REDWOOD OF KANSAS CITY SOUTH

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide dignity
to two sampled residents (Residents #21 and #32) by leaving hospital wristbands with care
information on them, and to trim or remove facial hair for one sampled resident (Resident
#21) out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s considerate and respectful treatment policy revised 9/1/13
showed instructions to staff to:
-Care for residents in a manner that maintains or enhances each resident’s dignity and
-Not post signs that are able to be seen by other residents and/or visitors that include
clinical or personal information.
1. Observation during initial tour on 6/6/18 at 10:00 A.M. showed multiple residents were
wearing wristbands that had clinical information regarding the resident such as fall risk.
2. Record review of Resident #21’s care plan revised 10/3/17 showed:
-The resident was a high fall risk and
-The resident required extensive assistance with personal hygiene.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool used by facility staff for care planning) dated 3/26/18 showed the
following staff assessment of the resident:
-Had clear speech;
-Had moderate hearing impairment;
-Had moderately impaired cognitive skills;
-Had disorganized thinking;
-Required extensive assistance with personal hygiene;
-One of his/her [DIAGNOSES REDACTED].
-Had not fallen since his/her last assessment (12/24/17).
Observation on 6/06/18 at 2:06 P.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
Observation on 6/11/18 at 5:25 A.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
Observation on 6/12/18 at 7:53 A.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
During an interview on 6/13/18 at 12:08 P.M., the Assistant Director of Nursing (ADON)
said:
-No one had tried to pull or trim the hairs coming out of the resident’s mole and
-He/she will ask the resident’s doctor if they can pull the hairs from the mole.
3. Record review of Resident #32’s admission MDS dated [DATE] showed the following staff
assessment of the resident:
-Had unclear speech;
-Sometimes understood others;
-Had short-term and long-term memory impairment;
-Received [MEDICAL TREATMENT] (a process of cleansing the blood by passing it through a
special machine when the kidneys are not able to filter the blood) and
-Required extensive assistance to being totally dependent upon staff for all cares.
Record review of the resident’s current care plan showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide privacy
by storing an employee’s personal belongings in a resident’s room for one sampled resident
(Resident #28) out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s privacy rights policy revised 11/28/16 showed residents
have a right to personal privacy.
1. Record review of Resident #28’s care plan dated 1/3/18 showed he/she:
-Was resistive to cares related to dementia (a progressive mental disorder characterized
by memory problems, impaired reasoning and personality changes);
-Had the potential to be verbally aggressive related to dementia and
-Had impaired cognitive function and impaired thought processes related to dementia.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by staff for care planning) dated 4/13/18 showed he/she:
-Was severely cognitively impaired and
-Had a [DIAGNOSES REDACTED].
Observation on 6/6/18 at 10:50 A.M. showed the Activity Assistant:
-Was in Resident #28’s room taking snacks out of an upper cupboard (The first half of the
room did not have a resident living in it. Resident #28 lived in the back half of the
room);
-No resident was present in the room;
-The Activity Assistant walked down the hallway stopped at the nurses’ station where
he/she gave a snack package to one of the Certified Nursing Assistants and
-He/she went into the dining room (where there was an activity in progress with the
residents), sat down and ate one of the snack packages.
During an interview on 6/6/18 at 2:00 P.M. the Director of Nursing (DON) said;
-He/she had talked to the Activity Assistant who told him/her those were his/her snacks
and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide notification to the
resident, and/or the resident’s representative(s) and the ombudsman (a resident advocate
who provides support and assistance with problems and/or complaints regarding the
facility) of the transfer or discharge and the reasons for the move in writing for three
sampled residents (Residents #48, #29, #57) out of 18 sampled residents and one closed
record resident (Resident #180). The facility census was 80 residents.
