ROYAL OAK NURSING & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a final accounting of
and/or the remaining funds in the resident trust account were sent to the individual or
probate jurisdiction administering the resident’s estate, in accordance with State and
Federal law (30 days for Federal, 60 days for State), for three of three accounts
reviewed. (Residents #379, #380 and #381) The census was 111.
1. Review of Resident #379’s account, showed he/she expired [DATE], with $995.67, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
2. Review of Resident #380’s account, showed he/she expired [DATE], with $664.11, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
3. Review of Resident #381’s account, showed he/she expired [DATE], with $85.04, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
4. During an interview [DATE], 1:07 P.M., business office manager said it was her fault
the letters were not sent and she had no explanation, why she did not send them. She knew
it should be sent within 30 days.
5. During an interview on [DATE] at 11:00 A.M., the administrator said she was not aware
the letters were not being sent as required.

Based on observation and interview, the facility failed to ensure residents’ mail was
secured until time of delivery and was delivered to residents on Saturdays. The census was
111.
During a resident group interview, in the activity room, on 7/26/18 at 8:30 A.M., 10 of 10
residents said the facility delivers their mail Monday through Friday, but not on
Saturdays. One resident said he/she did not like the facility leaving their mail out on a
table in the activity room prior to delivering it. Anyone could take it or snoop through
it. Observation at that time, showed a table directly behind where the residents sat
during the meeting, with a stack of numerous pieces of mail addressed to numerous
residents.
During an interview on 7/30/18 at 9:32 A.M., the Activity Director said mail is delivered
Monday through Friday by the activity staff. It is not delivered on Saturday because the
business office is closed and they are the ones who receive the mail and give it to them
for delivery. Activity staff are scheduled on the weekends, so if they had it they could
deliver it. Normally the mail is delivered as soon as they receive it. It should not be
left out on tables unsecured.
During an interview on 7/31/18 at 12:41 P.M., the administrator said mail should be
secured until it is delivered and she was not aware the mail was not being delivered on
Saturdays.

Based on observation and interview, the facility failed to post signage indicating where
residents and/or visitors could find the facility’s prior three years of survey results.
The census was 111.
During a resident group interview on 7/26/18 at 8:30 A.M., 10 of 10 residents attending
did not know where the facility kept the survey results from the three previous years and
none of them recalled seeing posted signs regarding the survey results.
Observation on 7/30/18 at 2:18 P.M., showed the receptionist sat at the front desk in the
lobby. There was no posted sign in the lobby showing where residents and/or visitors could
find the survey results from the three previous years. The receptionist did not know where
the survey results were kept. The Chief Operations Officer (COO) approached the
receptionist’s desk and found the survey results at the receptionist’s desk. The COO
pointed to the wall behind the receptionist’s desk and said there used to be a sign
hanging there. She did not know what happened to it. The administrator joined the
conversation and said she had worked at the facility since (MONTH) of (YEAR), and she did
not recall seeing a sign posted since starting at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
incontinence care was provided in a way that minimized resident exposure. Two residents
were observed receiving personal care and problems were identified during both
observations. (Residents #56 and #71) The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s comprehensive care plan updated 5/3/18, showed the following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help;
-Incontinence care after each episode;
-Staff to provide assistance with activities of daily living (ADLs, including perineal
care and dressing).
Observation on 7/27/18 at 6:45 A.M., showed Certified Nurse Aide (CNA) J did the
following:
-Entered the resident room, closed the door;
-Was unable to pull the privacy curtain because it was tied into a knot over the
resident’s bed;
-The resident lay on his/her left side in bed;
-CNA J pulled the covers off of the resident and left them at the end of the bed during
the entire process;
-Cleansed the resident’s perineal area and buttocks;
-Walked away from the bed and got a towel and dried the resident;
-Removed his/her gloves, donned new gloves without washing his/her hands, placed the

Based on interview and record review the facility failed to check the nurse aide (NA)
registry to see if new employees have a Federal Indicator for six of 10 employees
reviewed, hired since the previous survey. The census was 111.
