ST SOPHIA HEALTH & REHABILITATION CENTER

Based on record review and interview, the facility failed to ensure each resident was
afforded the right to manage his/her financial affairs, when the facility failed to advise
residents of money held in the facility operating account that belonged to the resident.
The facility failed to deposit funds, in excess of $100 for residents receiving Medicare
and $50 for residents receiving Medicaid, in an interest bearing account that was separate
from any of the facility’s operating accounts, and credit all interest earned on
resident’s funds to that account. The deficient practice affected 71 residents (Residents
#13, #38, #57, #68, #71, #80, #83, #113, #128, #154, #156, #168, #169, #170, #171, #172,
#173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187,
#188, #189, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202,
#203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217,
#218, #219, #220, #221, #222, #223, #224, #225, #226 and #227). Also, the facility failed
to provide the Social Security personal spending allowance on a monthly basis to the
residents for two residents (Residents #45 and #167). Additionally, the facility failed to
use the personal funds of a resident exclusively for the resident and only when authorized
in writing for 16 residents (Residents #13, #17, #21, #31, #35, #69, #77, #84, #93, #107,
#122, #132, #133, #148, #154 and #167) out of a sample of 28 residents’ funds reviewed.
The facility census was 177.
1. Record review of the facility maintained Accounts Receivable A/R Aging Report for the
period 5/1/18 through 5/13/19, showed the following residents with personal funds held in
the facility operating account:
Resident Amount Held in Operating Account
#13 $ 435.50
#38 $ 48.00
#57 $ 158.93
#68 $ 773.00
#71 $4,414.47
#80 $ 875.00
#83 $ 531.08
#113 $3,438.00
#128 $ 700.00
#154 $ 946.00
#156 $ 461.70
#168 $1,055.57
#169 $ 170.50
#170 $ 112.87
#171 $ 20.00
#172 $1,750.00
#173 $ 1.18
#174 $ 427.22
#175 $1,416.00
#176 $ 295.49
#177 $ 585.38
#178 $1,595.83
#179 $ 588.88
#180 $ 854.00
#181 $ 165.00

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
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Based on interview and record review, the facility failed to provide Medicaid spend down
letters when the balance of the resident’s trust fund account exceeded $2,800.00. This
deficient practice affected four residents (Residents #77, #84, #107 and #122).
Additionally, the facility failed to provide a final accounting of individual resident
trust fund balances within 30 days to the individual or probate jurisdiction administering
the resident’s estate for two residents (Residents #156 and #157). The facility census was
177.
1. Record review of the facility’s maintained Resident Trust Fund Account for the period
[DATE] through [DATE], showed the facility unable to provide documentation showing SSI
resource limit letters were provided to residents, their designee, guardian and/or
conservator when the resident trust fund account reached a balance of $2,800.00 or $200.00
from the SSI resources limit of $3,000.00.
Record review on [DATE] of the Resident Trust Fund Accounts of Residents #77, #84, #107
and #122, showed Resident Trust Fund Account balances that exceeded $2,800.00 several
times throughout the period of [DATE] through [DATE].
During an interview on [DATE] at 1:30 P.M., the business office manager said the previous
business office manager did not provide spend down letters to residents, their designee or
guardians when the balance of the resident trust fund account reached $2,800.00, or
$200.00 from the SSI resources limit of $3,000.00.
2. Record review of the facility maintained Expired Report for the period [DATE] through
[DATE], dated [DATE], showed Resident #156 expired on [DATE].
Record review of the facility maintained Resident Trust Fund Ledger for the period [DATE]
through [DATE], showed Resident #156 had $2,104.77 held in the resident trust fund account
as of [DATE] (152 days after Resident #156 expired).
During an interview on [DATE] at 1:00 P.M., the business office manager said Resident #156
received Medicaid and the previous business office manager did not submit a Personal Funds
Balance Report to Social Services showing the balance remaining in Resident #156’s
resident trust account within 30 days of expired date.
3. Record review of the facility maintained Expired Report for the period [DATE] through
[DATE], dated [DATE], showed Resident #157 expired on [DATE].
Record review of the facility maintained Resident Trust Fund Ledger for the period [DATE]
through [DATE], showed Resident #157 had $145.39 held in the resident trust fund account
as of [DATE] (80 days after Resident #157 expired).
During an interview on [DATE] at 1:00 P.M., the business office manager said Resident #157

Based on observation and interview, the facility failed to ensure residents who live on
the 100, 200 and 400 halls could exercise their right to private communication when they
failed to replace the resident telephones in a timely manner. The facility census was 177.

