SHANGRI LA REHAB & LIVING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s current
code status (whether or not the resident wants to be resuscitated during respiratory or
[MEDICAL CONDITION]) was accurate on the resident’s physician’s orders [REDACTED].#19) out
of 18 sampled residents. The facility census was 77 residents.
Record review of the facility’s Advance Directive policy dated 11/9/13 showed the
resident’s code status should be documented on the resident’s POS.
1. Record review of Resident #19’s Admission POS dated 2/23/18 showed there was an x by
Full Code (all life-saving measures are taken in order to treat a patient after/during a
respiratory or [MEDICAL CONDITION]) that was scribbled out and an x was by Do Not
Resuscitate (DNR – an order from a doctor that resuscitation should not be attempted if a
person suffers cardiac or respiratory arrest).
Record review of the resident’s Out of the Hospital DNR (OHDNR – documents the
instructions in an out-of-hospital setting not to initiate resuscitation if a person
suffers cardiac or respiratory arrest) showed it was signed 2/24/18.
Record review of the resident’s lifestyle preference care plan dated 3/22/18 showed he/she
signed a DNR Order.
Record review of the resident’s POS’s for (MONTH) (YEAR)-August (YEAR) showed a Full Code
order.
During an interview on 8/29/18 at 7:33 A.M., Certified Medication Technician (CMT) A said:
-They look at the front of the chart to see if the resident has an OHDNR and
-If the resident doesn’t have an OHDNR, they are a full code.
During an interview on 8/31/18 at 1:30 P.M., CMT A said he/she thinks the night shift
nurse does the monthly change over of the POS’s.
During an interview on 8/31/18 at 5:00 P.M. the Director of Nursing (DON) said:
-The Resident Care Coordinator (RCC) does monthly change over;
-When a resident admits to the facility, Admissions, Social Services, the Care Plan
Coordinator, the RCC and the DON review the resident’s POS with code status and
-He/she would expect the staff to notice the change in Code Status during the monthly
changeover to the next month’s POS.

Based on interview and record review, the facility failed to provide a Skilled Nursing
Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) when the resident was
discharged from Medicare A services (the federal health insurance program for people who
are 65 or older that covers some aspects of skilled nursing facility care) for one sampled
resident (Resident #1) out of three sampled residents (the other two sampled residents did
not require a SNFABN). The facility census was 77 residents.
1. Record review of Resident #1’s Notice of Medicare Non-Coverage letter showed the
resident’s responsible party was informed on 4/23/18 that the resident’s Medicare A

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
personal privacy during cares for two sampled residents (Resident #270 and #21) out of 18
sampled residents. The facility census was 77 residents.
1. Record review of Resident #270’s Admission Record Profile Face Sheet showed the
resident was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses:
[REDACTED].
-[MEDICAL CONDITION] Simplex (HSV- [MEDICAL CONDITION] causing contagious sores, most
often around the mouth or on the genitals);
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation); and
-Primary biliary [MEDICAL CONDITION] (an [DIAGNOSES REDACTED] disease that causes
progressive destruction of the bile ducts).
Record review of the resident’s Physicians Order Sheet (POS) dated (MONTH) (YEAR) showed
the following orders:
-Dated 8/10/18 [MEDICATION NAME] (an [MEDICAL CONDITION] drug that can treat [MEDICAL
CONDITION] virus infections, it does not cure [MEDICAL CONDITION] but may prevent [MEDICAL
CONDITION] sores or blisters) 200 milligrams (mg) five times a day times ten days for
genital [MEDICAL CONDITION];
-Dated 8/10/18 Foley catheter (a tube passed through the urethra into the bladder and left
to drain urine) until [MEDICAL CONDITION] healed;
-Dated 8/14/18 discontinue catheter;
-Dated 8/20/18 straight cath (a tube passed through the urethra into the bladder and
removed after draining urine) every six hours related to retention for 24 hours, call
doctor if output is over 300 milliliters (ml) and
-Dated 8/20/18 Discontinue the order to discontinue the Foley today. Continue Foley
catheter times two more weeks until 9/3/18.
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 7/24/18 showed
that the resident’s cognition was intact.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 1/16/18 showed he/she had an alteration in bladder elimination as related to
incontinence.
