Full report jan. 21 2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
335742
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
NAME OF PROVIDER OF SUPPLIER
NIAGARA REHABILITATION AND NURSING CENTER
STREET ADDRESS, CITY, STATE, ZIP
822 CEDAR AVENUE
NIAGARA FALLS, NY 14301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0157
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor and a family member of the resident
of situations (injury/decline/room, etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.
Based on interview and record review conducted during the Standard Survey completed on 1/21/16, the facility did not inform
the resident's legal representative or interested family member when there is a significant change in the resident's
physical,mental or psychological status;or an accident involving the resident which results in injury and has potential for
requiring physician intervention. Two (Resident's #89, 56) of three residents reviewed for notification of change had
issues involving abnormal laboratory test results which resulted in a change in the resident's ordered gastrostomy tube
feedings and flushes (a tube inserted directly into the stomach to feed a resident and provide fluids) as well as the
discontinuing of medications.The resident's responsible party was not informed of the changes (Resident #89) and the lack
of physician notification regarding the resident's hypoglycemic/ hyperglycemic (low/high blood sugar levels) episodes
(Resident # 56).
The finding are:
1. Resident #89 has [DIAGNOSES REDACTED]. As per the admission assessment dated [DATE], the resident is non ambulatory,
has
weakness of all extremities, and requires the total assistance of two persons with a lift machine to transfer from bed to
chair. The resident is alert to person but cannot speak words due to the placement of a [MEDICAL CONDITION].
Review of the facility Resident Notes revealed the following:
- 11/23/15 the resident is noted to cough up yellow sputum. The resident was suctioned with improvement.
- 11/24/15 the resident is noted to have a medium amount of yellow secretions from the [MEDICAL CONDITION] site.
- 11/24/15 the resident is noted to have critical labs called from the laboratory including a sodium (Na - the level of salt
in the blood, an indicator of hydration) of 161 (normal Na levels are 133- 147) and a blood urea nitrogen (BUN- blood test
to determine kidney function and hydration status) of 112 (Normal BUN levels are 5-27). The Physician was called with new
orders to increase the water flushes around the clock and with medications, discontinue two medications and repeat the
laboratory tests in the AM.
- 11/25/15 the laboratory called with critical laboratory results including a BUN of 126 and Na 156. The Nurse Practitioner
was called with no new orders.
- 11/25/15 at 5:15 PM the resident is noted to have an altered mental status with no response to staff, temperature
elevation of 100.9 degrees Fahrenheit, and oxygen level 84% (low- should be greater than 90) . The Physician was called and
ordered the resident to be transferred to the hospital emergency room for an evaluation. The responsible party was informed
and agreed with the transfer to the hospital.
Interview with the Registered Professional Nurse (RN) Unit Coordinator on 1/19/16 at approximately 11:45 AM revealed the RN
did not call the resident's responsible party on 11/24/15 after receiving new orders regarding the critical lab results.The
RN was unable to recall any specific events for the resident on 11/25/15 and did not call the responsible party on that
date.
Interview with the RN Director of Nursing (DON) on 1/19/16 at approximately 3:05 PM revealed the RN DON received the call
from the laboratory regarding the critical labs (labwork results that are very abnormal and need follow up with a
Physician) on 11/25/15 and she did not call the responsible party. The RN DON stated that the resident's responsible party
is to be informed of all changed in medications, treatment regime and health status. The RN DON reviewed the Resident's
Notes for 11/24/15 through day shift 11/25/15 and stated the responsible party was not informed in changes in the resident.
Interview with the Medical Director on 1/20/15 at approximately 11:25 AM revealed the Physician expects the staff to notify
the responsible parties when there is a change in status and treatment of [REDACTED].
Review of the facility policy and procedure entitled Notifying MD/ Responsible Party of Resident's change in condition dated
1/2016 revealed a change in condition may include an order for [REDACTED].
2. Resident # 56 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated
11/6/15
revealed that the resident has moderate cognitive impairment, understands and is understood. In addition the MDS revealed
documented that the resident is frequently incontinent of bowel and bladder.
Review of Admission Physician orders dated 9/23/15 revealed orders for [MEDICATION NAME] XL 10 milligram (mg) daily,
[MEDICATION NAME] 50 mg one tablet daily, [MEDICATION NAME] (insulin) 35 units every morning.(Diabetic medication).
In addition the Physician's Orders of 9/23/15 revealed Humulog Insulin Rainbow Coverage at 7:30 AM, 11:30 AM, 5:30 AM and HS
as follows:
70-130 = 0 UNITS
131-180 = 2 UNITS
181-240 = 4 UNITS
241-300 = 6 UNITS
301-350 = 8UNITS
351-400 = 10 UNITS
Over 400 12 UNITS AND CALL MD
Review of a Nurse Practitioner (NP) Acute Visit Progress Note revealed the resident was evaluated for pneumonia and diabetes
mellitus with plans to continue the resident on antibiotic treatment for [REDACTED].
Review of the Medication Administration Record [REDACTED]. The 9/25/15 7:30 AM glucose was 95.
Review of Nurses' Notes dated 9/24/15 by Licensed Practical Nurses (LPN's) at 7:00 AM and 3:00 PM to 11:00 PM revealed no
Physician notification for the low or high glucose levels documented in the MAR.
Review of a Registered Nurse (RN) Nurses' Note dated 9/25/15 10:55 AM revealed the resident exhibited [MEDICAL CONDITION]
activity in rehabilitation , 911 (emergency number) was called and the resident was transferred to the emergency department
(ED).
Interview with the NP on 1/20/16 at approximately 1:20 PM revealed that the NP was not aware that the resident had the
episode of low or high blood glucose levels and she would expect the staff to call for values 60 or below and above 400.
Additionally, the NP stated on 9/24/15 she probably evaluated the resident prior to those values were obtained.
Review of the facility's policy and procedures and confirmed by the Acting DON and Administrator, the facility does not have
a policy for glucose monitoring.
415.13(e)(2)(ii)b
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 335742 If continuation sheet
Page 1 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0157
harm
(continued... from page 1)
F 0225
harm
1) Hire only people with no legal history of abusing, neglecting or mistreating
residents; or 2) report and investigate any acts or reports of abuse, neglect or
mistreatment of residents.
Based on interview and record review conducted during a Complaint investigation (Complaint #NY 114) conducted during the
Standard survey completed on 1/21/16, the facility did not ensure that all alleged violations involving mistreatment,
neglect, or abuse, including injuries of unknown source, are thoroughly investigated. One (Resident #112) of five residents
reviewed for the investigation of medication omissions of an anticonvulsant had issues with reporting the occurrence
immediately to other officials in accordance with State law through established procedures in a timely manner (including to
the State survey and certification agency).
The finding is:
1. Resident #112 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated
11/11/15
revealed the resident was severely impaired for decision making.
Review of an Incident Investigation received by the New York State Department of Health (NYSDOH) called in by the
Administrator of record on 12/10/15 revealed the facility identified an occurrence of potentially five to seven doses of
[MEDICATION NAME] 500 milligram (mg)(an anti-[MEDICAL CONDITION] medication) that were not documented as given on
the
Medication Administration Record [REDACTED]
Interview with the Acting Director of Nursing (DON) on 1/19/16 at approximately 9:45 AM revealed the resident had a fall on
11/25/15. The medical record was reviewed after the incident and the medication omissions were discovered. Two Licensed
Practical Nurses (LPNs) provided written statements that they gave [MEDICATION NAME] 500 mg but did not sign it out or
signed in the wrong box on the MAR. Review of photo copies of the Blister packs revealed there were no medications left
over. Written warnings were issued and in-servicing provided to the all nurses. The ADON stated that the Administrator
notified the NYSDOH on 12/10/15 and signed off on the investigation on 1/14/16.
Interview with the Acting DON on 1/19/16 at approximately 11:00 AM revealed they conducted additional chart audits and there
were no other resident issues related to medication omissions.
Interview with the Administrator on 1/20/16 at 11:40 AM revealed after the resident's fall the medical record was reviewed.
The empty boxes on the MAR for the [MEDICATION NAME] 500 mg was discovered and an investigation was initiated. The
Administrator stated he knew the incident should have been reported to the NYSDOH within 24 hours of discovering the issue.
415.4(b)(1)(ii)
F 0226
harm
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of
resident property.
Based on interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not
implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation
of resident property. One of five employee files lacked verification with the New York State Nurse Aide Registry prior to
employment.
