department of health and human services centers for medicare ...

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

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FORM APPROVED 

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 

STATEMENT OF DEFICIENCIES 

AND PLAN OF CORRECTION 

(X1) PROVIDER/SUPPLIER/CLIA 

IDENTIFICATION NUMBER: 

(X2) MULTIPLE CONSTRUCTION 

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(X3) DATE SURVEY 

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295037 03/04/2011 

NAME OF PROVIDER OR SUPPLIER 

HENDERSON HEALTHCARE CENTER 

STREET ADDRESS, CITY, STATE, ZIP CODE 

1180 E. LAKE MEAD DRIVE 

HENDERSON, NV 89015 

(X4) ID 

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SUMMARY STATEMENT OF DEFICIENCIES 

(EACH DEFICIENCY MUST BE PRECEDED BY FULL 

REGULATORY OR LSC IDENTIFYING INFORMATION) 

ID 

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PROVIDER'S PLAN OF CORRECTION 

(EACH CORRECTIVE ACTION SHOULD BE 

CROSS-REFERENCED TO THE APPROPRIATE 

DEFICIENCY) 

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F 000 INITIAL COMMENTS F 000 

This Statement of Deficiencies was generated as 

a result of the annual Medicare recertification 

survey conducted at your facility from March 1, 

2011 through March 4, 2011, in accordance with 

42 Code of Federal Regulations (CFR) Chapter 

IV Part 483 Requirements for Long Term Care 

Facilities. 

The census was 229 residents. The sample size 

was 30 residents, which included three closed 

records. There were three unsampled residents. 

Four complaints were investigated during the 

survey: 

Complaint #NV00027512 alleged that because a 

diabetic diet was not provided to a resident over a 

five-day period, the resident's glucose levels 

needed to be managed with insulin. This 

allegation was not substantiated through clinical 

record review and interviews with facility staff. 

Complaint #NV00027692 was not substantiated 

through medical record review and interview. 

Allegation 1 - The resident was discharged too 

early. Not substantiated. The resident received 

Physical and Occupational Therapy and met his 

goals and caregiver training was provided prior to 

discharge. The resident's stay was also extended 

to ensure outpatient dialysis was set up, family 

caregiver assistance was appropriate, and 

durable medical equipment was arranged. 

Allegation 2 - The resident did not receive 

medications to take home and could not afford 

his medications. - Unsubstantiated. 

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: J8O811 

Facility ID: NVS263S If continuation sheet Page 1 of 68


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F 000 Continued From page 1 F 000 

Medications are not supplied to residents upon 

discharge. Prescriptions were given to the 

resident's family to fill. 

Complaint #NV00027572 alleged a resident did 

not see a doctor during the entire stay period, did 

not have a bath during the the stay, and had dry 

feet. The complaint also alleged the facility was 

going to transfer a resident without notification 

and improperly kept a resident when the facility 

should have discharged the resident. The 

complaint was unsubstantiated. 

Allegation #1: A physician saw the resident as 

documented in the file in the form of a history and 

physical. Therefore, this allegation was 

unsubstantiated. 

Allegation #2: The bath/shower log showed the 

resident had several bed baths and linen 

changes. Staff also showered the resident upon 

request prior to discharge. Therefore, this 

allegation was unsubstantiated. 

Allegation #3: The resident was status post left 

foot fluid collection with aspiration and cellulitis. 

The resident was provided a podiatry referral 

upon discharge. Therefore, this allegation was 

unsubstantiated. 

Allegation #4: The resident made several 

comments, which concerned social services 

about a safe discharge. The resident 

demonstrated borderline competency upon 

evaluation. Elder protective services became 

involved. The resident initially agreed to stay at 





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the facility. Upon proper notification of Medicare 

services ending and a long term bed opening, the 

resident changed her mind. The physician 

documented the pending discharge as unsafe. 

The facility eventually discharged the resident 

with a responsible party with follow up instructions 

and a home health referral. The facility tried to 

ensure a safe discharge. Therefore, this 

allegation was unsubstantiated. 

Complaint #NV00027432 alleged a resident did 

not receive proper hygiene care and call lights 

were not answered. This allegation was not 

substantiated through clinical record review, 

document review and interviews with facility staff. 

The findings and conclusions of any investigation 

by the Health Division shall not be construed as 

prohibiting any criminal or civil investigation, 

actions, or other claims for relief that may be 

available to any party under applicable federal, 

state or local laws. 

F 221 

SS=D 

The following regulatory deficiencies were 

identified: 

483.13(a) RIGHT TO BE FREE FROM 

PHYSICAL RESTRAINTS 

The resident has the right to be free from any 

physical restraints imposed for purposes of 

discipline or convenience, and not required to 

treat the resident's medical symptoms. 

F 221 

This REQUIREMENT is not met as evidenced 

by: 

Based on observation, interview, and record 

review, the facility failed to ensure residents were 





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maintained free from physical restraints for 1 of 

30 Residents (Resident #11). 

Findings include: 

Resident #11 

Resident #11 was a 52 year old female originally 

admitted to the facility on 10/22/10, and last 

re-admitted on 2/1/11, with diagnoses including 

end stage liver disease with cirrhosis of the liver, 

hypertension, hepatic encephalopathy and 

chronic pain. The resident was on hospice. 

Documentation in the nurse's notes revealed: 

- 2/3/11 "Non-self releasing seat belt in use at all 

times when on w/c (wheelchair) per order." 

- 2/6/11 "Sitting up in w/c with non-self releasing 

seatbelt - tab alarm in place." 

Resident #11's medical record for the 2/1/11 

admission, did not contain a physician's order for 

physical restraints or a consent for restraints. 

On 3/2/11, the Unit Manager (UM) confirmed 

there was no physician order for restraints for 

Resident #11. The UM verbalized there was an 

order for non-self-releasing restraints for 

Resident #11 for her previous admission and the 

UM had spoken to the husband to obtain the 

consent. 

On 3/2/11 The UM called the physician and 

obtained an order for self releasing seatbelt for 

Resident #11. 

On 3/3/11 at 6:30 AM, Resident #11 was 

observed in the hallway in a w/c with a non-self 





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releasing seatbelt in place. Resident #11 was 

awake and alert, but appeared drowsy. 

F 226 

SS=D 

The facility policy titled Restraints, dated 7/2009 

documented: 

PROCEDURES: 

- "1. New restraint Orders: 

- A. Complete Restraint Assessment, if 

appropriate then: 

- B. Obtain order for 

- 1) Type of restraint 

- 2) Duration (timeframe) to be utilized 

- 3) Medical diagnosis/ symptoms for need 

(reason) 

- 4) Parameters for use (including release 

schedule) 

- 5) Frequency of checking, and 

- 6) Removal schedule 

-C. Obtain consent from the patient/resident, 

family and/or surrogate or healthcare 

representative..." 

483.13(c) DEVELOP/IMPLMENT 

ABUSE/NEGLECT, ETC POLICIES 

The facility must develop and implement written 

policies and procedures that prohibit 

mistreatment, neglect, and abuse of residents 

and misappropriation of resident property. 

F 226 


by: 

Based on interview and record review, the facility 

failed to properly report allegation of theft from a 

resident for 1 of 30 sampled residents (Resident 

#17). 






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Resident #17 

Resident #17 was admitted on 5/5/2004, with 

diagnoses including anxiety, generalized pain, 

diabetes, gastritis, and depressive disorder. 

Resident #17's Nurse's Notes form dated 

2/5/2011, documented: 

-"...Resident very agitated and yelling. Resident 

stated that he "lost $10.00 and feels it was stolen 

sometime yesterday from his room." Offered to 

help resident search room but resident refused 

continuing to yell. Ativan given as rx'd 

(prescribed) for agitation. Redirected resident to 

see social worker on Monday to resolve money 

issue. Resident in room at this time quiet but 

easily agitated when spoken to..." 

F 240 

SS=D 

On 3/2/2011, in the morning, the unit Social 

Worker indicated she did not receive information 

from the staff regarding the stolen money with 

Resident #17. The unit Social Worker indicated 

that the incident should have been reported by 

the staff to her so that an investigation could be 

done immediately. 

483.15 CARE AND ENVIRONMENT 

PROMOTES QUALITY OF LIFE 

A facility must care for its residents in a manner 

and in an environment that promotes 

maintenance or enhancement of each resident's 

quality of life. 

F 240 






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review, the facility failed to ensure 2 of 30 

sampled residents were cared for in a manner 

which promoted maintenance of each resident's 

quality of life (Resident #19, #20). 


Resident #19 

Resident #19 was admitted to the facility on 

3/23/10, with diagnoses including status post 

intracranial hemorrhage, right-sided hemiplegia, 

hypertension, dysphagia, aphasia, and attention 

to gastrostomy tube. 

During the four day survey period of 3/1/11 

through 3/4/11, Resident #19 was observed to 

remain on his bed throughout the day. When 

asked how often the resident got out of his bed, 

two Certified Nursing Assistants (CNAs) and a 

unit nurse (Employee #17), reported that for the 

past year, the resident had only gotten out of bed 

two to three times a week for bathing. 

According to a quarterly note by an Activities 

Assistant, dated 12/15/10, "This resident remains 

non-verbal but will follow or make eye contact. 

He stays in bed daily and enjoys listening to 

music and watching TV..." The Activities Director 

confirmed attempts were never made to have the 

resident go out of his room for activities. 

Resident #20 







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stroke with left-sided hemiplegia, dysphagia, 

esophageal reflux, diabetes, hypertension, and 

attention to gastrostomy. 

A Nursing Assessment completed on 2/26/10 

indicated the resident was rarely able to make 

herself understood but was able to "follow simple 

one-step commands and answer very simple 

questions." 

F 241 

SS=E 

During the survey period between 3/1/11 and 

3/4/11, Resident #20 was observed to remain in 

bed throughout the day. When asked if the 

resident ever went out of her room or got out of 

bed into a chair, a CNA and the Unit Manager 

both reported she got into a chair just several 

times over the past year for "deep cleaning" of 

the room, and went out of her room about two 

times a week for bathing. 