Review of the facility policy dated, (MONTH) 14, 2014, titled Background Record Searches,
showed in accordance with Federal and State law the facility shall require, not later than
two working days from the date an applicant is to have contact with residents is hired .a
check of the CNA Registry on all employees.
1. Review of physical therapist M’s employee file, showed a hire date of 3/12/18, and no
record of the NA registry check.
2. Review of Licensed Practical Nurse N’s employee file, showed a hire date of 4/28/18,
and no record of the NA registry check.
3. Review of Registered Nurse O’s employee file, showed a hire date of 6/7/18, and no
record of the NA registry check.
4. Review of laundry worker P’s employee file, showed a hire date of 6/8/18, and no record
of the NA registry check.
5. Review of food service worker Q’s employee file, showed a hire date of 6/9/18, and no
record of the NA registry check.
6. Review of housekeeper/laundry worker R’s employee file, showed a hire date of 7/9/18,
and no record of the NA registry check.
7. During an interview on 7/26/18 at 10:15 A.M., the human resource person said he only
checked the Federal Register for the nurse aides. He did not know he needed to check it
for all staff.
8. During an interview on 7/26/18 at 1:49 P.M., the administrator said she was not aware
the NA checks were not being done. She thought there was a system to catch that. The check
is required for all employees and is included in their Background check policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to to follow their policy for
abuse and neglect by failing to report to the State Survey Agency, one resident’s
complaint to multiple staff members that $100 had been stolen from his/her wallet by a
current staff member a few months ago. (Resident #108) The census was 111.
Review of the facility’s Abuse Prevention Policy, dated 2/2017, showed the following:
-The facility affirms the right of their residents to be free from abuse, neglect,
exploitation, misappropriation of property or mistreatment. The facility prohibits abuse,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
policy and thoroughly investigate resident complaints of potential mistreatment and
misappropriation of resident funds. This affected two of 23 sampled residents. (Resident
#69 and #108) The census was 111.
Review of the facility’s Abuse Prevention Policy, dated 2/2017, showed the following:
-The facility affirms the right of their residents to be free from abuse, neglect,
exploitation, misappropriation of property or mistreatment. The facility prohibits abuse,
neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. The
purpose of the policy is to assure the facility is doing all that is within its control to
prevent occurrences of abuse, neglect, exploitation, misappropriation of property and
mistreatment of [REDACTED].>-Internal Reporting Requirements and Identification of
Allegations: Employees are required to report any incident, allegation or suspicion of
potential abuse, neglect, exploitation, mistreatment or misappropriation of resident
property they observe, hear about, or suspect to the administrator immediately, to an
immediate supervisor who must then immediately report it to the administrator or to a
compliance hotline or compliance officer. In the absence of the administrator, reporting
can be made to an individual who has been designated to act in the administrator’s
absence;
-All residents, visitors, volunteers, family members, or others are encouraged to report
their concerns or suspected incidents of potential abuse, neglect, exploitation,
mistreatment or misappropriation of resident property to the administrator or immediate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure resident
care plans were accessible to all staff 24 hours a day, which affected all facility
residents. In addition, the facility failed to ensure one resident’s care plan addressed
the resident’s feeding tube. (Resident #105) The census was 111.
1. During an interview on 7/25/18 at 8:28 A.M., the administrator said on 6/4/18, due to a
billing dispute, the company they used to have for electronic records shut down due to a
billing dispute. That company did not give the facility any way to access the resident
records, including care plans. The only care plans the resident’s have at this time were
printed out prior to 6/4/18. Those care plans are kept in the Care Plan Coordinator’s
(CPC) office. The CPC works Monday through Friday. No staff members have access to the
CPC’s office after hours. If staff wanted access to the care plans after hours, they would
have to contact someone from management to come in and open the CPC’s office.