Observation on 8/30/18 at 10:33 A.M. showed the Certified Nurse Assistant (CNA) D left the
resident’s lower private area uncovered and exposed while he/she removed his/her gloves
and washed his/her hands and donned new gloves to place a new incontinence brief under the
resident.
2. Record review of Resident #21’s Admission Record Profile Face Sheet showed he/she was

Based on observation, interview and record review, the facility failed to maintain the
residents’ ventilation ductwork (inside) and louvers (outside covers) free of dust located
in their toilet rooms. This deficient situation provides opportunities for contact and
airborne microorganisms to affect 77 residents who use their bathrooms and shower areas.
The facility’s census was 77 residents.
1. Observations on 8/28/18 between 9:25 A.M. and 1:11 P.M., during a segment of the
facility’s environmental/life safety tour with the Maintenance Director (MD), showed in
resident toilet rooms, ventilation ductwork (inside) and covers having heavy layers of
dust buildup and, white and green mold-like deposits covering the openings, specifically
in the following resident rooms: #101, #102, #104, #106, #202, #204, #205, #206, #207,
#208, #210, #212, #302, #306, #310, #314, #409, #501, #503, #504 and #511.
During an interview on 8/28/18 at 10:27 A.M., the MD said,
-It was the maintenance and housekeeping’s staff responsibilities to clean the vents in
the residents’ bathrooms areas; and
-Did not know whether or not the vents were on a cleaning schedule or when they were last
cleaned.
Record Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code,
Chapter 6-501.12, showed, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary
to keep them clean.
Record review of the 2013 edition of the Missouri Food Code, Chapter 6-501.12, showed,
(A) Physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document the reason a
resident was discharged , to obtain a physician’s order to discharge the resident, and to
obtain a signature to indicate the resident’s belongings were returned to the resident for
one closed record resident (Resident #70) out of three closed records sampled. The
facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed:
-A Post Discharge Plan of Care and a Discharge Care Plan shall be developed for each
resident anticipating discharge;
-Documentation of the discharge plan shall be recorded on the Post Discharge Plan of Care
and
-Upon discharges without anticipation of return, a discharge summary of care and services
shall be completed using the Interdisciplinary Discharge Summary.
Record review of the facility’s undated Transfer and Discharge policy showed a physician’s
discharge order shall be obtained in the resident’s medical record prior to the resident’s
discharge.
1. Record review of Resident #70’s current face sheet (undated) showed he/she was admitted
to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding his/her discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed he/she wanted to
live independently and the resident’s family wanted him/her to live in an assisted living
facility.
Record review of the resident’s discharge Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s telephone orders and (MONTH) (YEAR) Physician’s Order
Sheet (POS) showed no orders to discharge the resident from the facility.
Record review of the resident’s medical record showed no physician’s order to discharge
the resident, no reason the resident was being discharged and no documentation regarding
the resident’s discharge.
Record review of the resident’s current inventory sheet showed it was not signed to
indicate the location of the resident’s belongings.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and/or
their responsible party in writing of the reason for the transfer/discharge for six
residents (Residents #50, #373, #71, #44, #12 and #270) out of 18 sampled residents. The
facility census was 77 residents.
The facility did not have a policy regarding providing written notifications of transfers
and/or discharges.
1. Record review of Resident #50’s Minimum Data Sets (MDS-a federally mandated assessment
completed by facility staff for care planning) showed the resident:
-Was discharged on [DATE] and returned on 6/7/18;
-Was discharged on [DATE] and returned on 7/6/18 and
-Was discharged on [DATE] and returned on 8/13/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharges/transfers.
2. Record review of Resident #373’s MDS showed the resident:
-Was discharged on [DATE] and returned on 5/19/18;
-Was discharged on [DATE] and returned on 6/22/18;
-Was discharged on [DATE] and returned on 7/10/18;
-Was discharged on [DATE] and returned on 7/22/18 and
-Was discharged on [DATE] and had not returned by 8/31/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharges/transfers.
3. Record review of Resident #71’s MDS showed the resident was discharged on [DATE] and
did not return to the facility.
Record review of the resident’s medical record showed no documentation of resident or the
resident’s responsible party being notified of of the resident’s discharge.
4. Record review of Resident #44’s medical record showed:
-He/she was discharged to the hospital on [DATE];
-He/she stayed more than 48 hours and
-It did not include a transfer letter.
