Every finding on record at Fountain View of Monroe

Based on observation, interview, and record review, the facility failed to ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, pulled pork. This deficient practice had the potential to affect all the residents who consumed food from the kitchen, resulting in the potential for food borne illness. Findings include.On 12/3/25 at 10:45 AM, during observations of the kitchen with Certified Dietary Manager (CDM) A, a container with approximately one pound of previously cooked pulled pork cooked on 12/1/25 was stored with the active food stock in the walk-in cooler. CDM A said cooling logs were used to ensure cooked food was cooled properly and safely. CDM A was unable to produce the cooling log for the pulled pork. On 12/3/25 at 10:50 AM, Relief [NAME] (RC) B stated the pulled pork was cooked for dinner on 12/1/25. RC B said that following dinner service, the steam table was turned off. The pork was then transferred to another container after ten minutes and subsequently covered, dated, and placed in the walk-in cooler after another 45 minutes. RC B said that a cooling log was not used for the cooked pork and temperatures were not obtained during the cooling process. On 12/3/25 at 11:35 AM, CDM A noted that RC B failed to follow proper procedures for cooling the cooked pork. CDM A said it was important to properly cool previously cooked food to minimize the growth of harmful bacteria, thereby ensuring the food remained safe to eat when reheated. On 12/3/25 at 1:40 PM, the Nursing Home Administrator (NHA) said kitchen staff should follow the policy for cooling cooked food. On 12/3/25 at 3:45 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. According to the 2013 FDA Food code:- Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F (Fahrenheit) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. A review of the facility policy titled, Food Safety, dated 1/9/25, documented in part the following regarding cooling cooked foods:- Staff will use an ice bath to rapidly cool food items removed from the oven or steam table prior to refrigerating. - Larger food quantities, such as soups, should be placed in smaller pans (e.g. 2 inches deep) to allow cooling to occur more quickly.- Bulk items, such as roasts, will be cut in half or quarters to allow heat to escape- Items in ice bath will not be covered to prevent heat from becoming trapped.- Food will be placed in an ice bath until 41 F is reached then placed in refrigeration.- Foods will be rapidly cooled from 135 F to 70 F in two hours, then 70 F to 41 F in four hours.- Food items that have been out of safe temperatures for more than four hours will be discarded.

Based on observation, interview, and record review, the facility failed to identify, assess, and implement potential issues related to skin care for one resident (R104). Findings include:On 12/1/25 at 3:19 PM, R104 was observed alert and sitting up in his room. R104's scalp was observed to what appeared to be raised, crusted scabs. R104 said he keeps his hands off his scalp and denied getting cream or treatment for his scalp. On 12/3/25 at 9:10 AM, R104's scalp was observed with Registered Nurse/Unit Manager (RN/UM) C. R104 said the areas on his scalp do not bother him. RN/UM C stated even though the areas on his scalp do not bother him, It definitely looks like (R104) needs to see a dermatologist. R104's admission assessment was reviewed with RN/UM C and the area on his scalp was not noted on this document. RN/UM C added, We have no diagnoses or information on his scalp. If it was there upon admission, it should have been identified. On 12/3/25 at 2:01 PM, RN D was interviewed and said he has a clear memory of the yellow skin tag on top of R104's scalp. RN D feels like the yellow skin tag was on R104's scalp upon admission. On 12/3/25 at 2:18 PM, Licensed Practical Nurse (LPN) E identified the area on top of R104's head as a cuticle corn. LPN E said that the areas on his scalp have not changed since admission to the facility. On 12/3/25 beginning at 1:44 PM, the Director of Nursing (DON) was interviewed regarding the areas of concern on R104's scalp. The DON said she spoke with RN/UM C regarding the areas on top of R104's scalp. The DON said she was unaware of seeing it before today. The DON reported that R104's son was contacted regarding areas of concern on R104's scalp. R104's son said that R104 had not previously seen a dermatologist for the scalp issues and granted approval for the facility to schedule an appointment. The DON referred to a nursing note written on 12/3/25, in which the areas on R104's scalp were identified as seborrheic keratosis. A review of R104's physician documentation, conducted by the DON, revealed no record that the area on the resident's scalp had been observed or addressed. The DON said she participated in R104's admission assessment but did not document the area on his scalp. The DON said when the area on R104's scalp was first