ST LOUIS PLACE HEALTH & REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
have the right to choose schedules, including sleeping and waking times, consistent with
their interests, assessments, and plan of care, for one resident who voiced the desire to
sleep in (Resident #6). The sample size was 15. The census was 60.
Review of Resident #6’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/5/17, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 7 out
of a possible score of 15, showed the resident had severe cognitive impairment;
-Makes self-understood;
-Understands- clear comprehension;
-Total dependence for bed mobility and transfer;
-How important is it to choose your own bed time: Very important.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].>-A BIMS score of 8, showed the resident had moderately impaired
cognition;
-Makes self-understood;
-Understands- clear comprehension;
-Total dependence for bed mobility and transfer.
Review of the resident’s care plan, last updated 8/9/18, showed:
-Problem: Activities of Daily Living (ADL) Function/Rehabilitation Potential: The resident
needs extensive to total assist for ADLs related to having a [DIAGNOSES REDACTED].
-Goal: To be dressed and clean, season-appropriate clothing. Needs will be met;
-Approach: Bed mobility, assist of one extensive. Transfer, assist of one extensive, use
sit to stand (mechanical lift). Allow to participate in choosing what clothing to wear;
-Problem: Cognitive Loss/Dementia: Memory recall problem related to dementia. Impaired
insight and judgement:
-Goal: Improved memory/recall ability;
-Approach: Engage in conversation that is meaningful;
-The care plan did not address the resident’s preference regarding when to go to bed or
get up in the morning.
Review of the facility get up list, found at the nurse’s station in the staffing binder,
showed 10 residents on the get up list. Resident #6 included as one of the residents.
During an interview on 8/28/18 at 7:00 A.M., Certified Nursing Assistant (CNA) N said
there are set residents that night shift staff are responsible to get up. They use the get
up list and he/she pointed to the get up list at the nurse’s station.
Observation on 8/28/18 at 7:28 A.M., showed the resident sat in the assist dining room in
a wheelchair. He/she said staff got him/her up real early this morning. They always do
that. They do not ask if he/she wanted to get up, they just get him/her up. He/she would
rather sleep in.
Observation on 8/30/18 at 7:32 A.M., showed the resident sat in a wheelchair in the assist
dining room, asleep. Staff came in and woke the resident. During an interview at this
time, the resident said staff got him/her up early again today without asking. They just
come in and get him/her up.
During an interview on 8/30/18 at 1:00 P.M., with the administrator and Director of
Nursing (DON), the DON said residents who want to get up early or who require a lot of

Based on observation, interview and record review, the facility failed to ensure residents
had access to personal funds on the weekend. This had the potential to affect all
residents who have funds held by the facility. The census was 60.
During an interview on 8/28/18 at 10:08 A.M., the facility bookkeeper said the residents
are unable to request funds on the weekend because the office is closed.
During an interview on 8/28/18 at 1:20 P.M., Resident #4 said residents are unable to get
their funds on the weekend because the office is closed.
During an interview on 8/28/18 at 1:30 P.M., Resident #57 said the office is closed on the
weekend.
During an interview on 8/28/18 at the facility Administrator said no one is available on
the weekends to provide resident funds. The residents know to get any funds they need on
Friday before the office closes.