The finding is:
1. Review of the Employee File for Employee #5, a member of the maintenance staff, on 1/15/16, revealed the employee was
hired on 11/9/15 and the file contain documentation that a Nurse Aide Registry Verification Report had been conducted for
the employee on 11/13/15.
Review of a Provisional Employee Supervision Log for Employee #5 on 1/15/16 revealed the employee had worked at the facility
on 11/9/15, 11/10/15, and 11/12/15.
Interview with the Human Resources Director (Authorized Person) on 1/15/16 at approximately 9:41 AM revealed he was not the
authorized person who had conducted the Nurse Aide Registry Verification report for Employee #5. Further interview with the
Human Resources Director at this time revealed the authorized person that had conducted the Nurse Aide Registry
Verification report for Employee #5 was no longer working at the facility and he was not sure why it was not conducted
before the employee was hired.
415.4(b)
F 0241
harm
Provide care for residents in a way that keeps or builds each resident's dignity and
respect of individuality.
Based on observation,interview and record review conducted during the Standard survey completed on 1/21/16, the facility did
not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and
respect in full recognition of his or her individuality. Three (Resident's #36, 75, 145) of six residents observed for
dignity had issues involving staff standing while feeding residents (Residents #36, 75) and a urinary collection bag that
was visible from the hallway (Resident #145).
The findings are:
11/4/15
revealed the resident requires extensive assistance of one person with eating.
During an observation on 1/19/16 at 9:14 to 9:17 AM, CNA (certified nurse aide) #1 was observed standing at the bedside
while assisting the resident to eat breakfast in the resident's room.
2. Resident #75 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive
impairment and needs supervision, encouragement and cueing for eating.
An observation on 1/19/16 from 9:11 AM to 9:16 AM revealed CNA #2 entered the resident's room, retrieved an over bed table,
set up the meal tray, and started assisting the resident with her breakfast. The CNA was observed standing at the bedside
while assisting the resident to eat.
During an interview on 1/19/16 at 9:19 AM the RN (Registered nurse) Unit Manager stated that the CNAs should be sitting
while feeding a resident.
During an interview on 1/20/16 at 12:45 PM CNA #2 stated that she would usually sit down while feeding someone but there
wasn't a chair in the room.
3. Resident #145 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive
impairment and has an indwelling catheter.
Observation revealed:
-1/15/16 at 8:36 AM the urine collection bag is attached to the bedframe on the right side of the bed, facing the doorway.
Yellow urine is observed in the bag.
-1/19/16 at 9:15 AM the urinary collection bag is attached to the bedframe on right side of bed facing the doorway. Yellow
urine was observed in the bag.
During an interview on 1/19/16 at 9:17 AM the RN Unit Manager stated that they just got bag covers in and she's in there
right now covering it (the urinary collection bag). The RN further stated they ran out of them and they were ordered last
week.
During an interview on 1/20/16 at 1:42 PM the acting DON (Director of Nursing) stated it's not written into their policy to
cover the (urinary) collection bags.
415.5(a)
FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 335742 If continuation sheet

Previous Versions Obsolete Page 2 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0241
harm
F 0242
harm
Make sure each resident has the right to have a choice over activities, their schedules
and health care according to his or her interests, assessment, and plan of care.
Based on interview and record review during the Standard Survey completed on 1/21/16, it was determined that the facility
did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments,
and plan of care. Two (Resident's #213, 154) of three residents reviewed for choices were unable to choose the frequency of
showers each week.
The findings are:
11/25/15
revealed the resident usually is understood and usually understands and is severely impaired cognitively.
During an interview on 1/14/16 at 10:14 AM the resident's guardian stated My aunt used to take showers every day at home. I
did not know she could take more than one. I would like her to get at least three showers a week.
Review of the resident's Care Guide dated 1/13/16 under bathing, revealed the resident receives a shower one day a week on
Mondays during the 3:00 PM to 11:00 PM shift.
Review of Activity Admission assessment dated [DATE] revealed it is very important to choose between a tub bath, shower, bed
bath and sponge bath with bath and shower circled.
During an interview on 1/19/16 at 2:25 PM certified nursing aide (CNA #3) stated The resident gets a shower once a week. The
family or the resident has never mentioned to me that they would like more. I am not sure if they may have mentioned it to
the nurse.
During an interview on 1/19/16 at 2:29 PM Registered Nurse (RN #2), Unit Manager stated I think preferences are obtained
either prior to or upon admission. I think the preferences comes from the screener. I really do not know as it is different
all over.
During an interview on 1/19/16 at 2:32 PM Ward Clerk #1 stated The residents' are typically scheduled to only get one shower
a week. But if the resident wants more, the resident would have to ask for more than one.
During an interview on 1/20/16 at 7:37 AM the Activities Director (AD) stated We start the choices care plan. We usually add
what the residents prefer a shower, tub bath or bed bath. Nursing would ask preferences for shower times and frequencies.
10/14/15
revealed the resident is understood and understands and is cognitively intact.
During an interview on 1/14/16 at 8:45 AM the resident stated I only receive one shower a week. They say they will give me
one shower a week, but I sometimes do not even get that. I used to take a shower every day at home. I would like a shower
everyday here, but would settle for at least three a week.
Review of the resident's Care Guide dated 1/14/16 under bathing, revealed the resident receives a shower one day a week on
Fridays during the 7:00 AM to 3:00 PM shift.
Review of Activity Admission assessment dated [DATE] reveals nothing marked for how important it is to choose between a tub
bath, shower, bed bath and sponge bath.
During an interview on 1/20/16 at 9:04 AM CNA #2 stated I believe she gets one shower a week. Everyone gets at least one
shower a week. She has never asked me for more than one. If she did I would give her one.
During an interview on 1/19/16 at 2:29 PM Registered Nurse (RN #2), Unit Manager stated I think preferences are obtained
either prior to or upon admission. I think the preferences comes from the screener. I really do not know as it is different
all over.
During an interview on 1/19/16 at 2:32 PM Ward Clerk #1 stated The residents' are typically scheduled to only get one shower
a week. But if the residents wants more, the resident would have to ask for more than one.
During an interview on 1/20/16 at 7:37 AM the Activities Director (AD) stated We start the choices care plan. We usually add
what the residents prefer a shower, tub bath or bed bath. Nursing would ask preferences for shower times and frequencies.
415.5(b)(1)(3)
F 0250
harm
Provide medically-related social services to help each resident achieve the highest
possible quality of life.
Based on interview and record review conducted during the Standard survey completed on 1/21/16, the facility did not provide
medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial
well-being of each resident. One (Residents #213) of one resident reviewed for social services had issues involving the
lack of Social Work (SW) intervention for notification of care planning.
The finding is:
11/25/15
revealed the resident is severely impaired cognitively, usually is understood and usually understands.
During an interview on 1/14/16 at 10:38 AM the resident's guardian stated, No one from the facility has ever contacted me
about attending a care plan meeting. I did not even know they had them.
Review of the resident's entire chart revealed no documentation of the guardian being invited to the care plan meetings.
During an interview on 1/20/16 at 8:50 AM the Director of Social Work stated, The resident's responsible party lives out of
state. She calls me and I meet with her separately when she is in town. Her guardian is aware of the care plan meeting as I
called her. I initially met with her on 11/24/15 and the again on 12/23/15. During our meeting I updated her on the
resident's status. After reviewing the chart the SW stated, I guess I did not document that she was invited to the care
plan meeting. Maybe I did not invite her because she lives out of town. The resident's initial care plan meeting was
12/8/15. Usually I talk to the resident and if they are alert I invite them. If the resident is not alert, when I see the
family I will invite them. Many of the residents here do not have family members that visit. The families that I do not see
I call them and invite them. Before I worked here they used to send letters out, but it was stopped. Since I have been here
we have not been sending letters.
During an interview on 1/20/16 at 9:30 AM the SW stated, I have the policy in regards to care plan meetings. It does state
that SW sends out an invitation. I have been here five months and I have never sent out letters. I did not know we were
supposed to. I do not have time to send letters. I did speak to the Administrator about this and he promised SW would be
getting more help.
Review of the facility policy entitled Resident Team Care dated June 2014 revealed it is the policy of facility to educate
residents, families and staff about the resident's current health status on at least quarterly basis based on MDS
assessment and care plan development. Under Procedures #4, the Social Work Department sends an invitation to a resident's
responsible party and informs an alert resident of the upcoming care plan meeting and #5 invitations are sent out within
three weeks of the meeting date, sometimes sooner if the MDS assessment dates are added at a later date.
415.5(g)(1)(i-xv)

F 0253
harm
Residents Affected - Some
Provide housekeeping and maintenance services.