During an interview on 7/27/18 at 5:47 P.M., Certified Nurse Aide (CNA) H said he/she had
worked at the facility for about six months. If there are resident care plans, he/she had
not seen them or been made aware of them. If he/she wanted to know what type of care a
resident needs he/she would ask other staff.
During an interview on 7/27/18 at 8:59 A.M., Nurse L, working on the 4th floor, said
he/she could not find a care plan book at the nurse’s station. He/she thinks the care
plans were kept in the CPC’s office.
During an interview on 7/31/18 at 12:47 P.M., the CPC said she is the only CPC. She
printed all of the resident’s care plans in (MONTH) and (MONTH) (YEAR) and they had been
in her office since she printed them. She works Monday through Friday. Care plans are
important because they let staff know how to take care of residents and if there is
something they need to pay attention to. They are not useful to staff sitting in her
office. She had no explanation as to why the care plans had not been made available to
nursing staff after business hours. The Director of Nurses, present at that time, said she
was aware the care plans were being kept in the CPC’s office and unavailable to staff
after business hours. She had not discussed that as an issue with the CPC.
2. Review of Resident #105’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/13/18, showed the following:
-admitted : 2/28/18;
-Severe cognitive impairment;
-Total dependence with bed mobility, transfers, locomotion on the unit, dressing, eating
and personal hygiene;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide discharge planning to
two of two resident’s reviewed who left the facility to go to another facility and/or
home. (Residents #103 and #129) The census was 111.
1. Review of Resident #103’s electronic and paper record, showed an admission date of
[DATE]. The record contained no information prior to 6/11/18.
Review of a social service note dated 6/28/18 at 10:45 A.M., showed the resident had been
accepted to another facility and would be transported to the new facility 6/29/18. The
record did not contain a note about the actual date and time the resident left, the
resident’s discharge goals and needs, including caregiver support and referrals to local
contact agencies, or information sent to the new facility.
During an interview on 7/26/18 at 1:49 P.M., the administrator said they had no additional
information about the resident’s discharge plan.
2. Review of Resident #129’s paper and electronic record, showed no information in the
system about the resident.
During an interview on 7/26/18 at 1:49 P.M., the administrator said the resident was
discharged on [DATE], but there is no information in the system about him/her. She thought
he/she went home. They had no discharge plan for the resident.
3. During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired
a new electronic medical records company on 6/11/18. Their old company shut down on 6/4/18
due to a billing dispute. The facility used paper documentation from 6/4/18 through
6/11/18. The previous company had not given the facility access to the resident’s
information. Information not accessible included progress notes and assessments from
nursing, social services, activities, care plan summaries and dietary including progress
notes from the Registered Dietician. She was aware the facility was required to maintain
complete and readily accessible records on every resident, but until the billing issues
are resolved the facility was unable to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to complete a discharge summary
for two of two resident’s reviewed who left the facility to go to another facility and/or
home. (Residents #103 and #129) The census was 111.
1. Review of Resident #103’s electronic and paper record, showed an admission date of
[DATE]. The record contained no information prior to 6/11/18.
Review of a social service note dated 6/28/18 at 10:45 A.M., showed the resident had been
accepted to another facility and would be transported to the new facility 6/29/18. The
record did not contain a note about the actual date and time the resident left, the
resident’s discharge goals and needs, including caregiver support and referrals to local
contact agencies, or information sent to the new facility, what happened to the resident’s
medications and belongings.
During an interview on 7/26/18 at 1:49 P.M., the administrator said they had no additional
information about the resident’s discharge summary.
2. Review of Resident #129’s paper and electronic record, showed no information in the
system about the resident.
During an interview on 7/26/18 at 1:49 P.M., the administrator said the resident was
discharged on [DATE], but there is no information in the system about him/her. She thought
he/she went home. They had no discharge summary for the resident.