Based on interview and record review, the facility failed to ensure residents had access
to mail delivered on Saturday. This failure has the potential to affect all facility
residents. The census was 60.
During the group interview on 8/28/18 at 11:00 A.M., residents said they don’t receive
mail on Saturday.
During an interview on 8/28/18 at 1:20 P.M., Resident #4 said he/she watches the mailman
delivery mail on Saturday. There is no one available to pass the mail out until Monday.
During an interview on 8/28/18 at 2:07 P.M., the Activity Director said mail is delivered
to the facility on Saturday. The charge nurse will lock it in the medication room until
Monday.
During an interview on 8/28/18 at 2:15 P.M., the Administrator said she thought staff was
distributing the mail on Saturday. The facility has a activity aid on the weekend who
could pass out mail to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a system in place to
ensure an annual review of each resident’s code status and facility policies regarding
provision of emergency and life-sustaining care, was conducted with the resident and/or
the responsible party, to ensure full understanding and determine if they wanted to make
changes to their code status. This affected one resident and all residents living in the
facility for over a year. (Resident #49) The census was 60.
Review of Resident #49’s medical record, showed the following:
-A green FULL CODE sheet in the very front of the chart;
-An admit of 5/13/16;
-[DIAGNOSES REDACTED].
-A physician’s orders [REDACTED].
-No further information to indicate that the code status/emergency and life-sustaining
care had been reviewed annually with the resident.
During an interview on 8/30/18 at 10:00 A.M., the social service director said she did not
have any roll in updating resident code statuses periodically or during care plan
meetings.
During an interview on 8/30/18 at 11:22 A.M., the marketing/admissions director said she
is not involved in annual code status review/update.
During an interview on 8/30/18 at 11:37 A.M., the care plan coordinator said the social
service director was responsible for doing resident code status reviews/updates, at least
that’s how it was with the prior social service director.
During an interview on 8/30/18 at 2:05 P.M., the administrator said the code status annual
update was always the responsibility of the social service director, but the current one,
who has only been there fore four months, had not been made aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain a clean, comfortable
and homelike environment by not maintaining four resident rooms and one shower room clean
and in good repair. (Rooms 308, 309, 314, 102 and the 300A central shower room). The
census was 90.
1. Observation from 8/27/18 through 8/30/18 during the survey, in the 300A central shower
room, showed the following:
-The 100 hall entrance door to the central bath had horizontal dark colored scrapes
measuring 34 inches across the entire door;
-A 6 inch, 2 inch and 1 inch circular scraped areas on the drywall between the 100 hall
entrance door and the sink;
-The corner wall between the 100 hall entrance door and the sink had a 7 inch by 7 inch
hole/gash along with multiple small gashes/holes on the wall near the floor.
2. Observation from 8/27/18 through 8/30/18 during the survey, showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility’s abuse and neglect policies,
procedures and protocols, failed to identify when, how, and by whom determinations of
capacity to consent to a sexual contact will be made and where this documentation will be
recorded. The census was 60.
Review of the facility’s Abuse, Neglect, Exploitation or Mistreatment policy, dated
5/1/15, showed:
-Sexual abuse is non-consensual sexual contact of any kind with a resident;
-No requirement specified for the facility to identify when, how, and by whom
determinations of capacity to consent to sexual contact will be made and where this
documentation will be recorded.
During an interview on 8/30/18 at 7:41 A.M., the administrator said she was not sure if
the facility had a policy that addressed a resident’s capacity to consent to sexual