Based on observation, interview and record review conducted during a Standard survey completed on 1/21/16, the facility did
not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Three (Units 2, 3, 4) of three units had issues with unlabeled used urinals and fracture bed pans left in shared bathrooms,
used urine collection hat left behind a toilet, resident wheelchair pedals left next to the toilet, urine soiled clothing
not properly contained in a resident's closet, soiled tube feeding equipment including poles and pumps, foam positioning
wedge with holes and exposed foam, a bed headboard with missing veneer and particleboard, soiled floor mats, dirty room
floors, and a torn up mattress.
The findings are:
FORM CMS-2567(02-99)
Page 3 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0253
harm
1. Observations on 1/13/16 between 10:00 AM and 1:00 PM revealed the following:
- Room #417 - an unlabeled, used urinal on top of the toilet tank in a shared bathroom.
- Room #423 - resident wheel chair pedals left next to the toilet, a used urinal measuring collection hat left behind the
toilet, a floor mat covered in gray debris/ dust covering approximately four feet.
- Room #414 - a used urinal not labeled on the bathroom side rail.
- Room #418 - a used urinal not labeled in shared bathroom, floor mats with various amounts of gray/ white debris covering
length of four foot floor mat, and a brown stain on pillow case approximately eight inches in diameter.
- Room #304 - an unlabeled bedpan in a shared bathroom.
Observations on 1/14/16 between 8:00 AM to 12:00 PM revealed the following:
- Room #417 - an unlabeled, used urinal on top of the toilet tank in a shared bathroom.
- Room #423 - resident wheel chair pedals left next to the toilet, a used urinal measuring collection hat left behind the
toilet, a floor mat covered in gray debris/ dust covering approximately four feet.
- Room #418 - a used urinal not labeled in shared bathroom, floor mats with various amounts of gray/ white debris covering
length of four foot floor mat, and a brown stain on pillow case approximately eight inches in diameter.
- Room #323 - IV pole has dried feed on it and the bag to hold the feed is dirty.
- Room #332 - IV pole has dried feed on it and there is a seven inch by three inch dried feed spill on the floor.
- Room #419 - a bed headboard missing the veneer and the particleboard underneath was gouged out.
- Room #315 - food debris, brown liquid stains, and debris behind the room door.
- Room #213 - floors are stained.
During an interview with a family member on 1/14/16 at approximately 10:33 AM revealed that there is a strong odor in the
resident's room (Room #222).
Observations on 1/20/16 between 10:00 AM and 1:00 PM revealed the following:
Room #213 - floor has brown/ black debris, used tissues on floor, and white debris under the resident's bed.
- Room #222 - a strong smell of urine on the window side of the room.
- Room #304 - a used, unlabeled fracture bedpan on the floor of a shared bathroom.
- Room #315 - used Styrofoam cup on the floor, a used washcloth on the resident's television, and a foam wedge with torn and
frayed corners with the foam exposed.
- Room #323 - IV pole with dried feed on it.
- Room #332 - IV pole with approximately 40 drops of dried feed on the base of it, the feed pump with dried feed on it, and
the feed tube stopper with dried feed placed on top of the pole.
- Room #414 - an unlabeled fracture pan in a shared bathroom.
- Room #419 - a bed headboard with the veneer and particleboard missing approximately six inches by three inches in one top
corner and approximately three inches by two inches in the other top corner.
During an interview with a Housekeeping Aide on 1/20/16 at approximately 10:45 AM, the Housekeeping Aide stated that the
CNAs (certified nurse aides) are supposed to clean the IV poles of feed spills and it is not the responsibility of
housekeeping.
During an interview with Registered Nurse (RN) #2 on 1/20/16 at approximately 12:00 PM, when discussing strong urine odors
in Room #222, revealed that the resident's pants that were visibly wet and had a strong urine smell were left on the bottom
of the resident's closet and not placed in a plastic bag or hamper. RN #2 stated that clothes that are soiled with urine or
other debris should be placed in a plastic bag and put in their closet. She also stated that resident floors should be
cleaned at least every day.
During an interview with RN #1 on 1/20/16 at approximately 12:15 PM, RN #1 stated that she expects her staff to report to
her when resident's room floors are dirty or if their equipment is in disrepair. RN #1 stated having unlabeled equipment in
shared bathrooms is an infection control issue. RN #1 also stated that she did not know who is responsible for cleaning the
IV poles, pumps, or feed bags in the resident's rooms.
During an interview with RN #3 on 1/20/16 at approximately 12:30 PM, RN #3 revealed that she expects her housekeeping staff
to clean floor mats, and for fracture bed pans and urinals to be labeled, used urine hats to be thrown out, and her staff
to report that resident equipment is in disrepair stating anyone can report that a headboard needs to be repaired to
maintenance.
An interview with the Director of Environmental Services on 1/20/16 at approximately 1:00 PM revealed that nursing should be
cleaning the IV poles and feed equipment but if it is heavily soiled that maintenance will power wash the poles. She also
stated that nursing needs to report these issues to maintenance so they can follow up on any maintenance issues or resident
equipment issues. The Director of Environmental Services also stated that maintenance will follow up with maintenance
requests within 24 hours.
Review of an undated facility policy entitled Enteral Feeding Pump and Pole Cleaning revealed under Procedure #1 the 11-7
nurse will wipe down the feeding pump, IV pole, and the IV pole base daily using the house disinfectant/ cleaning agent and
in Procedure 2 the housekeeping staff will pressure clean the IV pole and base weekly, at time when the enteral feeding is
not being administered.
Review of facility policy entitled Cleaning and Housekeeping dated 5/1/13 revealed in Procedure #4 that every resident room
will have the floor dry mopped and then wet mopped every day, water and mop head to be changed every three rooms and as
needed.
2. Observation of Room #411 on 1/13/16 at 12:23 PM revealed the bed by the door was unmade and the mattress was exposed. The
mattress had three to four slits in the top and appeared ripped and tattered. The areas were approximately one foot in
length.
Second observation of the mattress on 1/19/16 at 9:45 AM with the LPN present revealed the mattress remained ripped. The LPN
stated that she was not aware the mattress was ripped and she would get a new one. The LPN further stated she does not know
if there are routine checks of mattresses.
Review of the policy entitled Bed Sanitizing, last revised 10/2012, revealed the Housekeeping Supervisor will make a monthly
schedule for bed washing, the schedule will follow residents shower schedule as close as possible.
415.5(h)(2)
F 0279
harm
Develop a complete care plan that meets all of a resident's needs, with timetables and
actions that can be measured.
THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED SURVEY COMPLETED ON 8/13/15.
Based on interview and record review completed during the Standard survey completed on 1/21/16, the facility did not develop
a Comprehensive Care Plan (CCP) for each resident that includes measurable objectives and timetables to meet a resident's
medical, nursing, and psychosocial needs. One (Resident #221) of five residents reviewed for unnecessary medications lacked
development of a care plan to address an antipsychotic medication ([MEDICATION NAME]).
The findings are:
1. Resident #221 has [DIAGNOSES REDACTED]. Review of the face sheet revealed the resident was admitted on [DATE].
Review of a Physician's Order dated 1/1/16 through 1/31/16 revealed an order for [REDACTED].
Review of the Care Plan identified as current on 1/19/16 revealed a lack of Care Plan development for depression and the use
of an antipsychotic medication for treatment.
Interview with the Registered Nurse (RN) Charge Nurse #2 on 1/19/16 at approximately 2:30 PM revealed she is new to the
facility but would think there should be a Care Plan for antipsychotics and depression.
Review of the facility policy entitled Care Plans dated 2/15 revealed upon admission, each discipline is responsible to
begin developing an individualized Care Plan for each resident.
415.11(c)(1)
F 0280
harm
Allow the resident the right to participate in the planning or revision of the resident's

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0280
harm
care plan.
THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON [DATE] & [DATE].
Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not
periodically review and revise the Comprehensive Care Plan (CCP). Five (Resident's #36, 102, 166, 174, 213) of 31 residents
reviewed for Care Plans had issues involving the lack of a Care Plan revisions to address changes in code status
(Resident's #36, 166), revisions to address low [MEDICATION NAME] levels, pressure sore development, changes in fluid
consistency (Resident's #102, 174), and a lack of inviting a residents guardian to participate in care planning (Resident
#213).
The findings include but are not limited to:
[DATE]
revealed the resident usually is understood and usually understands and is severely impaired cognitively.
During an interview on [DATE] at 10:38 AM the resident's guardian stated, No one from the facility has ever contacted me
about attending a Care Plan meeting. I did not even know they had them.
