Iowa Department of Inspections

Number Report date
FC# 6780 March 23, 2018

Facility name Survey dates: December 27, 2017
Casa De Paz thru March 8, 2018
Facility address
2121 W 19th Street
City MW
Sioux City, IA 51103
Rule or Code Nature of Violation Class Fine Correction
Section Amount Date
56.6 481—56.6 (135C) Treble and double fines. I $10,000 Upon

56.6(1) Treble fines for repeated trebled Receipt
violations. The director of the department ($30,000)
of inspections and appeals shall treble Held in
the penalties specified in rule 481— Suspensi
56.3(135C) for any second or subsequent on
class I or class II violation occurring
within any 12-month period, if a citation
was issued for the same class I or class II
violation occurring within that period and
a penalty was assessed therefor
58.19(2)j 58.19(2) j Provision of accurate

assessment and timely intervention for all
residents who have an onset of adverse
symptoms which represent a change in
mental, emotional, or physical condition.
(I, II, III)
Description:
Based on observation, record review, family,

physician and staff interviews, the facility failed
to provide the necessary care and services to
attain or maintain the highest practicable
physical, mental, and psychosocial well-being,
consistent with the resident's comprehensive
assessment and plan of care for 5 of 27
sampled residents. The facility failed to assess
significant changes in condition for 5 residents.
(Resident #6, Resident # 2, Resident #4 ,
Resident # 8, Resident #1). The facility
identified a census of 56 current residents.
Findings include:
If, within thirty (30) days of the receipt of the citation, you: (1) do not request a formal hearing or; (2) withdraw
your request for formal hearing; and (3) pay the penalty, the assessed penalty will be reduced by thirty–five
percent (35%) pursuant to Iowa Code section 135C.43A (2015).
Page 1 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
1. A Minimum Data Set (MDS) with

assessment reference date of 11/28/17,
assessed Resident #6 with a brief interview for
mental status (BIMS) score of "13" (no
cognitive impairment).The resident had
delusions and verbal behaviors 1 to 3 days out
of 7. The record did not identify rejection of
care. The resident required extensive staff
assistance with bed mobility, transfers,
dressing, toileting and bathing. The resident
did not ambulate. A "balance during transitions
and walking" test revealed the resident was not
steady and only able to stabilize with staff
assistance in all areas of testing. The resident
had falls since the prior assessment.
An incident report dated 11/6/17 at 3:08 p.m.

revealed staff observed the resident seated on
the floor of the doorway to her room. The
resident had to go to the bathroom. The
resident stated her ring finger hurt. Staff did
not observe injury. A post fall assessment
dated 11/6/17 at 3:08 p.m. did not contain any
information other than the resident's vital signs.
It was unknown when staff last saw or toileted
the resident. A post fall assessment dated
11/6/17 at 4:08 p.m. did not contain
information other than vital signs and that the
resident had a pain level of "2" on a scale of 0
to 10 with 0 being no pain and 10 being the
worst pain.
A progress note dated 11/6/17 at 3:17 p.m.

documented another resident saw the resident
Page 2 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
fall to the floor. Staff observed the resident in a

seated position and the resident said she
injured the ring finger of the right hand. The
resident could bend the finger and staff did not
observe bruising or swelling. Staff placed
gripper socks on the resident and assisted her
back in the wheelchair.
There was no further documentation regarding

the resident's finger/hand other than progress
notes dated 11/7/17 at 2:30 a.m. revealed the
resident had no new injuries visible.
Progress notes dated 11/8/17 at 3:31 p.m. the

resident returned to the facility from the
physician with a cast on the right arm/hand.
A clinic note dated 11/8/17 revealed the

resident had a 5th metacarpal fracture and the
cast must be left on at all times with a sling for
comfort. Progress notes did not identify the
resident leaving the facility or why the resident
had an appointment with the physician.
On 2/7/18 at 9:13 a.m. the Administrator stated

the resident went to the physician for
something else and when she returned she
had a cast on and there was a fracture. The
Administrator denied there was any evidence
of injury prior to the appointment.
On 2/28/18 at 1 p.m. the surveyor spoke with

the van driver that transported the resident to
the 11/8/18 clinic appointment. He denied any
type of incident occurred that injured her hand
Page 3 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
while she was out of the facility.
On 2/7/18 at 9:41 a.m. the surveyor spoke with

the ARNP (advanced registered nurse
practitioner) who stated the resident had an
appointment for her abdominal pain but when
she arrived she complained of hand pain.
When the ARNP assessed the hand it was
extremely swollen with significant ecchymosis
and tender. The ARNP said it was obvious the
resident had an injury but the facility easily
dismisses the resident's complaints and are
always angry with the resident. The ARNP
stated she ordered a follow up appointment 2
weeks after the 11/8/17 visit and the facility
never sent the resident.
Review of the November 2017 medication

administration record (MAR) revealed the
resident did not receive pain medication until
after the 11/8/17 fracture diagnosis.
Respiratory
A medication review report dated 10/26/17

contained a physician note and orders after a
physician visit. The physician documented the
resident's oxygen saturation reading was 89%
and pulse was 91. The resident complained of
shortness of breath and cough. The resident's
temperature was 99.1 degrees. The physician
heard rhonchi though the resident's lungs
bilaterally upper and lower. The physician
ordered Doxycycline (antibiotic) 100 milligrams
(mg.) for 7 days.
Page 4 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Progress notes identified staff documented the

resident received antibiotics for COPD (chronic
obstructive pulmonary disease)/ URI (upper
respiratory infection) on 10/26/17 at 11:18 p.m.
and 10/27/17 at 12:41 p.m.. The rest of the
entries on 10/29/17 at 9:08 p.m., 10/30/17 at
9:56 p.m., 10/31/17 at 9:51 a.m., 10/31/17 at
6:46 p.m., 11/1/17 at 9:03 a.m. and 11/1/17 at
9:19 p.m. stated the resident received the
antibiotic for a UTI (urinary tract infection).
Progress notes revealed the resident received

cough syrup for cough/ congestion/unable to
sleep on 11/28/17 at 7:24 a.m., 11/29/17 at
8:26 p.m., 11/30/17 at 10:36 p.m., 12/8/17 at
7:16 p.m., 12/12/17 at 4:51 p.m., 12/13/17 at
9:20 p.m., 12/14/17 at 11:24 p.m., 12/17/17 at
12:13 p.m., and 12/19/17 at 7:42 p.m. The
notes did not identify an assessment of the
resident when the resident continued to
complain of cough and wanted cough syrup.
On 12/23/17 at 5:56 p.m. the resident
complained of general pain including the chest.
The resident was sweaty and leaning to the left
side. The resident exhibited general weakness
even with transfers which was unusual for the
resident. There was no vital signs or physical
assessment documented. Staff notified the
physician who directed staff to send the
resident to the emergency room (ER).
The resident returned to the facility on

12/26/17 at 4:55 p.m. A hospital history and
physical dated 12/26/17 revealed the resident
Page 5 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
presented to the ER for chest pain of several

days. The resident also reported increased
shortness of breath. The resident had 3 plus
pitting edema of the bilateral lower extremities
and was wheezy in the bilateral lung bases.
The review of the systems identified positive
for cough, sputum production, shortness of
breath and wheezing. Positive for chest pain
and leg swelling. None of the symptoms
identified in the ER was assessed by the
facility. The diagnoses included: COPD
(chronic obstructive pulmonary disease)
exacerbation, fluid overload and leukocytosis
(elevated white blood count). The resident
returned with orders for daily weights and
notify the physician if the resident gains 3
pounds in one day or 5 pounds in one week
and levaquin (antibiotic). The resident's Lasix
(diuretic) was increased.
A December 2017 medication administration

record (MAR) identified initials on 12/28/17,
12/29/17, 12/30/17 that indicated weekly
weights were done. The entry 12/27/17 stated
to "see nurses notes". Nurses notes dated
12/27/17 at 11:48 a.m. contained the order
"daily weights and notify physician of the
resident gains 3 pounds in one day or 5
pounds in one week" and did not contain any
weight recording. There was no
documentation of the weight itself. Nothing
was recorded for 12/31/17.
On 1/3/18 the ARNP directed staff to weigh the

resident weekly and call if the weight gain was
Page 6 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
over 5 pounds. TED hose (compression

stockings) every morning and off at night.
Discontinue Levaquin.
A January 2018 MAR identified the first weight

recorded in January 2018 as 1/8/18 of 228.4
pounds. The weight on 1/25/18 was 228.4
pounds and the weight on 1/30/18 was 235.6
pounds and 1/31/18 was 236.6 pounds. There
was no evidence staff informed the physician.
The January 2018 MAR revealed staff
administered Levaquin on 1/4/18 even though
the medication was discontinued the day
before.
Progress notes dated 1/5/18 at 7:23 p.m.

revealed staff ordered TED hose for the
resident. Progress notes dated 1/8/18 at 7:47
a.m. revealed the TED hose did not arrive from
the pharmacy yet.
After readmission to the facility from the

hospital for COPD exacerbation and fluid
overload, the record lacked evidence there
were any respiratory assessments, edema
assessments or vital sign assessments until
progress notes dated 1/9/18 at 10:09 a.m.
revealed staff called the physician at 9:30 a.m.
The resident was very weak and had a
temperature of 101.1. Blood pressure 96/67,
heart rate 127, respiration 26 and oxygen
saturation 89%. Lung sounds were very coarse
and wet sounding throughout. Staff
reassessed the resident at 9:55 a.m. and
oxygen saturation was in the lower 80's,
Page 7 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
respirations 32 and more labored. Staff called

911 and the resident left per ambulance. The
resident returned to the facility on 1/11/18 at
4:49 p.m. with diagnoses of pneumonia, sepsis
and influenza.

revealed TED hose were not on. Progress
notes revealed the first respiratory
assessment, after the 1/11/18 hospital return,
was 1/23/18 at 10:55 a.m. Lung sounds were
clear, vital signs within normal limits and
oxygen saturation reading was 93%. There
was no edema assessment from 1/11/18 until
2/7/18. Progress notes dated 2/5/18 at 5:47
p.m. revealed there were no TED hose.
Progress notes dated 2/6/18 at 6:59 a.m.
revealed staff ordered new TED hose. On the
same date at 5:14 p.m. progress notes stated
staff could not locate the TED hose. Progress
notes dated 1/8/18 at 7:29 a.m. revealed the
TED hose did not arrive from the pharmacy.
An entry dated 1/17/18 at 10:54 p.m. identified
the TED hose as "not on".
On 2/12/18 at 1:15 p.m. the pharmacy stated

they sent TED hose on 1/5/18.
On 2/16/18 at 9:21 a.m. the ARNP stated the

facility absolutely should have assessed the
resident's respiratory status and done the
weights as ordered. Facility failure to conduct
the assessments contributed to the resident's
hospitalization. Sepsis causes organ damage
and with a proper assessment the situation
Page 8 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
would have been caught before she got septic.
Observation:
On 2/7/18 at 2:30 p.m. the surveyor asked the

director of nursing (DON) to accompany her to
the resident's room to check the resident's
feet. The resident's lower extremities appeared
edematous and the resident did not wear TED
hose.

DON documented the resident had 2 plus
pitting edema in bilateral lower extremities.
The DON contacted the physician's office.
On 2/7/18 at 4:18 p.m. end of the day meeting

the surveyor expressed concerns wondering if
staff would have noted the edema if the
surveyor had not taken the DON to the
resident's room.

the facility would have become aware of the
edema the morning of 2/8/18 because a staff
informed the DON that morning about the
resident's edema.
The 2/18 MAR revealed the resident's weight

on 2/7/18 was 237.4 pounds.
Observation showed on 2/12/18 at 10:30 a.m.

Staff B RN wheel the resident down the hall.
The resident wore white anklets and no Ted
hose. Staff B confirmed the resident did not
Page 9 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
have TED hose on.
On 2/12/18 at 4:30 p.m. the facility received a

verbal order from the physician for ace wraps
to bilateral lower legs daily. Observation
showed on 2/15/18 at 8:30 a.m. and 10 a.m.
the resident in a wheelchair with legs in the
dependent position. The resident's legs were
swollen and she did not have TED hose or ace
wraps on.
2/28/18 ER visit:
On 2/28/18 at 7:47 a.m. progress notes

identified the resident with a fever of 101 per
ear thermometer. The resident was lethargic.
The resident's blood sugar was 135. The
facility informed the physician. At 10:37 a.m.
the resident transported to the ER. The
progress notes did not contain lung
assessments or vital signs other than the
resident's temperature and blood sugar. On
2/28/18 at 1:15 p.m. Staff B RN stated she
listened to the resident's lungs but did not
complete blood pressure pulse or respirations.
On 2/28/18 at 2:46 p.m., Staff B stated the
resident's lungs sounded good. Staff B didn't
think of doing vitals. She stated she did not
recall attending an inservice on 2/20/18. A late
entry revealed Staff B RN assessed the
resident's lung sounds with no abnormal
sounds identified. The resident had normal
respirations and no labored breathing.
An after visit summary dated 2/28/18 identified

Page 10 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the reason for the visit was shortness of breath

and fever. The diagnoses was: COPD
exacerbation. The resident received a new
order for Doxycycline (antibiotic) 100 mg. twice
a day for 10 days and Prednisone (steroid) 10
mg 3 tablets a day for 3 days, 2 tablets for 3
days, one tablet for 3 days and then stop.
2. A MDS with assessment reference date of

4/22/17 assessed Resident #4 with a BIMS
score of "10" (moderate cognitive impairment).
The resident had no behavior symptoms
identified. The resident was independent with
bed mobility, transfers, ambulation and
toileting. The MDS identified the resident with
diagnoses that included: dementia and COPD
(chronic obstructive pulmonary disease).

revealed the resident received as needed
(PRN) morphine for shortness of breath. No
vital signs or physical assessment.

revealed the resident received PRN morphine
for shortness of breath. No vital signs or
physical assessment.