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their policy for
reporting a suspicion of a crime by failing to contact local law enforcement and the State
Agency regarding one resident’s stolen video game component, game controllers and video
games. The resident had been hospitalized and noticed the items missing upon readmission.
(Resident #26). The census was 60.
Review of the facility Reporting Reasonable Suspicion of a Crime policy, dated 5/1/2013,
showed the following:
-Pursuant to the requirements of section 1150B of the Social Security Act, covered
individuals will timely report any reasonable suspicion of a crime committed against a
resident of the facility to the appropriate State Agency and at least one local law
enforcement entity;
-The facility will notify covered individuals of their reporting requirements annually and
will not retaliate against any individual who makes a report regarding the suspicion of a
crime;
-If the events that cause the suspicion do not result in serious bodily injury, the
individual shall report the suspicion not later than twenty-four (24) hours after forming
the suspicion;
-A covered individual is anyone who is an owner, operator, employee, manager, agent or
contractor of the facility. Covered individuals are subject to a civil money penalty and
exclusion sanctions for failure to meet reporting obligations described herein;
-A crime is defined by law of the applicable political subdivision where the facility is
located. The facility must coordinate with local law enforcement entities to determine
what actions are considered crimes within their political subdivision;
-Individuals reporting suspicion of a crime must call, fax, or e-mail both local law
enforcement and the State Agency;
-All suspicions of a crime are reported verbally immediately to the
administrator/Designee, in addition to the reporting obligations stated above. Failure to
report in the required time frames may result in disciplinary action, including up to
termination.
Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to to follow their Abuse,
Neglect, Exploitation or Mistreatment Policy by failing to report to the State Survey
Agency, one resident’s missing video component and video accessories and two additional
resident’s complaints of missing money. (Residents #26, #43 and #29). The census was 60.
1. Review of the facility Abuse, Neglect, Exploitation, or Mistreatment policy, dated
9/13/17, showed the following:
-The facility’s leadership prohibits neglect, mental, physical and/or verbal abuse, use of
a physical and/or chemical restraint not required to treat a medical condition,
involuntary seclusion, corporal punishment and misappropriation of a patient’s/resident’s
property and/or funds and ensures that alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of
resident property, and are reported immediately;
-The facility shall report immediately, but not later than 2 hours after the allegation is
made, if the events that cause the allegation involve abuse or result in serious bodily
injury, or not later than 24 hours if the events that cause the allegation do not result
in serious bodily injury to the administrator of the facility and to other officials
(including to the State Survey Agency and adult protective services where state law
provides for jurisdiction in long-term care facilities) in accordance with state law
through established procedures. See also: Reporting Reasonable Suspicion of a Crime
Policy;
-The facility leadership will designate a staff member to oversee the abuse prohibition
policy (Facility Abuse Coordinator);
-All alleged violations concerning abuse, neglect, or misappropriation of property are to
be reported verbally immediately to the Facility Abuse Coordinator, the Administrator and
to other officials in accordance with state law including the State Survey and
Certification Agency;
-Complete the Investigation Summary Log, maintained by the administrator or his/her
designee;
-The facility maintains that all allegations of abuse, neglect, misappropriation of
property, etc. are thoroughly investigated and appropriate actions are taken.
2. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Extensive assistance of one person required for bed mobility, transfers, dressing and
personal hygiene;
-Walking in room/corridor: Activity did not occur;
-Physical impairment of both lower extremities;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their policy and
thoroughly investigate one residents stolen video game component, game controllers and
video games and failed to investigate two other resident’s complaints regarding stolen
money. (Resident’s #26, #43 and #29). The census was 60.
Review of the facility Abuse, Neglect, Exploitation, or Mistreatment policy, dated
9/13/17, showed the following:
-The facility’s leadership prohibits neglect, mental, physical and/or verbal abuse, use of
a physical and/or chemical restraint not required to treat a medical condition,
involuntary seclusion, corporal punishment and misappropriation of a patient’s/resident’s
property and/or funds and ensures that alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of
resident property, and are reported immediately;
-The facility shall report immediately, but not later than 2 hours after the allegation is
made, if the events that cause the allegation involve abuse or result in serious bodily
injury, or not later than 24 hours if the events that cause the allegation do not result
in serious bodily injury to the administrator of the facility and to other officials
(including to the State Survey Agency and adult protective services where state law
provides for jurisdiction in long-term care facilities) in accordance with state law
through established procedures. See also: Reporting Reasonable Suspicion of a Crime
Policy;
-The facility leadership will designate a staff member to oversee the abuse prohibition
policy (Facility Abuse Coordinator);
-All alleged violations concerning abuse, neglect, or misappropriation of property are to
be reported verbally immediately to the Facility Abuse Coordinator, the Administrator and
to other officials in accordance with state law including the State Survey and
Certification Agency;
-Complete the Investigation Summary Log, maintained by the administrator or his/her
designee;
-The facility maintains that all allegations of abuse, neglect, misappropriation of
property, etc. are thoroughly investigated and appropriate actions are taken.
1. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Extensive assistance of one person required for bed mobility, transfers, dressing and
personal hygiene;
-Walking in room/corridor: Activity did not occur;