483.15(a) DIGNITY AND RESPECT OF 

INDIVIDUALITY 

The facility must 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. 

F 241 


by: 

Based on observation, interview and record 

review, and policy review, the facility failed to 

ensure staff knocked before entering resident 

rooms, sat while feeding residents, did not use 

cell phones in resident areas, properly maintain a 

resident room, and provide proper clothing 

(Resident #4). 





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1. On 3/1/11 at 9:10 AM, during the initial tour a 

staff member entered occupied resident room 

1201 without knocking or announcing herself 

before entering. 

On 3/3/11 at 7:22 AM, Employee #19 entered 

occupied resident rooms 2303 and 2308 without 

knocking or announcing herself before entering. 

On 3/3/11 at 9:15 AM, Employee #21 stated she 

was taught to knock on the door and introduce 

herself to the resident. Staff knock because it is 

respecting the resident. 

On 3/3/11 at 11:50 AM, Resident #10 verbalized 

staff are usually half way in the room when they 

verbalize knock, knock. Resident #10 verbalized 

he would like the staff to wait a minute or so 

before entering, for privacy. 

On 3/4/11 ar 7:55 AM, Employee #22 entered 

occupied resident room 1209 without knocking or 

announcing herself before entering. 







The facility's policy Resident Rights (undated) 

required staff knock on doors for permission to 

enter. 





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2. On 3/3/11 at 7:20 AM, Employee #18 was 

standing while feeding Resident #2 her meal. 

On 3/3/11 at 7:45 AM, Employee #21 was 

standing while feeding a resident in room 1306. 

On 3/3/11 at 9:15 AM, Employee #21 verbalized 

staff were to sit down while feeding resident. 


standing while feeding a resident in room 1106. 

3. On 3/2/11 at 8:48 AM a staff member 

answered her cell phone while walking in the 

hallway in front of the nursing station on B-1. 

On 3/3/11 at 9:15 AM, Employee #21 stated staff 

were allowed to use cell phones on breaks. They 

were not allowed to talk on a cell phone in 

resident rooms or the hallways. 

The facility's policy Cell phones (undated) 

documented employees were allowed to carry 

and use personal cell phones only during 

break/lunch times, smoke breaks or any other 

time when not in the general clinical patient 

areas. 

4. On 3/4/11 at 1:05 PM, a facility employee was 

observed walking slowly with head bowed around 

the nursing station on the first floor in building A. 

The employee was checking cell phone 

messages, walked over to a time clock, and 

punched back in. 

On 3/2/11 at 10:00 AM, near the end of the group 

meeting, seven of twelve residents indicated they 

observed staff members using cell phones while 





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performing work duties. 

5. Resident #4 

Resident #4 was a 31 year old female who was 

treated at an area hospital from 1/21/2010 - 

2/13/2010, for status post anoxic encephalopathy 

secondary to drug overdose and status post PEG 

(percutaneous endoscopic gastrostomy) tube 

placement. Resident #4 was admitted to the 

facility on 2/13/2010, with diagnoses including 

anoxic brain damage, adult failure to thrive, 

anxiety, generalized pain, dysphagia, 

hypotension, convulsions, gastrostomy, and 

hypoglycemia. Resident #4 moved all extremities 

spontaneously, she was unable to follow direction 

and was not verbally responsive. Resident #4 

was unable to make her needs known. Resident 

#4 opened her eyes spontaneously but did not 

keep eye contact with verbal stimuli. 

On 3/1/2011, in the morning, standing in the 

hallway directly outside Resident #4's room, urine 

odor was noted coming from her room. Resident 

#4 was located on the B side of the room which 

was the bed closest to the window. Standing in 

the hallway directly outside Resident #4's room, 

one could not see Resident #4 due to the privacy 

curtain blocking the view. Upon entering the 

room, the only way to see Resident #4 was to 

enter and go directly to her area in the back of the 

room next to the wall. Resident #4's room was 

dim due to the window valence being partially 

closed. There was no television in the room and 

no radio. A black folded wheelchair was beside 

the wall in the resident's side of the room. 

On 3/1/2011, in the morning, Resident #4 was 





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sleeping in her bed. The right side of her bed was 

against the wall and the bed was low to the 

ground with mats on the floor on the left side of 

the bed. Pillows/sheets were stuffed under the left 

side of the mattress causing the entire mattress 

to tilt towards the the right side of the wall. 

Resident #4 was wearing a hospital gown but the 

lower portion of the gown was above her waist 

exposing her legs and underwear while she slept. 

The resident's legs were unshaven and both 

axillas were unshaven with copious amounts of 

long tangled bushy hair. The resident toenails 

were noted long and unkempt. Two toenails were 

noted curling around the toe. The resident 

fingernails were unkept and also long. There was 

no environmental stimuli set up in the room. 

On 3/1/2011, in the afternoon, Resident #4 was 

seen again in bed with her hospital gown on. The 


exposing her legs, thighs, underwear, and 

stomach. The resident was awake with her eyes 

open and spontaneously moving her lower 

extremities and upper extremities. The resident, 

while moving her lower extremities, was inching 

towards the lower portion of the bed causing her 

hospital gown to go upwards exposing her 

abdomen. The resident had her eyes open but 

was spontaneously staring at the ceiling and the 

wall. The resident did stare at the surveyor but did 

not respond with verbal stimuli. A urine odor was 

still present in the room. The privacy curtain was 

still drawn, hiding the resident, and the window 

valence was still partially closed leaving the room 

dim. The resident was not seen getting out of bed 

for the day. The wheelchair in the room was not 

touched. 





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On 3/2/2011 in the morning and afternoon, 

Resident #4 was observed in bed all day. A 

strong urine odor was noted in the room. The 

resident was wearing a hospital gown all day 

which continued to expose her legs and 

abdomen. The privacy curtain was still drawn and 

the window valence partially closed leaving the 

room dim. No environmental stimuli was noted in 

the room. The resident's feet/ankles were noted 

to be extended. There were no splints or shoes 

noted at the bedside. 


noted in bed all day. A strong urine odor was 

noted in the room. The resident continued to wear 

a hospital gown that exposed her lower half of her 

body due to her spontaneous movements with 

her upper and lower extremities. The privacy 

curtain was still drawn and the room was still dim 

due to the partially closed window valence. The 

folded wheelchair was not used. 

On 3/3/2011, in the afternoon, a male certified 

nurse assistant (CNA) was brought in Resident 

#4's room and asked if the resident had only 

hospital gowns to wear. The CNA indicated that 

she had a cabinet full of clothes in which he 

showed the surveyor. The CNA also indicated 

that the resident should be dressed in her proper 

clothing because she exposes herself due to her 

spontaneous movements lifting the gown up to 

her chest. 

After the surveyor questioned the CNA staff 

regarding the use of the hospital gown and 

resident's care it was noted that that the resident 

was changed into regular clothing and the odor of 

urine was not present in the room. 





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On 3/3/2011, in the afternoon, the Director of 

Nursing (DON), unit Manager, unit Social Worker, 

Physical Therapist and Assistant were brought 

into Resident #4's room after the resident was 

changed out of the hospital gown. The surveyor 

pointed out the areas of concern for the past 

three days in Resident #4's room to the staff. The 

room was dim due to the partially closed 

valences, the drawn privacy curtain, no television 

or radio in the room, no environmental stimuli in 

the room, the resident's unshaven leg hair and 

long bushy axilla hair, the unkept toenails and 

fingernails, and the tilted mattress from the 

pillows and sheets being stuffed under the 

mattress. Also, the surveyor questioned why the 

resident was bedbound since her admission over 

one year ago. 

There was no response from the staff and the 

DON indicated that she needed to review the 

chart. 

F 247 

SS=D 

There was no documented evidence why staff did 

not trim or maintain Resident #4's leg and axilla 

hair. On 3/4/2011, the DON indicated because 

Resident #4 spontaneously moved her 

extremities the staff may have been scared to 

use a razor on the resident. There was no 

documented evidence that alternative 

maintenance devices were used such as an 

electric trimmer. 

483.15(e)(2) RIGHT TO NOTICE BEFORE 

ROOM/ROOMMATE CHANGE 

A resident has the right to receive notice before 

the resident's room or roommate in the facility is 

changed. 

F 247 





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by: 


review, the facility failed to ensure a resident was 

notified and consent obtained to transfer the 

resident's room for 1 of 23 residents (Resident 

#12). 


Resident #12 


11/17/10 with diagnoses including paraplegia 

secondary to a motor vehicle accident, chonic 

pain, urinary tract infection and pressure ulcers. 

On 3/3/11 at 8:00 AM, Resident #12 revealed his 

room had been changed many times since his 

admission. Resident #12 indicated he had shared 

a room with Unsampled Resident #31. 

The resident verbalized, on one occasion he had 

been outside of the facility, and upon his return, 

all his belongings had been moved to another 

room, without his permission. Resident #12 

added he was moved into a room with 

Unsampled Resident #32, who was known to be 

uncooperative and throw soiled items at other 

residents. Resident #12 refused to remain in the 

room with Resident #32, and the nusing staff 

moved his room again, at his request. 

On 3/4/11 at 7:00 AM, Resident #32 was in his 

room at breakfast. Resident #32 was lying in bed 

and had just completed his breakfast when he 





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pushed over the bedside table, causing a loud 

noise and spilling the breakfast tray and other 

items to the floor. The CNA who worked on that 

hallway revealed, Resident #32 had done that on 

more than one occasion and had demonstrated 

other behaviors, such as yelling and throwing 

items at other residents. 

Resident #12's Nurse's notes dated 2/5/11 6 PM - 

6 AM, documented "Resident changed rooms to 

2201B secondary to unresolved conflict with 

mate. All belongings tranferred by staff including 

air bed. Admissions Director advised of room 

change by RN (Registered Nurse) this shift." 

Resident #31's nurse's notes dated 2/5/11 at 6:00 

PM documented "Resident noted with increased 

aggression with roommate. Unable to reassure. 

Mate changed rooms promptly. Decrease anxiety 

with change noted. No further behaviors noted 

this shift." 