revealed the resident's symbicort inhaler for
breathing was empty and there was not a new
one on hand. Staff charted the morphine given
earlier was "effective". No vital signs or
physical assessment.
Page 11 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

revealed the resident received PRN lorazepam
0.5 mg for rapid breathing.
Progress notes late entry dated 8/9/17 at 8:47

p.m. revealed the resident was short of breath
and requesting to use the commode. The
resident was confused and his oxygen was on
5 liters. Oxygen saturation reading was 95%
(normal). Pulse was over 100. Staff
administered PRN ativan and placed the
oxygen on 2 liters as ordered. There were no
vital signs or physical assessment
documented.

p.m. revealed the resident remained confused
and had difficulty talking due to shortness of
breath. The resident appeared calmer and his
pulse was below 100. Oxygen saturation
reading was 82% (low). Staff administered a
scheduled breathing treatment. There were no
vital signs or physical assessment
documented.

p.m. revealed the resident appeared calmer
and sleepy now. The resident remained
confused. Staff attempted to assist the
resident to the commode via EZ stand but the
resident was too weak to use it safely. 3 to 4
staff assisted the resident to bed with a gait
belt. Staff elevated the head of the bed and
applied the C-pap. The resident's oxygen
saturation remained in the lower 80's with
Page 12 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
oxygen at 2 liters. The oxygen saturation was

around 88 to 90% when the oxygen was at 3
liters The resident's fingertips were cool but no
mottling. There were no vital signs or physical
assessment documented.

p.m. revealed staff found the resident sitting at
the bedside leaning over the bedside table with
c-pap intact. The resident was calm and
comfortable. There were no vital signs or
physical assessment documented.
Progress notes late entry dated 8/9/17 at 10

p.m. revealed nurse aides paged the nurse to
come to the resident's room STAT. Staff found
the resident lying across the bed with oxygen
off and mottling all over the body. The resident
had no pulse or respirations. Staff contacted
hospice and the physician.
The record lacked evidence the facility notified

hospice or the physician when the resident
experienced a condition change. There were
no vitals documented, breath sounds or
physical assessments.
Staff working on the resident's hall the evening

of 8/9/17:
On 2/13/18 at 11:33 a.m. Staff I RN (registered

nurse) stated she was the resident's nurse that
evening. She stated she did not notify the
physician or hospice because the prior shift
told her they were aware of the resident's
Page 13 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
condition. Staff I stated the resident was

confused and removing his oxygen all day.
She heard the information in report. She stated
the resident was unable to reapply the oxygen
once he took it off. The resident would try but
could not get it on correctly. She stated she
thought staff last saw the resident when she
last documented on him prior to the discovery
he expired (30 minutes) She stated she turned
the resident's oxygen down because the order
was for 2 liters.
On 2/12/18 at 12:27 p.m. Staff J CMA (certified

medication aide) stated the resident ate a little
and said he was tired. The nurse gave him a
breathing treatment around 9:15 p.m. to 10
p.m. and the next thing Staff J knew, the
resident was gone. He stated he saw the
resident take off his oxygen a couple times. He
didn't know if the resident took it off
intentionally. They walked the resident to the
bathroom and he was weak. Staff J got the
nurse because he thought the resident was
slow to respond. His speech was slurred. he
usually put himself to bed but that night he was
too weak. Staff J stated the resident had the
oxygen on when he last saw him around 9:15
p.m. He was sitting up in bed and Staff I
checked the resident's vital signs.
On 2/12/18 at 2:53 p.m. Staff K CNA (certified

nurse aide) stated the resident was short of
breath that night. She recalled the resident
wanting to get to the bathroom. He got there
and just stayed in the chair. He was sliding
Page 14 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
over so they put him in bed. The resident had

no energy and later on expired. She stated the
resident had shortness of breath but that day it
was pretty bad. She stated the resident took
the oxygen on and off and he knew how to do
it. She stated she last saw the resident when
he got in bed maybe within the hour of when
he expired.
On 2/12/18 at 1:46 p.m. Staff L LPN (licensed

practical nurse) stated she wasn't sure she
knew who the resident was.
Hospice nurse:
On 2/13/18 at 9:53 p.m. the hospice nurse

stated no one reported the resident's change
of condition and she would have wanted to be
notified. She stated the resident did not usually
take his oxygen off. He was dependent on it.
She stated hospice calls the physician if there
are changes in the resident's status and the
facility should have called her. She would have
come to the facility right away and checked
when the resident last had roxanol (morphine
narcotic) which may help breathing and make
sure the resident was comfortable. She stated
she was not told of the changes preceding
staff finding the resident expired. She stated
she was shocked to hear the information from
the surveyor.
Review of the August 2017 medication

administration record (MAR) revealed staff
administered routine morphine 5 mg. at 6 p.m.
Page 15 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
The resident had routine norco (narcotic) 7.5

mg/325 mg. at bedtime. The last PRN dose of
morphine was at 7:40 a.m. on 8/9/17.
A death certificate identified the resident's

cause of death as clinical decline due to a
consequence of COPD.

score of "13" (no cognitive impairment). The
resident did not have delusions, hallucinations
or behaviors identified. The MDS revealed the
resident required extensive assistance with
bed mobility, dressing, toileting, personal
hygiene and total assistance with bathing. The
resident did not ambulate. The resident had
an indwelling urinary catheter and occasionally
incontinent of bowel. The MDS identified the
resident had occasional pain that did not
interfere with day to day activities. The resident
rated the pain level as a "2" with 0 being no
pain and 10 being the worst pain. The MDS
revealed the resident had shortness of breath
when lying flat. The resident had a surgical
wound. The MDS did not identify any other
areas of skin impairment. The resident
expected discharge to the community.
An ADL (activity of daily living) CAA (care area

assessment) worksheet dated 11/1/17
revealed the resident recently admitted to the
facility after an acute hospital stay for back
surgery, laminectomy. The resident was on
strict bedrest and received skilled care for IV
Page 16 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
(intravenous) therapy. The resident's goal was

to work with therapy once he was off bedrest
to improve ADL abilities and then return home.
A nutritional status CAA dated 11/2/17
revealed the resident's bed could not be
elevated higher than 15 degrees. A pressure
ulcer CAA dated 11/1/17 identified the resident
at risk for pressure ulcers.
A fax to the physician dated 10/25/17 informed

the physician the resident had increased
nausea and vomiting. Review of progress
notes failed to identify any nausea or vomiting
prior to the 10/25/17 fax. The physician
responded by ordering Zofran (antiemeitic) 4
milligrams (mg.) twice a day as needed
nausea vomiting.
Progress notes revealed the following:
10/23/17 at 4:58 p.m. revealed the resident

arrived at the facility per ambulance.
10/26/17 at 11:56 a.m. staff sent a fax to the

physician to report audible congestion. A
return fax dated 10/20/17 revealed the
physician responded by ordering Duoneb
treatments every 6 hours while awake.
There were no lung sound assessments.
Progress notes failed to contain any additional

information regarding congestion or lung
sound assessments.
Page 17 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
10/30/17 at 5:17 a.m. the resident complained

of pain across the abdomen and across "butt".
There was no abdominal assessment of

assessment of the resident's bottom.
10/31/17 at 12:24 a.m. revealed the resident

complained of pain across the lower back and
butt. The resident rated the pain as a "5". Staff
administered Oxycodone.
There was no assessment of the resident's

back or buttocks.
11/1/17 at 12:23 p.m.,. revealed staff

administered Zofran for nausea. There was no
assessment at the time. On the same date at
1:51 p.m. staff documented the Zofran was
ineffective and the resident now vomited dark
brown and mucus colored phlegm. There was
no assessment at that time. On the same date
at 3:10 p.m. revealed staff notified the
physician the resident vomited brown red
mucus. and that staff administered Zofran.
Staff did not do an abdominal assessment.
The resident blood pressure was 118/62, pulse
72 and temperature 97.6 degrees. On the
same date at 3:13 p.m. staff called the
physician again requesting a response since
the resident still had dry heaves and vomiting.
The physician directed staff to administer
another Zofran and said the dark colored vomit
may be bile from the stomach. Staff
documented the 2nd shift nurse would
administer the Zofran. Call the physician if the
Page 18 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
second Zofran did not help.
The November 2017 medication administration

record (MAR) revealed the resident did not
receive a second Zofran as the physician
ordered.

coughed up phlegm and had nausea. The
resident had congested lungs throughout. The
DON (director of nursing) documented the
charge nurse informed the physician of the
lung congestion.
The record lacked evidence the charge nurse

ever documented she notified the physician of
the lung congestion when she called him that
day.
There was no further mention of the resident's

lungs or respiratory status until 11/2/17 at
11:10 a.m. when the resident went to the
emergency room (ER) for evaluation of
congestion. The resident returned on the same
date at 5:42 p.m. with a diagnosis of heart
failure and an order for Lasix (diuretic). The
physician requested an update in the morning.
Progress notes identified the facility placed a
call to the physician on 11/3/17 at 2:22 p.m.
The physician returned the call at 2:45 p.m.
and increased the Lasix order.

continued to have back and leg pain. The
resident had an occasional productive cough
Page 19 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
and no signs of dyspnea. Review of the

November 2017 MAR did not identify staff
gave the resident pain medication other than
one acetaminophen 325 mg at 12:21 a.m. and
7:41 p.m. on 11/3/17.
11/3/17 at 10:33 p.m. staff sent a fax to the

physician to update that the resident continued
with chest congestion
and productive cough.
There was no evidence the physician returned

the fax or the facility attempted to contact the
physician again for a response.
11/4/17 at 1:27 p.m. a nurse documented the

resident's lungs were clear and there was no
dyspnea or cough.
There was no further assessment of the

resident's lungs or vital signs.
Skin grid forms dated 11/5/17 revealed a 5

centimeter (cm.) by 6 cm. red are to the
coccyx, a 1 cm. by 1 cm, red blanchable area
to the right heel and a 3.5 cm. by 2.5 cm. red
blanchable area to the left heel.
On 2/1/18 at 10:09 a.m. the resident's

daughter stated she was informed the resident
had a red coccyx on 11/1/17 and the daughter
informed the facility about the resident's heels.
11/6/17 at 2 a.m. revealed the resident had

pain in the right side and the resident couldn't
Page 20 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
sleep with no assessment completed. Staff

administered Ibuprofen/Diphenhydramine
which an entry at 5:08 a.m. identified as
partially effective.. On the same date at 5:06
a.m. the IV antibiotic dose was not available
for administration.
11/6/17 at 7 a.m. the resident had a brown

liquid emesis and crackles audible when lungs
assessed. The resident had labored breathing.
revealed the resident went to the ER at 7:45
a.m.
A death certificate revealed the resident

expired on 11/7/17 at 12:35 a.m. due to
aspiration pneumonia.
Staff Interviews:
Staff Working the overnight shift prior to the

11/6/17 ER visit:
On 1/30/18 at 1:30 p.m. Staff C RN (registered

nurse) stated she worked the overnight shift
prior to the resident going to the hospital. She
stated she never heard the resident yell that
night. That morning at shift change she went in
to give the resident his antibiotic and he said
he was nauseated. Staff went in and turned
the resident and they came out and said he
vomited. She stated staff reported it at shift
change so the day shift took over the resident's
care.
Page 21 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
On 1/30/18 at 3:45 p.m. Staff P CNA stated at

the end of the night she saw the resident vomit
dark material in the emesis basin. He said his
tailbone and lower back hurt. She couldn't
remember if he had sores.
On 1/30/18 at 1:45 p.m. Staff H CNA (certified

nurse aide) stated she worked the overnight
shift prior to the resident going to the hospital
on 11/6/17. The resident was very anxious
from 2 a.m. to 5 a.m. He was on the call light
and complaining of shortness of breath. Staff H
stated she told Staff C but she didn't know if
the nurse checked him. The resident looked
short of breath and pulled at his oxygen. The
resident told her had had his call light on for 3
hours but Staff H stated it had only been 10
minutes. The resident also complained of a
"rotten gut" on previous nights and day shifts.
The last time Staff H checked on the resident
he had not vomited. At the end of the night, the
nurse told her the resident was incontinent of
bowel so Staff H went in the resident's room.
The resident had yellowish vomit on his face
and no bowel movement. Staff H stated he
had not vomited all shift until then. Staff H
stated the resident wasn't looking good so she
asked the nurse to check him. Staff H felt like
the resident was in trouble. After that, the
resident went to the ER. She stated the
resident had vomited at other times . She saw
emesis a couple times. Staff H stated she
didn't think Staff C was as concerned about the
resident as she should have been.
Page 22 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Other staff:
On 2/1/18 at 10:30 a.m. Staff F CMA (certified

medication aide) stated the resident vomited
quite often.
On 1/31/18 at 8:45 a.m. Staff A LPN (licensed

practical nurse) stated the resident told her an
evening shift CNA put the resident up higher
than 15 degrees one time so the resident could
eat. Staff A stated she guessed the staff didn't
know. That staff was educated. She did not
know who the staff was. Staff A also heard
that someone tried to get the resident out of
bed for an appointment. She did not know who
the staff was.
On 1/31/18 at 8:35 a.m. Staff G CMA stated

the resident felt like he would vomit a few
times but he never did. There were times the
resident really struggled to breathe. He was
sent to ER a couple times for breathing
problems.
On 2/13/18 at 8:53 a.m. Staff M CNA stated

the resident vomited on his gown and
pillowcase once and she reported it to the
nurse. She stated the resident had pain when
he was moved. She stated the resident was
always on his back except when they changed
him.
On 1/25/18 at 1:41 p.m. Staff N RN stated one

time the resident was nauseated and she gave
Page 23 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
him a Zofran. He didn't vomit on her shift.
On 1/31/18 at 11:25 a.m. Staff O RN stated the

resident was congested and in discomfort and
she sent him to ER. He came right back to the
facility. She couldn't recall nausea and
vomiting.
Review of the resident's October 2017 and

November 2017 medication administration
records revealed only 1 Zofran was
administered his entire stay (from 10/23/17 to
11/6/17).

daughter stated when she arrived the morning
of 10/25/17 the resident was sitting up in bed
in direct violation of the physician order.
On 2/14/18 at 3:29 p.m. the physician stated

the care could have been better related to the
lack of assessments and vital signs. No pain
medication for 4 days is also a concern. He
stated if the facility did conduct assessments
and vitals signs appropriately it probably would
not have changed the outcome for the
resident. It is hard to know the answer that
question.
Bowels:
A hospital dismissal form dated 10/23/17

revealed the resident's last bowel movement
(BM) while hospitalized was 10/22/17.
Page 24 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Review of the resident's facility bowel records

revealed the resident had a medium BM on
10/31/17 and 11/3/17. All other bowel
movements recorded were "small".
On 2/15/18 at 8:50 a.m. the Administrator

stated she conferred with the DON and the
MDS nurse and the facility does not count
small BMs as a bowel movement. She stated
there was nothing in the policy regarding this.
On 11/6/17 a diagnostic radiology report

identified the resident with severe distention of
the stomach. The impression was that the
distention could be from obstructive changes
or gastroparesis. A large amount of stool was
demonstrated and there appeared to be mild
fullness of portions of the colon.
Review of facility documentation prior to

sending the resident to the hospital on 11/6/17
revealed no documentation regarding a
severely distended stomach.
Review of the resident's MARs did not identify

any laxative administered.
Facility policy titled "bowel and bladder

continence management" did not contain any
information about administering laxatives to
constipated residents.

