ROSEWOOD CARE CENTER OF ST LOUIS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ right to self-administer medications had been determined as clinically
appropriate for one of 15 sampled residents (Resident #54). The census was 58.
Review of Resident #54’s medical record, showed the following:
-An admission Minimum Data Set (MDS), a federally required assessment instrument completed
by facility staff, dated 11/8/18, showed [DIAGNOSES REDACTED].
-No order to self-administer medications;
-No assessment for the ability to self-administer medications.
Review of the resident’s care plan, dated 11/2/18, showed no documentation for the ability
to self-administer medication.
Observation and interview on 12/11/18 at 8:22 A.M., showed a medicine cup on the
resident’s bedside table with four white pills inside the cup. The resident said that
he/she needed his/her cup of water refreshed, so he/she will wait to take his/her
medications until he/she receives his/her food. The resident said he/she did not know the
name of the staff that administered his/her medication. At 8:25 A.M., staff went into the
resident’s room with beverages and his/her meal. At 8:35 A.M., the medicine cup was empty.
During an interview on 12/13/18 at 9:45 A.M., the Director of Nursing (DON) said the
resident had not been assessed to administer his/her own medications. If the physician is
okay with the resident self-administering medications, the facility will still need to
assess the resident for their ability to do so and educate the resident. If it is
determined the resident can self-administer medications, it is care planned. Then facility
does not have a policy used for determining a resident’s ability to self-administer
medications. Staff should stay in the room with residents until they take their
medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a clean
and comfortable environment when the facility failed to repair a resident’s heater and
failed to ensure floors and a tube feeding stand were clean and free of debris for two of
15 sampled residents (Residents #107 and #6). The census was 58.
1. Observation and interview on 12/10/18 at 10:09 A.M., showed Resident #107 in bed with
the blanket covering his/her body. The resident said he/she was cold. The air temperature
was noticeably cooler inside the resident’s room than the hallway. The resident said
he/she was shivering. The heater did not work and it had not been working for a couple of
days. The heater blew out cold air. Staff did not offer to move him/her to another room.
He/she reported to staff that the heater was not working, but he/she did not remember who
he/she spoke to.
Review of the maintenance work order book, showed no work order for the resident’s heater.
Further review, showed no work orders after 11/17/18.
Observation on 12/10/18 at 10:16 A.M., showed the heater was turned on and the control
knob was turned to hot. Cold air blew out of the heater. At 10:22 A.M., the air from the

Based on interview and record review, the facility failed to establish a grievance policy
that allowed residents/visitors to file grievances orally or anonymously, identified a
grievance official and/or that required the facility to maintain evidence demonstrating
the result of all grievances for a period of no less than three years from the issuance of
the grievance decision. The census was 58.
Review of the facility’s grievance policy, revised (MONTH) 1999, showed:
-Grievances must be reduced to writing and signed by the resident or legal representative
before submission to the administrator. The Compliment/Complaint procedure and form will
be utilized for this purpose;
-Upon receipt of a written grievance, the administrator will investigate the grievance;
-If the administrator is unable to resolve the grievance, it will go to the Corporate
Section 504 Coordinator who will have a period of thirty (30) days to make a decision or
otherwise resolve the grievance;
-The policy failed to state residents have the right to file grievances orally or
anonymously, identify the grievance official and does not require the facility to maintain
evidence demonstrating the result of all grievances for no less than three years from the
issuance of the grievance decision.
During a group interview on 12/11/18 at 1:39 P.M., eight out of eight residents said they
did not know how to file a formal grievance at the facility. The eight residents did not
know if the facility had a grievance form and/or where to find one, or if the facility had
a grievance official.
During an interview on 12/13/18 at 8:15 A.M., Licensed Practical Nurse (LPN) M said if a
resident expressed the desire to file a grievance or complaint, he/she would fill out an
incident report and give it to the Director of Nursing (DON). He/she would have the
resident fill out a statement to provide to social services. No one has formally explained
to him/her what the facility’s grievance process is.