1. During an interview on 5/16/19 7:22 A.M., Resident #42 said he/she could not make a
private phone call. There used to be cordless phones at the nurse’s stations, but since
the facility rewired the phone system about three months ago, they took the cordless
phones away and never replaced them. If he/she wanted to make a call, he/ she had to ask
the nurse to dial and then could only go as far away as the cord would stretch. There were
always staff and other residents around. He/she felt bad about tying up the phone because
the nurse needed to use it too.
2. During an interview on 5/16/19 at 7:26 A.M., Nurse U, who worked regularly on the 100
Hall, said residents could use the desk phone or the cordless phone . Residents could take
the cordless phone to their room to use. Nurse U was unable to locate the cordless phone.
He/she said it sometimes happened when residents left the phone in their room and
eventually it showed back up. The locator button was pressed, but Nurse L was unable to
locate the phone.
3. During an interview on 05/16/19 08:11 A.M., Nurse L, who worked regularly on the 200
Hall, said the only phone available for resident use was at the nurse’s station. They used
to have a cordless phone, but there were wiring issues and it was taken away. They
encouraged residents to have cell phones.
4. Observation on 5/16/19 at 1:24 P.M., showed staff informed Resident #86 he/she had a
phone call at the 100 Hall nurse’s station. The resident wheeled up to the nurses’s
station and took the phone from staff. The resident could be overheard having a private
conversation while three residents, four staff, two visitors and a hospice representative
sat or stood around or near the nurse’s station within hearing distance of the
conversation. At 1:33 P.M., the resident ended his/her conversation, gave the phone back
to staff and wheeled away.
During an interview on 5/17/19 at 7:23 A.M., Resident #86 said residents always had to use
the phone at the nurse’s station. He/she would prefer to have a place to make calls
privately. He/he did not like having to take calls where everyone could listen in.
5. During an interview on 5/17/19 at 7:17 A.M., three nursing staff on the 400 Hall
confirmed the only phone currently available for resident use was the one at the nurse’s
station.
6. Review of the Resident’s Rights information provided to all residents in the admission
packet, showed residents had the right to privacy to make phone calls.
7. During an interview on 5/17/19 at 10:10 A.M., the administrator agreed the facility was
responsible to ensure residents could make private phone calls. He was not aware the
cordless phones on the 100, 200 and 400 Halls were not in working order or available for

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Based on observation, interview and record review, the facility failed to develop and
implement person-centered comprehensive care plans to meet preferences and goals and
address residents’ medical, physical, mental and psychosocial needs, by not including
depression, pressure ulcers, oxygen use, activities, restorative therapy, pain,
contractures, paralysis and [MEDICAL CONDITION] on the care plans, for eight of 35 sampled
residents (Residents #23, #151, #88, #49, #25, #28, #44 and #77). The census was 177.
1. Review of Resident #23’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/17/19, showed the following:
-No cognitive impairment;
-Total dependence on staff for activities of daily living;
-Upper and lower extremity impairment;
-Incontinent;
-No antidepressant medication administered in past 7 days;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 3/4/19, for [MEDICATION NAME] (antidepressant medication) 10 milligrams
(mg), give one tablet by mouth in the morning related to major [MEDICAL CONDITION];
-An order, dated 3/4/19, for duloxetine (antidepressant medication) 20 mg, give one
capsule by mouth in the morning related to major [MEDICAL CONDITION].
Review of the resident’s care plan, updated 2/17/19, showed no mention of the resident’s
[MEDICAL CONDITION] diagnosis, goals, or interventions associated with care.
2. Review of Resident #151’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Required extensive assistance from staff for transfers and dressing and required limited
assistance for hygiene and toileting;
-[DIAGNOSES REDACTED].
-At risk for pressure ulcers (Pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction).
Review of the resident’s (MONTH) 2019 POS, showed the following orders:
-An order, dated 4/30/19, to cleanse the right great toe with wound cleanser (WC) or
normal saline (NS) and apply [MEDICATION NAME] (an antiseptic used for skin disinfection)
one time a day for prevention;
-An order, dated 4/30/19, to cleanse the left hip with WC or NS, apply calcium alginate
(CA, provides a moist environment for wound healing) and cover with dry dressing.
Review of the resident’s undated care plan, in use during the survey, showed staff failed
to address the resident’s skin issues, including prevention and treatment.
3. Review of Resident #88’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive staff assistance for transfers, mobility, hygiene, dressing and
toileting;