Page 25 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

resident had no behaviors including rejection
of care. The resident required extensive staff
assistance with bed mobility, transfers, toileting
and bathing. The resident had an indwelling
urinary catheter and was frequently incontinent
of bowels. The MDS identified the resident at
risk for pressure sores and at the time of the
assessment staff documented the resident had
no skin impairment. The MDS identified the
resident with diagnoses that included: heart
failure and COPD (chronic obstructive
pulmonary disease). The resident admitted to
the facility 7/1/15.
12/11/17 at 1:32 p.m. and 12/12/17 at 11:11

a.m. staff could not complete the resident's
daily weights due to scale not working.
12/12/17 3:22 p.m. revealed the resident

complained of trouble breathing. Staff
administered a ProAir inhaler. The resident's
oxygen saturation reading was 94% on 3 liters
of oxygen. Respirations were moderately
labored at 20. Heart rate was 60 and regular.
Staff notified the physician's office and awaited
a response.
There was no documentation that the facility

received a response. There was no further
assessment of the resident until 12/13/17 at
7:13 a.m. when the resident complained of not
feeling well. The resident said he couldn't
Page 26 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
breathe right. The resident was afebrile with

oxygen saturation of 94% on oxygen, pulse 40
and irregular, blood pressure 110/48,
respiration 20. Staff encouraged the resident to
take deep breaths and cough. staff noted
some congestion and posterior lung sounds
were coarse. On the same date at 8:29 a.m.
staff called the physician and made an
appointment for that morning.
A MD/nursing communications form dated

12/13/17 revealed the physician diagnosed the
resident with a URI (upper respiratory
infection) and directed staff to administer
coricidin HBP cold and flu 2 tablets TID (three
times a day) for congestion.
There was no follow up on the resident's

condition respiratory status after 12/13/17.

revealed the resident had an altered level of
consciousness, slow response time, mild chest
pain, decreased appetite and low blood sugar
that morning. The facility notified the physician
who directed staff to send the resident to ER
(emergency room). A late entry dated 12/16/17
at 3:15 p.m. revealed the resident admitted to
the hospital.
A hospital discharge summary dated 12/21/17

identified the resident with diagnoses that
included: heart failure. The instructions
included daily weight monitoring. Notify the
physician if the weight was up 2-3 pounds
Page 27 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
overnight or 4-5 pounds in 5 days. And any

change of condition. The resident returned to
the facility 12/21/17 at 4:06 p.m. on hospice
services.
Review of progress notes failed to identify

follow- up respiratory or edema assessments.

revealed the resident saw the physician with
no new orders.
Review of weights revealed the following:
12/14/17 at 1:07 p.m. 255.8 (chair scale)

12/27/17 at 11:43 a.m. 288.8 pounds
(wheelchair)
12/31/17 at 12:12 p.m. 275.4 pounds
(wheelchair)
1/1/18 at 10:18 a.m. 227.6 pounds
(wheelchair)
1/4/18 at 11:55 a.m. 270 pounds (chair scale)
1/6/18 at 12:09 p.m. 271.8 pounds (chair
scale)
1/9/18 at 9:08 a.m. 236.8 pounds (wheelchair)
1/10/18 at 2:49 250 pounds (wheelchair)
The record lacked evidence the facility

reported the weights to the physician,
assessed lung sounds for evidence of heart
failure or assessed for edema.
Progress notes revealed evidence of increased

anxiety beginning 1/1/18. Staff administered
lorazepam (antianxiety) 0.5 mg. on the
Page 28 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
following dates and times for anxiety:
1/1/18 at 3:20 a.m.

1/2/18 at 11:26 p.m.
1/3/18 at 9:32 a.m.
1/4/19 at 2:22 a.m.
A hospice note dated 1/3/18 revealed the

resident had increased agitation that got worse
through the night. The resident repeatedly
yelled "help me" and when asked what he
needed help with the resident replied he did
not know. The resident called out even when
staff were in the room.
Staff administered lorazepam 1 mg. on the

following dates and times for anxiety/agitation:
1/4/18 2:26 p.m., 11:14 p.m.

1/5/19 4:36 p.m.
1/6/18 4:20 a.m. 0.5 mg given, 5:53 a.m. 0.5
mg given
1/7/18 3:31 a.m., 7:36 a.m., 12:56 a.m. 0.5 mg
given
1/8/18 11:35 a.m. 0.5 mg given
1/9/18 3:54 a.m. 0.5 mg given
Staff administered haldol (antipsychotic) 0.5

ml. (milliliters) 2 mg/ml on the following date
and times for pain/anxiousness:
1/9/18 at 9:11 p.m.

1/11/18 at 12:48 a.m.
1/13/18 at 5:55 p.m.
1/14/18 at 2:05 a.m.
Page 29 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
The record lacked evidence the facility

attempted to determine the cause of the
anxiety or relate it to possible respiratory
issues due to increases in weight. The facility
conducted no assessments and did not notify
the physician of the weight changes.
Observation:
On 1/3/18 at 9:15 a.m. the resident sat in his

room in a recliner and stated he was sick. The
surveyor reported it to the charge nurse. There
was no documentation the charge nurse
assessed the resident.
On 1/14/18 at 6:59 a.m. the resident expired.
A death certificate identified cause of death as

"renal failure".
On 2/15/18 at 12"50 p.m. the PA (physicians

assistant) stated the facility should have
assessed the resident and called to report
weight changes and the results of the
assessment. He stated its hard to say if the
facility assessed and reported weights could
have changed the outcome for the resident-the
resident was sick anyway- it may have.
Skin Issues:

identified the head of the resident's penis
swollen and irritated. Staff applied antibiotic
Page 30 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
ointment.
There was no further

assessment/documentation of the penis.
Observation:
On 1/2/18 at 2 p.m. the resident was asleep in

the recliner with oxygen running at 3 liters. The
resident remained in this position at
subsequent observations of 2:35 p.m., 2:55
p.m., 4 p.m., 4:45 p.m. and 5 p.m. On the
same date at 4:12 p.m. the surveyor asked the
DON if the resident sat on a pressure
reduction cushion in the recliner chair. The
DON stated there was not a cushion in the
recliner. Observation showed a vicair vector
cushion in the resident's wheelchair.
On 1/3/18 at 7:35 a.m. observation showed a

dark red abraded peeling areas to the left
buttock approximately 3 centimeters (cm.) in
size. On the same date at 10:45 a.m. staff
assisted the resident off the toilet. When staff
wiped his bottom the resident said "ow". Staff
transferred the resident into bed. At that time,
Staff A LPN (licensed practical nurse)
cleansed the left buttock area with normal
saline and applied remedy phytoplex Z guard
paste. The hospice nurse told Staff A to also
apply it to a red excoriated area on the right
buttock approximately 3 cm. in size. Staff A
used the same gloves to apply the ointment to
both left and right buttocks. At that time Staff A
confirmed she did not change gloves. She
Page 31 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
stated she didn't have orders for the right

buttock so she did not plan on doing it when
she entered the room to perform treatments.
A physician order dated 12/26/17 apply thin

layer of barrier cream to coccyx area every
shift and PRN.
A January 2018 treatment administration

record (TAR) identified an order dated
12/26/17 that directed staff to provide
treatment to the right and left buttock as
follows: cleanse open areas with normal
saline, apply thin layer of barrier cream to
coccyx area every shift and PRN. The TAR
showed staff performed the treatment every
other day.
A skin grid form dated 12/21/17 identified an

open area to the left buttock that measured 0.4
centimeters by 0.5 cm. There were no follow
up measurements to the area. The right open
area was never measured.
A clinical progress note dated 1/4/18 revealed

an order for vaseline to excoriated areas on
buttocks once a shift. The January TAR did not
contain the order therefore it was never carried
out.
A care plan dated 9/26/17 identified the

resident with potential for skin impairment. The
care plan directed staff to provide pressure
reduction to the recliner and encourage and
assist with frequent repositioning throughout all
Page 32 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
shifts.

10/31/17, assessed Resident #1 with a brief
interview for mental status score of "15" (no
cognitive impairment). The MDS did not
identify behavior concerns. The resident
required extensive staff assistance with bed
mobility, transfers, dressing, toileting, personal
hygiene and bathing. The resident did not
ambulate. The resident had functional
limitations in range of motion in both lower
extremities. The resident used a wheelchair for
mobility. The resident had an indwelling
catheter and ostomy. The resident had
diagnoses that included: paraplegia, COPD,
diabetes mellitus and chronic pain. The
resident admitted to the facility 12/14/16. A
2/8/18 consultation report identified the
resident with a colocutaneous fistula of the
lower left quadrant and Stage 4 sacral
decubitus ulcers of the coccyx, left buttocks
and right ischial decubitus ulcers.
A hospital history and physical (H & P) dated

2/8/18 revealed the resident discharged from
the hospital on 1/23/18.
Review of facility progress notes revealed no

documentation regarding the resident going to
the hospital on 1/18/18 or returning from the
hospital on 1/23/18. Progress notes failed to
identify any symptoms or rationale for the
hospitalization prior to the 1/18/18 hospital
admission.
Page 33 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
A hospital history and physical dated 1/18/18

revealed the chief complaint as: shortness of
breath, fever, diaphoresis. The H & P also
revealed the resident had a congested cough,
tachycardia and appeared dehydrated. Lung
sounds contained diffuse rhonchi, crackles in
lung bases, expiratory wheezes heard
throughout the lungs as well as a prolonged
expiratory phase.
A hospital discharge summary dated 1/23/18

revealed the discharge diagnoses as: 1. sepsis
with tachycardia, tachypnea and influenza B 2.
complicated urinary tract infection with
extended spectrum beta-lactamase
escherichia coli.
2/21/18 Appointment Incidents:
A 2/15/18 hospital wound note revealed a

PICC line was placed for IV (intravenous)
administration of antibiotics for 2 weeks.
A 2/21/18 nursing progress note revealed the

resident arrived at the hospital for port
placement. At the time of arrival, the resident's
wound vac was full and alarm sounding. The
resident's Foley bag also contained 800 cc of
urine on arrival. The resident had a urostomy
with an outdated bandage which leaked and
ran down to the resident's groin causing the
resident's undergarment to be soaked with
urine. The resident's PICC line dressing was
outdated and coming off.
Page 34 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
February 2018 treatment administration

records (TARs) revealed no entry for PICC line
care (no PICC care for 7 days). The last
urostomy bag change signed for was dated
2/2/18.
On 2/26/18 at 1:30 p.m. Staff R CMA (certified

medication aide) stated the resident's wound
vac was beeping the morning the resident left
for 2/21/18 appointment. At that time, Staff R
stated the wound vac was not plugged in all
night.
On 2/28/18 at 11:48 a.m. Staff F CMA stated

the wound vac was beeping when the resident
left the facility.
On 2/26/18 at 11:20 a.m. Staff B RN stated

she wanted to change the resident's urostomy
before she left on 2/21/18 but the resident
refused. She only allowed Staff B to reinforce it
with tape. The resident told Staff B she could
change the wound vac when the resident
returned to the facility. Staff B said the wound
vac was not beeping when she was with the
resident. On the same date at 2:07 p.m. Staff
B stated the resident's urostomy was actually
leaking when she reinforced it with tape. She
confirmed she observed the wound vac
unplugged when she arrived to the resident's
room that morning.
On 3/7/18 at 1:23 p.m. the resident stated the

wound vac was not plugged in all night before
Page 35 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the appointment. She did not recall if she

refused the urostomy change.
The facility did not have any policies regarding

IV therapy or PICC line care.
PICC line manufacturer information revealed

staff may need to change the PICC dressing
daily, 3 times a day or weekly if it is soiled or
loose. The physician or nurse would select the
most appropriate supplies routine care. The
record lacked evidence the facility checked
with the physician regarding the PICC line
care.
Review of 2/15/18 wound clinic final report

consultation notes did not identify orders for
the PICC line.
On 2/26/18 at 12:50 p.m. the Administrator

stated the facility did not have policies for
IV/PICC lines.
Facility Response:
Page 36 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
58.28(3) 58.28(3) Resident safety. I $2,000 Upon

Held in Receipt
e. Each resident shall receive adequate Suspensi
supervision to protect against hazards from on
self, others.
Description:
Based on observation, record review and staff

interview, the facility failed to ensure that the
resident environment remained as free of
accident hazards as possible; and each
resident received adequate supervision and
assistance devices to prevent accidents for 3
of 27 residents reviewed. The facility failed to
investigate incidents and failed to implement
appropriate interventions after incidents for
Resident #5, Resident #6 and Resident #18.
Resident #6 received a fractured metacarpal.
Resident #18 transported to the emergency
room for evaluation of head injury. The facility
also had hot water temperatures over 140
degrees resulting in hazards. The facility
identified a census of 56 current residents.
Findings include:
1. On 2/27/18 at 3:25 p.m. the surveyor

washed her hands in the women's rest room
and the hot water felt extremely hot. The
surveyor then checked Resident #9 and
Resident #17's room and the hot water was
145 degrees per facility thermometer. The
surveyor notified the Administrator and further
hot water checks were completed as follows:
Page 37 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
2/27/18 at 3:39 p.m. Resident #9 and Resident

#17's room measured 143.7 degrees and
143.3 degrees via facility thermometers.
Visible steam arose from the faucets when hot
water was tested. On 2/27/17 at 4:10 p.m.,.
Resident #17 stated the water had been hot for
a week. If it gets too hot she cools it with cold
water. She didn't report it to anyone.
On 2/27/18 at 3:42 p.m. Resident #1's room

water temperature was 142.8 degrees and
142.3 degrees via facility thermometer.
2/27/18 at 3:50 p.m. Resident #20 and

Resident #21's water temperature was 141.6
degrees and 141.3 degrees via facility
thermometers. At that time, Resident #20
stated the water was very hot. She stated she
had to turn the cold all the way on when she
used the hot water. At that time Resident #21
stated the water was hot but she just turned
the cold on when it got hot. The residents
stated they didn't report it to anyone, they just
turned on the cold water.
2/27/18 at 3:52 p.m. Resident #22 and

degrees and 138.5 degrees via facility
thermometer. Both residents denied concerns
with the water temperature.
2/27/18 at 3:53 p.m. Resident #25's water

temperature was 138.6 degrees and 138.3
degrees via facility thermometers. Visible
Page 38 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
steam was seen when checking the water.