Record review of the facility’s Discharge and Transfer Policy effective dated of 6/1/96,
reviewed date of 10/10/’16 and revision date of 11/28/16 showed:
-All residents will receive a Notice of Transfer or Discharge whenever a voluntary or
involuntary transfer/discharge occurs;
-Residents and/or legal representatives will be provided proper notice in accordance with
state and federal regulations should a transfer or discharge be initiated;
-Social Services will ensure systems are implemented to provide written notification to
the resident/responsible party;
-For unplanned, acute transfers, residents, family, and legal guardian will be notified
verbally;
-Written notice will follow verbal notification per state requirements; and
-A copy of the written notice of transfer will be placed in the resident’s medical record.
1. Record review of Resident #48’s discharge return anticipated assessment dated [DATE]
showed he/she was transferred from the facility on 5/17/18.
Record review of the resident’s medical record showed there was no letter notifying the
resident and the resident’s representative(s) of a transfer and the reasons for the
transfer.
Record review of the resident’s entry tracking form dated 5/24/18 showed the resident
returned to the facility on [DATE].
2. Record review of Resident #29’s Nurses Note dated 5/23/18 at 9:25 A.M. showed he/she
was transferred to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and/or
the resident’s representative(s) of the facility’s bed-hold policy before transferring or
discharging the resident to the hospital for three sampled residents (Residents #48, #29,
and #57) out of 18 sampled residents and one closed record resident (Resident #180). The
facility census was 80 residents.
Record review of the facility’s Bed-Holds Policy effective date of 3/15/00 and revision
date of 11/28/16 showed:
-When a resident is transferred to a hospital the designee (e.g., Admissions, Social
Services, etc.) will provide the resident/resident representative with the written Bed
Hold Policy Notice & Authorization form and
-If the resident representative is not present at time of transfer to receive the written
notice a copy is delivered via e-mail or a hard copy by mail.
1. Record review of Resident #48’s discharge return anticipated assessment dated [DATE]
showed he/she was transferred from the facility on 5/17/18.
Record review of the resident’s medical record showed there was no letter notifying the
resident and the resident’s representative(s) of a transfer and the reasons for the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide a Preadmission
Screening and Resident Review (PASRR- a federally mandated preliminary assessment to
determine whether a resident may have a mental illness (MI) or an intellectual disorder
(ID), to determine the level of care needed. A level I is required for all residents and a
level II if the resident tests positive for any MI or ID) for three sampled residents
(Residents #48, #8 and #57) out of 18 sampled residents. The facility census was 80
residents.
Record review of the facility’s Pre-admission Screening for Mental Illness and
Intellectual/developmental disability Policy with an effective date of 6/1/01 and revision
date of 11/28/’16 showed:
-Social Services (SS) will coordinate and/or inform the appropriate agency to conduct the
evaluation and obtain results if:
–It is learned after admission that the PASRR was not completed or is incorrect, or
–There is a significant change in status that results in new evidence of possible MI, ID,
or a related condition;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and
his/her representative with a summary of the resident’s baseline care plan for two sampled
residents (Resident #32 and #34) and one closed record (Resident #80B) out of 18 sampled
residents and three closed records. The facility census was 80 residents.
Record review of the facility’s Person-Centered Care Plan policy revised on 2/13/17 showed
instructions for staff to:
-Develop and implement a baseline person-centered care plan within 48 hours of admission
for each resident that includes the instructions needed to provide effective and
person-centered care and
-Provide the resident and his/her representative with a summary of the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop
comprehensive assessments for two sampled residents (Residents #32 and #26) out of 18
sampled residents. The facility census was 80 residents.
Record review of the facility’s Person-Centered Care Plan policy revised on 2/13/17 showed
a comprehensive, individualized care plan will be developed within seven days after
completion of the comprehensive assessment for each resident that includes measurable
objectives and timetables to meet the resident’s needs that are identified in the
comprehensive assessments.
1. Record review of Resident #32’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed he/she
received [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a
special machine when the kidneys are not able to filter the blood).
Record review of the resident’s (MONTH) (YEAR) Physician order [REDACTED].