**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 comprehensive person-centered care plan for each resident for thee of 15
sampled residents (Resident #2, #25 and #38). The census was 60.
1. Review of Resident #2’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/12/18, showed no interview for
activities preference completed. Staff assessment for activities preference, showed
interests included participating in favorite activities, doing things with groups of
people, listening to music, staying up past 8:00 P.M. and snacks between meals. Review of
the care area assessment summary, showed activities triggered as a care area and the
facility indicated activities to be addressed in the care plan.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 1 out
of a possible score of 15;
-A BIMS score of 0-7, showed the resident had severe cognitive impairment;
-Disorganized thinking: Behavior continuously present;
-Wandering: Behavior of this type occurred daily.
Review of the facilities (MONTH) fall summary for the resident, showed:
-Fall 6/25/18 on the 3:00 P.M. to 11:00 P.M. shift, resident got out of the wheelchair at
the nurses station and lost balance and fell to floor- no injuries;
-Fall 7/11/18 on the 7:00 A.M. to 3:00 P.M. shift, resident leaned forward to pick up
something from the floor and fell forward out of the wheelchair- no injuries.
Review of the resident’s transfer form, dated 7/11/18, showed reason for transfer,
[MEDICAL CONDITION] grand mal (a [MEDICAL CONDITION] characterized by severe shaking,
trembling and contracting of the muscles). The resident had been hospitalized recently two
times for [MEDICAL CONDITION] activity. Readmitted [DATE]. Had a fall this morning on the
7-3 shift. Resident had three [MEDICAL CONDITION], grand mal, and [MEDICATION NAME] 2-3
minutes each. Is now post [MEDICAL CONDITION] and not much response noted. The primary
care physician notified and wants the resident sent to the hospital. Next of kin notified
and wants the resident sent to the hospital.
Review of the resident’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Activity and mobility: Up as desired in wheelchair;
-An order dated 8/7/18, for [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 0.5
milligram (mg), three tabs three times a day. [DIAGNOSES REDACTED].>Review of the
resident’s nurse’s notes, showed:
-On 8/8/18 at 7:00 P.M., the resident continues to wander;
-On 8/8/18, next of kin called and aware the resident went outside of the building today;
-On 8/18/18 at 7:00 P.M., the resident in front of building. Returned to inside of
building. Wander guard remains on, elopement sheet started. On call nurse called, Director
of Nursing (DON) called, physician called;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
resident’s received their medications consistently without interruption, failed to access
the facility emergency medication kit when medications were not available in the
resident’s stock and failed to notify the resident’s physicians when they were unable to
administer medications as ordered. (Residents #42, #109, #57, #15, and #7). The census was
60.
1. Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/18/18, showed the following:
-admitted on [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Supervision/oversight required for transfer, dressing and eating;
-[DIAGNOSES REDACTED].
Review of the resident’s MAR, dated 8/1/18 through 8/31/18, showed an order [MEDICATION
NAME] (medication used to treat DM) 1000 mg. The following doses were circled by the
nurses (an indication the medication was not administered) and there was no documentation
as to why:
-6:00 A.M.: 26th;
-5:00 P.M.: 24th, 25th and 26th.
Review of the resident’s nurse’s progress notes, showed no physician notification
regarding the missed doses of [MEDICATION NAME].
During an interview on 8/28/18 at 7:38 P.M., the resident said he/she had missed a few
dose of [MEDICATION NAME] recently. He/she was told they were out of the medication.
Observation on 8/28/18 at 10:30 A.M., showed the facility emergency kit (where several of

-No reason was provided for the medication not being administered on 7/29/18 through
7/31/18
Record review of the resident’s (MONTH) (YEAR) POS, showed:
-[MEDICATION NAME] HCL 4mg take ½ tablet PO at HS for spasms. ½ tab = 2mg. Dated 5/7/18.
Record review of the resident’s (MONTH) (YEAR) MAR, showed:
-[MEDICATION NAME] HCL 4mg take ½ tablet PO at HS for spasms. ½ tab = 2mg. Dated 5/7/18.
-The [MEDICATION NAME] HCL 4mg was circled as not give on 8/1/18 through 8/6/18, left
blank on 8/7/18, and circled as not given on 8/8/18 through 8/15/18.
-The reason noted on the back on 8/2/18, 8/3/18 and 8/8/18 was the medication was not
available.
-No reason was provided for the medication not being administered on 8/1/18, 8/4/18
through 8/7/18, and 8/9/18 through 8/15/18.
During an interview on 8/27/18 at 9:07 A.M., the resident said:
-He/she found it unacceptable to go that long without an ordered medication;
-The physician would not have prescribed the medication if he/she did not feel the
resident needed it;
-He/she had been living with increased muscle spasms and pain related to the medication
not being available;
-The increased muscle spasms and pain has affected his/her daily activity and quality of
life;
-As far as he/she knew, the facility did not contact the physician to obtain a
new/replacement order until this medication was delivered by the pharmacy.
3. Record review of Resident #15’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (nerve pain);

-Pain.
Record review of the resident’s (MONTH) (YEAR) POS, showed:
-[MEDICATION NAME] (for nerve pain) 300mg PO four times daily.
-[MEDICATION NAME] (narcotic pain medication) 5/325mg one tablet every 6 hours for pain.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]

5. Record review of Resident #109’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-Heart failure;
-[MEDICAL CONDITION];
-[MEDICAL CONDITION].
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] 4mg 1 PO every 6 hours PRN
Observation of medication administration on 8/29/18 at 5:13 PM showed CMT K:
-Was asked by the resident for a dose of PRN [MEDICATION NAME] due to nausea.
-Was unable to find the medication in the medication cart and notified the nurse.
-Told the resident that the medication was unavailable and they were trying to get an
order for [REDACTED].>-Said the nurse called the resident’s physician and got a
one-time order for [MEDICATION NAME].
-Looked in the medication cart and the medication room and the [MEDICATION NAME] was not
available.
-Notified the resident that the medication was unavailable and the resident said that
he/she was going to vomit if he/she did not get the medication soon.
-Notified the nurse that the [MEDICATION NAME] was unavailable and the nurse called the