Resident #25 denied concerns with the
temperature.
2/27/18 at 3:55 p.m. Resident #26's water

temperature was 139.1 degrees and 138.5
degrees via facility thermometers. Resident
#26 denied concerns with water temperature.
2/27/18 at 4 p.m. Resident # 5 and Resident

#12's water temperature was 140.1 degrees
and 139.5 degrees via facility thermometers.
Resident #12 stated there water gets awful
hot and he has to watch it. He didn't report it to
anyone.
2/27/18 at 4:02 p.m. Resident #27's

temperature was 139.3 and 138.9 degrees via
facility thermometers. He stated the water gets
too hot so he uses cold to cool it down.
On 3/1/18 at 7:56 a.m. Resident #9 and

degrees per surveyor thermometer. At 9:20
a.m. Resident #5 and Resident #12's water
temperature was 109.2 degrees per surveyor
thermometer.
On 3/1/18 at 10:50 a.m. the maintenance

person stated he just checked water
temperatures. Resident #26's water
temperature was 108.7 degrees. Resident # 9
and Resident #17's water temperature was
initially 114 then as the water ran it was 109
degrees. Resident #5 and Resident #12's
Page 39 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
water temperature was 109.4 degrees. At that

time, the maintenance person stated the
mixing valve was not functioning. The facility
would get one from out of town and have it
installed tomorrow. He stated he adjusted the
gauge and this morning temperatures were
cooler. Since the mixer valve is out, the
temperatures are not steady. Yesterday
morning the water temperature gauge was set
on 150 degrees. Around 9:30 a.m. he turned it
down to 138 degrees and yesterday a round 4
p.m. he turned it down to 120 degrees. This
morning (2/28/18) water was too cool so
around 7:30 a.m. he turned it back up to 138
degrees.
On 3/1/18 at 11:40 a.m. Resident # 9 and

water temperature was 134.6 degrees.
degrees. On the same date at 11:50 a.m. the
maintenance person stated he turned the hot
water gauge down to 125 degrees.
On 3/7/18 at 11:02 a.m. Resident # 9 and

water temperature was 115.1 degrees.
Resident #26's water temperature was 107
degrees.
Staff
On 2/27/18 at 4:20 p.m. Staff T CNA stated

Page 40 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
she noticed the water was hot in one room one

day. She wasn't sure what day. She did not
report it.
On 2/27/18 at 4:20 p.m. Staff B RN stated the

water had been hot but she didn't tell anyone.
She just adds cold water.
On 2/27/17 at 4:25 p.m. the Administrator

stated maintenance checked the water
temperatures weekly until the old maintenance
person left 2/15/18 and the new one started.
On 2/27/18 at 4:38 p.m. Staff A LPN (licensed

practical nurse) stated she scalded her hands
on the hot water last Sunday in the women's
rest room. She stated she did not receive any
actual burns but it felt like it burned. She did
not report the hot water to anyone.
A weekly hot water temperature test sheet

identified the last time staff checked the hot
water was on 2/8/18. At that time, staff
checked 3 rooms and the hot water measured
111 degrees in all 3 rooms.
A policy in place at the time of the discovery of

hot water temperatures undated revealed
resident rooms should have a water
temperature between 95 degrees to 110
degrees. The policy did not identify frequency
of checks.

assessment reference date of 5/3/17,
Page 41 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

mental status (BIMS) score of "2" (severe
cognitive impairment). The MDS identified the
resident had difficulty focusing attention and
keeping track of what was said. The resident
had disorganized thinking and delusions. The
resident required limited staff assistance with
bed mobility, toileting and transfers. The
functional loss of range of motion of one upper
and one lower extremity. A "balance during
transitions and walking" test revealed the
resident as not steady and only able to
stabilize with staff assistance in all areas of
testing. Staff did not test the resident's walking
balance. The resident had falls in the month
prior to admission and falls since admission.
The resident was occasionally incontinent of
bladder. The resident admitted to the facility
4/27/17 with diagnoses that included stroke
with right sided weakness.
A care plan dated 4/27/17 identified a problem

of "risk of accidents and injuries". The care
plan revealed they would minimize the risk of
accidents and injuries by providing appropriate
staff assistance in completing ADLs (activities
of daily living) and mobility while encouraging
the resident's highest functioning level. An
intervention dated 4/27/17 revealed the
resident used the toilet and directed staff to
assist the resident with toileting needs on
request. The care plan identified the resident
transferred with 1 to 2 staff assist. The care
plan also directed staff to keep the call light
Page 42 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
within the resident's reach and encourage the

resident to use it.
An incident report dated 5/1/17 at 10:30 a.m.

revealed a fall in the resident's bathroom. The
resident laid on the floor on the right side with
pants down to thighs. The resident used the
toilet rail for assist and the one side bent as
the resident slid to the floor. The immediate
action following the incident was 2 staff
assisted the resident from the floor and the
resident agreed to ask for assistance from now
on. The resident did not sustain injury. A post
fall assessment dated 5/1/17 at 10:30 a.m.
revealed staff last toileted the resident at 8
a.m. The post fall assessment identified the
intervention following the incident as: remind
the resident not to transfer self. The brake on
the left side of the wheelchair broke and staff
notified maintenance.

revealed staff found the resident leaning
against the bed. The resident tried to get in
bed and slipped to the floor. The resident was
not injured. The incident report did not identify
an intervention following this incident. There
was no post fall assessment after the incident.

revealed the resident's call light activated. Staff
answered it and observed the resident on the
floor laying on his right side next to the bed.
The resident fell out of bed as he slept. The
resident was not injured. The incident report
Page 43 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
did not identify a new intervention following the

incident. A post fall assessment dated 5/12/17
at 10:18 p.m. revealed the bed was in a higher
position when the fall occurred. Staff last
toileted the resident at 9:30 a.m. After the
incident, staff put the bed in low. The care plan
did not contain an intervention of low bed.
There was no incident report for an incident on

6/1/17 but a post fall assessment dated 6/1/17
at 9:32 p.m. revealed the resident tried to
stand and get into bed. Staff observed the
resident laying on his chest on the bed with
arm underneath him. Staff assisted the
resident to the floor so they could assist the
resident into bed correctly. The resident denied
pain. Staff last toileted the resident at 6:30
p.m. Following the incident, staff reminded the
resident to use the call light. (not effective
since resident's BIMS was "2")

revealed a fall in the resident's bathroom. The
resident fell when flushing the toilet. The
resident did not sustain injury. The intervention
following the incident was to tighten/fix grab
bars on toilet. (Toilet bar was also a factor in
5/1/17 incident)
The post fall assessment dated 8/30/17 at 1:10

p.m. revealed the resident used the toilet and
he lost his balance when he stood up. The
resident denied injuries. Staff observed the
resident seated on his buttocks with feet
extended straight on the right side of the toilet.
Page 44 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
The assessment did not identify when staff last

toileted the resident. Following the incident,
staff assisted the resident to the wheelchair
and encouraged the resident to call staff for
assistance. The assessment identified that the
resident was noncompliant with using the call
light.

revealed an unwitnessed fall in the resident's
room at approximately 11:50 p.m. The resident
was on his knees with his head between the
night stand and bed. The resident stated he
was asleep and then on the floor. He rolled the
wrong way and fell from bed. The resident did
not sustain injury. The incident report did not
identify an intervention after the incident. An
addendum on the care plan dated 9/3/17
revealed the resident was changed to a
scooped/winged edge bed to assist with barrier
recognition and an every 3 hour toileting plan.
A post fall assessment dated 9/2/17 at 12:30
a.m. revealed the resident rolled over and fell
out of bed. Staff last toileted the resident at
9:45 p.m. Following the incident, staff lowered
the bed from normal position. The care plan
did not contain the low bed intervention.

revealed the resident roommate came to the
nurse's station and reported a fall. The resident
laid on the floor by the bedside. The resident
had a scratch and bump on the upper right
forehead. The resident reported hitting his/her
head on the end of the bed. The resident said
Page 45 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the bed moved when he tried to get up. The

incident report revealed that immediately after
the fall, they locked the bed wheels and
lowered the bed. A post fall assessment dated
9/11/17 at 5:41 a.m. revealed the resident fell
trying to get out of bed. Staff observed a
scratch to the upper right forehead after the
fall. The assessment did not identify when staff
last toileted the resident. Following the
incident, staff put the bed in lowest locked
position.

revealed staff would check the resident during
the night and awaken him to see if he needed
the toilet on rounds. The resident agreed to
this. The entry revealed a lowered bed
intervention was not appropriate for the
resident. (Although staff documented they had
lowered the bed on prior incident reports and
post fall assessments) A care plan intervention
dated 9/11/17 directed staff to wake the
resident on rounds to see if he needed the
toilet.

revealed the facility sent a request for physical
therapy and speech therapy orders to the
physician.
Progress notes dated 9/17/17 at 5:30 a.m.,

revealed the resident was noncompliant with
calling for assistance. The resident also stands
and transfers without assistance. Staff gave
the resident reminders to call for help but the
Page 46 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident refused.

revealed the resident's granddaughter
requested the physician see the resident for
right shoulder pain and spasms in the right arm
and leg.

revealed the resident returned from the
physician who noted the resident had resolving
bruises to the right shoulder from fall and
directed staff to administer Tylenol (analgesic)
if the resident wants it.
An incident report dated 10/20/17 at 10:26

p.m. revealed the roommate reported the
resident fell. Staff observed the resident on the
floor with his back next to the bed. There was
blood on gripper strips. The resident was noted
in bed 20 minutes earlier with urinal available.
The resident stated he stood and his foot
slipped when he tried to get back into bed. The
incident report identified the immediate
intervention as: apply gripper socks. A post
fall assessment dated 10/20/17 at 10:26 p.m.
revealed the resident tried to get into bed. Staff
observed the resident sitting on his buttocks
with his legs out in front of him. Staff last
toileted the resident at 8 p.m.
A physical therapy note while in the hospital

from 12/9/17 to 12/19/17 revealed the resident
required 2 staff total assistance with supine to
sit, sit to supine, sit to stand, stand to sit. The
Page 47 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident was nonambulatory.
An incident report dated 1/2/18 at 6 p.m.

revealed the resident was on the floor on his
hands and knees. The resident dropped the
plastic lid from supper tray and slid off the bed
when he tried to grab it. Staff observed a
lesion on the left ankle measuring 2
centimeters (cm.) by 2 cm. The immediate
action after the incident was: encourage the
resident to eat in the dining room for closer
supervision. There was no post fall
assessment for the incident.

revealed the resident's roommate alerted staff
that the resident fell out of bed. The resident
sat on the floor leaning against the bed. The
resident stated he thought he would go to the
bathroom and couldn't make it so he sat on the
floor. The report did not identify when staff last
saw or toileted the resident. There was no post
fall assessment for the incident.
Observation:
On 1/3/18 at 4:15 p.m. the resident laid in bed

in a concave mattress. The bed was regular
height. The resident complained of left arm
and shoulder pain.
Care Plan
A care plan dated 7/18/17 with revision on

12/29/17 revealed the resident was at risk for
Page 48 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
falls related to CVA (stroke) with right side

weakness and history of falls. The resident had
a history of impulsiveness and did not wait for
staff assistance. Therapy recommended staff
assist although resident continued to not use
his call light and transfers self. Resident
agreed to be checked on at rounds during the
night. The resident had a history of seizures
with hospital 12/17 and now with contractures
to right leg and arm, increasing need for ADL
(activities of daily living) assistance and fall on
10/20/17 from bed. The care plan contained an
intervention dated 9/5/17 that directed staff to
toilet the resident every 3 hours.
Interviews:
On 1/30/18 at 3:12 p.m. Staff S CNA (certified

nurse aide) stated the resident sits up on the
bed and staff would go in for rounds and find
the resident on the floor. The resident tried to
self transfer.
On 1/30/18 at 3:45 p.m. Staff P CNA stated the

residents self transfers and tries to sit up per
self.