Resident #12's medical record included 2 room 

change notification forms dated 11/17/10 and 

1/20/11, with verbal consent by Resident #12. 

There was no documented evidence a consent 

was obtained for Resident #12's room change on 

2/5/11. 

On 3/3/11 at 8:40 AM, the Licensed Social 

Worker (LSW) (Employee #33) was interviewed. 

The LSW verbalized Resident #12 had been 

moved on several occasions but indicated she 

obtained consent prior to changing Resident 

#12's room. The LSW added she was not aware 

of any instance where Resident #12 was moved 

without giving consent. Employee #33 added the 

Social Workers were only here Monday through 





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Friday. If a resident was moved in the evening or 

on the weekend, it would be the nursing staff's 

responsibility to obtain consent from the resident. 

On 3/3/11, Employee #34 revealed she recalled 

when Resident #12 was residing with Unsampled 

Resident #31 and there was a conflict between 

both residents. Employee #34 believed one of the 

residents should be moved to prevent the 

situation from escalating. Employee #34 indicated 

this happened at the change of shift and 

endorsed the residents to Employee #35. 

Employee #34 revealed she did not obtain 

consent from Resident #12. She added she never 

obtained consent from a resident when she 

moved them. She indicated it was the 

responsibility of the Social Worker to obtain 

consents when a resident was moved. Employee 

#34 also verbalized she would not have moved 

Resident #12 into a room with Resident #32 due 

to the behavior problems of Resident #32. 

On 3/4/11 at 11:00 AM, Employee #35 indicated 

she had assumed care of Resident #12 & 

Resident #31. She recalled the conflict between 

the two residents and did move Resident #12 to 

another room. However, she did not recall if 

Resident #12 was moved in with Resident #32. 

Employee #35 added, she never obtained 

consent from the resident prior to moving them. 

She added that was the responsibility of the 

Social Worker. 

The facility policy titled Room Changes/Transfers 

within the facility dated 10/2008, indicated: 

- "...2. . Social Services staff will assess how 

room relocation will impact patient's/resident's 





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psychosocial status by evaluating the following: 

- A. The patient's/resident's ability to cope with 

and adapt to change, 

- B. The patient's/resident's willingness to move 

to a new location, and ...." 

- "3. Social Services staff works with the 

Interdisciplinary Team to consider roommate 

compatibility and physical care needs to arrive at 

the most appropriate location for a 

patient/resident." 

- "4. Written notice of all room transfers, utilizing 

current forms, will be provided to the 

patient/resident or his/her qualified legal 

representative before the anticipated transfer. If 

applicable, the notice of room transfers will 

include or be accompanied/replaced by written 

notice that includes all appeal rights and 

processes." 

483.15(f)(1) ACTIVITIES MEET 

INTERESTS/NEEDS OF EACH RES 

The facility must provide for an ongoing program 

of activities designed to meet, in accordance with 

the comprehensive assessment, the interests and 

the physical, mental, and psychosocial well-being 

of each resident. 

F 248 


by: 

Based on observation, interview, record review, 

and policy review, the facility failed to provide an 

ongoing program of activities designed to meet 

the interests and psychosocial well-being of 

residents who spent most of the time in their 

rooms for 3 of 30 sampled residents. (Residents 

#19, #20, and #4). 





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Resident #19 





to gastrostomy tube. Physician recapitulation 

orders included the following standing orders: 

"Resident may participate in social activities as 

tolerated;" and "May have sunscreen for outdoor 

activities PRN (as needed)." 






Unit Nurse (Employee #17), reported that for the 



Review of Resident #19's record revealed an 

Activities Evaluation, dated 3/23/10. Under the 

Activity Pursuit Patterns and Preferences section 

was written the words, "Unable to Assess." The 

Activities Director also wrote, "Patient has family 

support." 




He stays in bed daily and enjoys listening to 

music and watching TV..." 

A review of Resident #19's Record of 

One-to-One Activities, completed in January and 





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February 2011 by the Activities Assistant, 

revealed the resident received 14 visits from 

Activities staff during the two-month period. Most 

of the one-to-one visits lasted five minutes and 

involved turning on the radio or TV, and some 

conversation. For four visits, the Activities 

Assistant massaged the resident's arm with 

lotion. On two visits, the resident was sleeping. 

The Activities Director (Employee #13) reported 

on 3/3/11 at 1:00 PM, activity preferences for 

Resident #19 were never reassessed, and family 

members were not contacted for input into the 

development of the resident's Activities Plan of 

Care. The Activities Director confirmed attempts 

were never made to have the resident go out of 

his room for activities. 

The Activities Director acknowledged an updated 

Activities Evaluation and Care Plan, identifying 

the resident's activity preferences, should have 

been developed with the involvement of the 

resident's family. The Director further 

communicated one-to-one visits should occur at 

least three times per week, and last at least 15 

minutes. 

The facility's Activities Policies and Procedures, 

dated 2/2008, included the following protocols: 

"Activity/Recreation programs are based on the 

abilities, interests, and needs of the residents 

expressed through the Activity individual 

assessment; Resident's or resident's 

representative(s) expressed needs and interests 

are included in the development of programs; 

Activity programs are designed based on 

resident's leisure interests, and implemented to 

address the needs (physical, cognitive, creative, 





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social, spiritual, independent, empowerment, and 

sensory stimulation) of the residents; Those who 

cannot participate in a group setting are provided 

one-to-on individual programming; The 

Activity/Recreation Director and/or staff regularly 

(at least quarterly) assess the ability or the 

interest of the resident to join small and large 

group activities/events." 

Resident #20 





attention to gastrostomy. A Nursing Assessment 

completed on 2/26/10 indicated the resident was 

rarely able to make herself understood but was 

able to "follow simple one-step commands and 

answer very simple questions." 

Review of Resident #20's record revealed an 

Activity Care Plan, with the following goals: "will 

accept room visits 3 - 4 times per week; will 

respond to sensory stimulation; will accept 

materials to aid in self recreation; will respond to 

in-room visits." 

According to the Record of One-to-one Activities 

for the months of January and February, Resident 

#20 received 15 visits from Activity staff, with a 

range of one minute to ten minutes per visit. For 

three of those visits, the resident was sleeping. 

Most of the visits consisted of "TV and sensory 

touch." The resident's last Activity Assessment 

was conducted on 5/27/08, and it indicated the 

resident liked to listen to music. 





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Resident #4 

















A complete physical therapy evaluation was 

initiated by the facility on 3/4/2011, after the 

facility was informed by the surveyor regarding 

the issues documented below and the surveyor 

questioned why Resident #4 had been bedbound 

for over one year since admission on 2/13/2010. 

On 3/4/2011, in the afternoon, the physical 

therapist who performed the assessment 

indicated there was no reason why Resident #4 

should have been bedbound since her admission 

and should have out of bed on a regular basis 

since her admission to the facility. 

On 3/1/2011 in the morning, standing in the 










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closed. There was no television in Resident #4's 

area and no radio. A black folded wheelchair was 

beside the wall in the resident's side of the room. 







to tilt towards the right side of the wall. Resident 

#4 was wearing a hospital gown but the lower 

portion of the gown was above her waist exposing 

her legs and underwear while she slept. The 

resident's legs were unshaven and both axillas 

were unshaven with copious amounts of long 

tangled bushy hair. The resident toenails were 

noted long and unkept. Two toenails were noted 

curling around the toe. The resident fingernails 

were unkempt and also long. There was no 

environmental stimuli set up in the room. 


seen again in bed with her hospital gown on. The 


exposing her legs, thighs, underwear, and 

stomach. The resident was awake with her eyes 

open and spontaneously moving her lower 

extremities and upper extremities. The resident, 

while moving her lower extremities, was inching 

towards the lower portion of the bed causing her 

hospital gown to go upwards exposing her 





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abdomen. The resident had her eyes open but 

was spontaneously staring at the ceiling and the 

wall. The resident did stare at the surveyor but did 

not respond with verbal stimuli. A urine odor was 

still present in the room. The privacy curtain was 

still drawn, hiding the resident, and the window 

valence was still partially closed leaving the room 

dim. The resident was not seen getting out of bed 

for the day. The wheelchair in the room was not 

touched. 

On 3/2/2011, in the morning and afternoon, 

Resident #4 was observed in bed all day. A 

strong urine odor was noted in the room. The 

resident was wearing a hospital gown all day 

which continued to expose her legs and 

abdomen. The privacy curtain was still drawn and 

the window valence partially closed leaving the 

room dim. No environmental stimuli was noted in 

the room. The resident's feet/ankles were noted 

to be extended. There were no splints or shoes 

noted at the bedside. 

On 3/3/2011, in the morning, Resident #4's room 

mate located in bed A was sitting up in her 

wheelchair on her side of the room. Resident # 33 

was very alert and oriented to person, place, and 

time. Without giving the name of Resident 4, 

Resident #33 was asked how the staff treated her 

room mate, Resident #4. Resident #33 informed 

the surveyor what Resident #4's first name was. 

Resident #33 began nodding her head side to 

side and indicated Resident #4 was very young 

and stays in bed all day long. The surveyor asked 

if Resident #4 was placed in her wheelchair and 

left in the room. Resident #33 indicated again that 

it's sad she stays in bed all day long. 





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noted in bed all day. A strong urine odor was 

noted in the room. The resident continued to wear 

a hospital gown that exposed her lower half of her 

body due to her spontaneous movements with 

her upper and lower extremities. The privacy 

curtain was still drawn and the room was still dim 

due to the partially closed window valence. The 

folded wheelchair was not used. 

On 3/3/2011, in the afternoon, a female CNA was 

asked regarding the care for Resident #4. The 

CNA indicated that the resident was bedbound 

and rarely got out of bed. The CNA indicated that 

the resident would sometimes be placed in a 

gerichair so she could be brought outside when 

her family came by to visit but indicated that the 

family rarely visits and would come one time 

every two to three months. The CNA indicated 

the black folded wheelchair in the resident's room 

was not used and would not be appropriate for 

the resident due to her spontaneous movements 

but the resident had no problems with the 

specialized chair. There was no specialized 

wheelchair in the resident's room and there was 

no specialized wheelchair being stored or 

assigned to the resident to use. 







three days in Resident #4's room to the staff. The 

room was dim due to the partially closed 

valences, the drawn privacy curtain, no television 

or radio in the room, no environmental stimuli in 





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the room, the resident's unshaven leg hair and 

long bushy axilla hair, the unkept toenails and 

fingernails, and the tilted mattress from the 

pillows and sheets being stuffed under the 

mattress. Also, the surveyor questioned why the 

resident was bedbound since her admission over 

one year ago. 



chart. 