5. Record review of Resident #12’s Nurses Notes dated 5/10/18 at 11:18 A.M., showed the
resident left via ambulance to the hospital at 11:25 A.M.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharge/transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and/or
their responsible party of the bed-hold policy at the time of the resident’s
transfer/discharge for six residents (Residents #50, #373, #71, #44, #12 and #270) out of
18 sampled residents. The facility census was 77 residents.
The facility did not have a policy regarding providing the bed-hold policy at the time of
the resident’s transfer/discharge.
1. Record review of Resident #50’s Minimum Data Sets (MDS-a federally mandated assessment
completed by facility staff for care planning) showed the resident:
-Was discharged on [DATE] and returned on 6/7/18;
-Was discharged on [DATE] and returned on 7/6/18 and
-Was discharged on [DATE] and returned on 8/13/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharges/transfers.
2. Record review of Resident #373’s MDS showed the resident:
-Was discharged on [DATE] and returned on 5/19/18;
-Was discharged on [DATE] and returned on 6/22/18;
-Was discharged on [DATE] and returned on 7/10/18;
-Was discharged on [DATE] and returned on 7/22/18 and
-Was discharged on [DATE] and had not returned by 8/31/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharges/transfers.
3. Record review of Resident #71’s MDS showed the resident was discharged on [DATE] and
did not return to the facility.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharge/transfer.
4. Record review of Resident #44’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 complete a
significant change assessment when the resident declined in multiple areas for one sampled
resident (Resident #17) out of 18 sampled residents. The facility census was 77 residents.

Record review of the Long-Term Care Facility RAI 3.0 User’s Manual, Version 1.15, (MONTH)
(YEAR) showed:
A significant change is a major decline or improvement in a resident’s status that:
1. Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions.
2. Impacts more than one area of the resident’s health status.
3. Requires interdisciplinary review and/or revision of the care plan.
1. Record review of Resident #17’s care plan dated 6/20/14 showed:
-The Activities of Daily Living (such as bathing, grooming, hygiene, etc.) ADL care plan
showed the resident required:
–Supervision to moderate assistance of one person with bed mobility;
–Minimal to moderate assistance of one person with dressing, hygiene and toileting.
-The psychosocial care plan showed:
–The resident had a behavior of not eating.
–An update on 6/5/18 that the resident had behaviors such as kicking, pushing, and
pinching staff during ADLs; verbally abusive to staff and residents and throwing and
smearing feces in the room.
-The mood care plan showed the resident displayed sad/depressed mood indicators of staying

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide the
resident and/or their representative with a summary of a baseline care plan that is
developed within the first 48 hours of admission for three sampled residents (Residents
#19, #373 and #61) out of 18 sampled residents. The facility census was 77 residents.
Record review of the facility’s Baseline Care Planning policy dated as revised on 11/1/17
showed the baseline care plan shall be completed with 48 hours of admission and a summary
of the baseline care plan shall be provided to the resident and/or the resident’s
representative.
1. Record review of Resident #19’s entry tracking record showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
responsible party was provided with the resident’s baseline care plan.
Observation on 8/24/18 during the tour which began at 9:21 A.M. showed the resident was
sitting in a specialized wheelchair chair that was low to the ground and he/she was trying
to stand up out of the specialized wheelchair. Staff talked to the resident and asked the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
comprehensive care plan for one sampled resident (Resident #61) out of 18 sampled
residents. The facility census was 77 residents.
Record review of the Long-Term Care Facility RAI 3.0 User’s Manual, Version 1.15, (MONTH)
(YEAR) showed the comprehensive care plan must be completed within seven days of the
completion of the Admission Minimum Data Set (MDS-a federally mandated assessment tool
completed by staff and used for care planning) which must be completed by the 14th day.
1. Record review of Resident #61’s entry tracking form showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s admission MDS dated [DATE] showed the following staff
assessment of the resident:
-Moderately cognitively impaired;
-Required limited assistance to total dependence on staff for Activities of Daily Living
(ADL such as hygiene, bathing, using the toilet, etc.);
-Was incontinent of bladder and sometimes was incontinent of bowel;
-Received tube feeding and
-Had a pressure ulcer (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) that
was a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a
red/pink wound bed) that was present upon admission.