score of "13" (no cognitive impairment).The
resident had delusions and verbal behaviors 1
to 3 days out of 7. The record did not identify
rejection of care. The resident required
extensive staff assistance with bed mobility,
transfers, dressing, toileting and bathing. The
Page 49 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident did not ambulate. A "balance during

transitions and walking "test revealed the
resident was not steady and only able to
stabilize with staff assistance in all areas of
testing. The resident had falls since the prior
assessment.
A care plan dated 5/20/16 revealed the

resident was at risk for falls related to
unawareness of safety needs and history of
falls. The resident required standby assistance
with transfers. The resident was impulsive at
times and did not wait for staff assistance. The
resident would place self on the floor and crawl
to the doorway for staff assistance. When the
resident did not receive immediate care she
would slide self out of the wheelchair to the
floor. The care plan directed staff to toilet the
resident before and after meals and offer to lay
down or sit in front lobby. The care plan
directed staff to have gripper strips in front of
the bed and toilet and anti roll backs to the
wheelchair. Staff should keep the wheelchair
next to the resident's bed locked to allow the
resident to self transfer. A noodle to the call
cord to allow the resident better grasp of the
call cord.

revealed staff observed the resident on her
hands and knees in the doorway of the
resident's room. The resident had red areas to
both knees. The incident report identified the
areas as bruising. A post fall assessment
dated 7/13/17 at 2:56 p.m. identified the
Page 50 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident had pain in her knees after the

incident. The resident rated the pain as "5" on
a scale of 0 to 10 with zero being no pain and
10 being the worst pain. The resident reported
she crawled from the bathroom to the
doorway. The post fall assessment did not
identify if staff placed the resident in the
bathroom or if the resident went in the
bathroom per self or how long the resident was
in the bathroom. The post fall assessment did
not reveal when staff last toileted or saw the
resident.
A care plan intervention dated 7/14/17 directed

staff to remind the resident to wait for staff
assistance with pulling up pants when toileting.

revealed staff found the resident laying in her
left side in the doorway of her room. The
resident's head was out of the doorway and
the resident's legs were in front of the bed. The
resident stated she needed to use the
bathroom and that she had the call light on.
Staff documented the call light was not on. The
resident did not sustain injury. The post fall
assessment dated 7/16/17 at 11:50 p.m. did
not identify when staff last toileted the resident.
The post fall assessment revealed the resident
received Risperdal (antipsychotic) at 6:23 p.m.
The post fall assessment identified that after
the incident staff reminded the resident to ask
for assistance. The resident had one sock on
and a blue boot to the right foot. Staff
reminded the resident to put slippers on when
Page 51 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
transferring to prevent slipping. An

intervention dated 7/17/17 directed staff to
apply a noodle to the call cord to allow resident
better grasp of call cord when pulling call light.
An incident report dated 7/24/17 at 7 p.m.

revealed staff heard the resident yell. Staff
observed the resident on her knees by the
bed. The resident had regular socks on. The
resident did not sustain injury. A post fall
assessment dated 7/24/17 at 7 p.m. revealed
the resident tried to put herself to bed. The
resident had weakness and could not
ambulate. The report revealed staff last
toileted the resident at 6 p.m.
The care plan dated 7/25/17 revealed the

intervention as staff reminded to apply nonskid
socks or keep feet bare when put to bed. Non
skid strips are reapplied next to resident's bed.

revealed the resident yelled loudly at the
nurse's station for assistance to go to bed.
Several staff were at the nurse's station and
asked the resident to wait a few minutes. The
resident continued to yell and then slid out of
the wheelchair. Staff then got the resident off
the floor via Hoyer lift and got the resident to
bed. The resident did not sustain injury. Staff
would provide nonskid socks. A post fall
assessment dated 8/3/17 at 10:07 p.m.
revealed staff last toileted the resident at
8/3/17 at 9 p.m. The intervention following the
incident was to encourage the resident to use
Page 52 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the call light and ask for assistance.

revealed staff observed the resident on the
floor on her left side. A witness stated the
resident asked staff to assist her to the toilet
and staff told the resident she would help her
in 3 minutes. The resident then became upset
and began to stand on the right leg but then
lowered the left knee to the ground followed by
the rest of the resident's body. Staff assisted
the resident from the floor and taken to the
bathroom. Staff reported the resident did this
when she did not get her way and the
resident's behavior symptoms have worsened.
There was no investigation or incident report
available for this incident.

revealed at 7 p.m. on 11/5/17 the resident
insisted her bed was wet and demanded staff
change it. When staff entered the room, the
resident yelled at staff. Staff observed the
resident scoot to the edge of the chair and
lower self to knees to the floor. The resident
then laid on the left side and rolled to her
stomach. There was no assessment for injury
or incident report/investigation available.

revealed staff observed the resident seated on
the floor of the doorway to her room. The
resident had to go to the bathroom. The
resident stated the left ring finger hurt (wrong
finger documented). Staff did not observe
Page 53 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
injury. A post fall assessment dated 11/6/17 at

3:08 p.m. did not contain any information other
than the resident's vital signs. It was unknown
when staff last saw or toileted the resident. A
post fall assessment dated 11/6/17 at 4:08
p.m. did not contain information other than vital
signs and that the resident had a pain level of
"2" on a scale of 0 to 10 with 0 being no pain
and 10 being the worst pain.
A progress note dated 11/6/17 at 3:17 p.m.

documented another resident saw the resident
fall to the floor. Staff observed the resident in a
seated position and said she injured the ring
finger of the right hand. The resident could
bend the finger and staff did not observe
bruising or swelling. Staff placed gripper socks
on the resident and assisted her back in the
wheelchair.
There was no further documentation regarding

the resident's finger. Progress notes dated
11/7/17 at 2:30 a.m. revealed the resident had
no new injuries visible.

resident returned to the facility from the
physician with a cast on the right arm/hand.
A clinic note dated 11/8/17 revealed the

resident had a 5th metacarpal fracture and the
cast must be left on at all times with a sling for
comfort. Progress notes did not identify the
resident leaving the facility or why the resident
had an appointment with the physician.
Page 54 of 85
Administrator Date
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

the resident went to the physician for
something else and when she returned she
had a cast on and there was a fracture. The
Administrator denied there was any evidence
of injury prior to the appointment.

revealed the resident lowered self to the floor.
The resident called for assistance and the
CNA (certified nurse aide) responded to the
call and promised to return after she finished
caring for the other resident she worked with.
The resident did not hit her head and there
was no injury.
On 2/12/18 at 2:47 p.m. the DON stated there

was no incident report or investigation because
the incident was documented as a behavior.
The doctor called back regarding the resident's
edema and said to continue with TED hose.

11/21/17 did not assess Resident # 18's
cognitive status. The resident had unclear
speech was usually understood others and
understood others. The resident required
transfers, dressing, toileting, eating, personal
hygiene and bathing. In the area "ambulation
in room" staff coded a "7" (indicating the
activity occurred once or twice). The resident
was frequently incontinent of bowel and
bladder. A "balance during transitions and
Page 55 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
walking" test identified the resident as not

steady and only able to stabilize with staff
assistance in all areas of testing. The resident
admitted to the facility 11/13/17 and had
diagnoses that included: Huntington's chorea,
dementia and bipolar disorder.
Incident reports (IR) identified the following

falls:
12/4/17 at 1:45 p.m. staff observed the

resident lying on the floor in front of her
wheelchair next to other resident's foot of bed.
There was no fall assessment completed to
determine causal factors. The IR identified no
injury. Staff placed the resident in bed.
A typed paper provided by the Administrator

indicated the intervention following this incident
as "encourage resident to come out to
commons area when up in wheelchair".
12/4/17 at 2:10 p.m. staff found the resident

on the floor in front of the wheelchair. Staff
placed the resident in bed. Under predisposing
environmental factors, staff checked "other".
No other factors were identified such as when
staff last toileted the resident. The IR identified
no injury.

as "encourage resident to rest in bed when in
room". According to the previous incident at
1:45 p.m. on the same date, staff placed the
Page 56 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident in bed less than 30 minutes before.
12/5/17 at 7:29 a.m. At 5:25 a.m. staff

observed the resident on the floor in her room
by the bed and the roommate's bed. The
resident had an abrasion to the left knee and
swelling to the face and back of the head. A
post fall assessment dated 12/5/17 at 7:29
a.m. revealed the resident did not respond
when staff asked what she tried to do. The
resident had redness and swelling beside and
under the left eye and a raised area to the
occipital area of the head. Staff last toileted the
resident at 4 a.m.

as OT (occupational therapy) to evaluate the
resident's wheelchair for positioning and need
for specialized wheelchair.
12/13/17 at 2:23 p.m. revealed staff observed

the resident on the floor between the bed and
wall. There was no fall assessment completed
to determine causal factors. The IR identified
no injury. A typed paper provided by the
Administrator indicated the intervention
following this incident as A typed paper
provided by the Administrator indicated the
intervention following this incident as: adjusted
bed so wheels don't touch the floor.
OT daily note documentation dated 12/13/17

revealed modifications made to wheelchair to
increase safety with sitting upright and
Page 57 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
wheelchair propulsion.
12/14/17 at 3:42 p.m. revealed a visitor

observed the resident in the hallway in her
wheelchair kicking her legs out against the wall
causing the wheelchair to tip backwards. The
resident denied hitting her head. Staff assisted
the resident into the wheelchair. There was no
fall assessment completed to determine causal
factors. The IR identified no injury. A typed
paper provided by the Administrator indicated
the intervention following this incident as:
assist resident out of room and to commons
area when up in wheelchair. (The resident was
out of the room when the fall occurred)
12/31/17 at 9:15 a.m., revealed staff observed

the resident sitting on the floor of her room.
Predisposing environmental factors was
furniture and predisposing physiological factors
was weakness/fainted. Predisposing situation
factors was ambulating without assistance and
improper footwear. A post fall assessment
dated 12/31/17 at 9:15 a.m. revealed staff last
toileted the resident at 4 a.m. and the fall
occurred at 6:30 a.m. A typed paper provided
by the Administrator indicated the intervention
following this incident as: education on call
light use and staff determined the resident
purposely transitioned to the floor from bed.
PT notes dated 12/7/17 identified the resident

required verbal and tactile cues for balance
control during transfers due to disease
process.
Page 58 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
1/4/18 at 3:16 p.m. revealed the resident fell

backwards in the hallway and hit her head on
the floor. Staff applied pressure to a wound on
the back of the head to stop bleeding and
applied ice to a hematoma. There was no fall
assessment completed to determine causal
factors. A typed paper provided by the
Administrator indicated the intervention
following this incident as: room change.

identified a fall backwards in the wheelchair
and the resident striking the back of her head
sustaining a 5 cm. by 3 cm. bump with 0.3 cm.
by 0.2 cm. cut. The bump on the head grew to
8 cm. by 8 cm. and staff sent the resident to
ER (emergency room).
ER notes dated 1/4/18 at 11:32 a.m. identified

a laceration to the head due to fall from
nonmoving wheelchair. The resident could not
communicate regarding the event but did say
she had a headache. A CT performed in ER
did not reveal an acute intracranial process.
The physician documented there was a 0.5
cm. laceration to the back of the head that did
not require sutures. The resident needed
follow up with primary care provider (PCP) for
recheck of the hematoma. The order was to
follow up with PCP next week.
A care plan dated 1/2/18 revealed an

intervention dated 11/13/17 that directed staff
to review past falls and determine cause of
Page 59 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
falls and record root causes.
On 2/15/18 at 12:23 p.m. the DON stated the

facility did not conduct neuro checks after the
head injuries.
Observation showed on 2/6/18 at 2:30 p.m. the

resident in the center area seated in a
wheelchair with anti tip devices.
OT notes dated 1/5/18 revealed they worked

with the resident and wheelchair vendor to
implement temporary wheelchair with anti
tippers. OT made wheelchair modifications and
implemented a low profile cushion secured to
the wheelchair seat and Dycem on top of the
cushion.
On 2/12/18 at 3:54 p.m. the surveyor asked

the DON how a room change was an
appropriate intervention for the resident after
the 1/4/18 fall since it occurred in the hallway.
The DON stated they wanted the resident
closer so when she gets excited she will be
closer to the center area. The DON stated the
resident is self mobile in the wheelchair and
gets excited and starts pedaling self. She has
strength in her legs to kick them out and that
causes her to go backwards.
Facility Response:
Page 60 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Page 61 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
58.19(2) 58.19(2) Medication and treatment b. i $10,000 Upon