There was no documented evidence Resident #4 

participated in activities outside her room. There 

was no evidence that the resident had gotten out 

of her bed and placed in a specialized wheelchair 

by staff so that she could participate in activities 

throughout the facility or outside the facility. 

Resident #4's Activities Evaluation dated 

2/15/2010, documented under physical function 

that wheelchair was checked off on the the form. 

Resident #4's Activities Progress Notes dated 


-"...Activities staff will provide in room visits 3X 

wkly (3 times a week) for sensory stimulation 

such as touch and sound..." 



-"...She does not usually respond to stimuli but 

will sometimes shout. She remains in room in bed 

and receives frequent room visits by activity 

staff...She is awake morning and afternoons but 

retires early evenings..." 





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-"...She continues to be bedbound and 

unresponsive to most stimuli. Although she is in 

room and mostly unresponsive, her eyes are 

open at times but she does not follow stimuli. She 

is awake in the mornings..." 

Resident #4's Record Of One-To-One Activities 

form dated from 1/7/2011 - 3/3/2011 indicated the 

resident was bedfast, room bound, and 1 to 5 

minute visits were made three times a week in 

her room. The form also documented: 

-"...1/11/11 Conversation Non-verbal, no 

response, she makes eye contact and sometimes 

crye's(sic)..." 

On 3/4/2011, in the morning, the Interim Director 

of Activities indicated that she had not recalled 

seeing Resident #4 out of bed and confirmed that 

the resident received in room activities. The 

Interim Activities Director indicated if the resident 

was placed in a wheelchair or a specialized chair 

and could leave the room, the resident would be 

participating in all the activities outside her room. 

The Interim Activities Director was not aware 

resident did not have a television or radio in the 

room. The Interim Activities Director indicated 

getting Resident #4 out of bed was discussed in 

the care conference meetings but the response 

given to the Interim Activities Director was that 

Resident #4 squirms around too much. 

On 3/4/2011 in the morning, the Social Worker 

indicated she was involved in the monthly care 





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F 250 

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conference meeting for Resident #4. The Social 

Worker indicated the Activities Director and 

herself had brought up the issue of trying to get 

Resident #4 out of bed. The Social Worker 

indicated she was told the issue was being 

looked into. The Social Worker was not aware 

why the resident was bedbound. The Social 

Worker indicated Resident #4 was moved into the 

existing room sometime in November 2010. The 

Social Worker confirmed that the new room did 

not have a radio, television, or calender. Also, a 

teddy bear that was to be kept beside her was not 

placed near the resident. The Social Worker 

indicated the items should be in her room to give 

her some stimuli. 

483.15(g)(1) PROVISION OF MEDICALLY 

RELATED SOCIAL SERVICE 

The facility must provide medically-related social 

services to attain or maintain the highest 

practicable physical, mental, and psychosocial 

well-being of each resident. 

F 250 


by: 


and policy review, the facility failed to ensure 1 of 

30 sampled residents received appropriate social 

services interventions to attain the highest 

practicable physical and psychosocial well-being 

(Resident #19). 








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unit nurse (Employee #17), reported that for the 






He stays in bed daily..." The Activities Director 

confirmed attempts were never made to have the 

resident go out of his room for activities. 

Documentation for the April and May 2010, Plan 

of Care for Range of Motion (ROM) showed 

Restorative Assistant (RA) nursing services were 

provided five days each month for the resident's 

contractures and decreased ROM. In June 2010, 

RA services were provided to the resident each 

day of the month, but not at every shift. All RA 

intervention services for the resident's 

contractures were discontinued after June 2010. 

Review of Resident #19's record revealed a 

Social Service Progress Note, wherein the Social 

Worker (Employee #15) wrote on 12/16/10, a 

family member felt the resident "should have 

more PT (physical therapy), ST (speech therapy), 

should have electric bed, etc." On 3/3/11 at 2:00 

PM, the Social Worker communicated when she 

received the concerns from the resident's family 





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on 12/16/10, she did not take those concerns to 

Nursing. 

The Social Worker also reported she previously 

ordered an electric bed for Resident #19, but it 

went to another resident. There was no 

documentation as to why the resident did not 

have the electric bed as ordered. 

There was no documented evidence the Social 

Worker consulted with Activities regarding the 

concerns brought up by Resident #19's family 

about the lack of stimulation, social interaction, 

and out-of-room activities. 

F 309 

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The facility's Social Services Policies and 

Procedures, dated 3/2006, included the following 

protocols for Social Service Representatives: 

"Assist in meeting the mental, psychological, and 

psychosocial needs of the residents; provide 

orientation and in-service to facility personnel to 

assist in maintaining resident's dignity, 

individuality, and how to support resident's needs; 

consult with other staff members when needed 

concerning resident problems and policies; 

through the care planning process, identify and 

seek ways to support resident's needs, 

preferences, routines, concerns, and choices." 

483.25 PROVIDE CARE/SERVICES FOR 

HIGHEST WELL BEING 

Each resident must receive and the facility must 

provide the necessary care and services to attain 

or maintain the highest practicable physical, 

mental, and psychosocial well-being, in 

accordance with the comprehensive assessment 

and plan of care. 

F 309 





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by: 

Based on observation, interview, record review 

and document review, the facility failed to ensure 

services were provided to maintain residents' 

highest practicable physical, mental, and 

psychosocial needs for 4 of 30 residents 

(Residents #11, #19, #2, and #22). 


Resident #11 

Resident #11 was a 52 year old female originally 

admitted to the facility on 10/22/10, and last 

readmitted on 2/1/11, with diagnoses including 

end stage liver disease with cirrhosis of the liver 

alcoholic, hypertension, hepatic encephalopathy 

and chronic pain. The resident was on hospice. 

The physician's history and physical dated 

10/22/10, documented the resident was 

transferred from the acute care facility due to 

chronic pain and monitoring of lab values. The 

physician's plan included: 

- "Follow up baseline labs (laboratory) to be 

obtained 

- ammonia levels will be checked 

- She will continue on Lactulose" 

The initial nurse's assessment dated 10/2/10, 

indicated Resident #11 was alert and responsive 

"but becomes drowsy at times." 

The initial assessment by the hospice nurse 

dated 10/25/10, documented Resident #11 was 





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A&O x3 (alert and oriented to person, place and 

time), complained of intermittent back pain, and 

became drowsy at times. 

Over the course of the next several months, the 

nurse's notes documented Resident #11 

experienced increased confusion and agitation, 

resulting in Resident #11 being transferred to the 

acute care facility on 1/22/11 to rule out a 

psychiatric diagnosis. 

Nurse's notes documented: 

- "11/9/10, 6 AM to 6 PM - Resident alert with 

confusion. Talking out loud to herself at times..." 

- "12/31/10, 6AM to 6PM - Severe agitation this 

shift... Pt (patient) with hallucinations, screaming, 

cursing, yelling for staff to "get off her property... 

Wandering..." 

- "01/2/11, 02:30 (2:30 AM) - Severely agitated. 

Attempted to open fire door..." 

- "01/21/11, 06:15 AM - ...patient is so agitated, 

banging her head on the wall, hallucinating, 

screaming, combative and danger to herself..." 

- "01/22/11, 07:30 AM - ... starting to be agitated, 

hallucinating, screaming. Xanax 1 mg (milligram) 

given and then Ativan 0.5 mg...Patient still 

continuing crying, hallucinating...Patient 

wandering and screaming in hallways... Hospice 

called and decided to send her Legal 2000 

(Psychiatric Hold)." 

The physician's orders included: 

"10/23/10 - CBC, Liver panel, Ammonia level 

11/16/10 - Need labs done on 11/16/10; CBC 

Liver Panel, TSH, BMP, Ammonia level 

11/24/10 - Ammonia level in AM 

01/20/11 - Ammonia level" 





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Documentation in the medical record included : 

- Lab report dated 10/24/10, revealed "Ammonia 

test not performed. Specimen unsuitable for 

testing due to hemolysis." The physician was 

notified, however, there was no documented 

evidence the ammonia level was obtained. 

The nurse's notes dated 11/25/10 at 6:00 AM, 

documented "Unable to draw blood for ammonia 

level due to poor vein access, after several 

attempts made. RN (Registered Nurse) also tried 

but unsuccessful." There was no documented 

evidence the physician was notified or the 

ammonia level was ever obtained. 

On 3/3/11 in the afternoon, the medical records 

staff confirmed there were no ammonia level 

results in the computer system for Resident #11, 

and the last level that was drawn was on 

10/24/10. 

The physician's orders dated 10/23/10 included: 

- "Lactulose 30 cc (cubic centimeters) po (by 

mouth) daily prn (as necessary) for constipation" 

The physician's orders dated 1/20/11 indicated: 

- "Lactulose 30 cc po now then 30 cc routine daily 

elimination." 

Resident #11's Medication Administration 

Records documented the resident received 

Lactulose only on 1/20/11 and 1/21/11. There 

was no documented evidence Resident #11 

received Lactulose or was offered and refused 

Lactulose, in October, November or December, 

2010. 

The physician's History and Physicial (H&P) at 





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the acute care facility dated 1/23/11 documented: 

- "...She appeared more aggressive and agitated, 

and verbal altercations with the nursing staff at 

(SNF)." 

- "...An ammonia level was noted to be elevated 

to 133. (Normal ammonia levels 15 - 60 mcg/dL 

(micrograms per deciliter) or 21 - 50 mcmol/L 

(micromoles per liter)) She has been on 

Lactulose there at (SNF), but she has been 

refusing to take the Lactulose recently..." 