Record review of the facility’s care plan book showed there was no care plan for the
resident.
Observation on 8/28/18 at 12:17 P.M. showed the resident was in bed watching television,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow up on a
recommendation from the Registered Dietitian (RD) for one sampled resident (Resident #50),
and to provide a resident with 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) necessary treatment and services, consistent with professional
standards of practice for one sampled resident (Resident #375) out of 18 sampled
residents. The facility census was 77 residents.
Record review of the facility’s Resident Weight Monitoring policy dated as revised (MONTH)
2008 showed:
-The food service manager and/or RD should notify nursing of any recommendations that have
been documented and
-Nursing should contact the physician to convey recommendations and obtain any new orders.
1. Record review of Resident #50’s monthly weights sheet for (YEAR) showed the resident
weighed:
-151 pounds in (MONTH) (YEAR);
-150.6 pounds in (MONTH) (YEAR);
-162.4 pounds in (MONTH) (YEAR);
-151.4 pounds in (MONTH) (YEAR);
-157.8 pounds in [NAME] (YEAR);
-145.0 pounds in (MONTH) (YEAR);
-157.0 pounds in (MONTH) (YEAR);
-145.2 pounds in (MONTH) (YEAR) and
-146.8 pounds upon readmission on 8/13/18.
Record review of the resident’s Minimum Data Sets (MDS-a federally mandated assessment
tool completed by staff used for care planning) and entry tracking forms showed:
-The resident discharged from the facility with return anticipated on 6/1/18 and
-The resident returned to the facility on [DATE].
Record review of the resident’s 6/20/17 nutrition care plan that was updated on 6/7/18
showed the resident was back from the hospital, refused fluids and a diet waiver for thin
liquids was signed by the resident’s responsible party. Snacks twice daily were not on the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to obtain an accurate discharge
order for one sampled resident (Resident #71) out of 18 sampled residents, and to provide
discharge planning for one closed record resident (Resident #70) out of three closed
records sampled. The facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed:
-A Post Discharge Plan of Care and a Discharge Care Plan shall be developed for each
resident anticipating discharge and
-Documentation of the discharge plan shall be recorded on the Post Discharge Plan of Care.
1. Record review of Resident #70’s current face sheet (undated) showed he/she was admitted
to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed the resident
wanted to live independently and the resident’s family wanted him/her to live in an
assisted living facility.
Record review of the resident’s discharge Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s medical record showed no documentation of any discharge
plan.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said
discharge paperwork should have been filled out.
During an interview on 8/31/18 at 11:51 A.M., the Director of Nursing (DON) said there
should have been documentation regarding where the resident was discharging to and what
services the resident would need if he/she went home.
2. Record review of Resident #71’s entry tracking record showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s Social Services Note dated 6/26/18 showed the resident
reported to him/her that he/she would have another surgery the next week.
Record review of the resident’s nurse’s note dated 7/2/18 showed documentation that the
resident was going to the hospital the next day for surgery.
Record review of the telephone orders dated 7/3/18 showed there was a physician’s orders
[REDACTED].
During an interview on 8/31/18 at 9:56 A.M., the DON said the resident went to the
hospital.
During an interview on 8/31/18 at 10:04 A.M., the Social Services Director said:
-He/she did not have any documentation regarding the resident’s surgery;
-The resident told him/her about the surgery;
-The resident went to have surgery at a local hospital and told him/her he/she was going
to another long-term care facility for rehabilitation after the surgery;
-The other long-term care facility did not know anything about him/her going there for
rehabilitation after his/her surgery and
-He/she has a transportation note for the resident to go to the hospital.
During an interview on 8/31/18 at 11:07 A.M. LPN A said:
-The resident went to the hospital to have surgery on a wound and then was going to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document a summary of the
resident’s stay for one closed record resident (Resident #70) out of three closed records
sampled. The facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed upon
discharges without anticipation of return, a discharge summary of care and services shall
be completed using the interdisciplinary discharge summary.
1. Record review of Resident #70’s current face sheet (undated) showed the resident was
admitted to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed the resident
wanted to live independently and the resident’s family wanted him/her to live in an
assisted living facility.
Record review of the resident’s discharge Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s medical record showed no discharge summary was completed.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said
discharge paperwork should have been filled out.