observed, it should have been documented on the skin assessment. The DON said the area on R104's scalp was not brought up as a potential concern before today and acknowledged the clinical importance of addressing concerns and potential concerns of the facility residents. A review of the clinical record for R104 documented an admission date of 8/22/23 with diagnoses that included transient cerebral ischemic attack (TIA), anxiety disorder, and atherosclerotic heart disease of native coronary artery (CAD). A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. Review of R104's care plans documented in part the following:- (R104) is at risk for impaired skin integrity/pressure injury related to: resident with past medical history of: TIA, hypertension, CAD, hyperlipidemia, dementia, and diabetes mellitus. As evidenced by decrease mobility, continence of bowel and bladder, receive anti-hypertensive as ordered. Nursing note dated 12/3/25 documented: Resident observed to have thick, dry white raised areas on scalp. Upon assessment resident denies any pain or discomfort, denies itching. Contacted resident's son to discuss, resident's son requesting dermatology consult, stating that he has not been to dermatology for this issue before. Spoke to PCP (primary care physician), PCP states that resident has been without any complaint of pain, itching or discomfort and felt that areas are consistent with seborrheic keratosis and is fine with resident being seen by dermatology. At this time no treatment initiated due to areas being stable and nonbothersome for the resident. Scheduler to arrange derm appointment as soon as available. On 12/3/25 at 3:45 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. A facility policy titled, Skin Management, dated 9/14/24 was reviewed and documented in part the following:- Upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record.- Residents admitted with any skin impairment will have:-- Appropriate interventions implemented to promote healing,-- A physician's order for treatment, and-- Skin impairment location, measurements and characteristics documented

Based on observation, interview, and record review, the facility failed to properly date-label food stored in resident refrigerators affecting all the residents who consumed food from the unit refrigerators resulting in unidentifiable resident items and the potential for food-borne illness. Findings include: On 9/11/24 at 8:53 AM unit refrigerators were observed with the Nursing Home Administrator (NHA, the following were noted: Pleasant View Unit -One 16-ounce opened used jar of Betty's dressing expiration date unknown. Evergreen Unit -One box of unlabeled opened [NAME] Dean breakfast sandwiches in freezer. -One box of unlabeled opened ice cream Drumsticks in freezer. -Two 20-ounce bottles of diet mountain dew unlabeled in refrigerator. The NHA agreed all food items should be labeled and dated. Only resident food should be stored in the unit fridges. On 9/12/24 at 9:28 AM the Director of Nursing was interviewed and said that nursing staff are responsible to maintain the unit refrigerators and agreed food items in unit refrigerators should be labeled and dated. Review of the facility policy titled Food from Outside Sources revised 11/12/2021 revealed in part .All food brought in is to be checked by the Nurse, Dietary Manager, or Dietician. It must be placed in a sealed container and labeled for the content, the guest's/resident's name and date the food was received, and an expiration date of 3 days after food was brought in. It is recommended that only enough food be brought in for that visit.

This citation pertains to intake MI100145407. Based on interview and record review, the facility failed to ensure dignified and respectful treatment for three residents (R3, R5, and R69) of 28 residents reviewed for dignity, resulting in residents verbalization of feelings of helplessness, frustration, and discontentment when staff respond rudely when answering the call lights, repeatedly talk on their phones during care while ignoring the residents, and sit in resident's rooms when the resident is not present. Findings include: R3: On 9/10/24 at 9:40 AM, R3 said they felt ignored and disrespected by staff because, The CNAs (certified nursing assistants) sit on that [NAME] (sofa) right there (resident pointed to a sofa in the hallway) and play on their phones. They don't even hide it anymore. They just sit there ignoring us while they are on their phones. I came into my room the other day and a CNA was sitting on my chair on her phone. I was so upset. I told the manager about it, but nothing was done about it. R3 went on to say that this occurs regularly on the PM shift from the same staff members. R3 said this has been brought up in resident council meetings several times and nothing has changed. According to R3's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] and had no cognition impairment. The Minimum Data Set (MDS) dated [DATE] indicated