7. Review of Resident #44’s annual MDS, dated [DATE], showed the following:
-Original admission date of [DATE] and reentered on 9/25/18
-Severe cognitive impairment;
-Extensive assistance with all personal care;
-Unable to ambulate;
-Propels self in wheelchair;
-[DIAGNOSES REDACTED].
Observations on 5/13 at 2:54 P.M., 5/14 at 12:28 P.M., 5/15 at 10:01 A.M. and 1:22 P.M.
and 5/16/19 at 9:01 A.M. and 12:00 P.M., showed the resident sat in his/her wheelchair, a
trough (hard plastic device connected to the arm of the wheelchair to lay his/her arm on)
to the right arm of the wheelchair and his/her right arm lay across his/her lap.

**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 reflected current needs by not updating them to include psychotic medication
use and interventions, failed to reflect lower leg [MEDICAL CONDITION] (swelling) and
lower leg wraps, specific and current wound treatments, failed to reflect the change in
wound treatments used and reflect the long term use of antibiotic as a [MEDICATION NAME].
The affected five of 35 sampled residents (Residents #8, #144, #60, #56 and #47). The
census was 177.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/1/19, showed the following:
-Cognitively intact;
-No mood issues;
-Verbal behaviors daily;
-Daily antipsychotic medication;
-[DIAGNOSES REDACTED].
Review of the electronic physician order [REDACTED].
Review of the admission care plan, dated 10/15/18, showed the following:
-Focus: The resident has a behavior problem related to brain damage and he/she refused lab
work frequently;
-Goal: The resident will have fewer episodes of behaviors by review date.
-Interventions: Explain all procedures to the resident before starting and allow time for
the resident to adjust to the changes, staff intervene as necessary to protect the rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to administer
treatments as ordered (Residents #81, #51 and #5), failed to obtain orders for a
peripherally inserted central catheter (PICC, a thin, soft, long catheter (tube) that is
inserted into a vein. The tip of the catheter is positioned in a large vein that carries
blood into the heart and used to administer medication), code status and inflatable boots
(Residents #43, #44 and 56), failed to provide dietary supplements as ordered (Residents
#23 and #154), failed to clarify orders (Resident #94) and failed to apply medical
stockings as ordered (Residents #77 and #152). The census was 177.
1. Review of Resident #81’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/22/19, showed the following:
-Severe cognitive impairment;
-Limited staff assistance needed with hygiene;
-[DIAGNOSES REDACTED].
-Surgical wound treatment;
-Received ointments other than to the feet.
Review of the undated care plan, in use during the survey, showed the following:
-Problem: The resident picks at his/her skin, causing injuries. He/she picked at the top

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

Based on observation, interview and record review, the facility failed to provide and
ensure appropriate perineal (peri-care, cleansing the front of the hips, between the legs
and buttocks) care to two of three perineal care observations (Residents #77 and #152).
The facility also failed to provide meal service set up to one of 35 sampled residents
(Resident #58). The census was 177.
1. Review of Resident #77’s annual Minimum Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/23/19, showed the following:
-Moderate cognitive impairment;
-Extensive assistance required for all personal care and mobility;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 5/15/19 at 9:03 A.M., showed Certified Nurse Aide (CNA) A entered the
resident’s room, washed hands and donned gloves. He/she removed the wet with urine brief,
applied soap to a wet cloth and cleansed the genital area. He/she did not cleanse the
urinary meatus and did not rinse the genitals. He/she dressed the resident in a clean
brief, washed his/her hands and left the room.
During an interview on 5/15/19 at approximately 9:10 A.M., CNA A said if a man had been
circumcised it was not necessary to clean the urinary opening, and he/she did not feel the
need to rinse the genital area because he/she applied the soap to the cloth and not in the
water.
During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing (DON) said it did
not matter if a man was or was not circumcised, the meatus needed to be cleansed
regardless and always rinsed after using soap.
2. Review of Resident #152’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive staff assistance needed for hygiene, dressing and toileting;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the undated care plan, in use during the survey, showed the following:
-Problem: Occasional urine dribble;