During an interview on [DATE] at 8:50 AM the Director of Social Work (SW) stated, The resident's responsible party/guardian
lives out of state. She calls me and I meet with her separately when she is in town. Her guardian is aware of the Care Plan
meeting as I called her. I initially met with her on [DATE] and the again on [DATE]. During our meeting I updated her on
the resident's status. After looking through the chart the SW stated, I guess I did not document that she was invited to
the Care Plan meeting. MaybeI did not invite her because she lives out of town. The resident's initial Care Plan meeting
was [DATE]. Usually I talk to the resident and if they are alert I invite them. If the resident is not alert, when I see
the family I will invite them. Many of these residents here do not have family members that visit.The families that I do
not see I call them and invite them. Before I worked here they used to send letters out, but it was stopped. Since I have
been here we have not been sending letters.
During an interview on [DATE] at 9:30 AM the Director of Social Work (SW ) stated, I have the policy for you in regards to
Care Plan meetings. It does state that the Social Worker sends out an invitation. I have been here 5 months and I have
never sent out letters. I did not know we were supposed to. I do not have time to send letters. I did speak to the
Administrator about this and he promised Social Work would be getting more help.
Review of the resident's entire chart revealed there was no documentation noted of the guardian being invited to the Care
Plan meetings.
Review of the policy titled Resident Team Care dated [DATE] revealed it is the policy of the facility to educate residents,
families and staff about the resident's current health status on an at least quarterly basis based on MDS assessment and
Care Plan development. Under Procedure #4 the Social Work Department sends an invitation to a resident's responsible party
and informs an alert resident of the upcoming Care Plan meeting and #5 invitations are sent out within three weeks of the
meeting date, sometimes sooner if the MDS assessment dates are added at a later date.
2. Resident #102 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident
was
admitted [DATE] and is independent in decision making.
Review of a Nutrition Note dated [DATE] and the undated Fixed Care Plan revealed the resident was receiving a carbohydrate
consistent diet, liberal renal regular diet with 1200 cc( cubic centimeters) fluid restriction and had no pressure sores.
Review of Routine Chemistry results dated [DATE] revealed an [MEDICATION NAME] level (measure of protein in the blood) of
2.3 below normal values of 3XXX,[DATE].8. Review of the New/ Readmission Assessment initiated [DATE] revealed a notation
completed by the Registered Nurse (RN) dated [DATE] that the resident has a stage 2 pressure ulcer on the right Buttock.
Review of a Physician order [REDACTED].
Review of the undated Fixed Care Plan lacked revisions to include the low [MEDICATION NAME] levels, Stage 2 pressure sore,
and diet changes to reflect altered texture, thickened liquids, and a change in the therapeutic diet.
Interview with Registered Dietitian (RD) #1 on [DATE] at approximately 10:00 AM revealed Care Plans should be updated when a
problem arises and stated that is how RD #1 does it but isn't sure how the other RD's update the Care Plans.
3. Resident #166 has [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS- a resident assessment tool)
dated [DATE] revealed that the resident is cognitively intact, understands, and is understood.
A review of the facility new admission form dated [DATE] revealed that the resident is a full code for cardiopulmonary
resuscitation (CPR).
A review of the Care Plan dated [DATE] revealed that the resident wants to be a full code for CPR.
A review of the physician's orders [REDACTED].
A handwritten note on a Physician's Visit Note dated [DATE] revealed that resident was seen by the Physician that day and
the resident requested to no longer be a full code. Additionally, the note revealed wants no CPR, artificial feeds or
hydration. Spoke with family. Signed MOLST.
A review of the Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] revealed that the resident did not want to
be resuscitated with limited medical interventions, not to be intubated (breathing by artificial means), do not send to the
hospital, no feeding tube, no intravenous fluids, limited use of antibiotics, and no [MEDICAL TREATMENT]. This form was
signed by the resident and the Director of Social Work. Further review revealed the form was then signed by the Physician
on [DATE].
A review of the Care Plan revealed that there are no notations of the resident's updated do not resuscitate status.
An interview with the Director of Social Work (SW) on [DATE] at approximately 11:52 AM revealed that the Care Plan should be
updated right away or at least within 24 hours with the resident's new do not resuscitate status.
An interview with the Director of Nursing (DON) on [DATE] at approximately 12:34 PM revealed that Social Worker (SW) is
responsible for updating the Care Plan when it concerns the Advance Directives of the resident. The DON also stated that
the Care Plan should be updated right away or at least within 24 hours.
415.11(c)(2)(i-iii)
F 0281
harm
Make sure services provided by the nursing facility meet professional standards of
quality.
Based on interview and record review conducted during a Complaint Investigation (Complaint #NY 061) and during the Standard
survey completed on 1/21/16, the facility did not ensure that services were provided or arranged by the facility met
professional standards of care. Five (Resident #51, 56, 134, 154, 174) of 31 residents reviewed for professional standards
had an issue involving a lack of nutritional assessments completed within 14 days.
The findings include but are not limited to:
12/22/15
revealed the resident was admitted on [DATE] and is independent in decision making.
Review of physician's orders [REDACTED].
Review of Nutritional Progress Notes dated 12/16/15 revealed the resident is receiving a CCD, NAS Regular consistency diet.
The resident's admission weight is 363# (pounds). A Nutritional assessment will follow.
Review of routine laboratory (lab) Chemistry Results dated 12/24/15 revealed an [MEDICATION NAME] level of 3.1 (normal
values 3.5 - 5.0) and a glucose level of 58 (normal levels 60 - 100).
Review of routine Chemistry Results dated 12/31/15 revealed a further decline in [MEDICATION NAME] level to 2.8 and a
decline in total protein to 5.9 (normal levels 6.0 - 8.0).
Review of the Medical Record on 1/15/16 revealed a lack of a nutritional assessment or any further nutrition documentation
regarding nutritional needs or abnormal nutrition related labs.
Review of a facility policy entitled Nutritional Screening/ Assessment dated 5/2015 revealed all residents will receive a
complete nutritional assessment in their Medical Record on admission, annually and when there is a significant change in
FORM CMS-2567(02-99)
Page 5 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0281
harm
the resident's condition.
Interview with Registered Dietitian (RD) #1 on 1/19/16 at 11:30 AM revealed nutritional assessments should be completed
within 14 days of admission. In a later interview on 1/20/16 at approximately 10:00 AM revealed if a resident has a low
[MEDICATION NAME] level a worksheet should be completed reassessing the resident's nutritional needs for increased protein.
During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world nutrition assessments are done within
14 days after admission.
2. Resident #134 has [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS revealed the resident understands, is
understood and has an impaired decision making ability.
Review of the resident's Comprehensive Care Plan (CCP) dated 11/3/15 revealed the resident has [MEDICAL CONDITION] (low
blood count), is at risk for dehydration due to attending [MEDICAL TREATMENT] three times a week and is at risk for an
impairment in nutrition due to [MEDICAL CONDITION].
Review of the resident's admission physician's orders [REDACTED].
Review of the Physician's History and Physical dated 6/17/15 revealed the resident has [MEDICAL CONDITION] and attends
[MEDICAL TREATMENT] three times a week, has [MEDICAL CONDITION] and hypertension.
Review of the Nutritional Progress Note dated 6/17/15 revealed the resident was admitted to the facility with a NAS renal
diet and a fluid restriction of 1200 cc daily. The resident's weight data is pending and the dietary department will follow
the resident per protocol.
Review of the Nutritional Progress Note dated 7/23/15 revealed the resident is noted to refuse meals at times. The food
service supervisor is providing the resident with menu substitutions.
Review of the Nutritional Progress Note dated 9/2/15 revealed the resident has a noted weight loss of unknown origin.
Review of the Nutritional Progress Note dated 9/25/15 revealed the RD reviewed the chart for fluid requirements. The
resident is receiving a NAS renal diet with a 1200 cc per day fluid restriction per the physician's orders [REDACTED].
Review of the Nutritional Screening Assessment dated 10/20/15 revealed the resident was admitted to the facility on [DATE]
on a NAS renal diet with a 1200 cc per day fluid restriction.
Review of the resident's CCP dated 11/3/15 revealed the resident has a potential for an alteration in nutritional status and
a risk for dehydration. Approaches include to provide a NAS renal diet with a 1200 cc per day fluid restriction total from
medications, meals and snacks.
Interview with the RD on 1/19/16 at approximately 1:35 PM revealed that all residents admitted to the facility are to have a
nutritional assessment completed within 10 days of admission. The RD reviewed the resident's record and stated the resident
was admitted to the facility on [DATE] and the Nutritional Screening Assessment was not completed until 10/20/15.