During an interview on 8/31/18 at 11:51 A.M., the Director of Nursing (DON) said there
should have been documentation regarding the resident’s stay and discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that properly trained
personnel certified in cardiopulmonary resuscitation (CPR-a lifesaving technique useful in
many emergencies, in which someone’s breathing or heartbeat has stopped) were certified to
provide basic life support to residents requiring emergency care prior to the arrival of
emergency medical personnel, and subject to accepted professional guidelines, by allowing
the staff to certify/recertify for CPR online. The facility census was 77 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide an
activity program based on the residents’ comprehensive assessments, care plans and
activity preferences to meet the residents’ interests and needs for six sampled residents
(Residents #8, #17, #19, #37, #50 and #56) that resided on the secure care unit out of 18
sampled residents. The facility census was 77 residents.
Record review of the facility’s Activity Policy last reviewed in (MONTH) (YEAR) showed:
-The facility would provide an ongoing program of activities designed to meet, in
accordance with the comprehensive assessment, the interests and the physical, mental and
psychosocial well-being of each resident;
-The Activity Director shall have a specific planned program of group and individual
activities based upon the residents’ needs and interests and
-The facility will obtain sufficient, detailed information to determine what activities
each resident prefers and what adaptations may be needed.
1. Record review of Resident #8’s activities care plan dated 11/10/16 showed instructions
for staff to:
-Provide the monthly activity calendar;
-Invite, remind and escort the resident to and from activities;
-Provide one-on-ones if necessary;
-Encourage the use of radio and of television;
-Provide the resident with independent leisure materials as requested;
-Develop a program that accommodates the resident’s limitations and
-Provide positive feedback about the resident’s independent activities.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff used for care planning) dated 11/13/17 showed
the resident liked reading, music, pets, keeping up with the news, doing activities with
groups of people, doing his/her favorite activities, being outside and religious
activities were all very important to him/her.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Was severely cognitively impaired;
-Wandered one to three days of the seven-day observation period;
-Some of his/her [DIAGNOSES REDACTED].
-Walked with supervision/oversight.

Based on interview and record review, the facility failed to ensure their activities
program was directed by a qualified activities professional. The facility census was 77
residents.
Record review of the facility’s Policy for Activity Director reviewed (MONTH) (YEAR)
showed the activities program was directed by a qualified professional.
1. During an interview on 8/31/18 at 12:16 P.M., the Activities Director said:
-He/she had been the activity director at the facility for one year and
-He/she was going to take an on-line Activity Director class.
During an interview on 8/31/18 at 4:24 P.M., the Administrator said:
-The Activity Director did not meet the qualifications of a qualified activity director;
-He/she placed multiple ads for a qualified activity director and he/she had not found
anyone;
-The current Activity Director was going to take an Activity Director class and
-He/she did not have any proof that the Activity Director had registered for the Activity
Director class.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to identify the
resident’s pants were too long and too big and caused a fall hazard for one sampled
resident (Resident #8) out of 18 sampled residents. The facility census was 77 residents.
1. Record review of Resident #8’s care plan initiated 11/10/16 showed the resident:
-Had impaired cognition related to dementia (a progressive mental disorder characterized
by memory problems, impaired reasoning and personality changes)
-Was a fall risk and
-Had the potential for weight loss.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
completed by facility staff for care planning) showed the resident was 5 feet and 2 inches
tall and weighed:
-156 pounds on 11/19/16;
-155 pounds on 2/16/17;
-157 pounds on 5/15/17;
-159 pounds on 8/5/17;
-160 pounds on 11/17/17 and
-157 pounds on 2/12/18.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Had one non-injury fall since his/her last assessment (2/12/18);
-Was severely cognitively impaired;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide needed
oxygen via a portable oxygen tank for one sampled resident (Resident #47) out of 18
sampled residents. The facility census was 77 residents.
1. Record review of Resident #47’s entry tracking record showed that the resident admitted
to the facility on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation);
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness,
tension, fast heart rate, and breathing difficulty not associated with an apparent
stimulus) and
-Oxygen therapy.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 7/17/18 showed the resident:
-Used oxygen at 2 Litters (L) per Nasal Cannula (NC-tubing with prongs that insert into a
resident’s nose to deliver oxygen) and
-Had a cognitive (thought process) loss.