During an interview on 12/13/18 at 8:27 A.M., Certified Nurse Aide (CNA) E said if a
resident expressed the desire to file a grievance or complaint, he/she would refer the
resident to social services. Social services handles resident grievances.

Based on interview and record review, the facility failed to assure their abuse and
neglect policies and procedures identified when, how and by whom determination of capacity
to consent to sexual contact will be made and where this documentation will be recorded.
The census was 58.
Review of the facility’s Abuse, Neglect, Mistreatment and Misappropriation of Resident
Property policy, dated (YEAR), showed:
-It is the policy of this center to encourage and support all residents, team member,
families, visitors, volunteers and resident representatives in preventing and reporting
any suspected acts of abuse, neglect, exploitation, involuntary seclusion or
misappropriation of resident property;
-The policy failed to identify when, how and by whom determination of capacity to consent
to sexual contact will be made and where this documentation will be recorded.
During an interview on 12/12/18 at 12:25 P.M., the administrator said she thought the
policy regarding capacity to consent was included in the abuse and neglect policy. She
will look for it. On 12/13/18 at 9:45 A.M., the administrator said she was unable to
locate a policy to address capacity to consent to sexual activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 15 sampled residents, one had been recently
discharged to a hospital for various medical reasons, he/she was expected to return, and
he/she had not been issued a written transfer notice upon leaving the facility (Resident
#108). The census was 58.
Review of Resident #108’s medical record, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident or their
legal representative of the facility bed hold policy at the time of transfer to the
hospital, for one of one resident who was recently transferred to a hospital for various
medical reasons (Resident #108) of 15 sampled residents. The census was 58.
Review of Resident #108’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received information in
writing of the facility’s bed hold policy at the time of transfer.
During an interview on 12/10/18 at 7:45 A.M., the resident said he/she did not remember
getting any written bed hold policy when sent to the hospital.
During an interview on 12/12/18 at 10:02 A.M., the Director of Nurses (DON) said nursing
had not been issuing any written bed hold policy to the residents or legal representatives
on discharge to the hospital with return anticipated. The Marketing/Admission staff would
provide the written policy.
During an interview on 12/12/18 at 10:15 A.M., the Marketing/Admissions staff said she is
not responsible for issuing any written bed hold policy to the residents or their legal
representative when they were discharged to the hospital and their return was anticipated.
During an interview on 12/12/18 at 10:23 A.M., both Social Worker I and Social Worker J
said they do not issue any written bed hold policy to any resident or their legal
representative upon discharge to the hospital with a return anticipated. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the failed to assure comprehensive assessments were
completed not less than every 12 months, for two of 16 residents reviewed for resident
assessment completion (Residents #8 and #16). The census was 58.
1. Review of Resident #8’s medical record, showed:
-An admission date of [DATE];
-An admission Minimum Data Set (MDS, a federally required resident assessment completed by
facility staff), dated 10/31/17;
-No comprehensive assessment completed since 10/31/17.
2. Review of Resident #16’s medical record, showed:
-An admission date of [DATE];
-An annual MDS, dated [DATE];
-No comprehensive assessment completed since 11/8/17.
3. During an interview on 12/12/18 at 2:35 P.M., the MDS coordinator said comprehensive
MDS’s are to be completed on admission and annually. She is aware the facility is behind
on completion of MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to assure quarterly Minimum Data
Set (MDS, a federally required resident assessment completed by facility staff) were
completed not less than every three months, between comprehensive assessments, for 11 of
16 residents reviewed for resident assessment completion (Residents #2, #14, #7, #5, #4,
#3, #15, #13, #11, #9 and #10). The census was 58.
1. Review of Resident #2’s medical record, showed:
-An original admission date of [DATE];
-An admission MDS, dated [DATE];
-Quarterly MDS’s, dated 4/1/18 and 6/29/18;
-No quarterly MDS completed for (MONTH) (YEAR).