3. During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired
a new electronic medical records company on 6/11/18. Their old company shut down on 6/4/18
due to a billing dispute. The facility used paper documentation from 6/4/18 through
6/11/18. The previous company had not given the facility access to the resident’s
information. Information not accessible included progress notes and assessments from
nursing, social services, activities, care plan summaries and dietary including progress
notes from the Registered Dietician. She was aware the facility was required to maintain
complete and readily accessible records on every resident, but until the billing issues
are resolved the facility was unable to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
appropriate perineal care and follow their policy for providing perineal care. During the
survey, facility staff were observed providing perineal care to two residents and problems
were identified during both observations. (Residents #56 and #71). The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s comprehensive care plan updated 5/3/18, showed the
following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help.
-Incontinence care after each episode.
-Staff to provide assistance with activities of daily living (ADLs, including perineal

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
oversight and develop a plan of care for one resident who’s spouse had a history of
[REDACTED]. (Residents #126 and #48) The census was 111.
1. Review of Resident #126’s care plan, dated [DATE], showed the following:
-Primary language is not English, utilize the resident’s spouse for communication;
-Oxygen therapy related to [MEDICAL CONDITION] (a tube is surgically inserted through the
trachea creating an opening to deliver oxygen to the lungs) which is related to [MEDICAL
CONDITION];
-At risk for pulling out gastrostomy tube ([DEVICE], a tube is inserted through a surgical
incision in the abdominal wall to administer medication, hydration and nutrition);
-The care plan did not identify a problem, goal or interventions regarding the resident’s
spouse administering tube feeding independently without staff knowledge or a physician’s
orders [REDACTED].>-The care plan did not identify a problem, goal or intervention
regarding the resident’s spouse removing the resident’s [MEDICAL CONDITION];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-No speech;
-Sometimes understood/understands;
-Short/long term memory problem;
-Total dependence of one person required for bed mobility, dressing and personal hygiene;
-Shortness of breath or trouble breathing when lying down;
-Oxygen therapy, suctioning and [MEDICAL CONDITION] care not identified.
During an interview at the entrance conference on [DATE] at 8:28 A.M., the administrator
and Director of Nurses (DON) said they had a concern regarding the resident. His/her
spouse removed the resident’s [MEDICAL CONDITION] last night and the resident had to be
sent to the hospital for it to be replaced. This is the first time this has happened,
however the spouse has a history of giving the resident additional cans of tube feeding
through his/her gastrostomy tube without the physician or staff authorization. The spouse
thinks the resident is hungry. He/she had not been trained to give the feeding to the
resident. They had to remove the resident’s tube feeding supplies from his/her room which
seemed to have stopped the problem. The resident’s weights are stable. The resident and
the spouse are of a different ethnic background and both are difficult to communicate
with. Another family member assists with translation with the spouse.
During an interview on [DATE] at 12:34 P.M., Nurse L said he/she was working the day the
spouse removed the resident’s [MEDICAL CONDITION]. The resident had just returned from the
hospital with the spouse in attendance. He/she left the room for just a couple of minutes
before returning to find the resident’s [MEDICAL CONDITION] in the trash can. He/she did
not see the spouse remove the [MEDICAL CONDITION], but since it was in the trash can it
had to be him/her. He/she had also seen the spouse giving the resident tube feeding. They
had to take the tube feeding supplies out of the room. The spouse visits a couple of times

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
acceptable parameters of nutritional status by not providing supplements as ordered and
not completing dietary recommendations for two residents who experienced weight loss. The
sample was 23. (Residents #83 and #179) The census was 111.
1. Review of Resident #83’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/10/18, showed the following:
-[DIAGNOSES REDACTED].
-Short term memory loss;
-Required staff supervision for bed mobility, transfers, walking in room and corridor,
eating and toilet use;
-Required limited staff assistance for dressing and personal hygiene;
-Required extensive staff assistance for bathing;
-Weight 192 pounds;
-Not on a weight loss regimen.
Review of the resident’s care plan, updated 4/2/18, showed the following:
-Problem: High risk of malnutrition and weight loss related to [DIAGNOSES REDACTED].