Provision of the appropriate care and Held in Receipt
treatment of wounds, including pressure Suspensi
sores, to promote healing, prevent on
infection, and prevent new sores from
developing; (I, II)
Description:
Based on observation, record review, resident

and staff interviews, the facility failed to ensure
that-a resident with pressure ulcers receives
necessary treatment and services, consistent
with professional standards of practice, to
promote healing, prevent infection and prevent
new ulcers from developing for 4 of 27
residents reviewed. Resident #1 did not have
treatments done per order which resulted in
infection and insertion of a PICC line for IV
antibiotics. Resident #5 developed a pressure
sore to the right heel. The area opened on
1/28/18 after staff applied a shoe to the right
foot. (The physician previously ordered a heel
boot to be worn on 1/17/18 on the right foot at
all times) The TAR (treatment administration
record) revealed treatment for the open area
did not start until 2/1/18. The facility did not
notify the physician the area was open until
1/31/18. Resident #7 had a band-aide covering
an area on the outer right foot. There was no
documentation available regarding the area.
Later a wound nurse identified the area as a
pressure injury. Resident #2 had a red coccyx
for several days before the facility documented
Page 62 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the area as present. The resident also had red

heels that the family informed the facility of.
The facility identified a census of 56 current
residents.
Findings include:

assessment reference date of 10/31/17
mental status (BIMS) score of "15" (no
cognitive impairment). The MDS did not
identify behavior concerns. The resident
mobility, transfers, dressing, toileting, personal
hygiene and bathing. The resident did not
ambulate. The resident had functional
limitations in range of motion in both lower
extremities. The resident used a wheelchair for
mobility. The resident had an indwelling
catheter and ostomy. The resident had
diagnoses that included: paraplegia, COPD,
diabetes mellitus and chronic pain. The
resident admitted to the facility 12/14/16.
On 1/2/18 at 12:05 p.m. observation showed

the resident in a wheelchair seated on a Jay
cushion pressure reduction device. During
interview the resident stated she had open
areas on her bottom. She stated she was at
home and came into the facility with them. She
stated last week or the week before, a nurse
did not perform treatments to her sores for 4
nights and now it's infected requiring antibiotic
treatment. On 1/3/17 at 7:35 a.m. observation
Page 63 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
showed the resident on her back in bed with

feet on the bed. The right foot was in a green
boot resting on the bed. On the same date at
8:20 a.m. observation showed the resident on
her back in bed with right foot in green boot
resting on the bed. At that time, Staff A wound
nurse stated the resident had a pea sized area
on the heel that is treated by wiping it with skin
prep. The resident also had areas on the tops
of toes that received the same treatment.
Observation showed at 9:40 a.m. no change in
position. At 9:50 a.m. staff got the resident up
from bed via Hoyer lift. Observation showed
the resident's entire bottom covered with a
white bandage. Staff removed the green boot
and put a footie on the resident. The foot
rested on the foot rest of the wheelchair. The
resident left the facility at 11 a.m. and did not
return until 5:30 p.m.
On 1/2/18 at 4 p.m. Staff B RN (registered

nurse) stated she was one of the wound
nurses at the facility. She confirmed Resident
#1 did not receive her skin treatment for 4
nights in a row last month. Staff B stated it
contributed to the infection the resident has in
the wounds at the present time. Staff B stated
there was more drainage so she sent the
resident to the wound clinic and they had to
put in a PICC line to treat infection. Staff B
identified Staff C as the nurse that did not
perform the treatments.
On 1/3/18 at 1:30 p.m. Staff A LPN (licensed

practical nurse) identified herself as one of the
Page 64 of 85
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Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
facility wound nurses. She stated the night

nurse did not do Resident #1's treatments at all
for the last couple months. The sore got worse
and infected and the lack of treatment
contributed to that. She stated the night nurse
told her she didn't have time to do the
treatments.
A note from the wound clinic undated revealed

the clinic would insert a PICC line today and
then directed staff to administer ampicillin
(antibiotic) 1 gram daily for a month. A final
report dated 12/20/17 identified the resident as
having beta lactamase positive
peptostreptococcus in the wounds.
Measurements 11/24/17 from nursing progress

notes:
Left ischium 15 cm. by 6.2 cm. by 1.7 cm.
Right gluteal crease 1.8 by 1.9 cm.
Coccyx 8.4 by 11.9 by 2.4 cm.
Right ischium 9.1 by 3 by 1.7 cm.

notes:
Back of right thigh 1.5 centimeters (cm.) by 1.5
cm. by 0.1 cm.
Left ischium 12.8 cm. by 6.2 cm. by 1 cm.
Right gluteal crease 1.2 by 1.4 cm.
Coccyx 8.1 by 10.7 by 2.4 cm.
Right ischium 9 by 3.2 by 1.2 cm.
Treatments not done between these

measurements
Page 65 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

notes:
Back of right thigh 1.5 cm. by 1.5 cm. by 0.1
cm. with scant amount of serosanguineous
drainage
Left ischium 13 cm. by 7.2 cm. by 1.5 cm.
scant amount of serosanguineous drainage
Right gluteal crease 1.2 cm. by 1.5 cm. by 0.1
cm. red granulation tissue
Coccyx 8 cm. by 10.2 cm. by 2.4 cm. with
scant amount of serosanguineous drainage.
Right ischium 9 cm. by 3.5 cm. by 1.5 cm.
The resident begins IV antibiotics today.
On 2/12/18 at 12:30 p.m. the director of

nursing (DON) confirmed the treatments were
not performed sometime between 12/14/17 to
12/21/17.
On 1/23/18 at 9:23 a.m. the wound nurse from

the wound clinic stated anytime dressing were
not changed as ordered, it could contribute to
infection. Not doing the dressing changes
gives the bacteria a nice warm wet spot to
multiply. The resident used Dakins solution
and Dakins becomes ineffective once it dries
out. The wound nurse stated they inserted a
PICC line 12/20/17 to treat the infection and
deliver the IV antibiotics every 24 hours for 30
days. She stated the resident's noncompliance
did not help matters but since she is
noncompliant it is important to do what she
allows to treat the sores.
Page 66 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Review of the December 2017 treatment

administration record (TAR) revealed Staff C
LPN (licensed practical nurse) signed she
performed the treatment 12/12/17 through
12/16/17.
On 1/24/18 at 2:55 p.m. Staff C LPN stated

she was the only nurse those nights and she
had 4 other major treatments to complete. By
the time she got to the resident, she would be
asleep. The resident would get angry and was
hard to wake up so sometimes she did not get
the treatment done. Staff C was signing they
were not done but the DON said she couldn't
do that. The DON said she couldn't document
"asleep" or "only one nurse working". The
DON instructed her to mark it off as done and
just" try to get it done" so lots of times that is
what Staff C did. She stated she worked 3
times a week and would get the treatment
done half the time. She stated she informed
the Administrator it was impossible to complete
the treatments and the Administrator said she
knew that. On 2/6/18 at 1 p.m. the
Administrator denied saying she knew that.
She stated she spoke with the ADON
(assistant director of nursing) when they
terminated Staff C and he said he could get
the treatments done so they thought Staff C
could too.
Care Plan:
A care plan dated 1/16/17 with revision on

9/28/17 revealed the resident had actual skin
Page 67 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
impairment related to ulcer that encompasses

the ischials, coccyx and buttocks. MRSA
(methicillin resistant staphylococcus aureus)
infection of skin. Resident admitted with these
wounds. Resident with long standing ulcers to
these areas that are unresolved due to her
noncompliance with treatments and refusing to
lay down or reposition side to side. She is to
be up only for 1 hour at a time but she refuses
once she is up. Abrasion to right great toe,
ulcer to right heel, open area to right gluteal
crease. Right knee abrasion.
The care plan directed staff to use a dolphin

mattress and pressure reduction to the
wheelchair, encourage and assist with frequent
repositioning to each shift and document
refusals, document refusals, monitor document
location, size and treatment of skin injury.
Report abnormalities. resident to have chux
under her when in bed, treatments per doctor's
orders, weekly skin assessments.
On 2/12/18 at 12:30 p.m. the DON confirmed

the resident refused repositioning in bed and
wheelchair.
OT (occupational therapy):
An OT note dated 9/20/17 revealed the OT

directed staff to replace the Jay cushion with a
Vector X seat cushion and also obtain a Rook
boot.
On 1/25/18 at 12:26 p.m. the rehab director

Page 68 of 85
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Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
examined the green heel boot the resident

used. He stated there was a white boot
ordered for pressure in September and the
green boot was not what was ordered. He
stated he didn't know where the green boot
protector came from.
On 1/31/18 at 1:21 p.m. the OT stated she

spoke with the person that wrote the 9/20/17
OT note. She stated he wrote the vector
cushion order to indicate the resident needed a
high end cushion to get better pressure
reduction but then he came to the facility and
did pressure mapping and disovered what the
resident had in place provided adequate
pressure reduction so no change was made.
She stated the green boot the resident
currently used was also adequate for the heel.
An OT discharge summary dated 10/20/17

revealed the current wheelchair pressure
cushion was appropriate. The discharge
summary stated a new pressure relieving boot
ordered and they awaited delivery. The record
failed to contain information that the current
green boot was adequate and the new ordered
boot was not needed.
Observation:

the resident on her back in bed with the right
foot in a green foot boot which lay on the bed.
Staff A RN identified the resident as on an air
mattress. Observation showed the right inner
Page 69 of 85
Administrator Date
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
heel with a closed pea sized brown area and a

brown area on the resident's toes. At that time,
Staff A RN swabbed the areas with skin prep.
Observation showed a large white bandage
covering the entire coccyx/buttock areas. The
bandage contained the date 1/24/18 and staff
initials. Staff A identified the initials as hers
from yesterday morning, indicating staff did not
perform the treatment last night. Staff A
confirmed the treatment was ordered twice a
day. Staff A removed the large white bandage
to expose large deep beefy red sores on the
entire coccyx/buttock areas. Guaze 4 by 4's
were present increases of the sores. At that
time, the DON (director of nursing) stated the
areas "looked good". Staff A stated alot of
slough was gone and the resident had "good
fresh tissue present". Staff A scrubbed back
and forth on the areas with 1/2 peroxide and
1/2 normal saline. Staff A used a new 4 by 4 to
cleanse each area. Staff A then cleansed each
separate area with normal saline and sponge
dried the areas with clean 4 by 4's. Staff then
applied Dakins soaked gauze to the open
areas and covered the areas with a new
bandage. Staff A then applied a new Optifoam
bandage to a small open area on the back of
the right thigh. At that time, the surveyor
questioned the lack of cleansing of the area
prior to applying the new bandage. Staff A
stated that is the way the doctor wants it.
Review of the January 2018 treatment

administration record (TAR) indicated the
resident refused the buttock treatment the
Page 70 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
evening of 1/24/18.
On 1/25/18 at 8:40 a.m. the resident stated

she did not refuse the treatment last night.
Review of the January 2018 TAR revealed

staff should clean the right back of the thigh
wound with normal saline and pat dry prior to
applying Mepilex to the wound. (Observation
showed staff did not clean the wound). On
1/25/18 at 8:46 a.m. Staff A came to the
surveyor and stated yes she normally did clean
the right back of the thigh wound but she was
nervous when she performed the treatment.
She stated the resident got the wounds on the
back of the thigh from tape.
The record did not contain information of

resident repositioning refusals each shift. On
2/13/18 at 11:44 a.m. the DON stated there
was no documentation regarding the resident
refusing repositioning.
A consultation final report identified a hospital

admission on 2/8/18. The reason for the
consultation was listed as: decubitus ulcers of
the sacrum. The report identified the right
ischial ulcer measured 8 by 2.2 by 1.3 cm. The
right gluteal ulcer measured 21 by 12 by 2.1
cm. The left posterior upper leg ulcer
measured 1.5 by 1 by 0.2 cm. The assessment
was Stage IV decubitus ulcers of the coccyx,
left buttocks and right ischial decubitus ulcers.
Stage 4 Pressure Ulcer: Full-thickness skin

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and tissue loss

Full-thickness skin and tissue loss with
exposed or directly palpable fascia, muscle,
tendon, ligament, cartilage or bone in the ulcer.
Slough and/or eschar may be visible on some
parts of the wound bed. Epibole (rolled edges),
undermining and/or tunneling often occur.
Depth varies by anatomical location.

score of "4" (severe cognitive impairment). The
resident had the following signs and symptoms
of delirium: inattention and disorganized
thinking. The resident had delusions and no
other behavioral symptoms including rejection
of care. The resident required supervision with
bed mobility and transfers. The resident
required limited staff assistance with bed
mobility, toileting. The MDS identified the
resident with functional range of motion
impairments of one side of the upper and lower
extremities. The MDS identified the resident as
continent of bowel and bladder. The skin
condition section of the MDS revealed the
resident was at risk for developing pressure
sores. The MDS identified the resident used
pressure reduction in the wheelchair and bed.
The resident did not have pressure sores or
venous or arterial sores.
A Braden assessment dated 10/31/17 revealed

"in progress".
Page 72 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Observations:
On 1/2/18 at 4:35 p.m. observation revealed

the resident in bed with no heel protectors on
and heels in bed. The resident lay on his back.
On 1/3/18 at 4:15 p.m. observation showed the
resident in bed with no heel protectors on and
heels in bed. The resident lay on his back on a
concave pressure reduction mattress. On the
same date at 5:15 p.m. the resident remained
in bed as before.
On 1/24/18 at 4:25 p.m. observation revealed

the resident in a wheelchair. The resident had
the right foot in a boot. The resident foot was
bare with the top of foot and toes exposed.
The resident's bare toes hit the resident's
athletic shoe when the resident used the left
foot to move the wheelchair. The resident
came inside from being outside with bare foot
exposed. On 2/15/18 at 8:53 a.m. per email
the stage climatologist stated the temperature
at the Sioux City airport on that date at 4:52
p.m. was 27 degrees with a wind chill of 17
degrees. The resident had a Band-Aid on the
fourth and fifth toe of the right foot and a scab
was present on the second toe.
On 1/25/18 at 7:55 a.m. the resident sat in the

dining room with the right foot in a blue boot
that rested on the floor with the top of the foot
and toes exposed. On the same date at 10
a.m. observation revealed the Band-Aid off the
right foot toes. The resident had blood on the
tip of the second toe and also a scab on the
Page 73 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
second toe and blood on the 4th toe. There

was blood on the heel protector directly below
the toes. At that time, the surveyor summoned
Staff B (facility wound nurse) . When Staff B
arrived there was blood on the floor from the
toes. Staff B stated she knew the resident had
scabs on his toes. At that time Staff B stated
the resident needed a gripper sock to protect
the exposed foot and toes. Staff B cleaned up
the blood and threw it in the garbage. Staff B
stated it appeared something cut the end of
the second toe. She cleansed the area with
normal saline and patted it dry with gauze. She
then applied triple antibiotic ointment. At that
time, observation revealed a large black area
on the resident's right heel that Staff B
swabbed with skin prep. Staff B stated she
thought the heel sore developed from the
position the resident's foot laid on the bed due
to the right leg contracture. Staff B stated the
contracture caused the heel to constantly
press into the bed. Staff A left the resident in
the wheelchair in the foot protector that rested
on the floor. The resident sat with the left heel
touching the tips of the toes of the right foot.