Observation on 6/6/18 at 2:04 P.M. showed the resident was not in his/her room. Licensed
Practical Nurse (LPN) E said the resident was at [MEDICAL TREATMENT].
Record review of the resident’s current care plan showed the care plan did not include
[MEDICAL TREATMENT].
2. Record review of Resident #26’s dental note dated 5/16/16 showed the border on the
resident’s upper denture was broken and the resident’s upper denture was taken to the lab
to repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed develop a comprehensive care
plan within seven days of the resident’s comprehensive assessment for one sampled resident
(Resident #34) out of 18 sampled residents. The facility census was 80 residents.
1. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Minimum Data Set (MDS – a federally mandated assessment
instrument completed by facility staff for care planning) dated 4/22/18 showed the
resident:
-Was severely cognitively impaired;
-Did not have any pressure ulcers (localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction);
-Did not have any venous ulcers (venous stasis ulcer – open lesion caused by poor
circulation) or arterial ulcers (arterial stasis ulcer – open lesion caused by poor
circulation or blocked arteries);
-Did not have any foot wounds;
-Did not have any wounds or skin irregularities;
-Required total staff assistance for bathing, transfers, bed mobility, personal hygiene,
eating, dressing, toileting;
-Received tube feeding nutrition;
-Had a Foley catheter (a tube with retaining balloon passed through the urethra into the
bladder to drain urine);
-Was always incontinent of stool;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to document the
change in condition and death of one supplemental Resident (Resident #65) and the hospital
return and relevant health information regarding the resident’s hospital stay for one
sampled resident (Resident #48) out of 18 sampled residents. The facility census was 80
residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop a discharge plan
according to the resident’s wishes for one sampled resident (Resident #80A) out of 18
sampled residents and three closed records. The facility census was 80 residents.
1. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Admission Summary dated 2/23/18 showed he/she was admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a comprehensive
discharge summary which included a recapitulation of stay for one sampled closed record
(Resident #80A) out of 18 sampled residents and three closed records. The facility census

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the Out
of the hospital Do Not Resuscitate (OHDNR-documents the instructions in an out-of-hospital
setting not to initiate resuscitation if a person suffers cardiac or respiratory arrest)
was fully complete for one supplemental Resident (Resident #65) out of 18 sampled
residents. The facility census was 80 residents.
Record review of the facility’s undated Cardiac and/or Respiratory Arrest policy showed:
-Every resident has the right to accept or decline cardiopulmonary resuscitation (CPR-a
lifesaving technique used when someone’s breathing or heartbeat has stopped) and
-CPR will be performed unless there is a written physician’s orders [REDACTED].

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to document the
condition and size of the resident’s wounds and to update the resident’s care plan for one
sampled resident (Resident #32), to notify the physician of a change of condition for one
closed record resident (Resident #180), to obtain a valid [DIAGNOSES REDACTED]. in a
timely manner of a resident’s pressure and non-pressure wounds for one sampled resident
(Resident #34), and to accurately document and account for a resident’s narcotic
medications and to obtain a valid physician’s orders [REDACTED].#80A) out of 18 sampled
residents. The facility census was 80 residents.
Record review of the facility’s controlled substance medications policy dated 3/22/18
showed instructions that any discrepancy in controlled substance medication counts should
be reported to the Director of Nursing (DON) consultant pharmacist and Administrator.
1. Record review of Resident #32’s entry tracking form showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s Resident Data Set (RDS) assessment dated [DATE] showed the
resident had a wound (the type of wound was not documented) on his/her right buttock, the
front of his/her left lower leg and his/her left heel.
Record review of the resident’s nurse’s note dated 3/19/18 showed he/she had the following
wounds:
-A left heel wound (which included measurements);
-Multiple abrasions on both legs;
-A buttock wound (which included measurements);
-A fluid filled blister to his/her abdomen;
-A right great toe had blister and
-A blister underneath the resident’s right foot.
