DON said he/she expected urine graduates
were:
-Changed weekly;
-Labeled with resident’s name, room and bed number and date and
-Covered or in a bag.
3. Record review of the facility’s Resident Census and Condition of Residents dated 6/5/19
showed there were six residents who received antibiotics.
Record review for the 12 consecutive months of Infection Prevention and Control Program
records (June (YEAR) through (MONTH) 2019) showed:
-Three months of records were missing:
–July (YEAR);
–August (YEAR) and
–May 2019.