4. Resident #154 admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is
cognitively intact, understood and understands. The resident has a Body Mass Index (BMI) of less than 22 and is not
receiving nutritional supplements.
Review of physician's orders [REDACTED].>Review of Nutritional Progress Notes dated 11/6/15 revealed the resident was
admitted on [DATE]. Diet: Regular. Assessment to follow.
Review of Nutritional Screening/ Assessment revealed the completion date of the assessment was on 12/21/15; 10 weeks and 6
days after admission.
During an interview with RD #1 on 1/19/16 at 3:07 PM, RD #1 stated I knew there was going to be an issue with the
assessments and them not being written in time. Initial assessments should be written within 14 days of admission, then
every quarter and annually. When she was due I had just started and I did not have that unit assigned to me.
During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world the assessments are to be done within
14 days of admission. After that quarterly assessment and after three quarterly notes they would get an Annual Assessment.
I did not do the assessment. I have no excuse. I do not know if I was notified. I really do not know. I was the only RD
here at the time and I only work part-time two days a week covering all three floors.
5. Resident #51 readmitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is
severely cognitively impaired, is understood and understands.
Review of Nursing Progress Notes revealed the resident had loose stools on 11/22/15 and 11/23/15.
Review of the last Annual Assessment revealed it was completed on 10/14/14, followed by Quarterly Assessments on 1/2/15,
4/10/15 and 7/8/15.
Review of a Nutritional Progress note written on 11/24/15 revealed loose stools continue. Receiving Hy-fiber BID (twice per
day) for bowel management. Stool sample taken for [MEDICAL CONDITION]. Will add 120 cc fluids to each meal to ensure proper
hydration and [MEDICATION NAME] lost fluids through stools.
Review of the Meal Acceptance Sheets dated 11/22/15 through 11/27/15 revealed 11 out of 18 meals for food and fluid were
left blank.
During an interview with RD #1 on 1/19/16 at 3:07 PM, RD #1 stated I knew there was going to be an issue with the
assessments and them not being written in time. Initial assessments should be written within 14 days of admission, then
every quarter and annually. When she (Resident #51) was due I had just started and I did not have that unit assigned to me.
I only went up there and wrote a note because I had heard something about the resident having loose stools.
During an interview with RD #2 on 1/20/16 at 9:43 AM, RD #2 stated In a perfect world the assessments are to be done within
14 days of admission. After that quarterly assessment and after three quarterly notes they would get an Annual Assessment.
I did not do the assessment. I have no excuse. I do not know if I was notified. I really do not know. I was the only RD
here at the time and I only work part-time two days a week covering all three floors.
415.11(c)(3)(i)
F 0282
harm
Provide care by qualified persons according to each resident's written plan of care.
THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/9/15.
Based on observation, interview and record review conducted during a Standard survey completed on 1/21/16, the facility did
not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each
resident's written plan of care. Three (Resident's # 36,37,145) of 31 residents reviewed for care planning did not receive
care and services per the plan of care. Specifically, Resident #37 did not have Dycem (a non-slip material that prevents
residents from slipping out of their chairs) on the Geri chair cushion, rolled washcloths in both hands and incontinent
care every two hours; Resident #36 suprapubic catheter was not secured with tape; and Resident #145's Foley (tube inserted
into the bladder to drain urine) catheter was not secured with a leg strap.
The findings are:
1. Resident #37 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool)
dated
9/30/15 revealed that the resident is cognitively intact, understands and is understood. The resident is incontinent of
bowel and bladder, and is totally dependent on staff for bathing, toileting, and dressing.
Review of the Care Plan dated 11/24/15 revealed that the resident is care planned to have incontinent care every two hours
or as needed, bilaterally wash cloths to be worn daily and removed as needed and during hygiene and cleaning, and to have
Dycem on top of their cushion.
During an observation on 1/15/16 at approximately 8:00 AM revealed no Dycem on the top of the cushion on the resident's
chair. Continued observation at approximately 8:30 AM, after the Certified Nurse Aide (CNA) #6 provided the resident
morning care, CNA #6 did not apply the hand rolled up wash cloths in his hands.
Multiple observations on 1/15/16 between approximately 8:40 AM through 1:00 PM revealed the resident sitting in the unit
dining room to eat breakfast and lunch. He remained in the same position at the same table. In addition, the resident did
not to have rolled wash cloths in his hands.
During an interview with CNA #6 on 1/15/16 at approximately 1:00 PM, CNA #6 stated The last time I did incontinent care (for
Resident #37) was this morning during morning care (approximately 8:15 AM). CNA #6 stated, I'll be doing incontinent care
again when he goes to bed after lunch. When asked if she had provided incontinent care between 8:15 AM through 1:00 PM, she
stated that no.
FORM CMS-2567(02-99)
Page 6 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0282
harm
During an observation of the resident seated in his chair on 1/15/16 at approximately 2:00 PM revealed no Dycem on the top
cushion.
During an interview with Registered Nurse (RN) #3 on 2/15/16 at approximately 2:15 PM, RN #3 revealed that she expects her
staff to report to her that the resident does not have Dycem on his chair and if the resident refused or was not wearing
the wash cloths in both hands. RN #3 stated she expects her staff to perform incontinent care on the resident every two
hours per his care plan.
2. Resident #36 has [DIAGNOSES REDACTED]. The resident had no behaviors directed towards others, and no rejection of care.
The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use and personal hygiene.
Review of the certified nurse aide (CNA) Care Guide dated 1/19/16 revealed the resident has a Foley and the nurse is to
secure the suprapubic tubing to the resident's abdomen with tape.
Observation on 1/19/16 from approximately 8:30 AM to 8:45 AM revealed two CNA's (#4 and #8) provided personal care for the
resident. The suprapubic tube was not secured to the resident's abdomen with tape. After care was provided the tube
remained unsecured.
The RN Unit Coordinator stated during an interview on 1/20/16 at approximately 12:00 PM that the suprapubic tube is required
to be anchored with tape in accordance with the resident's Care Plan.
3. Resident #145 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has severe cognitive
impairment, usually understands and is sometimes understood. The resident requires extensive staff assistance for bed
mobility, dressing, toilet use, and personal hygiene.
Review of the Care Guide dated 12/30/15 revealed the resident has a Foley and requires a leg strap to secure the tubing.
Observation of personal care on 1/19/16 and on 1/20/16 revealed the Foley tubing was not secured with a leg strap in
accordance with the plan of care.
The RN Unit Coordinator stated during an interview on 1/20/16 at approximately 12:00 PM that the suprapubic tube should be
secured with a leg strap in accordance with the plan of care.
415.11(c)(3)(ii)
F 0309
Level of harm - Actual
harm
Provide necessary care and services to maintain the highest well being of each resident
THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED SURVEY COMPLETED ON [DATE] AND THE
ABBREVIATED SURVEY COMPLETED
[DATE].
Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility
did not provide the necessary care and services to maintain a resident's highest practicable physical, mental, and
psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Three (Residents #36, 37, 56) of
thirty-one residents reviewed for quality of care had issues. Specifically, Resident #36 had a change in condition and
there was a lack of a timely, comprehensive assessment by a registered nurse (RN), lack of timely physician notification,
and lack of ongoing monitoring of the resident's condition. The resident expired in the facility prior to obtaining
physician ordered bloodwork and a diagnostic test. This resulted in actual harm that is not immediate jeopardy for Resident
#36.
In addition, Resident #56 did not have a renal consult as ordered by the physician and did not receive a recommended
follow-up [MEDICATION NAME] appointment after a colonoscopy. Resident #37 had an order for [REDACTED].
The findings are:
[DATE]
revealed the resident is cognitively intact, understands, is understood, had no behaviors directed towards others, and no
rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, and
personal hygiene. The resident did not receive scheduled or as needed (PRN) pain medication and had no pain per resident
interview.
Review of the current comprehensive Care Plan (CCP) revealed that the resident has a [MEDICAL CONDITION] (artificial
connection of the bowel to the surface of the skin)/[MEDICAL CONDITION] (surgical creation of opening in the small
intestine) with planned approaches for an ongoing assessment for abdominal distention and stool character. The CCP for
Nutrition documented that the resident has the potential for altered BM (bowel movement) function with a goal to maintain
normal ostomy (surgically created opening between an internal organ and the body surface) function.
Additional review of the CCP revealed the problem area for Choices documented that the resident prefers the call bell to be
clipped to his chest for easy accessibility.