Record review of the resident’s skin/wound note dated 3/20/18 showed:
-The resident:
–Was re-admitted on [DATE] and present on admission were:
—Several open blisters on his/her right shin.
—Open blisters on his/her right hip and thigh open blisters.
—Open diabetic wounds diabetic wound (a complication of diabetes (a condition in which
the pancreas no longer makes insulin and therefore blood glucose cannot enter the cells to
be used for energy, the pancreas does not make enough insulin or the body is unable to use
insulin correctly) on his/her right heel and right ankle.
-Descriptions of the wounds were included.
-Measurements were not included.
Record review of the resident’s medical record showed there were no weekly wound notes
between 3/20/18 and 5/6/18.
Record review of the resident’s discharge with his/her return anticipated assessment dated
[DATE] showed he/she was discharged from the facility.
Record review of the resident’s entry tracking form showed he/she was re-admitted to the
facility on [DATE].
Record review of the resident’s RDS assessment dated [DATE] showed he/she did not have any

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
maintained proper positioning of a catheter (a flexible tube inserted through a narrow
opening into the bladder, drains into a collection bag, used for removing fluid from the
body) for two sampled resident (Resident #32, and #23) out of 18 sampled residents. The
facility census was 80 residents.
Record review of the facility’s Catheter Care policy revised date of 1/2/14 showed
instructions to keep the catheter drainage bag below the level of the resident’s bladder
and off of the floor.
1. Record review of Resident #32’s care plan dated 3/19/18 showed he/she had an indwelling
catheter and was totally dependent on two staff for transferring from one surface to
another with a mechanical lift.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed the
following staff assessment of the resident:
-Rarely or never understood;
-Had an indwelling catheter and
-Totally dependent upon two or more staff for transferring from one surface to another.

-The catheter bag leaked urine and
-The resident was lowered to the bed to be changed and cleaned.
Observation on 6/8/18 at 10:17 A.M. showed during a mechanical lift transfer from the
resident’s bed to his/her and CNA A placed the resident’s catheter bag on his/her legs
above the level of the bladder.
During an interview on 06/14/18 at 11:15 A.M., the Director of Nursing (DON) said:
-The resident’s catheter should be kept below the bladder when the resident is transferred
and
-The catheter bag is not allowed on the lift even if it is below the resident’s bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to manage and treat
pain to the extent possible when pain medication was not administered according to the
physician’s orders [REDACTED].#16 and #23) and facility staff did not offer or attempt
non-pharmacological interventions prior to administering a narcotic as needed pain
medication for one sampled resident (Resident #80A) out of 18 sampled residents. The
facility census was 80 residents.
Record review of the facility’s Pain Management Policy with revision date of 11/26/16
showed:
-Patients will be evaluated as part of the nursing assessment process for the presence of
pain upon admission/re-admission, quarterly, with change in condition or change in pain
status;
-At a minimum of daily, patients will be evaluated for the presence of pain by making an
inquiry of the patient or by observing for signs of pain;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to accurately
document the administration of pain medication, to administer pain medication as ordered;
to ensure medication administration records were consistent for controlled medications
(drugs that are regulated by laws that aim to control the danger of addiction, abuse,
harm, etc.) for four sampled residents (Resident #7, #48, #16 and #23) and to ensure a
resident’s narcotic medications were accurately documented as administered and accounted
for on the resident’s Controlled Substance log for one sampled resident (Resident #80A)
out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s Medication: Administration: General Policy with revision
date of 5/15/17 showed:
-If discrepancies, including medication not available, notify physician and/or pharmacy as
indicated;
-If medication is refused by the patient, discard the medication and attempt to administer
again at a later time;
-Document administration of medication on the Medication Administration Record (MAR) and
-Document medication refused by patient on the back of the MAR, or for electronic order
management by entering the refusal code on the MAR.