that R3 had bilateral upper extremity impairment and needed assistance with all Activities of Daily Living (ADL). R5: On 9/10/24 at 9:26 AM, R5 said approximately two weeks ago when returning to their room from an activity the resident found two CNAs sitting on the resident's bed looking at their phones. R5 said, I was very upset they were in my room when I wasn't there. They were both sitting on my bed. I asked them why they were in there and they said they had to find their friend and were on facebook trying to figure out where their friend was. R5 said, They sit there and talk to each other in my presence in my room even when they are giving me a bath. I don't want to hear about their personal lives. They don't even include me in the conversation. It's like I'm not even there. It's awful feeling like that. R5 said they did not report this to the manager at this time because they felt helpless because nothing had been done to stop this from earlier complaints. R5 also said that the same two CNAs often sit on the sofa in the hallway and talk to each other or look on their phones instead of checking in on the residents. According to R5's EHR the resident has resided in the facility since 5/20/19 and had no cognition impairment. The MDS dated [DATE] indicated that R5 required assistance for all ADLs. R69: On 9/11/24 at 11:40 AM, R69 said, Some of the CNAs on the afternoon shift are disrespectful and condescending. They either ignore us because they are on the phone the whole time or talk to us like we are two years old. R69 went on to say, When they answer the call lights they say 'What do you want?' or 'I don't have time for that right now, I'll come back.' then they shut the call light off and never come back. We told the manager several times but feel helpless because nothing changed. What can we do? We are at their mercy. R69 said, One time I was napping and woke up because I heard voices. A CNA was in my room, sitting on my chair on the phone while I was asleep. It upset me. It made me feel like I had no privacy. According to R69's EHR the resident had resided in the facility since 9/1/2023 and had no cognition impairment. The MDS indicated that R69 had impairment to one upper extremity and required assistance with all Activities of Daily Living (ADL). On 9/11/24 at 11:02 AM, nurse manager, Registered Nurse (RN) B was asked about use of cell phones during resident care. RN B said, It is in the employee handbook that they (staff) are not supposed to be on their phones during work hours. They can use their phones during their break, but not during care. RN B said she had never heard that CNAs were in resident's rooms sitting on the resident's beds/chairs. RN B said, That's a concern. We will be having an education on that. On 9/11/24 at approximately 12:00 PM the Director of Nursing (DON) was asked about staff's use of cell phones and said, The staff are educated on that. They know they are not supposed to be on their phones during work hours. It is in the employee handbook and I believe there is a policy as well. The DON was unaware that residents had found staff in their rooms sitting on the resident's furniture without an invitation. The DON said that type of behavior would not be considered appropriate. On 9/12/24 at approximately 11:00 AM staff member D who wished to remain anonymous said that she had witnessed staff members looking at their phones while in a resident's room when the resident was not present. Staff member D said that she had notified a unit manager but nothing was really done about it. According to the facility's Telephone, Pager and Electronic Device policy last revised 12/14/2023, reads in part; It is the policy of this facility that, unless specifically designated otherwise, cellular phones . or any other electronic devices are not permitted to be worn or used in any area outside of the designated staff member break room. According to the facility's Resident Rights policy last revised 5/14/2024, reads in part; The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

This citation pertains to intake MI100145407. Based on interview and record review, the facility failed to act promptly on grievances and concern forms reported in resident council meetings and provide responses and resolutions for two grievances filed in the last four months, as reported during confidential resident council meetings, resulting in unresolved resident concerns, residents expressing feelings of helplessness, and decreased quality of life. Findings include: Review of the Resident Council Meeting (RCM) Minutes, written by Activity Director (AD) C, dated 5/20/24 had the following nursing concerns; Complaints about Certified Nursing Assistant (CNA) E. Complaints about multiple staff in one room at a time. The complaints were not specified. A Resident Assistance Form, completed by AD C from the RCM dated 5/21/24 documented that CNA E was rude and had no bedside etiquette. There were no specific behaviors