Review of the certified nurse aide (CNA) Care Guide dated [DATE] revealed the resident is to have the call bell placed on
his blanket at chest level at all times for independent use.
Review of an RN Assessment Documentation form dated [DATE] revealed the resident's abdomen was soft, non-tender and bowel
sounds were active.
A Nursing Home Follow-up Note, written by the physician, dated [DATE] documented that the resident had a [MEDICAL
CONDITION]
and had normoactive bowel sounds in all quadrants, soft, non-distended.
Review of Nurses' Notes revealed the following:
- [DATE] for the 11:00 PM to 7:00 AM shift - At 2:00 AM, a Licensed Practical Nurse (LPN #5) documented that the resident
complained of abdominal pain and the right upper quadrant of the abdomen had some distention. Tylenol 650 milligrams (mg)
was administered and will monitor. The LPN documented that the resident complained of nausea with no emesis (vomit). There
is no documented evidence that the RN Supervisor was contacted at 2:00 AM.
- [DATE] at 4:40 AM - RN #6 assessed the resident and documented that the resident had a distended, tympanic (drum like
sound) abdomen, tender with palpation, right upper quadrant bowel sounds somewhat present but hypoactive, [MEDICAL
CONDITION] patent with brown loose stool, bowel large and protruding through abdomen. Will monitor for continuation of
signs and symptoms for possible new order from MD (medical doctor).
Additional review of the Nurses' Notes dated [DATE] from 2:00 AM through 4:40 AM revealed no documented evidence that the
resident's vital signs (temperature, blood pressure, pulse, respiratory rate) were assessed or that the physician was
notified.
Review of the Medication Administration Record [REDACTED]little relief. Additional review of the MAR indicated [REDACTED].
Review of the 24 Hour Report Summary Data dated [DATE] for the 11:00 PM to 7:00 AM shift ([DATE]) revealed at 2:00 AM, the
resident complained of abdominal pain with some distention, Tylenol given, complains of nausea, no emesis. At 4:40 AM,
abdomen very distended, hypoactive bowel sounds, stoma is enlarged, BM in bag. At 5:30 AM still complains of pain, Tylenol
repeated. Temperature 98 (normal 98.6 degrees). No other vital signs were documented and there was no documentation that
the physician was notified.
Review of the facility investigation entitled Phone Conversation Notes, documented by the Acting Director of Nursing (DON)
dated [DATE] revealed the RN Supervisor assessed that the resident was probably constipated and directed [MEDICATION NAME]
(stool softener) to be given. The RN Supervisor told the Acting DON that at 5:30 AM, the resident's temperature was 96.4
degrees Fahrenheit (normal 98.6), pulse 100 (average 80), respirations 22 (normal 12 to 20), and no blood pressure (BP)
could be taken due to the resident's shaking from [MEDICAL CONDITION].
Review of the medical record, including Nurses' Notes, the 24 Hour Report Summary Data or any other facility document
provided to the survey team, revealed no documented BP reading from 2:00 AM when the resident's change of condition
occurred to 7:00 AM
Observation of morning activities on Unit 4 on [DATE] at 6:30 AM revealed the resident was lying in bed on his back,
repeatedly calling out I need help. The observation revealed that the resident resided on the door side of the semi-private
room. The resident's call light was not on, however the door was open. Continued observation for 10 minutes revealed two
CNAs (#4 and #9) walked up and down the hallway arranging linens and checking rooms. During the 10 minutes, the resident
intermittently called out Help, help, help or I need help for prolonged intervals, particularly when staff walked by the
resident's room. Continued observation at approximately 6:40 AM revealed the resident's call light was located at the end
of the bed and not within the resident's reach. The resident continued to call out I need help here, as CNA #4 passed the
resident's room. CNA #4 went into other residents' rooms to wake them up and CNA #9 walked down the hall passing Resident
#36's room. At 6:43 AM, CNA's #4 and #9 were two resident rooms down the hall and the resident was calling Help, I need my

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0309
harm
nurse. CNA #4 walked past the resident's room again as he was mumbling Help and CNA #4 walked down the hall and attended to
another resident. The resident began to yell loudly Please help, several times. At approximately 6:46 AM, CNA #9 walked
down the hall and passed the resident's room as he was calling out Help, I need help.
At approximately 6:55 AM, the surveyor entered Resident #36's room and asked the resident what he needed assistance with and
the resident stated his stomach was hurting and motioned towards his left lower abdomen.
Interview with CNA #10 on [DATE] at approximately 6:56 AM revealed she was finishing the night shift and she was not
assigned to the resident. CNA #10 stated she attended to the resident several times during the night because he was
complaining of abdominal pain which was unusual for the resident. CNA #10 stated the resident usually sleeps through the
night and is fairly cooperative.
During an interview with the 11:00 PM to 7:00 AM shift LPN (#5) on [DATE] at approximately 6:57 AM, the surveyor informed
LPN #5 of the resident's left lower abdominal pain. LPN #5 stated that the resident started complaining of abdominal pain
at 2:00 AM and at 4:40 AM his abdomen became more distended. LPN #5 stated she did not notify the physician about the
resident's change of condition, however she did notify the RN Supervisor who evaluated the resident, and she believed they
will be ordering an abdominal flat plate. LPN #5 stated the resident did have MOLST (Medical Orders for Life-Sustaining
Treatment) limitations of care. LPN #5 stated that a long time ago, the resident had similar complaints with flu-like
symptoms. LPN #5 stated it was unusual for this resident to complain about abdominal pain.
Review of an RN Assessment Documentation form dated [DATE] at 7:00 AM revealed the resident had a BP of ,[DATE], a pulse of
102, and respiratory rate of 26 and a temperature of 96.1. The resident had shallow breathing; a tender distended abdomen
with hypoactive bowel sounds and the [MEDICAL CONDITION] stoma was bright red. The RN documented that the resident's
abdomen was tender with palpation and the resident had emesis x 1 brown.
Observation on [DATE] at 7:37 AM revealed that CNA #8 entered the resident's room to answer the call light, the resident
told CNA #4 that his abdomen hurts, and CNA #8 told the resident that staff were getting help for him.
Review of Physician's Telephone Orders dated [DATE] at 8:30 AM revealed orders for a Stat (immediate) abdominal flat plate
(X-ray of the abdomen), a CBC (complete blood count (CBC - blood test to determine the components of cells in the blood)
with differential, BMP - (basic metabolic profile - blood test including basic chemistry studies of the blood), a Chest
x-ray, and to provide a clear liquid diet for 24 hours.
Review of a Nurses' Note dated [DATE] at 10:45 AM revealed at 9:30 AM the resident had no pulse and no respirations.
Additional review of Nurses' Notes and the 24 Hour Report Summary Data report dated [DATE] revealed no documented evidence
that the resident was monitored, including vital signs and a comprehensive assessment of the resident including an
examination of the resident's abdomen, pain, and nausea, from 7:15 AM to 9:30 AM when the resident expired.
Interview with the Acting DON on [DATE] at 9:47 AM revealed at approximately 6:40 AM the night RN Supervisor reported to her
that the resident had a change of condition with abdominal distention and the resident's vital signs were stable.
The RN Supervisor stated during an interview on [DATE] at approximately 12:35 PM, that he went to assess the resident after
the night charge LPN informed him of her concern regarding the resident's abdomen. The RN Supervisor stated that the
resident's abdomen was tympanic, hard and more distended than normal as he documented in his note at 4:40 AM on [DATE]. The
RN Supervisor stated he told the DON that we may want to get an abdominal flat plate and stated he did not notify the
Physician because he did not know what the resident's baseline abdominal assessment was like. The RN Supervisor stated that
the resident had hypoactive bowels sounds, everything else was normal, and the plan was to continue to monitor the
resident. Regarding physician notification, the RN Supervisor stated since it was late in the shift he notified the
oncoming supervisor. The RN Supervisor stated that he should have been informed at 2:00 AM when the change first occurred.
Further interview with the Acting DON on [DATE] at approximately 12:50 PM revealed that when the RN Supervisor gave her
report at approximately 5:30 AM and she (the DON) did not know whether the physician was notified; she left the night RN
Supervisor to handle the issue. When questioned about the delay in LPN #5 notifying the RN Supervisor about the resident's
change of condition at 2:00 AM, the DON stated that LPN #5 should have contacted the RN Supervisor immediately, and
physician notification for a change of condition should happen right away.