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

2. Review of Resident #94’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] and reentered on 1/16/19;
-No cognitive impairment;
-Dependent on staff for personal hygiene and mobility;
-[DIAGNOSES REDACTED].
Review of the care plan, in use during the survey, showed the following:
-Problem: Requires SP catheter due to a [DIAGNOSES REDACTED].
-Goal: Will not have any injuries or discomfort from catheter usage;
-Interventions: Assess for pain and discomfort, avoid pulling on catheter tubing, change
catheter monthly and as needed (PRN), dependent on staff for catheter care, empty catheter
bag prior to transfers, empty and measure output every shift, keep catheter bag below the
level of the bladder, give good catheter every shift, monitor for and report to the
physician any burning, pain, blood tinged urine, no output, fouls smelling urine, fever,
chills and/or mental status changes and position the catheter bag away from the room door.

Observations of the resident, showed the following:
-On 5/13/19 at 10:41 A.M., the resident lay in bed. The catheter drainage bag, not covered
by a privacy bag, hung on the bed frame visible from the door. The bag contained
approximately 100 cc of urine;
-On 5/14/19 at 7:47 A.M., the resident lay in a low bed. The catheter bag, not covered
with a privacy bag, hung from the bed frame and was visible from the hallway. The bag lay
on the floor, half-way under the bed and contained an undetermined amount of urine;
-On 5/14/19 at 10:18 A.M., the resident remained in bed on his/her back and the catheter
drainage bag, not covered with a privacy bag, hung on the bed frame. The bottom third of
the bag rested on the floor. The bag contained approximately 300 cc of urine;
On 5/15/19 at 8:16 A.M., the resident lay in bed and the uncovered catheter drainage bag
hung from the bed frame. The bag contained approximately 500 cc of urine and the lower
half of the bag rested on the floor;
-On 5/16/19 at 6:40 A.M., the resident lay in bed and the uncovered urinary drainage bag
lay on the floor.
3. Review of Resident #154’s quarterly MDS, dated [DATE], showed the following:
-Cognitive pattern not assessed;
-Total dependence on staff for all activities of daily living;
-Three Stage III pressure ulcers (involves full-thickness skin loss potentially extending
into the subcutaneous (under the skin) tissue layer);
-SP catheter;
-Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach to provide
hydration, nutrition and medications);
-[DIAGNOSES REDACTED].
Review of the resident’s medical chart, showed the following:
-An order, dated 3/25/2019, for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) by
[DEVICE] for 7 days for infection;
-A nurses’ note, dated 3/30/19, admitted to hospital for urinary tract infection [MEDICAL
CONDITION] and fever;
-An order, dated 4/15/19, for Linezolid (antibiotic) 600 mg., via [DEVICE] twice daily for
infection until 4/28/19.
Review of the resident’s care plan, updated on 4/22/19, showed the following:
-Problem: SP catheter;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to adequately
assess pain, record the degree and location of pain, re-evaluate the effectiveness of pain
medication, notify the physician of ineffective pain control and failed to follow a
physician’s orders [REDACTED]. This practice affected two residents (Resident’s #80 and
#88). The sample size was 35. The census was 177.
1. Review of Resident #80’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/20/19, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-Extensive assistance required by staff for all personal care and mobility;
-Frequent severe pain that limits day to day activities;
-[DIAGNOSES REDACTED].
Review of the care plan, dated 3/8/19, showed the following:
-Problem: Chronic pain related to spinal stenosis;
-Goal: Will verbalize adequate pain relief or ability to cope with incompletely relieved
pain;
-Interventions: Administer [MEDICATION NAME] (pain relief medication) as ordered, give
[MEDICATION NAME] one half hour before treatment or care, anticipate need for pain relief
and respond immediately to any complaint of pain, monitor/document for side effects of
pain medication, observe for constipation, new onset or increased agitation, restlessness,
confusion nausea, vomiting or falls and report to the physician.
Review of the physician’s orders [REDACTED].

2. Review of Resident #88’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive staff assistance with transfers, mobility, hygiene, dressing and
toileting;
-[DIAGNOSES REDACTED].
-Should pain assessment interview be conducted? Yes. Interview: No presence of pain.