Record review of the facility’s Controlled Substance (drugs that are regulated by laws
that aim to control the danger of addiction, abuse, harm, etc.) Medications Policy dated
3/12/18 showed:
-The Director of Nursing (DON) is responsible for the control of these medications at the
facility;
-Controlled substances will be dispensed by the pharmacy with an individual Charting
Record;
-The Charting Record will be maintained by the nursing staff at the time of each
administration of the medication as follows:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure that as needed (PRN)
orders for [MEDICAL CONDITION] drugs (any drug capable of affecting the mind, emotions,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
medications were stored, labeled and dated correctly in two sampled medication carts out
of four medication carts and one sampled medication room out of two medication rooms. The
facility census was 80 residents.
Record review of the facility’s policy revision date [DATE] Storage and Expiration Dating
of Drugs, Biologicals, Syringes, and Needles said:
-Drugs, biologicals, syringes, and needles are stored under proper conditions with regard
to sanitation, temperature, light, moisture, ventilation, segregation, safety, security,
and expiration date as directed by state and federal regulations and manufacturer/supplier
guidelines;
-Food is not stored in the refrigerator, freezer, or general storage areas where drugs and
biologicals are stored;
-Drugs and biologicals that have an expired date on the label or are after
manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are
stored separately, away from use, until destroyed or returned to the provider; and
-Storage location of the interim/stat/emergency boxes is known to all personnel handling
medications and located in an area readily available to licensed staff.
1. Observation on [DATE] at 5:15 A.M. with Licensed Practical Nurse (LPN) C of the North
Medication Cart showed the following medications were found to be opened without an open
date marked on them or were expired:
-[MEDICATION NAME] (medication to treat heartburn) 16 fluid ounces opened without an
opened date marked on the bottle;
-Dicto Liquid ([MEDICATION NAME] Sodium)(medication to treat constipation) 16 fluid ounces
opened without an opened date marked on the bottle;
-Melox .09% Lamotr 2.6% Lidocane spray (medication that numbs an area) which had expired
on ,[DATE];
-[MEDICATION NAME] (medication used to treat depression) 240 milliliters (ml) bottle
opened without an opened date marked on the bottle and
-Medications, batteries, a flashlight, and cigarettes were observed in the same drawer.
During an interview on [DATE] at 5:15 A.M. LPN C, said:
-Medications should have an opened date on them if they have been opened; and

Based on observations and interviews the facility failed to prevent food and trash debris
on the floor of the walk-in refrigerator and the kitchen perimeter; to monitor produce
freshness; to refrigerate food properly; to maintain a clean can opener blade; to separate
dented cans from undented ones in the dry storage; to cover individual food bowls for
transport; and to ensure the cleanliness of an ice cooler. These practices potentially
affected all residents who ate food from the kitchen. The facility census was 80 residents
with a licensed capacity for 100.
1. Observations in the kitchen and kitchenette on 6/6/18 between 9:09 A.M. and 12:48 P.M.,
showed the following:
– The walk-in refrigerator had various debris, i.e, fruit, grapes, and butter packages,
under storage racks,
– Two separate undated produce boxes of wilted lettuce and shriveled peppers in the dry
storage,
– The double sink food preparation area had eggshells and trash underneath,
– A one gallon opened jug of soy sauce on the shelf under the double sink area read
refrigerate after opening for quality on the label,
– The kitchen perimeter floor had numerous small trash, food debris, and cups,
– Three six pound ( lb.) dented cans of pineapple chunks were not properly separated from
undented cans on a rack in the dry storage,
– A cart with individual bowls of chunk pineapple were being transported to the main
dining room uncovered, and
– An unsecured lid on an ice cooler in the kitchenette next to the main dining room fell
on the floor and a staff member picked it up, placed it back on the base, and proceeded to
fill it with ice from the ice machine for one of the units.