- "...She was initially put on legal hold, but at this 

point it is felt that she does not need a legal 

hold...She is somewhat confused and lethargic, 

with some slurred speech, again as a result of 

some baseline encephalopathy." 

- ..."Plan: She will continue on the lactulose for 

the elevated ammonia levels..." 

Physician's orders at the acute care facility dated 

1/23/11, included: 

- "Lactulose 10 mg (milligrams)/15 ml (milliliter) 

30 ml po (by mouth) qid (four times a day)" 

The physician's discharge summary dated 

1/31/11 documented: 

- "...Here, she was put back on Lactulose. 

Ammonia level has shown improvement...over 

the past 24 to 48 hours, she has at least been 

more calm...She is able to at least answer 

questions and carry on a conversation..." 

The National Institute of Alcohol Abuse and 

Alcoholism (NIAAA) publication titled Hepatic 

Encephalopathy (HE) - A Serious Complication of 

Alcoholic Liver Disease, dated 7/2004 revealed: 

"HE is a serious complication of alcoholic liver 

disaese that contributes to cognitive dysfunction 

in chronic alcoholic patients. In patients with HE, 





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the damaged liver can no longer remove 

neurotoxic substances such as ammonia and 

manganese from the blood. As a result, these 

molecules may enter the brain, where they can 

exert a variety of harmful effects that interfere 

with normal neurotransitter activity, impair motor 

functions, and cause structural alterations in the 

astrocytes. To prevent or treat HE in alcoholic 

patients with cirrhosis, physicians currently rely 

primarily on strategies to lower blood ammonia 

concentrations as well as on liver transplantation 

in patients with end-stage liver disease..." 

"Treatment of Patients with HE : Strategies to 

lower ammonia levels. One approach - 

administering certain sugar molecules (e.g. , 

lactulose) or antibiotics (e.g., neomycin) - reduces 

the production of ammonia in the gastrointestinal 

tract..." 

In summary: 

- Resident #11 had 4 physician orders to obtain 

ammonia levels during the admission of 10/22/10 

through 1/22/11. 

- There was no documented evidence ammonia 

levels were obtained during the admission. 

- The physician was notified only one time, on 

10/25/10, of the inability to obtain the ammonia 

levels. 

- Resident #11 had a significant change in 

cognitive function due to increased ammonia 

levels, which required an acute care 

hospitalization. 

- Resident #11 was treated with Lactulose to 

reduce the ammonia levels in the acute care 

facility and returned to the skilled facility when the 

ammonia levels had decreased and her cognitive 

function improved. 





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Resident #19 






Resident #19's diet order was "NPO (nothing by 

mouth); enteral feeding: Glucerna 1.2 x 70 ml 

(milliliters) per hour x 21 hours, to provide 1764 

calories each day; special instructions: on at 1200 

and off at 0900." 

On 3/3/11 at 8:35 AM, Resident #19 was 

observed to be receiving a tube feeding of 

Glucerna. The time of 1845 was written on the 

1500 ml bottle. There was 1100 ml of formula 

remaining in the bottle, and this was confirmed by 

the Unit Nurse, Employee #12. If the feeding had 

been running since 6:45 PM on 3/2/11, at a rate 

of 70 ml per hour, there should have been 555 ml 

left in the bottle. 

On 3/3/11 at 9:00 AM, a licensed nurse on the 

500 Hall (Employee #38) was interviewed. The 

nurse confirmed a new Glucerna bottle for 

Resident #19 was started at 1845, because the 

previous bottle ran out at that time. The nurse 

could not explain why the feeding did not run 

through the night. The nurse reported the 

resident's tube feedings were not always started 

at 12:00 PM and turned off at 9:00 AM as 

ordered. 

Resident #2 





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11/30/10, with diagnoses including baseline mild 

dementia, hypertension and constipation. 

Resident #2's medical record documented a 

physician's order dated 11/30/10, for Milk of 

Magnesia (MOM) 30 milliliters (ml) orally as p.r.n 

(as needed) if no bowel movement (BM) in 3 

days. Dulcolax suppository 10 milligram p.r.n per 

rectum if MOM is ineffective in 12 hours 

The Medication Administration Record (MAR) 

dated 12/10, documented Resident #2 received a 

Dulcolax suppository for the complaint of 

constipation on 12/9/10 at 7:35 AM. The resident 

then received MOM 30 cc orally for the complaint 

of constipation on 12/9/10 at 9:00 AM. 

On 3/1/11 at 1:45 PM, a Licensed Nurse (LN) 

stated according to the physician's orders the 

resident was to receive MOM first, then if there 

were no results after 12 hours, to receive a 

suppository. The LN verbalized the physicians' 

orders had not been followed. 

Resident #22 


2/9/11, with diagnoses including severe 

peripheral vascular and atherosclerotic disease, 

and renal insufficiency. 

The medical record contained a physician's order 

for Metoprolol 25 milligrams orally twice a day. 

Hold for systolic blood pressure less than or 

equal to 110 and a pulse rate less than or equal 

to 60. 





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The facility's reference book titled, "30th 

Anniversary Edition Nursing 2010 Drug 

Handbook" pages 385-387 documented "always 

check a patient's apical pulse rate before giving 

the drug. If it's slower than 60 beats per minute 

with hold the drug and call the prescriber 

immediately." 

Resident #22's Medication Administration Record 

(MAR) dated 2/11, lacked documentation the 

resident's pulse rate was recorded prior to each 

dose of Metoprolol 25 milligrams orally during the 

month. 

According to the MAR the resident's pulse rate 

was not taken prior to administration of her 8:00 

AM medication dose 12 times and not taken prior 

to administration of her 8:00 PM dose 5 times in 

2/11. 

The MAR documented Resident #22 received 

Metoprolol 25 milligrams orally on 2/14/11, when 

her blood pressure was documented as 108/72 

and a pulse rate of 60. 


stated the drug Metoprolol "lowers the blood 

pressure and heart rate. The heart rate and blood 

pressure should be taken before the medication 

was given." The LN stated if the medication was 

given to a resident with a low blood pressure/or 

heart rate the medication would cause them to 

drop further and could cause dizziness or a fall. 

The LN reviewed the MAR for 2/11 and stated the 

physician's order was not followed regarding 

monitoring the pulse rate and the medication 

should not have been given on 2/14/11. 

F 311 483.25(a)(2) TREATMENT/SERVICES TO F 311 





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SS=G 

IMPROVE/MAINTAIN ADLS 

A resident is given the appropriate treatment and 

services to maintain or improve his or her abilities 

specified in paragraph (a)(1) of this section. 


by: 


and document review, the facility failed to give 

appropriate treatment to maintain or improve his 

or her abilities for 3 of 30 residents (Resident 

#19, #20, #4). 


Resident #4 

















A complete physical therapy evaluation was 

initiated by the facility on 3/4/2011, after the 





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facility was informed by the surveyor regarding 

the issues documented below and the surveyor 

questioned why Resident #4 had been bedbound 

for over one year since admission on 2/13/2010. 

On 3/4/2011, in the afternoon, the physical 

therapist who performed the assessment 

indicated there was no reason why Resident #4 

should have been bedbound since her admission 

and should have out of bed on a regular basis 

since her admission to the facility. 

On 3/1/2011 in the morning, standing in the 












closed. There was no television in her area of the 

room and no radio. A black folded wheelchair was 

beside the wall in the resident's side of the room. 







to tilt towards the the right side of the wall. 


seen again in bed. The resident was awake with 

her eyes open and spontaneously moving her 





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lower extremities and upper extremities. The 

resident, while moving her lower extremities, was 

inching towards the lower portion of the bed. The 

resident was not observed out of bed for the day. 

The wheelchair in the room was not touched. 

On 3/2/2011, in the morning and afternoon, 

Resident #4 was observed in bed all day. No 

environmental stimuli was noted in the room. The 

resident's feet/ankles were noted to be extended. 

There were no splints or shoes noted at the 

bedside. 

On 3/3/2011, in the morning, Resident #4's room 

mate located in bed A was sitting up in her 

wheelchair on her side of the room. Resident # 33 

was very alert and oriented to person, place, and 

time. Without giving the name of Resident 4, 

Resident #33 was asked how the staff treated her 

room mate, Resident #4. Resident #33 informed 

the surveyor what Resident #4's first name was. 

Resident #33 began nodding her head side to 

side and indicated Resident #4 was very young 

and "stays in bed all day long." The surveyor 

asked if Resident #4 was placed in her 

wheelchair and left in the room. Resident #33 

indicated again "it's sad she stays in bed all day 

long." 


noted in bed all day. The folded wheelchair was 

not used. 

On 3/3/2011, in the afternoon, a female Certified 

Nursing Assistant (CNA) was asked regarding the 

care for Resident #4. The CNA indicated the 

resident was bedbound and rarely got out of bed. 

The CNA indicated that the resident would 





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sometimes be placed in a gerichair so she could 

be brought outside when her family came by to 

visit but indicated that the family rarely visited and 

would come one time every two to three months. 

The CNA indicated the black folded wheelchair in 

the resident's room was not used and would not 

be appropriate for the resident due to her 

spontaneous movements but the resident had no 

problems with the specialized chair, but there was 

no specialized wheelchair in the resident's room, 

and there was no specialized wheelchair being 

stored or assigned to the resident to use. 

After the surveyor questioned the CNA staff 

regarding the use of the hospital gown and 

resident's care it was noted that that the resident 

was changed into regular clothing and the odor of 

urine was not present in the room. 







three days in Resident #4's room to the 

staffincluding the tilted mattress from the pillows 

and sheets being stuffed under the mattress and 

questioned why the resident was bedbound since 

her admission over one year ago. 



chart. 

There was no documented evidence that an order 

was obtained or a care plan initiated to place 

pillows and sheets under Resident #4's left side 





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of the mattress tilting the entire mattress against 

the wall. 

There was no documented evidence Resident #4 

participated in activities outside her room. There 

was no evidence that the resident had gotten out 

of her bed and placed in a specialized wheelchair 

by staff so that she could participate in activities 

throughout the facility or outside the facility. 

Resident #4's Activities Evaluation dated 

2/15/2010, documented under physical function 

that wheelchair was checked off on the the form. 