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Based on interview and record review, the facility failed to provide thorough assessments,
monitoring and ongoing communication with the [MEDICAL TREATMENT] center for a resident

Based on interview and record review, the facility failed to ensure each nurse aide had no
less than 12 hours of in-service education per year, based on their individual performance
review, calculated by their employment date rather than the calendar year. The facility
failed to ensure three of eleven randomly selected certified nurse aides (CNAs), employed
by the facility over one year, received the required annual 12-hour resident care
training. The census was 177.
Review of the CNA individual service records, showed the following:
-CNA M hired 8/24/2009, received eight and one half hours of in-service education;
-CNA N hired 5/17/2010, received nine and one half hours of in-service education;
-CNA O hired 6/5/2007, received eight hours of in-service education.
During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing said she was aware
of the need for CNAs to receive 12 hours of resident-centered care inservicing every year.

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation. The facility failed to properly document narcotic counts for the
controlled substances for four of the four facility medication carts. The facility census
was 177.
1. Review of the 100 wing controlled substance shift change count sheet (three shifts:
days, evening and nights), dated (MONTH) 2019, showed the following:
-On 5/1/19: Three packages of narcotics at 7:00 A.M.
-No nurse signatures for the 7:00 A.M. on-coming shift;
-No nurse signature or narcotic package counts for the 3:00 P.M. on-coming or off- going
shift;
-Three narcotic packages and no nurse signature noted for the 11:00 P.M. off-going shift;
-On 5/2/19: Three packages of narcotics at 7:00 A.M.;
-No on-coming nurse signature at 7:00 A.M.;
-No total narcotic package count or on-coming and off-going nurse signature for 3:00
P.M.;
-Three narcotic packages and no off-going or on-coming nurse signature for 11:00 P.M.;
-On 5/3/19: Three narcotic packages at 7:00 A.M.;
-No nurse signature off-going at 7:00 A.M.;
-No total narcotic package count or on-coming, off-going nurse signature at 3:00 P.M.;
-Three narcotic packages, no off-going nurse signature at 11:00 P.M.;
-On 5/4/19: No nurse signatures or total narcotic package counts at 3:00 P.M. or 11:00
P.M., on-coming or off-going;
-On 5/5/19: Three total narcotic packages at 7:00 A.M.,
-No off-going or on-coming nurse signatures at 11:00 P.M., 7:00 A.M., and 3:00 P.M.;
-On 5/6/19 and 5/7/19: no narcotic package count, or nurse signatures off-going or
on-coming for all shifts of 7:00 A.M., 3:00 P.M., and 11:00 P.M.;
-On 5/8/19: Three narcotic packages at 7:00 A.M.
-No off-going nurse signature at 11:00 P.M.,

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Based on record review and interview, the facility failed to attempt a gradual dose
reduction (GDR) for a [MEDICAL CONDITION] medication for one resident (Resident #41) and
failed to obtain a new order, or discontinue the use of an as needed (PRN) [MEDICAL
CONDITION] drug beyond the 14 day limit for one resident (Resident #144). The sample size
was 35. The facility census was 177.
1. Review of Resident #41’s electronic physician order [REDACTED]. No reduction of the
medication was indicated in the POS since 9/15/18.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/27/19, showed the following:
-Moderate cognitive impairment;
-No mood or behaviors;
-Received hospice services;
-[DIAGNOSES REDACTED].
-No GDR completed;
-The physician had not documented that a GDR had been contraindicated.
Review of the undated facility care plan, showed the following:
Problem: The resident has impaired cognitive function related to dementia or impaired
thought processes;
Goal: The resident will maintain current level of cognitive function through the review
date;
Interventions: Ask yes/no questions in order to determiReview of the electronic physician
order [REDACTED]. No reduction of the medication was indicated in the POS since 9/15/18.
ne the resident’s needs, keep the resident’s routine consistent and try to provide

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to date insulin flex pens
(prefilled insulin pens) once opened, discard outdated insulin pens and ensure the
resident’s name appeared on the medication for 10 of 30 insulin pens and vials observed on
two of two medication carts. The census was 177.
1. Observation on [DATE] at 9:04 A.M., of the medication cart on 100 hall, showed the
following:
-A total of 18 flex-pens and two vials of insulin opened and in use;
-One Humalog (fast acting) insulin flex-pen, opened and dated [DATE];