identified. The Facility Response section indicated that the staff member (CNA E) was educated. There was no specific education identified. Review of the RCM Minutes, written by AD C, dated 6/23/24 had the following nursing concerns; Complaints about multiple CNAs, including CNA E for repeatedly talking about their personal life and being on their cell phones during care, and something else that is whited out and unable to be seen. A Resident Assistance Form written by AD C, from the RCM dated 6/23/24 documented the following concerns; CNA E rude to residents. CNA E stated to a resident We are really busy, Let's get this over with, and What do you need now? The Facility Response section indicated that a manager would talk with staff member (CNA E) and the residents to ensure correct information. There was no additional follow-up documentation. Review of the RCM Minutes written by AD C for both 7/22/24 and 8/26/24 had no Old Business that listed follow-up from the last months minutes. There was no documentation to indicate the previous concerns from the 5/21/24 or 6/23/24 RCM had been resolved. On 9/12/24 at approximately 11:00 AM AD C was asked about the 'whited out' section on the RCM minutes for 6/23/24 and replied, The residents had complained about CNAs being rude and on their phones in May. The residents brought it up again in June, but then retracted it and did not want me to bring it up again, so I whited it out. AD C acknowledged that multiple residents continued to complain about CNA E at both the May and June RCM. AD C said, I did bring the resident's concerns to the manager and the Administrator. Review of the RCM minutes for both 5/21/24 and 6/23/24 included the Nursing Home Administrator's (NHA) signature. AD C could not say if the resident's concerns had been completly addressed to the resident's satisfaction. AD C could not explain why there were no Old Business notes on the July or August RCM minutes. R3: On 9/10/24 at 9:40 AM, R3 said they felt ignored and helpless because they had brought up concerns with certain staff members in resident council meetings several times and nothing has changed. The CNAs sit on that [NAME] (sofa) right there (resident pointed to a sofa in the hallway) and play on their phones. They don't even hide it anymore. They just sit there ignoring us while they are on their phones. I came into my room the other day and a CNA was sitting on my chair on her phone. I was so upset. I told the manager about it, but nothing was done about it. R3 went on to say that this occurs regularly on the PM shift from the same staff members. According to R3's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] and had no cognition impairment. The Minimum Data Set, dated dated dated [DATE] indicated that R3 had bilateral upper extremity impairment and needed assistance with all Activities of Daily Living (ADL). R5: On 9/10/24 at 9:26 AM, R5 said approximately two weeks ago when returning to their room from an activity the resident found two CNAs sitting on the resident's bed looking at their phones. R5 they did not report this to the manager at this time because they felt helpless because nothing had been done to stop this from their earlier complaints. According to R5's EHR the resident has resided in the facility since 5/20/19 and had no cognition impairment. The MDS dated [DATE] indicated that R5 required assistance for all ADLs. R69: On 9/11/24 at 11:40 AM, R69 said, We told the manager several times about CNAs being on their phone but feel helpless because nothing changed. What can we do? We are at their mercy. According to R69's EHR the resident had resided in the facility since 9/1/2023 and had no cognition impairment. The MDS indicated that R69 had impairment to one upper extremity and required assistance with all Activities of Daily Living (ADL). On 9/12/24 at 11:40 AM nurse manager, Registered Nurse (RN) B and the Director of Nursing (DON) was asked about the RCM minutes form 5/2024 and 6/2024 and said that the CNAs had received training and had write ups for those incidents. RN B said that she was unaware that the cell phone use in resident care areas had continued or that CNAs were in resident's rooms sitting on the resident's beds/chairs. On 9/12/24 at approximately 12:00 PM the Nursing Home Administrator (NHA) was asked to review the RCM minutes from April - August 2024. The NHA acknowledged there was white-out on the concern section for nursing department for June and then no follow-up on the July or August meetings. The NHA said she was aware there were concerns with CNAs and could not explain why there was no documented follow-up on the RCM minutes. According to the facility's Resident Rights policy last revised 5/14/2024, read in part; The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility These rights include the resident's right to: Voice grievances and have the facility responds to those grievances. According to the facility's Guest/Resident Council last revised 8/25/21 and effective 6/2/22, read in part: The Guest/Resident council provide a formal, organized means of guest/resident input in to facility operations. Procedure: 10. Minutes of the meeting will be recorded and maintained for at least two years. Minutes will not include residents names in regard to issues and complaints. 