-Approach: Encourage diet compliance and activity as tolerated. Encourage good food and
fluid intake. Monitor progress. Monitor for weight fluctuations. Weights as per
physician’s orders [REDACTED].
Review of the resident’s monthly weight sheet for (MONTH) (YEAR), showed a weight of 187.4
pounds.
Review of the resident’s undated physician’s orders [REDACTED].
Review of the resident’s weekly weight sheet, completed by the restorative aide, dated
5/15/18, showed the following:
-Reason for weekly monitoring: weight loss checked;
-admitted [DATE];
-Admit weight of 162.0;
-Week 1: 152.4, 9.6 pound loss;
-Week 2: 145.0, 7.4 pound loss;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure two of
two residents with [MEDICAL CONDITION] and humidified oxygen received the humidified
oxygen as ordered and failed to ensure one resident’s continuous positive airway pressure
mask was in good working order. (Resident’s #48, #126 and #37) The census was 111.
1. Review of Resident #48’s care plan, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Staff to assist with activities of daily living;
-The care plan did not identify a problem, goal or interventions related to the resident’s
[MEDICAL CONDITION] or humidified oxygen;
-Full code status (CPR to be initiated).
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-admission date of [DATE];
-Understood/understands;
-Extensive assistance of one person required for bed mobility, transfers and dressing;
-[DIAGNOSES REDACTED].
-Shortness of breath with exertion and while lying flat;
-Oxygen therapy and [MEDICAL CONDITION] care not identified.
Review of the resident’s physician’s orders [REDACTED].
-Oxygen, 4 liters as needed (PRN) with HHTC (high humidity [MEDICAL CONDITION] collar);
-HHTC 28% humidity (the percent of humidification to be used to keep secretions thin to
avoid mucus plugs) PRN;
-(Humidified oxygen is delivered by a compressor. The compressor has a humidity bottle
attached to it. An oxygen concentrator is used to deliver (bleed) oxygen into the
corrugated oxygen tubing via an oxygen cannula. The humdified oxygen is forced from the
humidity bottle through corrugated tubing to the [MEDICAL CONDITION] collar).
Observation on [DATE] at 5:37 A.M., showed the resident lay in bed. The compressor was on
and a humidity bottle was attached. The humidity was set at 98%. No oxygen concentrator
was in the room. Certified Nurse Aide (CNA) H was in the room assisting the resident. The
CNA said he/she had worked with the resident all night. The compressor and the [MEDICAL
CONDITION] collar had been on all night long. He/she had not seen an oxygen concentrator
in the room all night. The resident had been complaining of there being too much water in
the tube.

Based on interview and record review, the facility failed to forward monthly pharmacy
recommendations to residents physicians for their review for two of two months reveiwed.
The census was 111.
During an interview on 7/30/18 at 12:00 P.M., the survey team requested the facility
monthly pharmacy recommendations for (MONTH) and (MONTH) of (YEAR).
During an interview on 7/31/18, the Director of Nurses (DON) said she did not have the
pharmacy recommendations from (MONTH) and (MONTH) (YEAR) until the day before, when she
contacted the pharmacy and they received them via e-mail. She realized there was a problem
receiving the recommendations timely a few months ago and she spoke to the pharmacist at
that time. The pharmacist’s solution was to e-mail the recommendations to her within one
week of the review date. She did not follow up with the pharmacist after speaking to him.
It is her responsibility to ensure the recommendations were being received. Ideally, after
the facility received the recommendations, the facility should forward them to the
residents’ physicians for review within 24 to 48 hours after receiving them from the
pharmacist.
Review of the recommendations presented by the DON on 7/31/18, showed 12 residents had
recommendations completed on 5/23/18, and 22 residents had recommendations completed on
6/30/18. The DON said none of the 34 recommendations had been forwarded to the residents’
physicians for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure it was
free from significant medication errors during insulin administration via insulin pen for
one resident. (Residents #74) The census was 111.
Review of Resident #74’s admission face sheet, showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-Accuchecks (blood sugar level check) three times daily (TID – AM, Lunch, Supper).