2. Review of Resident #14’s medical record, showed:
-An original admission date of [DATE];
-A significant change MDS, dated [DATE];

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to electronically transmit
encoded, accurate, and complete Minimum Data Set (MDS, a federally required resident
assessment completed by facility staff) data to the Centers for Medicare and Medicaid
(CMS) System within 14 days after a facility completes a resident’s assessment. In
addition, the facility failed to complete and transmit a discharge assessment for one of
four discharged residents sampled and one of 15 sampled residents (Residents #17 and
#108). The census was 58.
1. Review of the facility’s MDS submission reports for the prior six months, showed:
-CMS Submission Report, dated 6/15/18, showed five records submitted. Of those five, two
submitted late;
-CMS Submission Report, dated 6/20/18, showed seven records submitted. Of those seven, one
submitted late;
-CMS Submission Report, dated 6/21/18, showed six records submitted. Of those six, three
submitted late;
-CMS Submission Report, dated 6/27/18, showed two records submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 6/27/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 6/29/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 6/29/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 6/29/18, showed four records submitted. Of those four, four
submitted late;
-CMS Submission Report, dated 7/5/18, showed six records submitted. Of those six, two
submitted late;
-CMS Submission Report, dated 7/5/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 7/5/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 7/9/18, showed five records submitted. Of those five, two
submitted late;
-CMS Submission Report, dated 7/1018, showed four records submitted. Of those four, two
submitted late;
-CMS Submission Report, dated 7/10/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 7/11/18, showed eight records submitted. Of those eight,
five submitted late;
-CMS Submission Report, dated 7/11/18, showed two records submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 7/13/18, showed three records submitted. Of those three, one
submitted late;
-CMS Submission Report, dated 7/16/18, showed eight records submitted. Of those eight,
five submitted late;
-CMS Submission Report, dated 7/16/18, showed five records submitted. Of those five, one

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure that each
resident receives an accurate assessment, reflective of the resident’s status, for two of
15 sampled residents (Residents #30 and #32). The census was 58.
1. Review of Resident #30’s quarterly Minimum Data Set (MDS), a federally required
resident assessment completed by facility staff, dated 9/30/18, showed:
-[DIAGNOSES REDACTED].
-Resident rarely/never understood;
-Total dependence for transfers and toilet use, full staff performance. One person
physical assist.
Review of the resident’s undated certified nurse’s aide (CNA) care plan guide, located in
the care plan binder, showed for mobility: Right sided weakness, full weight bearing,
transfer assist times 2 staff with mechanical lift.
Review of the resident’s care plan, dated 10/16/18 and in use at the time of the survey,
showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a baseline care plan consistent with the resident’s specific conditions, needs
and risks within 48 hours of admission to properly care for two out of three newly
admitted sampled residents and one closed record (Residents #56, #255 and #108). The
sample was 15. The facility census was 58.
1. Review of Resident #56’s medical record, showed:
-admitted to the facility on [DATE] under hospice care;
-expired on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, undated and in use at the time of survey,
showed no documentation of the resident’s hospice care or [DIAGNOSES REDACTED].
During an interview on [DATE] at 8:00 A.M., the Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, coordinator said if a resident
was admitted to hospice when he/she was admitted , it should be documented on the baseline
care plan.
During an interview on [DATE] at 9:45 A.M., the Director of Nursing (DON) said he would
expect the resident’s care plan to include hospice care. He would expect all baseline care
plans to be person centered.
2. Review of Resident #255’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a care
plan to thoroughly address the use of a gastrostomy tube ([DEVICE], a feeding tube placed
into the abdomen of the stomach) and indwelling urinary catheter (a sterile tube inserted
into the bladder to drain urine) for two of 15 sampled residents (Residents #19 and #6).
The census was 58.
1. Review of the Resident #19’s physician’s orders [REDACTED].
-An order, dated 12/15/18, for [MEDICATION NAME] 1.2 (high protein tube feeding formula),

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure residents
who were unable to carry out activities of daily living (ADLs) receive the necessary
services to maintain good nutrition, grooming, and personal and oral hygiene, for two of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with limited mobility received appropriate services, equipment and assistance to maintain
or improve mobility with maximum practicable independence by failing to provide
restorative services for five of nine residents investigated for positioning/mobility,
restorative and/or activities of daily living (Resident #31, #30, #32, #1, and #27). The
facility census was 58.