Interview with CNA #8 on [DATE] at 11:25 AM revealed she and CNA #9 were in the resident's room ,[DATE] times during the day
shift on [DATE] and the resident stated his stomach was real uncomfortable. CNA #8 stated that the floor nurse and the
charge nurse knew about the resident's pain/ discomfort and the doctor had been called. CNA #8 stated she responded to the
resident's cries for help an emergent situation happened at approximately 9:15 AM because the resident was saying Help me,
help me and when she entered the room, the resident was real congested. CNA #8 stated she immediately went to get the RN
Coordinator and when they arrived the resident was throwing up a lot and they got the suction equipment and suctioned the
resident.
Interview with the Nurse Practitioner (NP) on [DATE] at approximately 1:37 PM revealed the RN Coordinator called her and
informed her that the resident's [MEDICAL CONDITION] was not putting out stool and the resident's belly was distended. The
NP stated she ordered Stat diagnostic and labs (laboratory tests). The NP did not know at the time of the interview that
the resident's problems started at 2:00 AM; she thought the change of condition had just occurred at the time of the call
this morning at 8:30 AM. The NP stated that the providers should have been notified immediately; there is on-call service
,[DATE]. The NP stated the resident had recently signed his own DNR order with no hospitalization ; however, she was
familiar with the resident and stated he still wanted medical treatment and he could make his own decisions and people
change their minds all the time. And he may have opted for treatment. The flat plate most likely would have showed a need
for emergent treatment for [REDACTED].
Interview with the resident's physician on [DATE] at approximately 8:00 AM, in the presence of the Acting DON, revealed that
the physician provided medical care for the resident for years; the resident had a [MEDICAL CONDITION] for chronic
constipation and severe skin issues. The DON stated that the nurse suctioned fecal material from the resident yesterday
morning when the emergent situation occurred around 9:15 AM. The attending MD stated the cause of the resident's death was
probably bowel obstruction or perforation. When the MD was informed that the resident was alert until the final event, the
MD stated that although the resident recently made himself a DNR with no hospitalization s, the resident could (and
frequently did) change his mind and medical staff would honor his decision in that situation, he might have opted for
treatment.
Review of the facility policy entitled Notifying MD/ Responsible Party of Residents change of condition revised on ,[DATE]
documented an occurrence of resident change of condition must be communicated in a timely manner to the attending MD by the
nursing supervisor. Each Unit Nurse who identifies a change of condition must notify the Nursing supervisor immediately.
2. Resident #56 had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderate
cognitive
impairment, understands, is understood, and is frequently incontinent of bowel and bladder.
Review of an Acute Visit Note, written by the NP, dated [DATE] revealed that the resident was admitted to the facility for
short term rehabilitation. The NP documented a plan to refer the resident to a [MEDICATION NAME] (a physician specially
trained in the management of diseases of the gastrointestinal tract and liver) due to positive stool for occult blood
(blood in the stool that is not visible).
Review of a hospital Discharge Summary dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The Discharge
Summary
documented that the resident should be followed by a nephrologist and it will be up to the primary care Physician to
arrange this.
Review of an Acute Visit Note, written by the NP, dated [DATE] revealed the resident is to be referred to nephrology (a
kidney specialist) due to his Stage IV [MEDICAL CONDITION]. The NP documented that the resident had [MEDICAL
CONDITION]/
positive stool for occult blood and he is to follow-up with [MEDICATION NAME] after discharge from short-term
rehabilitation services.
Review of Physician's Orders dated [DATE] revealed an order to obtain a Nephrology consult.
Additional review of Acute Visit Notes, written by the NP, revealed the following:
- [DATE] - The resident was evaluated for rectal bleeding/diarrhea with plans to change the GI (gastrointestinal)
appointment to next week.
- [DATE] - The resident was evaluated again for rectal bleeding/diarrhea with plans for a [MEDICATION NAME] appointment for
[DATE].
- [DATE] - The resident was evaluated again for rectal bleeding/diarrhea. The resident was not seen by the [MEDICATION NAME]
due to a mix-up with transportation and the appointment was rescheduled or [DATE]. The NP documented that the resident
FORM CMS-2567(02-99)
Page 8 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0309
harm
continues with rectal bleeding with some diarrhea.
- [DATE] - The resident was seen for hematochezia (passage of bloody stools) and diarrhea. The NP documented that the
resident was seen by the [MEDICATION NAME] on [DATE], who recommended a colonoscopy. The resident continues with loose
stools on a frequent basis.
- [DATE] - The resident was evaluated status [REDACTED].
Review of a [MEDICATION NAME] Colonoscopy Preliminary Report/ Communication Form dated [DATE] revealed a biopsy was
taken
and a polyp was removed. A sticky note was attached to the top of the form directing to make a follow-up appointment with
the [MEDICATION NAME].
Review of the entire medical record on [DATE] revealed there was no documented evidence of a follow-up appointment with the
[MEDICATION NAME] and there was no Nephrology consult completed for Resident #56.
During an interview on [DATE] at approximately 10:00 AM, the NP stated that she could not identify whether the resident had
a Nephrology consult performed after the [DATE] order.
The Registered Nurse (RN) Coordinator stated during an interview on [DATE] at approximately 8:20 AM that as of [DATE] there
was no follow-up appointment made with the [MEDICATION NAME] and the colonoscopy report was not in the medical record.
The
RN Coordinator was not aware that the Nephrology consult was not completed.
3. Resident #37 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact,
understands, and is understood.
Review of a Psychological Services Progress Note dated [DATE] revealed the resident is in good spirits, denied AH (auditiry
hallucination) ameable to supportive Rx (treatment). Plan: Supportive Rx to increase reality orientation.
Review of Nursing Progress Notes dated from [DATE] through [DATE] revealed no documentation of behaviors.
Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed that problem areas include antipsychotic drug use,
potential for behaviors related to a [DIAGNOSES REDACTED].
Review of a Physician's Order dated [DATE] revealed an order to refer for psych (psychiatric) medication evaluation and
possible gradual dose reduction (GDR) for psychiatric medications.
Review of an Acute Care Visit note, written by the NP, dated [DATE], revealed A referral has been placed for psychiatric
evaluation of medication usage and possible GDR.
Review of the chronological medical record revealed no documented evidence that the resident was seen by the Psychiatrist or
the psychiatric NP in [DATE], [DATE], or [DATE].
Interview with the Unit Clerk on [DATE] at approximately 11:00 AM revealed there was no documentation to be filed for
Resident #37 related to a psychiatric visit.
During an interview on [DATE] at approximately 11:11 AM, the Social Worker stated that the resident was not scheduled to be
seen by the Psychiatrist and the last time the resident saw the Psychiatrist was last May (2015).
Review of a list of residents to be seen by the psychiatric NP or the Psychiatrist, dated [DATE] to [DATE], revealed that
Resident #37 was not on the list.
Interview with the Director of Social Work on [DATE] at approximately 11:12 AM revealed that a resident is put on a list to
be seen by the psychiatric NP or by the Psychiatrist after the residents are discussed during morning report. The Director
stated that she will put the resident on the list to be seen [DATE].
Review of a facility policy and procedure entitled [MEDICAL CONDITION] Medications and BMARC (Behavioral Management
Review
Committee) Team dated [DATE] revealed Nursing/ Social Work will report to the facility interdisciplinary team changes in
medication, behavioral response, and intervention recommendations during morning report and during quarterly care plan
meetings.
415.12
F 0311
harm
Make sure that residents receive treatment/services to not only continue, but improve the
ability to care for themselves.
Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/15, the facility
did not ensure that residents are given the appropriate treatment and services to maintain or improve ambulation abilities.
One (Resident #56) of four residents reviewed for therapy services was not ambulated by staff as planned/ recommended by
physical therapy.
The finding is:
1. Resident #56 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated
11/6/15
revealed that the resident has moderate cognitive impairment, and understands, and is understood. The MDS documented that
the resident requires total staff assistance for locomotion on and off the unit, limited assistance for ambulation, and has
no limitations in range of motion (ROM) of the upper and lower extremities.
Review of a Communication Form dated 11/5/15 revealed skilled Physical Therapy(PT) was discontinued with recommendations for
restorative nursing ambulation for a distance of 150 feet (') with a rolling walker, gait belt, and limited assistance of
one staff person.
Review of the CNA (certified nurse aide) Care Guide dated 1/8/16 revealed an approach to ambulate the resident with the
limited assistance of one staff, using a gait belt and rolling walker for a distance of 150'.