11. The Guest/Resident Council grievances and recommendations will be documented on the Guest/Resident Assistance Form The completed forms are brought to the attention of the Administrator who will forward the forms to the respective department head for attention and response. 12. Responses regarding resolution are to be documented on the Guest/Resident Assistance Form, reviewed by the Administrator and a copy of the completed forms are sent to [NAME], and kept with the Guest/Resident council minutes. 13. Action taken and/or considerations given to issues will be reported back to the Guest/Resident Council at the following meeting and documented within the minutes.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 109 residents. Findings include: On 8/16/23 at 9:00 AM, three live flies were observed in the kitchen's dishwashing area. On 8/16/23 at 9:19 AM, two live flies were observed near the kitchen's janitors closet area. Upon observation the surveyor inquired with Dietary Manager staff A on the current state of the insects in this area to which they responded, We've had an issue with gnats and are in the process of starting with a new pest company. They have some new chemical that is supposed to help. At this time the surveyor requested the facility's pest control policy to review. On 8/16/23 at 10:08 AM, one live fly was observed on the kitchen's main food preparation table. On 8/16/23 at 11:13 AM, one live fly was observed in the kitchen's clean equipment storage room. On 8/16/23 at 11:36 AM, two live flies were observed near the kitchen's bread storage rack. On 8/16/23 at 2:43 PM, record review of the facility's most recent Commercial Services Agreement dated, 7/28/23 revealed under the section titled, scope and nature of work that specific targeted pests to be treated in the building were not listed. Instead, the document listed in the other box selected that, Actizyme Drain Cleaning Service (11 Drains), Fill Actizyme Dispenser (1 Gallon). Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B)Routinely inspecting the PREMISES for evidence of pests; (C)Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12,7-206.12, and 7-206.13; Pf

Based on interview and record review the facility failed to report an allegation of employee to resident abuse (per R32) to the State Agency for one resident (R59) out of a sample of one resident reviewed for abuse, resulting in the potential for feelings of not being protected or safe within the facility, and for abuse to continue without being reported. Findings include: On 8/15/23 at 11:44 a.m., R32 said a report was made to the Nursing Home Administrator (NHA) about an incident that was witnessed (by R32) that occurred about 3 weeks ago, on a weekend day. R32 witnessed R59 kicked and yelled at by an aide at the nurse's station of the Meadowview Unit. R32 said the incident was reported to the NHA on Monday. R32 expressed concern about the incident because the aide continued to work at the facility after the incident was reported. On 8/15/23 at 3:05 p.m. the NHA was interviewed. The NHA said they were aware of the allegation made by R32. The NHA was asked was the incident reported to the State Agency. The NHA said the incident was not reported to the State, but an investigation was conducted. The facility concluded the incident did not occur. On 8/15/23 at 4:16 p.m. the NHA submitted a document titled Quality Assurance Interview Summary of Resident Interview. According to the report, the incident occurred on 7/10/23 (no time). R59 was interviewed but was unable to recall the incident. The staff member involved was interviewed on 7/11/23 (no time) and gave their statement of what occurred. On 8/16/23 at 9:49 a.m. review of the clinical record documented R59 was admitted into the facility on [DATE] with diagnoses that included Alzheimer's dementia and peripheral vascular disease. According to the quarterly Minimum Data Set assessment dated [DATE], R59 was severely cognitively impaired (brief interview for mental status/BIMS of 6) and required limited one person assist with activities of daily living. On 8/16/23 at 2:05 p.m. the NHA with the Director of Nursing (DON) present was interviewed about not reporting the incident to the State Agency. The NHA stated, I thought because it wasn't abuse that happened and after I investigated and unsubstantiated, I didn't have to report it. I was unaware I had to report allegations. Review of the facility's policy titled Abuse Prohibition dated 9/9/22 documented: The Administrator or designee will notify the guest's/ resident's representative. Also, any State or Federal agencies of allegations per state guidelines .