Record review of the facility’s restorative nursing program, dated 9/21/07, showed:
-Policy: The facility will assure that all Restorative Nursing Programs follow the
Resident Assessment Instrument (a comprehensive, standardized tool used by facilities to
assess residents in long term care settings, (RAI) guideline established by Center of
Medicaid and Medicare Services (CMS) and State requirements);
-RAI-Restorative nursing guidelines requirements:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
residents’ environment remains as free of accident hazards as possible and each resident
receives adequate supervision and assistive devices to prevent accidents, for three of
three residents observed during a mechanical lift transfer who were transferred with a
broken lift (Residents #1, #32, #30). In addition, the facility failed to assure safely

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
appropriate treatment and services to prevent urinary tract infections by failing to
provide appropriate indwelling urinary catheter positioning for one of three residents
sampled with an indwelling urinary catheter (Resident #6). The facility identified three
residents with a urinary catheter, Resident #6 was not identified by the facility as
having an indwelling urinary catheter. The census was 58.
Review of the facility’s undated Catheter policy, showed:
-Policy: In order to ensure proper technique is utilized to reduce the possibility of
infection with the insertion and maintenance of a Foley (brand of indwelling urinary
catheter) catheter, to relieve bladder distention, to determine amount of residual urine
and to uphold resident dignity, facility will follow specific procedures;
-Maintenance: Precede any entry into the drainage system by thoroughly cleansing with an
alcohol sponge to prevent bacterial contamination;
-To avoid urinary back flow never elevate the drainage bag to or above the bladder level;
-Empty the bag through the distal value into a receptacle and close it appropriately
afterward;
-Measure urinary output at the end of each 8 hour shift;
-Maintain input and output;
-Change the catheter as ordered by the physician and per facility policy;
-Cleanse the urinary meatus and adjacent catheter each shift to minimize [MEDICAL
CONDITION] discharge (the emission or secretion of fluid containing mucus and pus).
Review of Resident #6’s significant change Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/1/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview for mental status (BIMS) score of 10 out of 15, which showed the resident
is cognitively impaired;
-Always incontinent of urine.
Review of the resident’s physician’s orders [REDACTED].
-An order, undated, for a Foley catheter, 16 French (fr, size) 30 cubic centimeter (cc)
balloon;
-An order, undated, to change Foley catheter as needed (PRN) for blockage or obstruction;
-An order, dated 12/3/18, to record urine output every shift;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, orders, monitoring and ongoing communication with the [MEDICAL TREATMENT]
center. The facility identified three residents who received [MEDICAL TREATMENT]. Of those
three, two were selected for the sample of 15 and issues were found with one resident
(Resident #108). The census was 58.
Review of Resident #108’s medical record, showed:
-admitted to the facility on [DATE], and readmitted from a local hospital on [DATE];
-[DIAGNOSES REDACTED]. Can be caused by [MEDICAL CONDITION]);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure side
rails were assessed as a necessary device and failed to ensure side rails fit properly to
reduce the risk of entrapment, for one of 15 sampled residents (Resident #255). The census
was 58.
Review of Resident #255’s medical record, showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure nursing
staff with appropriate competencies and skill sets to assure resident safety and attain or
maintain the highest practicable physical, mental and psychosocial well-being of each
resident by failing to assure nursing staff were competent in the use of insulin pens for
two of two residents observed to receive insulin via an insulin pen (Residents #32 and
#28). The census was 58.

Based on interview, and record review, the facility failed to establish a system of
records of receipt and disposition of all controlled drugs in sufficient detail to enable
an accurate reconciliation. The facility census was 58.