Record review of the resident’s Minimum Data Set (MDS – a federally mandated assessment
tool completed by the facility staff for care planning) dated 7/17/18 showed that the
resident’s cognition was moderately impaired.
Observation on 8/24/18 at 9:41 A.M., showed the resident in his/her room wearing oxygen
per NC at 2 L from an oxygen concentrator (a machine that provides oxygen).
Observation on 8/27/18 at 9:22 A.M., showed: the resident:
-The resident had oxygen tubing with the NC in his/her nares;
-The resident had a portable oxygen tank on the back of his/her wheelchair and
-The portable oxygen tank level indicator was on empty.
Observation on 8/27/18 at 11:58 A.M., showed the resident’s portable oxygen tank level
indicator was still on empty.
During an interview on 8/30/18 at 11:45 A.M., the resident’s family member said that
sometimes when he/she visits that he/she finds the portable oxygen tank empty and has to
tell the staff to change it.
During an interview on 8/30/18 at 1:30 P.M., Certified Nurse Assistant (CNA) A said:
-CNA’s can check the level of oxygen on the portable oxygen tanks;
-If a tank is close to being empty or empty they can get a new tank;
-CNA’s can’t switch the tanks and
-The nurse has to switch the tanks because it is considered a medication.
During an interview on 08/31/18 at 4:42 P.M. the Director of Nursing (DON) said:
-Oxygen tanks should be checked each shift by the CNA or the Nurse and
-The Nurse is the one to change the tank since oxygen is a medication order.

**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 one sampled medication room of two
sampled medication rooms and two sampled medication carts of three sampled medication
carts for opened medications that had been prescribed by the physician. The facility
census was 77 residents.
Record review of the facility’s Procurement and Storage of Medications policy dated
(MONTH) 2006 showed all medication containers should be labeled with the date opened by
the person breaking the container seal.
1. Observation on 8/27/18 at 3:00 P.M. with the Director of Nursing (DON) of the
medication room between 100 and 200 hallways showed the following medications in the
refrigerator were opened without an opened date written on them:
-[MEDICATION NAME] (medication used to treat infections caused by bacteria) a 250
milligram (mg) bottle and
-[MEDICATION NAME] (medicine used to treat anxiety) a 2mg/milliliter (ml) bottle.
The 200 hallway medication cart showed the following medications were opened without an
open date written on them:
-Robofen DM (cough medication) syrup a 479 ml bottle and
-Senna (medication used to treat constipation) syrup a 237 ml bottle.
The 300 hallway medication cart showed the following medications were opened without an
open date written on them:
-[MEDICATION NAME]/APAP (pain medication) 7.5/325 mg a 120 ml bottle;
-[MEDICATION NAME] (pain medication) 100/5 ml a 30 ml bottle with a used oral syringe in
the box and
-Cough Syrup 100/5 ml a 473 ml bottle.
During an interview on 8/27/18 at 3:00 P.M., the DON said:
-He/she did not know why all the opened medications were not dated and
-The nursing staff had dated some of the medications and knew they were supposed to be
labeled when opened.

Based on observation, interview and record review, the facility failed to prevent a
combination of a buildup of grease, dust and dirt on the kitchen lights and vents located

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
appropriate infection control practices when staff failed to properly change their gloves
and wash their hands during incontinence care for four sampled residents (Resident #12,
#22, #270, and #375); to provide a clean surface for cleaning supplies for one sampled
resident (Resident #375); to keep a nephrostomy (a passage way maintained by a thin tube
placed through the back into the kidney to temporarily drain urine that is blocked) bag
below a resident’s bladder and off of the floor for one sampled resident (Resident #375)
and to properly change gloves and clean hands during a medication pass out of 18 sampled
residents . The facility census was 77 residents.
Record review of the facility’s Hand Washing policy dated revised 10/09 showed hand
washing was to be done:
-Before putting on gloves and
-After removal of gloves.
Record review of the facility’s Perineal cleansing policy dated revised 9/21/10 showed:
-After cleaning area remove gloves and wash hands with soap and water, cleansing gel or
Theraworx (a brand name of cleansing product that the facility uses);
-Note in bold type at end of policy:
–The basic infection control concept for peri-care is to wash from the cleanest to the
dirtiest area and
–Remember to change or remove gloves and wash hands when going from working with
contaminated items to clean items.