the resident up in the wheelchair with blue boot
on the right foot. Staff B removed the boot and
a bandage to the right heel. Observation
revealed a large open area with dark drainage
on the bandage. Also at that time Staff A
applied a footie sock over the exposed toes
and top of foot.
Page 74 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

the resident in bed with the right foot in the
blue boot that rested on the bed directly on the
resident's pressure area. At that time, the
surveyor summoned the DON (director of
nursing) who agreed the pressure area was
directly on the bed while in the boot. She
stated they ordered the resident a brace to
help with the situation. Subsequent
observations at 9 a.m. 9:20 a.m., 10 a.m.,
10:25 a.m. and 11 a.m. showed the resident in
bed with the right foot in the boot that rested
on the bed directly on the pressure sore site.
At that time, 2 staff were in the room to get the
resident up for lunch. Observation showed at
11:40 a.m. the resident at the table with right
foot in the boot with the top of the foot and toes
uncovered and exposed. The right foot sat on
the floor with the resident's left heel resting
directly on top of the right 1st and 2nd toes.
observation at 12:20 p.m. and 12:55 p.m.
showed the resident's right foot on the floor
with nothing protecting the exposed toes. The
boot rested directly on the floor.
A fax to the physician dated 1/17/18 revealed

an order for skin prep daily to the right heel
and heel protector boot at all times.
A skin wound note faxed to the physician

dated 1/26/18 at 6:15 a.m. revealed the right
heel pressure sore measured 5.6 cm. by 7.4
cm. epithelial tissue (not open) dark purple.
On 1/13/18 a physician order on the fax
revealed staff should cleanse the ulcer to the
Page 75 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
right heel with normal saline, pat dry and apply

Mepilex dressing daily. On 2/28/18 at 2:46
p.m. Staff B RN confirmed when she charted
"epithelial" that meant the wound was not
open.
Treatment orders dated 1/31/18 revealed the

physician ordered the following treatment to
the heel: cleanse ulcer to right heel with
normal saline, pat dry and apply Mepilex
dressing daily.
Review of the January and February 2018

TARs revealed staff started the treatment on
2/1/18.
Observation revealed on 2/1/18 at 12:08 p.m.

the resident with the blue boot on the right foot
with the top of right foot and toes exposed.
On 2/7/18 at 4:15 p.m. the surveyor asked if

the dietician assessed the resident's dietary
needs since he had an open area. On 2/8/18
at 9:55 a.m. the Administrator stated the
dietician comes weekly and would assess the
resident tomorrow.
A wound center history and physical dated

2/7/18 revealed the resident would have
recommendations for 1 can of Glucerna
(protein supplement for healing) daily to meet
nutritional needs during the course of healing.
The assessment of the wound was identified
as :Diabetic heel ulcer Wagner grade II
originating as pressure ulcer unstageable
Page 76 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
nonhealing secondary to diabetes fat layer

exposed. They directed the facility to use a
ProCare shoe for the right foot.
Wagner Grade 2 is a deep ulcer penetration

through the subcutaneous tissue, potentially
exposing bone, tendon, ligament or joint
capsule
A wound culture dated 2/7/18 revealed the

resident had methicillin resistant staph aureus
(MRSA) in the right heel wound. A telephone
order dated 2/8/18 at 11:27 a.m. revealed an
order for Bactrim DS (antibiotic) 800-150 mg
daily for 14 days to treat the infection.
On 3/7/18 at 3:03 p.m. the DON stated

Glucerna was not ordered and the facility did
not ask the physician about ordering it. The
information found about the resident needing
Glucerna was in a history and physical
progress note.
A dietary nutrition progress note dated 2/8/18

at 12:28 p.m. revealed the resident had a
significant weight loss of 5% in the past 30
days and 10% in the past 6 months. The
dietician recommended the physician order
Juven supplement for skin impairment one
packet BID (twice a day). The dietician
documented the resident had MRSA
(methicillin resistant staphylococcus aureus) in
the wound.
Review of the February 2018 MAR/TAR

Page 77 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
revealed an order for Juven daily 2/27/18.

When the surveyor asked to view the order on
3/7/18 they could not locate it. On 3/8/18 at
11:33 a.m. the corporate nurse stated the
facility couldn't find the original order so they
had the physician reorder it today. He didn't
know why it was ordered daily instead of BID
as the dietician recommended.
On 3/8/18 at 12:53 p.m. the physician's nurse

stated she could not find an order for Juven
until todays order. She stated the physician
didn't object to Juven twice a day. The facility
request was for daily so that is what they
ordered.
A progress note dated 2/10/18 at 4:27 a.m.

revealed the resident's right heel pressure sore
measured 5 cm. by 9.3 cm. by 0.1 cm. with
scant serosanguineous drainage. The upper
right heel area measured 1.1 cm. by 1.8 cm.

revealed Staff A LPN (licensed practical
nurse) entered the room to perform the
58.19(2)a resident's right heel treatment and
assessment. There was no bandage on the
heel. Staff S cleansed the area and applied a
new bandage.
Interviews:
On 2/1/18 at 2:20 p.m. Staff A LPN stated the

resident's heel opened because on Sunday
(1/28/18) the CNAs placed a shoe on the right
Page 78 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
foot causing the heel to open. She stated she

had not measured the area since it opened. At
that time, the surveyor asked if they could get
measurements of the right heel today before
the surveyor left. Staff A measured the wound
as 5 cm. in length and 9.3 cm. in width. At that
time, Staff A also noticed an open area on the
back of the resident's heel measuring 1.1 cm.
by 2.1 cm.
On 1/30/18 at 3:45 p.m. Staff P CNA stated

she wasn't sure how he got the sore on his
heel. Last week it was bleeding and staff had
to change his sheets. Staff P stated the
resident's right leg contracture makes the heel
go into the bed.
On 1/30/18 at 12:54 p.m. Staff R CMA stated

the resident's heel was open and there was
Mepilex on it when she gave him a bath. She
stated his right leg is contracted and the foot
scrapes the floor. The resident's heel rests on
the mattress when in bed because of the
contracture.
On 1/30/18 at 3:12 p.m. Staff S CNA the

resident's didn't use a heel boot until about a
week and a half ago. The resident's heel digs
into the bed even with the boot on.

12/4/17 assessed Resident # 7 with a BIMS
score of "12" (moderate cognitive impairment).
The resident had no behaviors identified
Page 79 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
including rejection of care. The resident

mobility, dressing, toileting and personal
hygiene. The resident required total staff
assistance with transfers and bathing. The
functional limitations in range of motion of both
lower extremities. The resident had an
indwelling catheter and was always incontinent
of bowel. The resident had diagnoses that
included: neurogenic bladder, diabetes mellitus
and pain in feet. The MDS identified the
resident at risk for pressure sores. The MDS
identified the resident with 6 venous and
arterial ulcers but no pressure sores.
A final report dated revealed the resident was

hospitalized 11/17/17 to 11/27/17 with
nonhealing diabetic ulcer of the left lower
extremity left heel ulcer with exposed tendon
and bone, Wagner grade III with wound
infection and muscle necrosis. The resident
had cellulitis of the left lower extremity and
positive wound cultures.
A Wagner Grade 3 is a deep ulcer with osteitis,

abscess or osteomyelitis.
Observation showed on 1/2/18 at 2:05 p.m. the

resident in bed on her back with the head of
the bed up. The resident used an indwelling
urinary catheter. On the same date at 2:08
p.m. observation showed a foam boot on the
left foot. The left foot was wrapped in white
gauze that was dated 1/2/18 and that was
Page 80 of 85
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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
wrapped in chux and then the foam boot. The

resident's left foot laid to the left. The right foot
was bare and there was a Band-Aid present on
the outer right foot just below the small toe and
laid on the bed. The resident laid on a blue
pressure reduction mattress. Observations at
2:26 p.m., 4 p.m. and 4:25 p.m. revealed the
resident laying in bed as before with no
change in feet position. The right foot laid on
the bed. At 4:48 p.m. the resident was up in a
wheelchair and had a gripper sock on the right
foot on pedal and the left foot remained in a
boot.
Observation showed on 1/3/18 at 8 a.m. the

resident in bed with both feet on the bed and
the left in a boot and the right foot bare with a
band aid on the outer right as observed on
1/2/18. At 9:03 a.m. the right foot remained on
the bed. Staff A LPN (licensed practical nurse)
provided treatment to the left foot. The left foot
had a very large open area. Staff A used
Dakins. Hydsept 50 on gauze and wrapped the
left foot with gauze. The band aid remained on
the right foot. At that time, Staff A viewed the
area on the right outer foot with the surveyor.
The area was approximately 25 cent size,
deep and open. . On 1/3/18 at 11:30 a.m. the
hospice wound nurse arrived. The wound
nurse stated the area on the outer right foot
was a new pressure injury and stated it would
be better if the resident's feet were free-
floating.
The hospice wound nurse note dated 1/3/18

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FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
directed staff to apply full strength Dakins

solution moistened 4 by 4's or small ABD to
the unstageable pressure injury to the right
medial foot near the 5th digit (little toe). Secure
with Kling and change daily. The wound nurse
also directed staff to apply a Prevalon boot to
the right lower leg at all times.
Review of progress notes did not identify when

the area opened or who/when a band aide was
applied.
A skin grid form dated 11/27/17 identified a 2

centimeter (cm.) by 1.8 cm. scabbed area to
the right lateral foot present on admission from
the hospital on 11/27/17. The skin grid
contained dates 12/29/17, 1/5/18 and 1/12/18.
The dates did not contain follow up
assessments but stated the resident refused
measurements because of pain.
A MD/nursing communication identified the

right lateral foot area present on 11/3/17 when
the physician ordered betadine and Mepilex to
the right lateral ulcer.
A hospice wound note dated 11/28/17 directed

staff to discontinue all current treatment to the
right foot. Staff should monitor for
drainage/erythema and notify hospice wound
nurse of changes.
On 2/1/18 at 1:06 p.m. Staff A LPN confirmed

the skin grid form for the right lateral foot was
the same area she viewed with the surveyor
Page 82 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
on 1/3/18. Staff A stated after she viewed the

area with the surveyor she got treatment
orders for the area.

MDS revealed the resident required extensive
assistance with bed mobility, dressing,
toileting, personal hygiene and total assistance
with bathing. The resident did not ambulate.
The resident had an indwelling urinary catheter
and occasionally incontinent of bowel. The
resident had a surgical wound. The MDS did
not identify any other areas of skin impairment.
The resident expected discharge to the
community.

surgery, laminectomy. The resident was on
strict bedrest and received skilled care for IV
(intravenous) therapy. The resident's goal was
to work with therapy once he was off bedrest
to improve ADL abilities and then return home.
A nutritional status CAA dated 11/2/17
revealed the resident's bed could not be
elevated higher than 15 degrees. A pressure
ulcer CAA dated 11/1/17 identified the resident
at risk for pressure ulcers.
Page 83 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

arrived at the facility per ambulance.
Admission progress notes identified the
resident's buttocks were intact and without
redness.
10/30/17 at 5:17 a.m. the resident complained

of pain across the abdomen and across "butt".
There was no abdominal assessment of

assessment of the resident's bottom.
10/31/17 at 12:24 a.m. revealed the resident

complained of pain across the lower back and
butt. The resident rated the pain as a "5". Staff
administered Oxycodone.
There was no assessment of the resident's

back or buttocks.
Skin grid forms dated 11/5/17 revealed a 5

centimeter (cm.) by 6 cm. red are to the
coccyx, a 1 cm. by 1 cm, red blanchable area
to the right heel and a 3.5 cm. by 2.5 cm. red
blanchable area to the left heel.

daughter stated she was informed the resident
had a red coccyx on 11/1/17 and the daughter
informed the facility about the resident's heels.
On 1/31/18 at 8:45 a.m. Staff A LPN (licensed

practical nurse) stated the day she saw the
resident had red heels the resident's daughter
asked her about the heels. That day was the
Page 84 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
resident's assessment day. Staff A then

realized the resident better have something on
his heels since he was in bed all day. She
stated there was no treatment for the surgical
incision on the resident's back. Staff A stated
the resident's coccyx was looking rough when
he came and he had Mepilex for it when he
came.
Review of admission documentation and

orders dated 10/23/17 failed to identify any
concerns with the resident's coccyx on
admission or orders for Mepilex. Facility
documentation failed to identify concerns until
11/5/17.
On 1/31/18 at 8:35 a.m. Staff G CMA stated

the resident's bottom was red. The resident's
incision was seeping gooey drainage that was
green.
On 1/30/18 at 1:45 p.m. Staff H CNA stated

the resident did have skin breakdown on his
bottom.
On 1/31/18 at 11:25 a.m. Staff O RN

(registered nurse) stated she thought the area
around the surgical back wound was a little
red.
On 1/30/18 at 3:12 p.m. Staff S CNA (certified

nurse aide) stated the resident's bottom was
red but not open.
Facility Response:
Page 85 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Page 86 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
58.19(2)a 58.19(2) Medication and treatment. I $3,250 Upon

a. Administration of all medications as Held in Receipt
ordered by the physician including oral, Suspensi
instillations, on
topical, injectable (to be injected by a
registered nurse or licensed practical nurse
only); (I, II)
b. Provision of the appropriate care and
treatment of wounds, including pressure
sores, to promote
DESCRIPTION:
Based on observation, record review resident

and staff interview, the facility failed to ensure
that pain management is provided to residents
who require such services, consistent with
professional standards of practice, the
comprehensive person-centered care plan,
and the residents' goals and preferences for 4
of 27 sampled residents. Resident #12,
Resident #13, Resident #2 and Resident #14
went without needed pain medication. The
facility identified a census of 56 current
residents.
Findings include:

assessment reference date 11/21/17 assessed
Resident #12 with a brief interview for mental
status (BIMS) score of "11" (moderate
cognitive impairment). The MDS identified the
resident with occasional pain with the worst
Page 87 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
pain rated a "6"(with 0 being no pain to 10

being the worst pain) in the previous 5 days.
The resident had diagnoses that included:
Parkinson's disease.
During observation of medication pass on