-"...Activities staff will provide in room visits 3X 

wkly (3 times a week) for sensory stimulation 

such as touch and sound..." 



-"...She does not usually respond to stimuli but 

will sometimes shout. She remains in room in bed 

and receives frequent room visits by activity 

staff...She is awake morning and afternoons but 

retires early evenings..." 



-"...She continues to be bedbound and 

unresponsive to most stimuli. Although she is in 

room and mostly unresponsive, her eyes are 

open at times but she does not follow stimuli. She 

is awake in the mornings..." 





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Resident #4's Record Of One-To-One Activities 

form dated from 1/7/2011 - 3/3/2011 indicated the 

resident was bedfast, room bound, and 1 to 5 

minute visits were made three times a week in 

her room. The form also documented: 

-"...1/11/11 Conversation Non-verbal, no 

response, she makes eye contact and sometimes 

crye's(sic)..." 

On 3/4/2011, in the morning, the Interim Director 

of Activities indicated that she had not recalled 

seeing Resident #4 out of bed and confirmed that 

the resident received in room activities. The 

Interim Activities Director indicated if the resident 

was placed in a wheelchair or a specialized chair 

and could leave the room the resident would be 

participating in all the activities outside her room. 

The Interim Activities Director indicated getting 

Resident #4 out of bed was discussed in the care 

conference meetings but the response given to 

the Interim Activities Director was that Resident 

#4 "squirms around too much." 

On 3/4/2011 in the morning, the Social Worker 

indicated she was involved in the monthly care 

conference meeting for Resident #4. The Social 

Worker indicated the Activities Director and 

herself had brought up the issue of trying to get 

Resident #4 out of bed. The Social Worker 

indicated she was told the issue was being 

looked into. The Social Worker was not aware 

why the resident was bedbound. The Social 

Worker indicated Resident #4 was moved into the 

existing room sometime in November 2010. The 

Social worker confirmed that the new room did 

not have a radio, television, or calender. Also, a 





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teddy bear that was to be kept beside her was not 

placed near the resident. The Social Worker 

indicated the items should be in her room to give 

her some stimuli. 

On 3/4/2011, in the morning, the unit manager for 

(A) building could not reply why Resident #4 had 

not been getting out of bed routinely since her 

admission over one year ago. The unit manager 

indicated the resident had so many involuntary 

movements. The unit manager confirmed the 

resident was not initially assessed for getting out 

of bed or assessed for proper specialized devices 

when up from her bed. She confirmed that the 

wheelchair located in the resident room would not 

be appropriate to use and the resident would 

need a specialized chair. 

Resident #4's Comprehensive Plan of Care form 

regarding the resident's ADL (activity of daily 

living) functions with a review date of 8/13/2010, 

11/4/2010, and 1/27/2011, documented transfers 

did not occur. 

Resident #4's Minimum Data Set (MDS) version 

3.0 section annual assessment dated 1/27/2011, 

documented on section G0110, 1. B. Transfers 

did not occur during the entire period. 

Resident #4's Rehabilitation Services Screening 

Request form signed by the physical therapist 

and dated 2/15/2010 referred for R/A (restorative 

assistant)services to begin bilateral lower 

extremity and upper extremity AAROM (active 

assistive range of motion) and bed mobility 

exercises. 

Resident #4's nurse's notes dated 2/23/2010, 





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documented that a R/A evaluation was completed 

but was deferred at the time. 

There were no other rehabilitation screenings, 

assessments, treatments completed for 2010. 

Resident #4's Rehabilitation Services Screening 

Request signed by the physical therapy assistant 

and dated 1/25/2011 documented under the 

contractures section: 

-"...B (bilateral) Ankles Foot Drop." 

On the same form under Comments 

documented: 

"...Refer to R/A (restorative aid) ROM (range of 

motion) and exe (exercises) and bed mobility." 

On 3/3/2011, in the afternoon, the Director for 

R/A services indicated that R/A services were not 

initiated on Resident #4 because she did not 

receive a communication form to initiate services. 

On 3/4/2011, in the morning, the Director of 

Rehabilitation Services indicated they have had a 

communication problem and R/A staff may have 

not received the information to start R/A services 

for Resident #4. The Director of Rehabilitation 

Services indicated quarterly screenings should be 

performed for each resident. There was no 

documented evidence quarterly screenings were 

completed for Resident #4 after the initial one on 

2/15/2010. The next rehabilitation screening was 

completed 11 months later on 1/25/2011, which 

possibly identified foot drop for Resident #4. R/A 

services were referred but never initiated until the 

surveyor informed the facility. The Director of 





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Rehabilitation services indicated the nurses could 

have gotten the resident out of bed and could 

have requested the Rehabilitation department to 

obtain a special chair for the resident but there 

was no indication a request was made. 

The Nursing, Rehabilitation, Social Services, R/A, 

Activities, and MDS departments documented or 

verbalized the resident was bedbound but there 

was no documented evidence why the resident 

should have been bedbound and not out of bed 

on a regular basis. There was no documented 

evidence Resident #4 had any physical limitation 

for getting up in a specialized chair. There was no 

documented evidence proper equipment such as 

a gerichair was recommended so Resident #4 

could be taken out of bed on a regular basis. 

Some departments verbally questioned other 

departments regarding the resident's bedbound 

status but there were no attempts to get the 

resident out of bed for over a one year period. 

Resident #19 






The resident had a right hand contracture and a 

left leg contracture upon admission. An initial 

Rehabilitation Services Screening, conducted on 

3/23/10 by an Occupational Therapist (OT), 

included the following documentation in the 

Comments section: "Pt (patient) alert and 

oriented x 1...Unable to speak due to 

aphasia...will not be appropriate for skilled OT 





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services - will benefit from RA (restorative nursing 

assistant) program for PROM (passive range of 

motion) of right position of right UE (upper 

extremities) to prevent further contracture at this 

time." 

There were sections on the Screening form to 

document information about Mobility and 

ROM/contractures - including location, function 

affected, and whether existing or new - but this 

part of the form was left blank. 

Another Rehabilitation Services Screening was 

conducted by a Physical Therapy Assistant (PTA) 

on 3/24/10, who wrote, "Appears to be at PLOF 

(previous level of functioning). Recommend RA 

for ROM of B (both) UE (upper extremities) and B 

LE (lower extremities), and bed mobility." The 

Mobility section, indicating impairment of bed 

mobility, balance, transfers, and ambulation, was 

checked off by the PTA. The ROM/Contractures 

section was left blank. The PTA checked the box 

for "Need for skilled therapy not warranted at this 

time." 


Nursing Rehab/Restorative Plan of Care ROM to 

All Extremities, with a goal to "maintain/improve 

adequate AROM (Active ROM)/PROM to all 

extremities to maintain mobility." The duration of 

the plan was for 7 times per week, 5 minutes 

each shift for 90 days, beginning 3/29/10. 

Documentation for the April and May 2010 Plan 

of Care ROM showed the resident received RA 

nursing services for five days during each month. 

For the month of June 2010, RA services were 

provided to the resident each day of the month, 





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but not at every shift. All RA intervention services 

for the resident's contractures were discontinued 

after June 2010. 

There was no evidence a quarterly screening was 

conducted in June by Rehabilitation Services for 

Resident #19's Contractures/ROM. On 9/9/10, a 

Speech Therapist conducted a quarterly 

screening but did not document the need for RA 

services. There was no quarterly screening by 

Rehabilitation Services in December 2010. 

The Director of Rehabilitation Services 

(Employee #8) confirmed on 3/3/11 at 8:30 AM 

that residents identified as having mobility and 

ROM limitation were to be assessed by the 

Rehabilitation department quarterly. The Director 

explained that after each quarterly screening, the 

Rehabilitation Therapist was to determine if the 

resident would benefit from continuing RA 

services and then make a referral to the RA 

program. According to the Director, "Definitely 

(Resident #19) would benefit from passive range 

of motion (exercises). We can increase it a little 

bit...If we don't do anything, it will decrease range 

of motion even further. You want to maintain it to 

prevent it from getting worse." The Director was 

unable to explain why the Rehabilitation 

department did not make RA nursing referrals for 

Resident #19 after June 2010. 

Record review revealed the Nursing department 

was aware Resident #19 was not receiving any 

interventions for the resident's contractures and 

limited ROM. A Care Plan Conference Summary, 

dated 9/30/10, indicated topics discussed, and 

Rehabilitation was one of the topics. Noted next 

to that topic was "No RA." On 3/3/11 at 2:00 PM, 





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the Social Worker (Employee #15) 

communicated that this Care Plan Conference 

was attended by herself, the Dietitian, the 

Activities Director, and the Unit Manager. The 

Social Worker explained the information about 

the resident not receiving RA services came from 

the Unit manager. 

A Comprehensive Plan of Care addressing 

Resident #19's limited range of motion, 

developed on 6/28/10, and reviewed on 9/17/10 

and 12/15/10. There was no indicated goal on 

the Care Plan. A listed Approach was, "Develop 

a restorative nursing program to provide PROM." 

On 3/4/11 at 8:15 AM, the Unit Manager was 

asked about restorative nursing assistant 

programs. The Unit Manager indicated it was the 

responsibility of the Rehabilitation department to 

contact the Nursing department to order 

continuing RA interventions for residents with 

contractures and limited ROM. 

The facility's Restorative Nursing Policies and 

Procedures, dated 3/2006, included the following 

screening protocols: "Any resident identified by 

the interdisciplinary team as requiring a 

rehabilitation screen will have the screening 

initiated by a Physical, Occupational Therapist or 

Assistant, or Speech Language Pathologist within 

48 hours of notification of the request and 

quarterly...A resident is referred for a 

rehabilitation screen in response to any of the 

following... contracture risks or splinting needs; 

mobility, balance, and safety concerns; seating 

and positioning concerns; self-feeding and 

swallowing difficulty; adaptive equipment needs; 

difficulty performing self-care tasks; and difficulty 





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communicating needs..." 