During separate interviews on 6/6/18 at 10:29 A.M. and 1:51 P.M., the Director of
Nutrition Services (DNS) said the following:
– When dented cans are found they usually just throw them away; they must have just got a
bad case,
– It is the day dishwasher’s responsibility to sweep the refrigerator daily and the night
dishwasher is to mop the whole kitchen at that shift’s end,
– If an item’s label suggested refrigeration after opening it should absolutely be done,
– It is expected that individually prepared dessert bowls be covered during transport,
– The can opener blade should be cleaned after each use, and
– If a piece of equipment that comes in to contact with food or beverages fell on the

Based on record reviews and interviews the facility failed to readily produce an on-site
policy, in the kitchen or at either nurse’s desk, regarding the acceptance, usage, and
storage of foods brought into the facility for residents by family and other visitors, to
ensure the food’s safe and sanitary handling and consumption, and failed to have fully
educated all staff as to its existence, whereabouts, and content. This deficient practice
had the potential to affect all residents who ate food brought in by visitors. The
facility census was 80 with a licensed capacity of 100.
1. Observation during Entrance Conference on 6/6/18 at 9:07 A.M., showed the Administrator
was given a list of required documents with a subheading entitled Information Needed from
the Facility Within One Hour of Entrance, which included the policy for food brought in
from visitors.
Request for and subsequent record review of kitchen documents on 6/6/18 at 9:09 A.M., in
the Dietary Office failed to show a policy for outside food brought in for residents.
During an interview on 6/6/18 at 9:13 A.M., the Director of Nutrition Services (DNS) said
the following:
– There was a policy for outside food brought in for residents, but he/she did not know
where the policy was currently located,
– That copies of the policy should be at each nurse’s desk, and
– That a copy would be provided later for review.
During an interview on 6/6/18 at 11:24 A.M., the DNS said he had spoken with the
Administrator and he/she would provide a copy of the outside food policy.
During an interview on 6/7/18 at 1:45 P.M., at the south nurse’s desk, Licensed Practical
Nurse (LPN) E said the following:
– He/she thought they had read somewhere that staff was to make sure anyone who brought
food in for a resident knew their particular diet and texture needs,
– The food would have to be dated with the resident’s name on it and stored in the unit
refrigerator, and
– He/she did not know where an actual written policy may be located.
During an interview on 6/7/18 at 1:53 P.M., the Director of Human Resources said:
– He/she thought the policy was mentioned to all staff during the last in-service; and
– Record review of the last in-service dated 5/25/18 showed the subject of an outside food
policy was not listed as a covered topic.
During an interview on 6/7/18 at 2:37 P.M., at the north nurse’s desk, LPN F said he/she
was unaware of any outside food policy, but there was a refrigerator for such items if
they ensure there is a name and date on them.
During an exit interview on 6/8/18 at 12:07 P.M., the Administrator provided the
following:
– A corporate policy titled Foods Brought by Family/Visitors that was not facility
specific and included procedures that staff interviews failed to disclose,
– A staff in-service topic sheet dated 6/8/18 with Foods Brought in by Family Members

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, and record review, the facility failed to establish and maintain an
infection prevention and control program designed to provide a safe, sanitary and
comfortable environment by not maintaining an infection control program, and to ensure the
Infection Control program policies were reviewed at least annually. This could potentially
affect all of the residents in the facility. The facility census was 80 residents.
Record review of the facility Infection Control Surveillance and Reporting policy dated
9/1/04 and revised on 11/28/16 showed:
-The Infection Preventionist will conduct regular outcome surveillance which consists of
collecting and documenting data on individual cases and comparing the collective data to
standard, written definitions of infection;
-The Infection Preventionist will conduct regular process surveillance to review which
practices directly related to patient care. Examples of this type of surveillance include
monitoring of compliance with Transmission Based Precautions, proper hand washing, the use
and disposal of gloves, and observation of the environment and
–The policy of the previous ownership was adopted by the current facility on 4/25/18.