Intermittent observations on Unit 4 on 1/19/16 and 1/20/16, from 6:00 AM to 3:30 PM, revealed staff transported the resident
to the Main Dining Room and the 4th Floor Dining Room in a wheelchair. The resident was observed in bed or seated in the
wheelchair during the intermittent observations on 1/19/16 and 1/20/16. Staff were not observed to assist the resident with
ambulation.
Interview with the resident on 1/20/16 at approximately 8:00 AM revealed staff have not provided him assistance with
ambulation for quite a while, They don't have time. The resident also stated that he wants to go home and he came to the
facility for rehabilitation services.
Interview with the Physical Therapy (PT) Assistant on 1/20/16 at approximately 1:00 PM revealed the resident was initially
planned for discharge back to home. The PT Assistant stated that when the resident's status changed to long term care,
recommendations for the restorative nursing ambulation program were made and the CNAs are responsible to ambulate the
resident once daily.
Interview with the Unit 4 ROM (range of motion) CNA on 1/21/16 at approximately 7:45 AM revealed she is responsible to
ambulate residents who on the restorative nursing ambulation program on Unit 4. The ROM CNA stated she has not worked as a
ROM CNA during the survey and was assigned to work as a regular CNA with a resident assignment. The ROM CNA stated
Resident
#56 was not in her assignment on 1/19/16 and 1/20/16 and she did not ambulate the resident on those days.
415.12(a)(2)
F 0312
harm
Assist those residents who need total help with eating/drinking, grooming and personal
and oral hygiene.
Based on observation, interview, and record review conducted during the Standard Survey completed 1/21/16, the facility did
not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to
maintain good personal hygiene. Two (Resident's #36, 37) of three residents reviewed for ADLs involved for Resident #37
incomplete morning care with no oral care performed, nails had brown debris underneath after the resident's hands were
washed and barrier cream was not applied after incontinent care. Resident #36 had an ill-kempt appearance upon entrance to
the facility .
The findings are:
1. Resident #37 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool)
dated
9/30/15 revealed that the resident is cognitively intact, understands and is understood. The resident is incontinent of
FORM CMS-2567(02-99)
Page 9 of 16

PRINTED:9/8/2016
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
335742
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
01/21/2016
822 CEDAR AVENUE
F 0312
harm
bowel and bladder, and is totally dependent on staff for bathing, toileting, and dressing.
Review of the resident's Care Plan dated 11/24/15 revealed that the resident is care planned for alteration in function
related to decreased functional ability and debility and that he is a total assist for bathing, grooming, dressing and to
provide oral care in the morning and at night.
During an observation of morning care on 1/15/16 at approximately 8:10 AM revealed the resident laying on his back in bed.
Certified Nurse Aide (CNA) #6 removed the resident's hospital gown and proceeded to wash the resident's face and hands. The
resident's fingernails were noted to have brown debris underneath after being washed. CNA #6 removed the resident's brief
and provided incontinent care. CNA #6 did not apply a barrier cream. After completing care CNA #6 transferred the resident
from his bed to his Geri chair via the mechanical lift. CNA #6 did not provide oral care. When CNA #6 was asked if she was
done with morning care she stated Yes.
During an interview with CNA #6 on 1/15/16 at approximately 8:41 AM, CNA #6 stated in discussing the resident's morning care
that she did not apply a barrier cream after incontinent care. She also stated that the resident is supposed to get oral
care in the morning and she didn't perform it and have her fingernails cleaned.
An interview with Registered Nurse (RN) #3 on 1/15/16 at approximately 11:50 AM revealed that RN #3 expects her staff to
perform complete morning care including cleaning nails and oral care.
An interview with RN #4 on 1/15/16 at approximately 2:27 PM revealed that she expects the staff to apply a barrier cream on
the resident after incontinent care.
Review of the facility policy entitled Perineal Care - Female/ Male dated 1/2013 revealed under the Procedures section
Procedure #21 to Apply barrier cream topically to buttocks per policy/ procedure.
2. Resident #36 has [DIAGNOSES REDACTED]. The resident had no behaviors directed towards others, and no rejection of care.
The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and eating.
During an observation on 1/14/15 at approximately 9:09 AM and at approximately 11:15 AM revealed the resident had
fingernails with brown debris underneath, food debris on his upper lip and right index finger, and food debris on his
clothing.
During an interview with Registered Nurse (RN) #3 on 1/15/16 at approximately 11:50 AM revealed that RN #3 expects her staff
to clean resident's nails and that residents should be clean.
CNA #8 stated during an interview on 1/19/16 at approximately 8:45 AM that the resident is totally dependent on staff for
all ADL's.
415.12(a)(3)
F 0318
harm
Make sure that residents with reduced range of motion get propertreatment and services to
increase range of motion.
did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase
ROM and/ or prevent further decrease in ROM. One (Resident #36) of four residents reviewed for ROM did not receive passive
range of motion (PROM - exercises provided by staff) as planned and recommended by therapy.
The finding is:
1. Resident #36 has a [DIAGNOSES REDACTED]. The MDS documented the resident had no behaviors directed towards others, no
rejection of care, and requires total staff assistance for bed mobility, transfer, dressing, toilet use, and personal
hygiene. The MDS also documented that the resident has limitations in range of motion (ROM) of bilateral upper and lower
extremities.
Review of a Physical Therapy - Rehabilitation Screening assessment dated [DATE] revealed the resident has bilateral
contractures (loss of joint mobility) of the lower extremities (hips, knees, ankles, feet) with recommendations for PROM to
the bilateral lower extremities daily.
Review of an Occupational Therapy - Rehabilitation Screening Evaluation dated 11/5/15 revealed the resident has contractures
of bilateral shoulders, elbows, and wrists with recommendations for PROM to the bilateral shoulders, elbows, and wrists one
to two times daily for 15 minutes.
Review of the CNA (certified nurse aide) Care Guide dated 1/19/16 revealed a plan to provide PROM to bilateral lower
extremities (hips, knees, and ankles) and bilateral upper extremities daily (shoulder, elbow and left wrist) daily.
Observation on 1/19/16 from approximately 8:30 AM to 8:45 AM revealed two CNA's (#4 and 8) provided personal care to the
resident. PROM was not attempted or provided during the observation.
Interview with the resident on 1/19/16 at approximately 8:50 AM revealed that staff do not provide exercises to his hands
and feet.
Interview with CNA #8 on 1/20/16 at approximately 11:25 AM revealed she did not provide ROM to Resident #36 yesterday. The
CNA stated that the ROM CNA normally provides ROM to the residents.
Interview with the Unit 4 ROM (range of motion) CNA on 1/21/16 at approximately 7:45 AM revealed she has not worked as a ROM
CNA during the survey and she was assigned to work as a regular CNA with a resident assignment. The ROM CNA stated there
used to be ROM books on the Unit, however, they have disappeared and she performs the case load by memory. Unit 4 ROM CNA
stated she did not have Resident #36 in her resident assignment on 1/19/16.
415.12(e)(2)
F 0323
harm
Make sure that the nursing home area is free from accident hazards and risks and provides
supervision to prevent avoidable accidents
did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident
#47) of three residents reviewed for accidents had issues. Specifically, multiple observations of the resident being
transported by staff while seated on a four wheeled walker without foot pedals.
The finding is:
12/2/15
revealed the resident is independent with locomotion.
Multiple observations revealed:
-1/15/16 at 7:11 AM the resident is being pushed in rolling walker backwards by the Certified Nurse Aide (CNA) into the
dining room. Resident is wearing nonskid socks on feet.
-1/15/16 at 1:17 PM the CNA is pushing resident, who is sitting on the seat of the four wheeled walker, backwards down
fourth floor long hallway approximately 40 feet. Resident is wearing nonskid socks on feet.
Review of the Care Guide dated 12/1/15 revealed the resident ambulates with a four wheeled walker approximately 150 feet and
has a wheelchair for distance.
During an interview on 1/15/16 at 1:23 PM CNA #4 stated that she does transport the resident this way if his legs start to
hurt, he'll sit down and she'll push him the rest of the way to his room. CNA #4 further stated that the resident doesn't
have a wheelchair.
During an interview on 1/19/16 at 9:26 AM the RN #3 ,Unit Manager stated the CNA should put the resident into a wheelchair
or let him rest a while, while seated and shouldn't use the walker to transport the resident.
During an interview on 1/20/16 at 12:11 PM the Director of Rehab stated that he would not recommend transporting a resident
this way and this resident has a wheelchair if he needs to use it.
415.12(h)(2)
F 0325
harm
Make sure that each resident gets a nutritional and well balanced diet, unless it is not
FORM CMS-2567(02-99)
Page 10 of 16

Full report jan. 21 2016

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