Review of the facility’s Controlled Substance policy, dated 5/11/12, showed:
-A master narcotic count record will be maintained in a binder on each medication cart;
-At shift change, the oncoming and off going nurses will:
-Count controlled substances;
-Sign the master narcotic count record to verify the count is accurate for all controlled
substances;
-Notify the Director of Nursing (DON) or the Assistant Director of Nursing (ADON)
immediately if a discrepancy cannot be resolved.
1. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR), for the 300 and 400 halls, showed:
-For the 300 cart, 9 out of 90 shifts the same nurse (and only nurse) documented for both
the on and the off shift narcotic count, and 9 out of 90 shifts only one nurse documented;
-For the 400 cart, 10 out of 90 shifts the same nurse (and only nurse) documented for both
the on and the off shift narcotic count, and 3 out of 90 shifts only one nurse documented;
-For the 300/400 nurses station, 80 out of 90 shifts the same nurse (and only nurse)
documented for both the on and the off shift narcotic count, and 1 out of 90 shifts only
one nurse documented.
Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR) and reviewed on 12/12/18, for the 300 and 400 halls, showed:
-For 300/400 nurse’s cart, 7 out of 35 shifts, one nurse documented, and 3 out of 35
shifts without count of narcotics;
-For the 300/400 nurse’s station, 16 outof 35 shifts with one nurse documented, and 10 out
of 35 shifts without count of narcotics;
-For the 300/400 certified medication technician (CMT) cart, 19 out 35 shifts with one
nurse documented, and 8 out 35 shifts without count of narcotics.
2. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR), for the 100 and 200 halls, showed:
-For the 100/200 nurses station, 1 out of 90 shifts, the same nurse (and only nurse)
documented for both the on and the off shift narcotic count, and 7 out of 90 shifts with
one nurse documented;
-For the 100/200 CMT cart, 23 out of 35 shifts, one nurse documented for both the on and
the off going shift, and 4 out 35 shifts without count of narcotics.
3. Review of the facility’s controlled substance shift change count check sheet with an
illegible label, dated (MONTH) (YEAR), showed 5 out of 90 shifts with the same nursing
staff documenting for both the on and the off shift narcotic count, and 11 out of 90
shifts with one nurse documented.
4. During an interview on 12/12/18 at 11:16 A.M., the DON said he expects the oncoming and
off going nursing staff to count the narcotics together before starting and ending their
shifts, and to document their findings on the controlled substance shift change count

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 25 opportunities observed, 4 errors occurred
resulting in a 16% error rate (Residents #32, #28 and #31). The census was 58.
1. Review of Resident #32’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order dated 8/30/18, for [MEDICATION NAME] (long acting
insulin) 50 units subcutaneous (SQ, under the skin) two times a day;
-An order dated 9/5/18, for Humalog (short acting insulin) 12 units SQ three times a day
with meals routine;
-An order dated 9/5/18, for Humalog per sliding scale. For a blood sugar of 181 through
220, administer 2 units of Humalog.
Observation on 12/10/18 at 8:32 A.M., showed Licensed Practical Nurse (LPN) A administered
insulin to the resident. LPN A obtained the residents blood sugar level of 201, dialed 14
units on the residents Humalog insulin pen and placed a needle on the pen. He/she then
dialed 50 units on the residents [MEDICATION NAME] pen and placed a needle on the pen.
He/she entered the residents room, wiped off the left and right side of the resident’s
abdomen with alcohol wipes and administered the Humalog into the right abdomen and
[MEDICATION NAME] to the left abdomen. LPN A failed to prime the pens prior to
administration of the insulin via insulin pens.
2. Review of Resident #28’s POS, dated 12/1/18 through 12/31/18, showed an order dated
4/13/18, for Humalog insulin pen per sliding scale insulin. For a blood sugar of 221
through 280, administer 3 units of Humalog.
Observation on 12/11/18 at 12:23 P.M., showed LPN D administered insulin to the resident.