The facility's Rehabilitation Services Policies and 

Procedures, dated 9/07, outlined the following 

procedures for screening; "All documentation is to 

be kept in the medical record; each form is to be 

completed in its entirety...The two 

recommendations from a screen are 1) therapy 

evaluation; 2) referred to another discipline.. If 

restorative services are indicated ...the restorative 

coordinator is responsible for obtaining the 

physician's order and proper documentation of 

each program. Therapist will provide the 

necessary education and training to the 

restorative nursing staff of the recommended 

programs." 

The Restorative Nursing Policies and Procedures 

further detailed protocols for Mobility/Range of 

Motion: "Residents will be assessed for joint 

mobility limitation upon admission, readmission, 

quarterly, annually, and with significant change 

through the comprehensive nursing assessment. 

A restorative program will be implemented 

through the care plan to increase, maintain, or 

prevent deterioration of joint mobility and to 

maximize physical function when referral to 

therapy is not indicated or upon discharge from 

skilled therapy...The Restorative Coordinator 

completes the proper documentation regarding 

the resident's current status, the type and 

frequency of the restorative program, and the 

goals (with) a Care Plan, Restorative Care Flow 

Record, and Passive Range of Motion Exercise 

Guides...The Restorative Nurse completes the 

Restorative monthly summary to include overall 

status in the program, progress toward care plan 

goals, and program recommendation...The plan 





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of care is reviewed by the interdisciplinary team, 

and revised as needed. Reassess as per nursing 

assessment and follow trigger guidelines." 

On 3/3/11 at 4:00 PM, the MDS (Minimum Data 

Set) Comprehensive Assessment Nurse, 

Employee #16, stated, "There should be a 

specific care plan for contractures...It seems like 

it's (Resident #19's hand) is weaker from the last 

time (December Quarterly Assessment)." 

Resident #20 










questions." The Assessment also noted the 

resident had a left hand contracture, with 

"decreased ROM (range of motion) in right 

hip/knee." The most recent MDS Assessment, 

dated 11/11/10, indicated the resident had 

limitation in range of motion on both sides for 

both upper and lower extremities. 

Review of Resident #20's record revealed the 

resident had not received any restorative 

interventions for the contractures/limited ROM for 

over a year. In 2010, two screenings were 

conducted by the Rehabilitative Services 

department. On 9/8/10, a Speech Therapist 

noted the resident was not a candidate for 





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physical therapy, occupational therapy, or speech 

therapy services. On 12/4/10, a Physical 

Therapist noted the resident was not a candidate 

for physical therapy (PT) services. There was no 

documentation of a referral or necessity for a 

restorative program on either of the two 

screenings. 

On 2/4/11, Resident #20 was screened by a 

Physical Therapy Assistant (PTA). The PTA 

indicated the need for the resident to proceed 

with a PT services/evaluation. There was no 

evidence this recommendation was carried out, 

and this was confirmed by the Rehabilitation 

Director on 3/4/11 at 11:30 AM. According to the 

Director, "This one was missed...The PTA felt 

(the resident) would benefit from PT services." 

The Director further communicated Resident #20 

not only had a left hand contracture, but also had 

contractures in both ankles. 

F 323 

SS=D 

Cross-reference Tag F406 

483.25(h) FREE OF ACCIDENT 

HAZARDS/SUPERVISION/DEVICES 

The facility must ensure that the resident 

environment remains as free of accident hazards 

as is possible; and each resident receives 

adequate supervision and assistance devices to 

prevent accidents. 

F 323 


by: 

Based on observation, interview and policy 

review, the facility failed to secure medications 





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and Biohazard waste to ensure the environment 

remained as free from accident hazards as 

possible. 


1. On 3/1/11 at 3:35 PM, a medication cart was 

unlocked and unattended in the hallway outside 

resident room 1302. 

On 3/1/11 at 3:50 PM, a medication cart was 

unlocked and unattended in the hallway outside 

resident room 307. Employee #28 verbalized the 

medication carts should be locked for safety 

reasons, so no one can have access to the 

medications. 

On 3/2/11 at 1:56 PM, a medication cart was 

unlocked and unattended by resident room 2101. 

Employee #27 stated the medication cart should 

be locked. 

The facility's policy dated 4/03, on medication 

storage in the facility documented rooms, carts 

and medication supplies are locked or attended 

by persons with authorized access. 

2. On 3/1/11 at 9:45 AM, during the initial tour 

with Employee #4 a bottle of antacid tablets was 

on a night stand in room 1206. Employee #4 

stated the unit did not have residents that self 

administered medications. Employee #4 stated 

she did not know if the resident had an order for 

medications at the bedside. 

On 3/1/11 at 10:20 AM, during the initial the initial 

tour with Employee #29 a tube of Calmoseptine 





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ointment and antifungal cream and powder were 

in a basin located on the bed side table in room 

303. Employee #29 stated he did not think the 

resident could self administer medications. The 

medications should not be at bedside. 

3. On 3/1/11 at 3:27 PM, the door to where the 

Biohazard waste was stored had not been closed 

or locked. A sign located on the Biohazard door 

read keep door closed and locked at all times. 

On 3/1/11 at 3:30 PM, Employee #30 stated the 

door was to remain locked at all times. 

On 3/3/11 at 2:40 PM, the door to where the 

Biohazard waste was stored had not been closed 

or locked. Two large red bins and a refrigerator 

labeled Biohazard waste where in th room. 

F 329 

SS=D 

On 3/4/11 at 11:20 AM, Employee #5 indicated 

the Biohazard room was to be locked to prevent 

anyone from accessing any biohazard material 

and to prevent exposure to contaminated material 

such as sharps. 

483.25(l) DRUG REGIMEN IS FREE FROM 

UNNECESSARY DRUGS 

Each resident's drug regimen must be free from 

unnecessary drugs. An unnecessary drug is any 

drug when used in excessive dose (including 

duplicate therapy); or for excessive duration; or 

without adequate monitoring; or without adequate 

indications for its use; or in the presence of 

adverse consequences which indicate the dose 

should be reduced or discontinued; or any 

combinations of the reasons above. 

F 329 





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Based on a comprehensive assessment of a 

resident, the facility must ensure that residents 

who have not used antipsychotic drugs are not 

given these drugs unless antipsychotic drug 

therapy is necessary to treat a specific condition 

as diagnosed and documented in the clinical 

record; and residents who use antipsychotic 

drugs receive gradual dose reductions, and 

behavioral interventions, unless clinically 

contraindicated, in an effort to discontinue these 

drugs. 


by: 

Based on interview, record review and policy 

review, the facility failed to ensure a gradual dose 

reduction for sleeping medication was attempted 

for 1 of 30 sampled residents (Resident #23). 


Resident #23 


11/6/07, with diagnoses including renal cell 

carcinoma, syncope and high blood pressure. 

Documentation in the medical record indicated 

Resident #23 had memory problems and was 

moderately impaired with daily decision making 

skills. 


dated 11/18/10, for Restoril 7.5 milligrams (mg) 1 

capsule by mouth at bedtime for insomnia. May 





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give 15 mg (two 7.5 mg capsules) if 7.5 mg (1 

capsule) is ineffective at bedtime for insomnia. 

The nurse's notes lacked documentation 

Resident #23 had been assessed for the 

medication Restoril or a consent had been 

obtained for the use of Restoril. There was no 

documentation the facility attempted a dose 

reduction or re-assessed the resident to 

determine medical justification for the continued 

use of the medication Restoril. 

Skilled Nursing Notes dated from December 2010 

to February 2011, documented Resident #23 had 

been sleeping between 16-18 hours per day. 

The Medication Administration Record (MAR) 

November 2010 through March 2011, 

documented Resident #23 received Restoril 7.5 

mg every night. 

On 3/4/11 at 8:50 AM, Employee #31 was not 

able to locate the consent for Restoril in the 

medical record, or documentation Resident #23 

had been assessed for why Restoril was 

required. Employee #31 verbalized sleeping 

medications should have a consent and be used 

short term. If a resident still required the 

medication, the physician would be contacted and 

the resident re-assessed for continuing the 

medication. Employee #31 was not able to locate 

documentation Resident #31 was re-assessed for 

the continued need for Restoril. 

On 3/4/11 at 9:15 AM, a Licensed Nurse (LN) 

stated there was no documentation in the medical 

record a dose reduction had been done. The LN 

reviewed the documentation in the medical record 





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and verbalized it was not good the resident had 

been sleeping more than 16 hours per day. 

On 3/4/11 at 12:30 PM, Employee #12 stated 

there was no documentation in the medical 

record to show a a consent was obtained or a 

dose reduction was done. 


stated the Pharmacist consultant form should 

have been completed. The facility's expectation 

of the physician was for the physician respond to 

the pharmacist's recommendations with in 7 

days. The LN stated the consent for hypnotic 

medications was a standard practice/protocol. 

The facility's policy on Psychotropic/Psychoactive 

Drugs dated 7/09, documented as part of the 

procedure Residents would be assessed for the 

use of the medications. When a sedative/hypnotic 

is first ordered, it should be considered for use for 

no more than 10 consecutive days at which point 

a gradual dose reduction must be attempted. 

F 406 

SS=D 

The facility's reference book titled, "30 th 

Anniversary Edition Nursing 2010 Drug 

Handbook" page 773 documented under 

indications and dosages Short term treatment (7 

-10 days) of insomnia. 

483.45(a) PROVIDE/OBTAIN SPECIALIZED 

REHAB SERVICES 

If specialized rehabilitative services such as, but 

not limited to, physical therapy, speech-language 

pathology, occupational therapy, and mental 

health rehabilitative services for mental illness 

and mental retardation, are required in the 

resident's comprehensive plan of care, the facility 

F 406 





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must provide the required services; or obtain the 

required services from an outside resource (in 

accordance with §483.75(h) of this part) from a 

provider of specialized rehabilitative services. 


by: 


and policy review, the facility failed to ensure its 

rehabilitation department conducted required 

screenings and obtained physician orders to 

implement restorative nursing programs for 

residents with contractures/limited range of 

motion (Residents #19 and #20). 