8. During an interview on 8/30/18 at 7:39 A.M., the resident’s physician said:
-Anything over 3 doses of a medication not being available and not administered is
excessive;
-He/she expects staff to notify him/her if a medication is not available;
-It is not always the facility’s fault, sometimes pharmacy doesn’t get the medications to
them;
-He/she expects staff to follow all orders as written.
9. Record review of the facility’s Medication Management Program Policy revised on 7/1/16,
showed:
-If the resident is unable to take the medication or refuses it, the authorized
licensed/certified staff member circles his/her initials on the MAR, and documents the
reason refused or not given on the designated area of the MAR. The Physician is notified
as necessary.
MO 080

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to accurately
identify the amount of staff required to transfer one resident at risk for falls and
failed to ensure staff used a gait belt during two observations of the resident being
transferred. In addition, staff failed to secure one can of ant and roach spray while
unattended and observed in one resident’s room for four consecutive days. (Residents #39
and #47). The census was 60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

**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 28 opportunities, five errors occurred which
yields a medication error rate of 17.86%. The facility census was 60 residents.
1. Record review of Resident #15’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with diagnoses that included:
-[MEDICAL CONDITION] (nerve pain);
-Pain.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-[MEDICATION NAME] (for nerve pain) 300mg (milligrams) by mouth (PO) four times daily;
-Creon DR (delayed release-for pancreatic insufficiency) 12,000 units, two capsules four
times daily with meals and snacks;
-[MEDICATION NAME] (narcotic pain medication) 5/325 mg one tablet every 6 hours for pain.
Observation of medication pass on 8/29/18 at 5:32 P.M., showed certified medication
technician (CMT) K:
-Popped [MEDICATION NAME] into a medication cup;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure medications, on two of
four medication carts, were appropriately labeled and dated after being opened. The census
was 60.
1. Observation of 8/29/18 at 8:01 A.M., of the 200/300 hall medication cart, showed:
-One bottle with approximately 100 capsules, with no label. There had been a label, but it
had been peeled off;
-One bottle of latanoprost 0.005% (eye drop used to treat [MEDICAL CONDITION]), with no
open date.
During an interview on 8/2/9/18 at 8:10 A.M., Certified Medication Technician Q said
he/she knows the medication in the bottle was [MEDICATION NAME] [MEDICATION]) and who it
belongs to. The resident doesn’t have an order for [REDACTED]. The latanoprost eye drop
bottle was good for 30 days after being opened. Whoever opened it didn’t put the date it
was opened.
2. Observation on 8/29/18 at 8:54 A.M., of the 100/700 medication cart, showed:
-One open bottle of [MEDICATION NAME] 0.5% (eye drop used to treat [MEDICAL CONDITION]),
with no open date;
-One bottle of olopatadine 0.2% (drop to treat allergy related itchy watery eyes), with an
open date of 7/23/18.
During an interview on 8/30/18 at 6:56 A.M., Registered Nurse L said staff should write
the date opened on a bottle of eye drops and then it was good for 28 to 30 days depending
upon the specific medication.
3. During an interview on 8/30/18 at 7:24 A.M., the administrator said the facility policy
doesn’t state the days to discard after opening an eye drop, but staff are taught to
discard after 28 days. Medications should be labeled with the residents name, the type of
medication and the order.
4. During an interview on 8/30/18 at 12:57 P.M., the Director of Nurses said medications
that were unlabeled and not in use should not be left on the medication cart.