LPN D obtained the resident’s blood sugar level of 229, dialed 3 units of the resident’s
Humalog insulin pen and placed a needle on the pen. He/she entered the resident’s room,
wiped off the residents left arm and administered the Humalog insulin to the resident. LPN
D failed to prime the insulin pen prior to administration of the insulin via insulin pen.
3. Review of the facility’s Safe Medication Administration policy, dated 9/2018, showed:
-All injectable medications must be prepared and administered in accordance with safe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
are free of any significant medication errors by failing to prime insulin pens before use
to assure the correct does of the medication was administered, for two of two residents
observed to receive insulin via an insulin pen (Residents #32 and #28). The census was 58.
1. Review of Resident #32’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order dated 8/30/18, for [MEDICATION NAME] (long acting
insulin) 50 units (subcutaneous SQ, under the skin) two times a day;
-An order dated 9/5/18, for Humalog (short acting insulin) 12 units SQ three times a day
with meals routine;
-An order dated 9/5/18, for Humalog per sliding scale. For a blood sugar of 181 through
220, administer 2 units of Humalog.
Observation on 12/10/18 at 8:32 A.M., showed Licensed Practical Nurse (LPN) A administered
insulin to the resident. LPN A obtained the residents blood sugar level of 201, dialed 14
units on the residents Humalog insulin pen and placed a needle on the pen. He/she then
dialed 50 units on the residents [MEDICATION NAME] pen and placed a needle on the pen.
He/she entered the residents room, wiped off the left and right side of the resident’s
abdomen with alcohol wipes and administered the Humalog into the right abdomen and
[MEDICATION NAME] to the left abdomen. LPN A failed to prime the pens prior to
administration of the insulin via insulin pens.
2. Review of Resident #28’s POS, dated 12/1/18 through 12/31/18, showed an order dated
4/13/18, for Humalog insulin pen per sliding scale insulin. For a blood sugar of 221
through 280, administer 3 units of Humalog.
Observation on 12/11/18 at 12:23 P.M., showed LPN D administered insulin to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure drugs
and biologicals were labeled in accordance with currently accepted professional principles
and facility policy and failed to discard expired medications for three of five medication
carts checked. The facility census was 58.
Review of the facility’s storage of medications policy, undated, showed:
-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.
All such drugs shall be returned to the dispensing facility or destroy;
-Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be
stored separately from other medications;
-Antiseptics, disinfectants, and germicides used in any aspect of resident care must have
legible, distinctive labels that identify the contents and the directions for use, and
shall be stored separately from regular medications.
1. Observation on 12/10/18 at 9:53 A.M., of the certified medical technician (CMT)
medication cart on 300 hall, showed a Breo Ellipta medication delivery device ([MEDICATION
NAME][MEDICATION NAME], medication used to open the lung airways by inhalation), unlabeled
with a resident’s name and stored loose in the top drawer of the cart.
2. Observation on 12/10/18 at 10:01 A.M., of the CMT cart on 400 hall, showed one tube of
barrier cream (used to prevent skin breakdown on an incontinent resident), opened,
unlabeled with a resident’s name, and stored in a compartment with packaged oral
medications.
3. Observation on 12/13/18 at 7:30 A.M., of the nurse’s medication cart on 300 hall,
showed:
-One opened bottle of Liquid Iron, expired 10/2018;
-One bottle of rubbing alcohol, opened, unlabeled with a resident’s name and stored with
packaged oral medications;
-One bottle of [MEDICATION NAME] (cleansing solution usually used on wounds), opened,
unlabeled with a resident’s name and stored with 4 containers of nutritional liquid

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service
safety by failing to store food in sanitary conditions, properly label food and beverages,
and dispose of expired thawed food. The facility also failed to keep the floors free of
food and debris and/or ensure staff covered their hair with restraints when preparing
food. These deficient practices had the potential to affect all residents who ate at the
facility. The census was 58.
Review of the facility’s food preparation policy, dated (MONTH) (YEAR), showed all foods
that are to be held for more than 2 hours at a temperature of 41 degrees Fahrenheit or
less will be labeled and dated with a prepared date (day one) and a use by date (day
seven).