Resident #19 






The resident had a right hand contracture and a 

left leg contracture upon admission. An initial 

Rehabilitation Services Screening, conducted on 

3/23/10 by an Occupational Therapist (OT), 

included the following documentation in the 

Comments section: "Pt (patient) alert and 

oriented x 1...Unable to speak due to 

aphasia...will not be appropriate for skilled OT 

services - will benefit from RA (restorative nursing 

assistant) program for PROM (passive range of 

motion) of right position of right UE (upper 

extremities) to prevent further contracture at this 





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time." 

There were sections on the Screening form to 

document information about Mobility and 

ROM/contractures - including location, function 

affected, and whether existing or new - but this 

part of the form was left blank. 

Another Rehabilitation Services Screening was 

conducted by a Physical Therapy Assistant (PTA) 

on 3/24/10, who wrote, "Appears to be at PLOF 

(previous level of functioning). Recommend RA 

for ROM of B (both) UE (upper extremities) and B 

LE (lower extremities), and bed mobility." The 

Mobility section, indicating impairment of bed 

mobility, balance, transfers, and ambulation, was 

checked off by the PTA. The ROM/Contractures 

section was left blank. The PTA checked the box 

for "Need for skilled therapy not warranted at this 

time." 


Nursing Rehab/Restorative Plan of Care ROM to 

All Extremities, with a goal to "maintain/improve 

adequate AROM (Active ROM)/PROM to all 

extremities to maintain mobility." The duration of 

the plan was for 7 times per week, 5 minutes 

each shift for 90 days, beginning 3/29/10. 

Documentation for the April and May 2010 Plan 

of Care for ROM showed the resident received 

RA nursing services for five days during each 

month. For the month of June 2010, RA services 

were provided to the resident each day of the 

month, but not at every shift. All RA intervention 

services for the resident's contractures were 

discontinued after June 2010. 





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There was no evidence a quarterly screening was 

conducted in June by Rehabilitation Services for 

Resident #19's Contractures/ROM. On 9/9/10, a 

Speech Therapist conducted a quarterly 

screening but did not document the need for RA 

services. There was no quarterly screening by 

Rehabilitation Services in December 2010. 

The Director of Rehabilitation Services 

(Employee #8) confirmed on 3/3/11 at 8:30 AM 

that residents identified as having mobility and 

ROM limitation were to be assessed by the 

Rehabilitation department quarterly. The Director 

explained that after each quarterly screening, the 

Rehabilitation Therapist was to determine if the 

resident would benefit from continuing RA 

services and then make a referral to the RA 

program. According to the Director, "Definitely 

(Resident #19) would benefit from passive range 

of motion (exercises). We can increase it a little 

bit...If we don't do anything, it will decrease range 

of motion even further. You want to maintain it to 

prevent it from getting worse." The Director was 

unable to explain why the Rehabilitation 

department did not make RA nursing referrals for 

Resident #19 after June 2010. 

The facility's Rehabilitation Services Policies and 

Procedures, dated 9/07, outlined the following 

procedures for screening; "All documentation is to 

be kept in the medical record; each form is to be 

completed in its entirety...The two 

recommendations from a screen are 1) therapy 

evaluation; 2) referred to another discipline.. If 

restorative services are indicated ...the restorative 

coordinator is responsible for obtaining the 

physician's order and proper documentation of 

each program. Therapist will provide the 





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necessary education and training to the 

restorative nursing staff of the recommended 

programs." 

Resident #20 










questions." The Assessment also noted the 

resident had a left hand contracture, with 

"decreased ROM (range of motion) in right 

hip/knee." The most recent MDS Assessment, 

dated 11/11/10, indicated the resident had 

limitation in range of motion on both sides for 

both upper and lower extremities. 

Review of Resident #20's record revealed the 

resident had not received any restorative 

interventions for the contractures/limited ROM for 

over a year. In 2010, two screenings were 

conducted by the Rehabilitative Services 

department. On 9/8/10, a Speech Therapist 

noted the resident was not a candidate for 

physical therapy, occupational therapy, or speech 

therapy services. On 12/4/10, a Physical 

Therapist noted the resident was not a candidate 

for physical therapy (PT) services. There was no 

documentation of a referral or necessity for a 

restorative program on either of the two 

screenings. 





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On 2/4/11, Resident #20 was screened by a 

Physical Therapy Assistant (PTA). The PTA 

indicated the need for the resident to proceed 

with a PT services/evaluation. There was no 

evidence this recommendation was carried out, 

and this was confirmed by the Rehabilitation 

Director on 3/4/11 at 11:30 AM. According to the 

Director, "This one was missed...The PTA felt 

(the resident) would benefit from PT services." 

The Director further communicated that Resident 

#20 not only had a left hand contracture, but also 

had contractures in both ankles. 

F 428 

SS=D 

Cross-reference Tag F311 

483.60(c) DRUG REGIMEN REVIEW, REPORT 

IRREGULAR, ACT ON 

The drug regimen of each resident must be 

reviewed at least once a month by a licensed 

pharmacist. 

The pharmacist must report any irregularities to 

the attending physician, and the director of 

nursing, and these reports must be acted upon. 

F 428 


by: 

Based on interview, record review and policy 

review, the facility failed to ensure the consulting 

pharmacist drug report was acted upon for the 

use of the sleeping medication Restoril for 1 of 30 

sampled residents (Resident #23). 





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11/6/07, with diagnoses including renal cell 

carcinoma, syncope and high blood pressure. 

Documentation in the medical record indicated 

Resident #23 had memory problems and was 

moderately impaired with daily decision making 

skills. 


dated 11/18/10, for Restoril 7.5 milligrams (mg) 1 

capsule by mouth at bedtime for insomnia. May 

give 15 mg (two 7.5 mg capsules) if 7.5 mg (1 

capsule) is ineffective at bedtime for insomnia. 

A consultant pharmacist drug regimen review 

form dated 12/27/10, documented change 

Restoril 7.5 mg to prn (as needed). The 

consultant pharmacist drug regimen review form 

lacked documentation the pharmacist's 

addressed the resident's use of Restoril after the 

12/27/10 recommendation. 

The medical record lacked documentation to 

show the pharmacist recommendation was 

addressed by the physician. There was no 

documentation in the medical record to show a 

dose reduction was attempted per the pharmacist 

recommendation or documentation from the 

physician to justify why attempting a trail 

reduction was not appropriate at the time of the 

recommendation. 

On 3/4/11 at 9:00 AM, Employee #12 verbalized 

the pharmacist does a drug review and 1-2 days 

later the Director of Nursing (DON) receives the 

recommendations. The DON splits up the 





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recommendations by unit and the 

recommendations were given to the unit 

managers. The can physician agree or disagree 

with the pharmacist's recommendations. When 

the recommendation form has been signed by the 

physician, and an order received the 

documentation goes into the chart and the 

original form goes to the DON. 

On 3/4/11 at 12:30 PM, Employee #12 stated she 

was not able to locate documentation in the 

medical record to show a dose reduction was 

attempted or the physician had addressed the 

pharmacists recommendation to decrease the 

resident's Restoril. 


stated the Pharmacist consultant form should 

have been completed. The expectation of the 

facility was the physician was to respond to the 

pharmacist's recommendations with in 7 days. 

F 441 

SS=D 

The facility's policy on Psychotropic/Psychoactive 

Drugs dated 7/09, documented Both the 

consulting pharmacist and the physician review 

the progress of the patient/resident and advise 

the nursing staff in the development of goals and 

a plan to maintain the patient/resident at the 

lowest possible dose necessary to control 

symptoms. 

483.65 INFECTION CONTROL, PREVENT 

SPREAD, LINENS 

The facility must establish and maintain an 

Infection Control Program designed to provide a 

safe, sanitary and comfortable environment and 

to help prevent the development and transmission 

of disease and infection. 

F 441 





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(a) Infection Control Program 

The facility must establish an Infection Control 

Program under which it - 

(1) Investigates, controls, and prevents infections 

in the facility; 

(2) Decides what procedures, such as isolation, 

should be applied to an individual resident; and 

(3) Maintains a record of incidents and corrective 

actions related to infections. 

(b) Preventing Spread of Infection 

(1) When the Infection Control Program 

determines that a resident needs isolation to 

prevent the spread of infection, the facility must 

isolate the resident. 

(2) The facility must prohibit employees with a 

communicable disease or infected skin lesions 

from direct contact with residents or their food, if 

direct contact will transmit the disease. 

(3) The facility must require staff to wash their 

hands after each direct resident contact for which 

hand washing is indicated by accepted 

professional practice. 

(c) Linens 

Personnel must handle, store, process and 

transport linens so as to prevent the spread of 

infection. 


by: 

Based on observation, interview and policy 

review the facility failed to transport and store 

linen in an manner which prevent the spread of 

infection and failed to ensure personal hygiene 





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supplies were labeled with the resident's name. 


1. On 3/1/11 at 8:30 AM, during the initial tour a 

staff member was holding linen up against the 

uniform while walking in hallway. 

On 3/1/11 at 9:20 AM, a Certified Nursing 

Assistant (CNA) was holding linen up against the 

uniform outside room 1205. 


standing at the nurse's station holding linen up 

against her uniform. 

On 3/3/11 at 9:30 AM, Employee #21 stated she 

was taught to carry clean linen away from her 

body. 

2. On 3/1/11 at 10:12 AM, three tooth brushes 

were unlabeled in the shared residents bathroom 

in room 301. Employee #29 verbalized the tooth 

brushes should be labeled because two residents 

shared the bathroom. "You do not know whose is 

whose." 

3. On 3/3/11 at 7:35 AM, box of gloves , 2 boxes 

isolation face masks and a half bottle of 

Epi-cleaner were in the clean linen closest on the 

shelf with stacks of clean linen. 

On 3/3/11 at 1:05 PM, Employee #4 verbalized 

isolation masks,boxes of gloves and half bottle of 

Epi-cleaner were "absolutely not to be in the 

clean linen closet." 





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The facility's policy on Laundry dated 3/2006, 

documented, "Linens are to be handled in a safe 

manner to prevent contamination of the linen, the 

personnel and the environment. Clean linen is 

never held up against personnel's body."

department of health and human services centers for medicare ...

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