-[MEDICATION NAME] (fast acting insulin) [MEDICATION NAME] (prefilled insulin device)
Inject sub-cutaneous (SQ) per sliding scale:
–150-200 = 1 unit;
–201-250 = 2 units;
–251-300 = 3 units;
–351-400 = 4 units.
Observation on 7/27/18 at 5:35 A.M., showed Certified Medication Technician (CMT) I did

Based on observation, interview and record review, the facility failed to ensure menus
were followed for 10 of 10 prepared pureed diets. The census was 111.
1. Observation on 7/30/18 at 7:01 A.M., showed Cook A prepared pureed 10 servings of pork
sausage. The cook said he/she used 10 three ounce scoops of ground pork sausage. He/she
blended them and added 8 ounces of chicken broth. Cook A said he/she was looking for a
thick consistency. A test taste at that time, showed the mixture had a gritty rough taste
and was not smooth or thick.
Review of the pureed recipes used by the facility, showed the following for cooked pureed
sausage patty:
-For 10 servings of meat, use 1 patty which equals one ounce serving and 10 tablespoons of
chicken broth. Place portion of prepared meat in a food processor with hot broth and blend
to a smooth consistency.
2. Observation on 7/30/18 at 1:03 P.M., showed Cook B prepared pureed 10 servings of green
peas. The cook said he/she used 10, 1/2 cups of green peas. He/she added 10, 1/2 cups of
2% milk and blended for approximately two minutes. The mixture had a liquid consistency.
During an interview at that time, the cook said he/she realized he/she used too much milk
because the consistency was liquid.
Review of the pureed recipes used by the facility, showed the following for cooked pureed
green peas:
-For 10 servings of green peas use 1/2 cup of peas per serving and 10 ounces of 2% milk.
Place green peas and milk in a blender and blend until smooth.
3. During an interview on 7/30/18 at 1:34 P.M., the Dietary Manager said she expected the
recipes to be followed as written.

Based on observation and interview, the facility failed to ensure the meal service tray
temperatures were maintained at least at 120 degrees Fahrenheit (F). This potentially
could effect residents who received hall trays or ate in their rooms. The census was 111.
1. During the resident group interview on 7/26/18 at 8:30 A.M., 10 of 10 residents
attending said the food temperatures are fine if you eat in the dining room, but if you

Based on observation and interview, the facility failed to keep kitchen walls, baseboards
and sinks clean and free of grease, dirt and grime on four of four days of observation. In
addition, the facility failed ensure tray lids used for meal service were dry. This had
the potential to affect residents who ate from the facility’s kitchen. The census was 111.
1. Observation on 7/25/18 at 8:38 A.M., 7/26/18 at 7:06 A.M., 7/27/18 at 6:00 A.M. and
7/30/18 at 7:01 A.M., showed the following:
-The wall near the convection oven was stained with black marks and the baseboards under
the convection oven were peeling;
-The walls under the hand sink near the dishwasher area had dirt and grime;
-The baseboards were peeling along side the refrigerators near the bread rack. The dump
sink near the dishwasher area was covered inside with black grime;
-The column wall near the dishwasher was covered the dirt, grease and missing
approximately eight tiles;
-The wall behind the fryer, flat grill top, stove and convection was covered with grease
and grime.
2. Observation on 7/27/18 at 12:10 P.M., showed a Dietary Aide dried approximately 20 wet
lids with the same cloth towel used during the meal service and used the lids for meal
service.
3. During an interview on 7/30/18 at 1:20 P.M., the Dietary Manager (DM) the porters have
a daily cleaning schedule. The schedule does include walls, floors and equipment. She just
hired two new porters a week ago and has been working with them. It is important to keep
the kitchen clean because the residents eat food from the kitchen. Wet dishes should not
be used and should not be dried off with a towel. The dishes should air dry to prevent
cross contamination.