Record review of the facility’s Procedure: Infection Control Outcome Surveillance and
Reporting policy dated 9/1/04 and revised on 11/28/16 showed:
-Community acquired infections are those infections incubating at the time of admission or
that develop in less than two calendar days from admission;
-Healthcare acquired infections (HAI) are those in which there is no evidence of an
incubating infection at the time of admission to the facility (on the basis of clinical
documentation of appropriate signs and symptoms and not solely on screening microbiologic
data), and onset of clinical manifestation occurs more than two days after admission and
–The policy of the previous ownership was adopted by the current facility on 4/25/18.
1. Record review on 6/13/18 at 1:58 P.M. of the facility’s computer generated Infection
Control Log Tracking and Trending report showed:
-The facility had two infections in (MONTH) (YEAR);
-The next entry was dated on 11/2/17.
-Staff were directed to document the following information:
–The order date;
–The resident’s room number;
–The resident’s name;
–Was the infection community acquired or facility acquired;
–The resident’s admitted ;
–Any cultures or X-rays that were done;
–Any signs or symptoms that had been documented;
–Which type of infection (Urinary Tract Infection, upper respiratory infection, lower
respiratory infection, skin or soft tissue, gastrointestinal, other);
–Was the resident on isolation;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish a facility-wide
infection prevention and control program that included an antibiotic stewardship program
that included antibiotic use protocols and a system to monitor antibiotic usage. The
facility census was 80 residents.
Record review of the facility Infection Control Surveillance and Reporting policy dated
9/1/04 and revised on 11/28/16 showed:
-The Infection Preventionist will conduct regular outcome surveillance which consists of
collecting and documenting data on individual cases and comparing the collective data to
standard, written definitions of infection;
-The Infection Preventionist will conduct regular process surveillance to review which
practices directly related to patient care. Examples of this type of surveillance include
monitoring of compliance with Transmission Based Precautions, proper hand washing, the use
and disposal of gloves, and observation of the environment and
–The policy did not address antibiotic use protocols.
Record review of the facility’s Procedure: Infection Control Outcome Surveillance and
Reporting policy dated 9/1/04 and revised on 11/28/16 showed:
-Community acquired infections are those infections incubating at the time of admission or
that develop in less than two calendar days from admission and
-Healthcare acquired infections (HAI) are those in which there is no evidence of an
incubating infection at the time of admission to the facility (on the basis of clinical
documentation of appropriate signs and symptoms and not solely on screening microbiologic
data), and onset of clinical manifestation occurs more than two days after admission.
1. During an interview and record review on 6/13/18 at 1:58 P.M., the Assistant Director
of Nursing (ADON) said:
-He/She completes the facility Infection Control Log.
-He/She documents the following information each month: The resident’s name; physician;
room number; the resident’s date of admission; the date of onset of symptoms; if the
infection was HAI or community acquired, the type of symptoms; did the infection meet
McGeer’s criteria (infection surveillance definitions for long term care facilities); was
a culture or X-ray completed; what antibiotic was used; if any isolation precautions were
used; and the date the infection was resolved.
-He/She tracks the infections with an antibiotic in the facility each month;
-He/She does not keep track of infections not being treated with an antibiotic;
-He/She does not keep track of any labs to determine what bacteria is being treated and
-He/She does not keep track does not track the date the infections were resolved.
During an interview on 6/14/18 at 8:12 A.M., the ADON said:
-He/She thought community acquired infections were the infections that developed after the
resident was admitted to the facility;
-He/She thought healthcare acquired infections were infections the resident had prior to
being admitted to the facility;
-He/She did not have any way to determine if the antibiotics prescribed were appropriate
for the resident’s infectious organism;
-He/She thought the McGeer’s criteria definitions were in the Infection Control folder;
–McGeer’s criteria definitions were not located in the Infection Control folder and
-For antibiotic stewardship, he/she looks at the Infection Control logs to see if too many
antibiotics were being used in the facility, and if so, he/she would ask for an alternate