Based on observation and interview, the facility failed to follow recipes for three of
four pureed meals observed for five residents on puree diets. The facility census was 60.
1. Observation on 8/28/18 at 11:00 A.M., showed the dietary manager (DM) prepared pureed
meatloaf. He/she used five cups meatloaf, removed from the meatloaf tray, five slices of
bread and four cups milk. He/she placed the meatloaf, bread slices, and cups of milk into
the blender and pureed the items for approximately one minute. The DM took the top off the
blender and tested the consistency with a spatula. The puree was thin and soup like. The
DM said the consistency was not where it should be so he/she needed to add more bread. The
DM added three additional slices of bread at this time and pureed the meatloaf for an
additional minute. The consistency remained thin. The DM said the pureed meatloaf would
thicken as it warmed in the oven.
Review of the pureed meatloaf recipe, showed the following for five servings:
-15 ounces of meat;
-1 1/4 cups of broth;
-2 1/2 slices of bread;
-Place in the food processor.
2. Observation on 8/29/18 at 7:16 A.M., showed the dietary manager (DM) prepared pureed
pancakes. He/she use ten pancakes, removed from the pancake tray and syrup from a metal
container. The DM placed the ten pancakes into the blender and poured an unmeasured amount
of syrup into the blender. The DM said the recipe called for milk but he/she would use the
syrup instead. The DM pureed the items for approximately one minute. The puree was thick
like in consistency.
Review of the pureed pancake recipe, showed the following for five servings:
-5 servings of pancakes;
-1 cup of milk;
-Place in the food processor.
3. Observation on 8/29/18 at 7:23 A.M. showed the dietary manager (DM) prepared pureed
breakfast sausage. He/she use five cups sausage, removed from the sausage tray, and broth
from a metal container. The DM placed the sausage into the blender and poured an
unmeasured amount of broth into the blender. The DM pureed the items for approximately one
minute. The DM took the lid off the top of the blender and used a spatula to stir the
mixture. The puree was thin and watery like in consistency. The DM said when the
consistency is not achieved, he/she will not use thickener; bread will be used instead.
The DM used five slices of bread in the mixture and pureed the items for approximately
another minute.
Review of the pureed breakfast sausage recipe, showed the following for five servings:
-10 ounces of sausage;
-6 2/3 cups of broth;
-Place in the food processor.
During interviews on 8/28/18 at 8:59 A.M., and 8/30/18 at 12:30 P.M., the dietary manager
(DM) said when preparing puree meals, he/she use a spread sheet which tells her what size
each puree get and a recipe book to tell her what each puree need. The DM said he/she
should be consistent with following the recipe book or spread sheet instead of switching
back and forth between the two. The DM said it is important to follow the recipes as
written when preparing the puree meals. He/she further said it is important to follow the
policy when preparing the meals.

Based on observation, interview, and record review, the facility failed to date all food
inside the walk in cooler, storage room, and freezer. These deficient practices had the
potential to affect all residents who ate at the facility. The facility census was 60.
Observations on 8/27/18 at 9:20 A.M., 8/28/18 at 8:59 A.M., 8/29/18 at 7:30 A.M. and
8/30/18 at 8:30 A.M., showed:
-Container of beef base in the storage room on the shelf dated 3/8/18;
-Opened jar jelly in the cooler, date not legible;
-Four bags of sandwich buns on bottom shelf in freezer without dates;
-Three bags of fries on shelf in freezer without dates;
-Open box in freezer containing 4 bags of frozen mixed vegetables, without dates;
-Brisket on bottom shelf in freezer without a date.
During an interview on 8/30/18 at 9:00 A.M., the dietary manager said his/her method for
using items on the shelves is using old items first then the newer items. The DM said
he/she rotates the old items out for the new items so that he/she can get rid of old items
and then discard all old items. The DM said the meat on the bottom shelf in the freezer
was a brisket. He/she said he/she had forgotten about it. He said all foods in the storage
areas, cooler and freezer should have a date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed acceptable infection control standards during three of three observations of
staff providing incontinence care. In addition, the facility failed to ensure soiled
linens were not stored next to the clean linen. (Residents #39 and #43). The census was
60.
1. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/14/18, showed the following:
-Usually understood;
-Understands;
-Extensive assistance of one person required for dressing, personal hygiene and bathing;
-[DIAGNOSES REDACTED].
Observation on 8/28/18 at 4:58 A.M., showed the resident lay in bed wearing a wet
incontinence brief. Certified Nursing Assistant (CNA) A donned a pair of gloves, removed
the resident’s incontinence brief and washed the resident’s genitalia then the resident’s
buttocks. Without removing his/her gloves, the CNA touched the following items wearing the
soiled gloves: Side rail, bed remote control, privacy curtain, entrance door door handle
and as he/she dressed the resident, both of the resident’s ankles, the new incontinence
brief, pants and shirt. The CNA did not removed his/her soiled gloves until he/she stepped
out into the hall to discard the soiled linens. During an interview, the CNA said he/she
should have removed his/her soiled gloves after washing the resident’s genitalia and