Based on observation and interview, the facility failed to ensure food was stored and
served in a manner to prevent contamination by not covering desserts or the clean mixer
bowl after use, and serving oatmeal from a cart, table to table in the dining room, from
an uncovered pan. This deficient practice had the potential to affect all residents who
ate at the facility. The census was 177.
1. Observation of the kitchen showed the following:
-On 5/13/19 at 9:17 A.M. and 5/14/19 at 11:44 A.M., a sign on the wall behind the stand
mixer read clean mixer and slicer after use and cover. The mixer bowl sat underneath the
sign next to the mixer uncovered;
-On 5/14/19 at 11:24 A.M., a cart sat in front of the steam table and held three trays of
peach cobbler dessert cups. The top tray held five covered dessert cups, middle tray held
approximately 34 covered dessert cups and the bottom tray held 34 uncovered dessert cups.
The cart sat in the kitchen uncovered until meal service began at approximately 12:00 P.M.
2. Observation of the dining room on 5/17/19 at approximately 7:30 A.M. and 7:50 A.M.,
showed Dietary Aide (DA) P pulling a rolling cart with a metal pan of hot oatmeal and a
metal pan of another hot cereal on the top. Both pans were uncovered. DA P pulled the cart
to resident tables and dished out hot cereal. Numerous residents and staff walked past the
cart as DA P served from the uncovered pans. DA P served approximately 10 residents during
this time.
3. During an interview on 5/17/19 at approximately 1:00 P.M., the dietary manager said
they had served a lot of cakes this week so the mixer was in use a lot. It should be
covered when not in use. The peach cobbler cups that were covered were the ones going into
the hall carts. She was not aware the oatmeal was being served from a cart in the dining
room. Food items should be covered until served.

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Based on interview and record review the facility failed to ensure and collaborate care
with resident elected hospice providers and failed to obtain a physician’s orders
[REDACTED]. Problems with coordinated plans of care were found with four of four residents
reviewed for hospice services (Residents #151, #41, #85 and #43). The census was 177.
1. Review of Resident #151’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/26/19, showed the following:
-Moderate cognitive impairment;
-Required extensive assistance from staff for activities of daily living such as transfers
and dressing and limited assistance for personal hygiene and toileting;
-[DIAGNOSES REDACTED].
-Special treatments received while a resident: Hospice.
Review of the resident’s medical record, showed the following:
-The (MONTH) 2019 electronic physician order [REDACTED].
-The progress notes, showed staff did not document hospice visits or communication;
-The hospice binder, showed no documentation of communication between the hospice provider
and the facility.
Review of the resident’s undated care plan, in use during the survey, showed the
following:
-Problem, received hospice care, with name, address and phone number of hospice agency
shown;
-Goals, symptoms will be controlled and will remain in facility until death;
-Interventions, contact hospice team for symptom management issues, refer to clinical
record for hospice team contact information, contact hospice nurse as needed regarding
home health aide referral for additional care needs, refer to hospice plan of care as
needed;
-Facility staff did not show a collaboration with hospice to show what specific services
would be provided.
2. Review of Resident #41’s quarterly MDS dated [DATE], showed the following:
-Moderate cognitive impairment;
-Extensive staff assistance needed for transfers, hygiene and toileting;
-Incontinent of bowel and bladder;
-Received hospice services;
-[DIAGNOSES REDACTED].
Review of the ePOS, showed no hospice orders.
Review of the resident’s hospice interdisciplinary plan of care review, dated 5/1/19,
showed the following:
-Start of hospice care: 10/3/18;
-Increased dependence on staff to complete daily care tasks;
-Weight loss of 14 pounds in a month;
-Hospice provided pull-ups, body wash, lotion, shampoo, bed, over the bed table, wheel
chair, bed and chair alarms and bedside fall mats.
Review of the undated care plan, in use during the survey, showed the following:
-Problem: Receiving hospice care related to stroke and difficulty swallowing. Name,

Based on observation, interview and record review, the facility failed to maintain
appropriate infection control by ensuring staff handled medications to prevent the
potential spread of infection during medication administration by staff who used bare
hands to administer medications to one resident (Resident #81) and failed to sanitize
hands during medication administration for two of four observations and failed to handle
soiled linen appropriately. The census was 177.
1. During an observation and interview on 5/14/19 at 8:20 AM, Certified Medication
Technician (CMT) Q prepared to administer morning medications to Resident #81. He/she
dispensed medications into a medication cup. One tablet dropped from the medication card
and fell on to the top of the medication cart next to the plastic medication cup. CMT Q
used his/her bare hand, picked up the tablet and placed the tablet into the medication cup