1/2/18 at 12:27 p.m. the resident stated he
wanted his pain pill. At that time, Staff Q LPN
(licensed practical nurse) informed the resident
that his pain medication was not at the facility
yet. Staff Q then informed the surveyor that the
resident had not received his pain medication
since he returned from the hospital. She
planned to check and see if he still had it
ordered.
Review of Resident #12's records revealed the

resident went to the hospital 12/29/17 and
returned 12/30/17. Discharge orders from the
hospital dated 12/30/17 revealed the resident
returned with Oxycodone reordered as before.
Review of the resident's January 2018

medication administration record (MAR)
revealed the resident with an order for
Oxycodone 5 milligrams 2 tablets every 4
hours as needed (PRN) with order date of
9/20/16. The January 2018 MAR revealed the
resident did not receive the pain medication
until 1/10/18 at 12:03 a.m. The January 2018
MAR revealed pain levels ranging from 0 to 6
during 1/1/8 to 1/10/18.
On 2/13/18 at 9:49 a.m. the pharmacy stated

the first delivery of Oxycodone after the
Page 88 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
12/30/17 hospital was on 1/9/18.
On 2/6/18 at 1:57 p.m., the Administrator

stated the resident's methadone was increased
and they were trying to keep the resident from
using Oxycodone. She stated the resident has
OCD (obsessive compulsive disorder) and it's
more of a ritual thing for the resident.
A December 2017 MAR revealed the resident

received methadone 45 mg. daily in the
morning and 40 mg in the evening prior to
going to the hospital. Upon return from the
hospital on 12/30/17 the MAR showed the
methadone order was unchanged.
A care plan dated 3/21/17 identified the

resident with a problem of potential for pain
related to depression and chronic pain. The
care plan directed staff to anticipate the
resident's need for pain relief and respond
immediately to any complaint of pain as
needed.

pain section of the MDS identified the resident
in almost constant pain over the previous 5
days. The pain made it hard for the resident to
sleep at night and limited day to day activities.
The resident identified the worst pain on a
level of "7" (on a scale of 0 to 10 over the
previous 5 days with 0 being no pain and 10
being the worst pain). A health status progress
Page 89 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
note dated 1/18/18 stated the resident was at

the facility for skilled care and to receive PT
(physical therapy) and OT (occupational
therapy) . The resident was previously in the
hospital for total left knee replacement. The left
knee had 27 staples in place with scattered
bruising.
On 1/30/18 at 3 p.m. the resident stated he

had not received any pain medications all day
and the facility was out of pain pills for 3 days.
He stated he received tramadol but they were
barely helpful. He was supposed to get
Percocet. After visiting with the resident on
1/30/18, the surveyor reported the information
to the DON (director of nursing). On 1/31/18 at
8:20 a.m. the resident rated his pain during the
time of Percocet unavailability as 8.5 to 9. He
stated he did get a Percocet yesterday right
after he spoke with the surveyor.

revealed the resident worked with OT and
could not perform full range of motion due to
increased pain. The resident was out of
Oxycodone and the pharmacy would not refill
without an original script. Staff administered 2
tramadol and 2 Tylenol with little pain relief.
revealed the resident returned from an
appointment with a script to refill the Percocet.
The resident was upset that the PRN (as
needed) pain medication ran out. The DON
faxed the pharmacy the refill order and got the
authorization code to administer Percocet from
Page 90 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
the e-kit.
The care plan dated 1/31/18 revealed a

problem of adjustment issues since having
knee surgery and admission to the facility. The
resident stated his pain made it difficult to
enjoy things.
The January 2018 MAR showed the resident

rated his pain between 7 and 10 during the
time of Percocet unavailability.

MDS revealed the resident required extensive
assistance with bed mobility, dressing,
toileting, personal hygiene and total assistance
with bathing. The resident did not ambulate.
The resident had a surgical wound. The MDS
identified the resident with occasional pain.
The resident rated the pain as a "2" over the
previous 5 days.

surgery, laminectomy.
Review of admission orders dated 10/23/17

identified physician orders for
Oxycodone/acetaminophen 5/325 mg. give
one tablet every 4 hours as needed. Review of
the January 2018 MAR identified there was no
Page 91 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Oxycodone/acetaminophen administered
10/28/17 at 7:39 p.m.

revealed staff administered one Tylenol 325
mg, for bilateral leg pain. Progress notes dated
10/27/17 at 5:09 a.m. revealed the medication
was: ineffective.

revealed staff administered one
ibuprofen/Diphenhydramine capsule 200/25
mg. for continued complaints of discomfort and
resident unable to sleep. On 10/27/17 at 5:09
a.m. staff documented the medication was:
ineffective.
Progress notes dated 10/27/17 (4 days after

admission) at 3:23 p.m. revealed the charge
nurse spoke with the physician and the PA
(physician assistant) would write a prescription
for Oxycodone/acetaminophen and the
pharmacy would bring it that night.

daughter stated she visited almost daily. The
resident had a lot of pain when the narcotic
pain medication was not available. On
10/26/17 the resident was upset because a
nurse told the resident he should not be having
pain.
On 2/14/18 at 3:29 p.m. the physician stated

no pain medication for 4 days was a concern.
Page 92 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date

pain section of the MDS identified the resident
in almost constant pain. Pain limited the
resident's daily activities and affected the
resident's ability to sleep. The resident
identified the pain as a "6" in the previous 5
days (on a scale of 0 being no pain and 10
being the worst imaginable pain).
On 1/30/18 at 9:22 a.m. the resident stated

they did not have "the next script" to get her
pain medications refilled. She stated the last
pain medication she received was at 6 p.m. the
previous night. She stated she hurt and aches
all over at this time. She explained she had
torn rotator cuffs on both sides and other
issues that cause her a lot of pain. She rated
her pain as 6 to 7 at the time of interview. She
stated she was out of oxycontin and tramadol
both. She doesn't even get Tylenol at this time.
She stated she will be going through
withdrawals soon.
Review of the January 2018 MAR revealed the

resident had an order for
Oxycodone/acetaminophen 10/325 mg. 2
tablets between 4 a.m. and 6 a.m. and then
every 4 hours as needed. The resident did not
receive the 5 a.m. dose of the
Oxycodone/acetaminophen on 1/31/18.
5. On 1/31/18 at 8:45 a.m. Staff A LPN

(licensed practical nurse) stated the pharmacy
Page 93 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
doesn't let the facility know when the resident

is out of refills until they try to reorder the
narcotic. Then they have to wait for a script
from the physician to get more. She stated
Resident #14 needed a refill now. They can't
get the medication out of the emergency kit
unless staff has a code to open the box.
6. On 1/30/18 at 9:35 a.m. the Administrator

stated she was aware there was a problem
with initial admission scripts but not on refills.
Page 94 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Page 95 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
58.18(4) 58.18(4) The facility shall provide prompt II $500 Held Upon
response from qualified staff for the resident’s in Receipt
use of the Suspensi
nurse call system. (II, III) (Prompt response on
being considered as no longer than 15
minutes.)
DESCRIPTION:
Based on observation, record review, resident

and staff interviews the facility failed to have
sufficient nursing staff with the appropriate
competencies and skills sets to provide
nursing and related services to assure resident
safety and attain or maintain the highest
practicable physical, mental, and psychosocial
well-being of each resident, as determined by
resident assessments and individual plans of
care and considering the number, acuity and
diagnoses of the facility's resident population in
accordance with the facility assessment for 6
of 27 sampled residents. Call lights were not
answered within the required 15 minutes
resulting in incontinence and pain sitting on the
toilet. Staff did not get Resident #1's pressure
sore treatments completed due to not enough
time. The facility identified a census of 56
current residents.
Findings include:
1. Observation of call light response revealed

the following:
Page 96 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
On 1/3/18 at 8:34 a.m. Resident # 15's call

light activated. Staff did not answer the call
light until 8:57 a.m. (21 minutes) At that time,
Staff G CNA (certified nurse aide) stated the
resident wanted a glass of milk.
On 1/3/18 at 9:42 a.m. Resident # 9 activated

her call light. Staff did not answer the call light
until 10:10 a.m. (28 minutes later)
On 1/3/18 at 9:42 a.m. Resident #16's call light

was on. The resident was on the toilet. The call
light remained on until 10:15 a.m. (33 minutes)
At that time Resident #12 who shared a
bathroom with Resident #16 stated he waited
for the toilet forever. He needs it and can't wait
much longer. On 1/3/18 at 10:15 a.m. Resident
#16 stated his biggest complaint was waiting
on the toilet. He stated he was on the toilet for
quite a while. His butt sticks to the toilet and it
hurts.
A Minimum Data Set (MDS) with assessment

reference date (ARD) of 1/23/18 revealed
Resident #16's brief interview for mental status
(BIMS) score as "14" The resident required
extensive 2 or more staff assistance with
toileting. A care plan dated 1/11/18 revealed
the resident had a potential for alteration in
skin related to limited mobility. The care plan
directed staff to assist the resident with his
toileting needs as he requests and keep the
call light in reach and encourage the resident
to use it.
Page 97 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
2. A MDS with ARD of 12/6/17 assessed

Resident # 17 with a BIMS score of "15" (no
cognitive impairment). The resident required
extensive assistance of one staff with toileting.
The resident had diagnoses that included:
stroke with hemiplegia. On 1/25/18 at 10:22
a.m. the resident stated there are problems
with call light response. The resident stated
she needs help because she can't stand. Last
weekend she had to sit in wet pants for one
hour waiting for help. She looks at her watch or
clock for the time. It did not make her feel very
good and made her mad. She felt like she was
"a piece of nothing". The resident then became
tearful. She stated she also has had to sit on
the toilet for long periods. Sometimes 45
minutes to an hour. It causes her bottom to
hurt.
A care plan dated 3/14/16 directed staff to

keep the resident's call light in reach at all
times and encourage the resident to use it for
assistance as needed.
3. A MDS with ARD of 10/31/17 assessed

Resident #1 with a BIMS score of "15" (no
cognitive impairment). The resident required
transfers, dressing, toileting, personal hygiene
and bathing.
On 1/2/18 at 12:05 p.m. the resident stated call

lights take too long to get answered but she
had not timed them.
Page 98 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
On 1/24/18 at 2:55 p.m. when asked about not

performing Resident #1's extensive pressure
sore treatment on her shift, Staff C LPN stated
she was the only nurse those nights and she
had 4 other major treatments to complete. By
the time she got to the resident, she would be
asleep. The resident would get angry and was
hard to wake up so sometimes she did not get
the treatment done. Staff C was signing they
were not done but the DON said she couldn't
do that. The DON said she couldn't document
"asleep" or "only one nurse working". The
DON instructed her to mark it off as done and
just" try to get it done" so lots of times that is
what Staff C did. She stated she worked 3
times a week and would get the treatment
done half the time. She stated she informed
the Administrator it was impossible to complete
the treatments and the Administrator said she
knew that. On 2/6/18 at 1 p.m. the
Administrator denied saying she knew that.
She stated she spoke with the ADON
(assistant director of nursing) when they
terminated Staff C and he said he could get
the treatments done so they thought Staff C
could too.
4. Resident "beef and pie" resident meeting

notes for December 2017 revealed a resident
requested a pain pill at 4 a.m. and after waiting
50 minutes to have the call light answered, a
CNA (certified nurse aide) promised to tell the
nurse. The resident waited another 30 minutes
without the nurse appearing and put the call
light on again.
Page 99 of 85
Administrator Date
Number Report date
FC# 6780 March 23, 2018
Facility address
2121 W 19th Street
City MW
Section Amount Date
Page 100 of 85
Administrator Date

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Number Report date

FC# 6780 March 23, 2018

56.6 481—56.6 (135C) Treble and double fines. I $10,000 Upon

58.19(2)j 58.19(2) j Provision of accurate

Based on observation, record review, family,

1. A Minimum Data Set (MDS) with

An incident report dated 11/6/17 at 3:08 p.m.

A progress note dated 11/6/17 at 3:17 p.m.

fall to the floor. Staff observed the resident in a

There was no further documentation regarding

Progress notes dated 11/8/17 at 3:31 p.m. the

A clinic note dated 11/8/17 revealed the

On 2/7/18 at 9:13 a.m. the Administrator stated

On 2/28/18 at 1 p.m. the surveyor spoke with

while she was out of the facility.

On 2/7/18 at 9:41 a.m. the surveyor spoke with

Review of the November 2017 medication

A medication review report dated 10/26/17

Progress notes identified staff documented the

Progress notes revealed the resident received

The resident returned to the facility on

presented to the ER for chest pain of several

A December 2017 medication administration

On 1/3/18 the ARNP directed staff to weigh the

over 5 pounds. TED hose (compression

A January 2018 MAR identified the first weight

Progress notes dated 1/5/18 at 7:23 p.m.

After readmission to the facility from the

respirations 32 and more labored. Staff called

Progress notes dated 1/17/18 at 10:54 p.m.

On 2/12/18 at 1:15 p.m. the pharmacy stated

On 2/16/18 at 9:21 a.m. the ARNP stated the

would have been caught before she got septic.

On 2/7/18 at 2:30 p.m. the surveyor asked the

Progress notes dated 2/7/18 at 2:47 p.m. the

On 2/7/18 at 4:18 p.m. end of the day meeting

On 2/8/18 at 9:55 a.m. the Administrator stated

The 2/18 MAR revealed the resident's weight

Observation showed on 2/12/18 at 10:30 a.m.

have TED hose on.

On 2/12/18 at 4:30 p.m. the facility received a

On 2/28/18 at 7:47 a.m. progress notes

An after visit summary dated 2/28/18 identified

the reason for the visit was shortness of breath

2. A MDS with assessment reference date of

Progress notes dated 8/8/17 at 11:57 p.m.

Progress notes dated 8/9/17 at 7:40 a.m.

Progress notes dated 8/9/17 at 10:26 a.m.

Progress notes dated 8/9/17 at 8:39 p.m.

Progress notes late entry dated 8/9/17 at 8:47

Progress notes late entry dated 8/9/17 at 9:07

Progress notes late entry dated 8/9/17 at 9:22

oxygen at 2 liters. The oxygen saturation was

Progress notes late entry dated 8/9/17 at 9:30

Progress notes late entry dated 8/9/17 at 10

The record lacked evidence the facility notified

Staff working on the resident's hall the evening

On 2/13/18 at 11:33 a.m. Staff I RN (registered

condition. Staff I stated the resident was

On 2/12/18 at 12:27 p.m. Staff J CMA (certified

On 2/12/18 at 2:53 p.m. Staff K CNA (certified

over so they put him in bed. The resident had

On 2/12/18 at 1:46 p.m. Staff L LPN (licensed

On 2/13/18 at 9:53 p.m. the hospice nurse