Based on interview, the facility failed to maintain the ability to access resident’s
electronic records. On 6/4/18, the previous electronic record company shut down their
system and blocked the facility from accessing the resident’s electronic records. The
census on 6/4/18 was 114. The census at the time of the survey was 111 and 110 of those
residents resided at the facility prior to 6/4/18. Twenty eight of those 110 residents
were sampled during the survey and all 28 had electronic records prior to 6/4/18 that were
inaccessible to the facility, residents, ancillary services and the survey team.
During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired a
new electronic medical records company on 6/11/18. Their old company shut down their
system on 6/4/18 due to a billing dispute. The facility used paper documentation from
6/4/18 through 6/11/18. The previous company had not given the facility access to the
residents’ information. Information not accessible included progress notes and assessments
from nursing, social services, activities, care plan summaries and dietary including
progress notes from the Registered Dietician. She was aware the facility was required to
maintain complete and readily accessible records on every resident, but until the billing
issues are resolved the facility was unable to do so.

Based on interview and record record review, the facility failed to conduct ongoing
quarterly quality assurance and assessment (QAA) meetings for the previous 12 months. The
census was 111.
1. During an interview on 7/30/18 at 9:58 A.M., the Medical Director (MD) said he had not
been notified and had not attended a QAA meeting in several months.
2. During an interview on 7/30/18 at 10:30 A.M., the administrator said she began working
at the facility at the end of (MONTH) (YEAR). She looked for proof of QAA meetings for the
past 12 months and could only find the one that she had been a part of on 6/21/18. The
Medical Director did not attend that meeting. She thought the DON had notified the Medical
Director of that meeting.
3. Review of the facility Agenda for Quality Improvement Committee Meeting, undated,
showed the following:
-Determine the quality improvement issues on gathered information, opportunity for
improvement and severity of the issue as related to risk. For example: Falls, weight loss,
hydration, incontinence, pain management, restraints, activities, mobility, wounds,
medication errors, meal pass and results reflected on the quality indicators report;
-Each month the QA team determines which indicators are impacting the quality of care and
rank indicator to be brought before the committee;
-Keeping in mind the focus of the committee is to identify issues, plan interventions and
measure the effectiveness of the interventions
4. Review of the Medical Director Description of Services policy, signed by a facility
representative on 1/29/16 and the Medical Director on 3/31/16, showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure staff completed personal
care, during two of two observations, and blood glucose monitoring, during two of two
observations, using acceptable infection control nursing practices and standards.
(Residents #56, #71, #74 and #73) The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s comprehensive care plan updated 5/3/18, showed the following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help.
-Incontinence care after each episode.
-Staff to provide assistance with activities of daily living (ADLs, including perineal
care and dressing).
During perineal care observation on 7/27/18 at 6:45 A.M., Certified Nurse Aide (CNA) J did
the following:
-Entered the resident room, closed the door;
-The resident lay on his/her left side in bed;
-CNA J placed a wash basin into the sink and turned on the water to fill the basin;
-Gathered perineal wash and two wash cloths onto sink ledge;
-Placed a wash cloth into the basin, got it wet and added perineal wash;
-Pulled covers off of the resident and left them at the end of the bed during the entire
process;
-Cleansed the resident’s entire buttock area, then back of thighs, then inner perineal
area and rectum area;
-Turned wash cloth over and repeated same process;
-Took the wash cloth to the sink and rinsed it in the basin;
-Took the same wash cloth back to the resident, dripping water onto the floor, and rinsed
his/her buttock area with the same wash cloth using the same procedure as he/she did
washing the resident;
-Got a towel and dried the resident’s buttocks first then thighs;
-Opened a pouch of ointment and squeezed it onto his/her gloves and applied it to the
resident’s buttocks, thighs, and then perineal area;
-Opened a second ointment pouch and squeezed onto same gloves and repeated the process;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program that included antibiotic use protocols and a system to monitor
antibiotic use. The census was 111.
1. During an interview on 7/31/18 at 8:05 A.M., the Director of Nurses (DON) said she was