1. Observation of the walk in cooler on [DATE] at 8:05 A.M., showed a bag of thawed, raw
chicken on a metal pan, dated [DATE]. The bag of thawed chicken lay on top of pinkish
liquid inside the metal pan. There was a wrapped, undated piece of thawed meat on the
metal pan and lay in the reddish liquid.
2. Observation on [DATE] at 8:31 A.M., showed:
-Two partially thawed bags of chicken inside the walk in cooler without a date, one
partially thawed bag of chicken dated [DATE], and one thawed bag of chicken dated [DATE].
The bags were on top of each other with the bag dated [DATE] on the bottom;
-Crinkled French fries on the floor in front of the stove;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure all resident records
were complete and accurate by failing to ensure documentation of care provided was
documented at the time it was provided and/or available, by not documenting daily, weekly
and monthly weights and not having laboratory results in the resident’s medical records
for eight of 15 sampled residents (Residents #108, #49, #36, #1, #105, #28, #32 and #45,).
The census was 58.
1. Review of Resident #108’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-No order to check the arteriovenous (AV), fistula (connection or passageway between an
artery and a vein, surgically created for [MEDICAL TREATMENT] treatments) for bruit/thrill
(the thrill is the vibration you feel as blood flows through the fistula. The bruit is the
sound you hear, heard with a stethoscope);
-No order to check the AV fistula for signs/symptoms of infection and bleeding.
Review of the resident’s medical record, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain an
infection prevention and control program designed to provide a safe, sanitary and
comfortable environment and to help prevent the development and transmission of
communicable diseases and infections by failing to follow infection control standards of
practice during incontinence care and during the transfer of a resident with an indwelling
urinary catheter, for two of 15 sampled residents (Resident #30 and #1). The census was

-Problem: Incontinent of bowel and bladder:
-Goal: Experience no skin conditions related to incontinence;
-Interventions: Check or incontinence, change if wet/soiled. Apply moisture barrier,
reapply after each incontinence episode.
Observation on 12/10/18 at 1:57 P.M., showed CNA B obtained the Hoyer lift (mechanical
lift). CNA B, Licensed Practical Nurse (LPN) A and Restorative Aide C transferred the
resident to bed with the use of the Hoyer lift. After the staff transferred the resident
to bed, Restorative Aide C left room. CNA and LPN A remained in the room. CNA B obtained
supplies, assisted the resident to pull his/her pants down, and assisted the resident to
his/her right side. An undated dressing observed on the resident’s coccyx (tail bone). The
resident’s brief was wet with urine. CNA B unsecured the resident’s brief, LPN A assisted
the resident to turn to the other side and unsecured the resident’s brief on the right
side. CNA B rolled up and removed the resident’s brief. LPN A and CNA B assisted the
resident to turn to the right side. CNA B placed a clean brief under resident’s soiled
buttocks, obtained a disposable wipe and wiped the inside of the gluteal fold with several
wipes, folding the disposable wipe between each wipe. A small amount of stool was visible
in the resident’s gluteal fold. Without changing his/her gloves or sanitizing his/her
hands, CNA B dried the resident’s buttocks with a towel and applied protective ointment to
the resident’s buttocks that he/she obtained from the resident’s dresser while still
wearing the soiled gloves. LPN A positioned the resident to his/her back. CNA B removed
his/her gloves, washed his/her hands and placed new gloves on. CNA B cleansed the
resident’s genitals, dried the resident’s genitals with the towel used with the soiled
gloves to dry the buttocks, secure the resident’s brief and assisted the resident onto
his/her back. While wearing the same gloves, CNA B removed the resident’s pants, placed a
wedge cushion behind the resident’s back, and covered the resident with a sheet and
blanket. He/she used the bed controllers to elevate the head of the bed and lower the bed
to the floor before removing his/her soiled gloves and washing is/her hands.
Review of the facility’s Incontinence Assessment and Management policy, dated 9/2005,
showed:
-The facility will ensure each resident, who is incontinent, will be identified, assessed