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided timely for two Residents (R76, R489) of 7 residents reviewed for activities of daily living (ADLs), resulting in the residents being soiled and uncomfortable for a long period of time, verbalized frustration, and the potential for skin breakdown. Findings include: R489 R489 was observed on 6/8/22 at 1:14 p.m., lying in bed alert and interviewable. An odor of feces-like odor was noted coming from R489's bed. R489's bed sheets were observed with dried feces prior to R489 pulling the covers back himself. After R489 pulled back the sheet and blanket, dried greenish and brownish feces was observed from his chest area to the lower legs. R489 start to point at his [CONDITION(S)] (A plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall called a stoma .) bag and said, No, I'm not okay. R489 verified during an interview at this time that no one had been in his room that day to clean him up or assist with any ADL care. R489 said, They (staff) had been in the room only to give him his meal trays. A food tray was observed in a chair and a food tray was observed on R489's bed table. R489 said, Yes, I want to be cleaned up. R489' assigned Registered Nurse (RN) E and Unit Manager/Register Nurse F were summoned to R489's room for observation and interview. RN E agreed the feces appeared dried from chest to lower legs. RN E confirmed he did not see the assigned Certified Nursing Assistance (CNA) enter R489 to provide ADL care. UM/RN E said, No when asked did it appeared R489 had been provided with ADL care while she was preparing to assist R489 with ADL care. Um/RN E said, The last time I been in the room was about 10:00 this morning but did not turn the covers back to assess him. UM/RN said, Someone had to come in the room to bring his breakfast tray. UM/RN E denied after observing R489 that someone provided ADL care within two hours. R489 blue disposable brief was stuck to his upper back with greenish and brownish dried feces after UM/RN E assist R489 to a sitting positing in bed. A louder smell of a feces-like odor noted when R489 was assisted from a lying position to a sitting position. R489 said again while UM/RN F and RN E was assisting him with ADL care, that No one had been in the room to clean me up today (6/8/22). UM/RN F and RN E were then observed to provide a complete bed change due to R489 bed linen was covered in dried feces. During an interview on 6/8/22 at 3:05 P.M., DON 'B' verified that the facility's policy for ADL care is every two hours. On 6/8/22 at 3:10 p.m., the assigned CNA G was interviewed and said, his shift was from 6:45 a.m. through about 3:15: p.m. CNA G said, he is a regular on the unit and familiar with R489. CNA G said, About 7:20 a.m. before breakfast was the last time, I recall going into the resident's room to provide ADL care. Someone told me that the resident needed to clean up. I cannot recall going back into the room after 7:20 a.m. CNA G verified residents are to be check and provide ADL care every two hours. According to R489's electronic medical record, he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's annual Minimum Data Set (MDS) with a reference date of 4/22/22 indicated R489 was severely cognitively impaired with a BIMS (brief interview for mental status) score of 04. Required limited assistance of one person physically assistant with transfers, personal hygiene, and toileting. Required extensive assistance of one person for dressing and bathing. Review of the ADLs care plan-initiated date 1/16/21 and revision date 6/8/22 documented, R489 has an ADL self-care performance deficit and requires assistance with ADL's and mobility related to resident with recent re-admission from hospital with admission to hospice services for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions Assist with ADLs . According to the facility's Routine Guest/Resident Care policy revised date 6/16/2021 documented, Guest/Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Guidelines: 8. Incontinent care is provided timely according to each guests/resident's needs. Resident #76 In an observation on 6/8/22 at 10:56 a.m., Resident #76 (R76) laid in bed with eyes closed and wore a gown. In an observation on 6/8/22 at 1:17 p.m., rolled up linen with a brown spot the size of a basketball laid on R76's bed. R76 sat in a wheelchair and ate lunch. In an interview on 6/8/22 at 1:23 p.m., Certified Nursing Assistant (CNA) D reported she got R76 up at lunch time. CNA D reported she checked and changed R76 around 11:45 am. CNA D then reported she did not change R76 prior to 11:45. Review of an Admission Record revealed, R76 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/25/22 revealed R76 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. R76 required extensive assistance of two staff with bed mobility and toilet use. Review of a Care Plan with focus (R76) is at risk for complications of altered elimination pattern r/t (related to) admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . with a initiated dated of 5/18/22. Interventions included . Check q (every) 2 hr and prn (as needed) for incontinence . with a initiated dated of 5/23/22.

Based on interview and record review, the facility failed to administer anti-diabetic medication in accordance with physician's orders and plan of care for one resident (#46), of three residents reviewed for medication administration, resulting in the potential for hypoglycemic reaction. Findings include: The clinical record for Resident #46 (R46) was reviewed and documented an original admission date of [DATE] and readmission date of [DATE]. A Minimum (MDS) data set [DATE] documented intact cognition. R46's [DIAGNOSES REDACTED]. A review of R46's care plans documented the following: Focus: (R46) is at risk for fluctuation in blood sugars related to diabetes mellitus. Interventions included in part: Administer medication as ordered. A review of physician's orders stipulated to administer Insulin [MEDICATION NAME] (a rapid-acting insulin used to lower the amount of sugar in the blood) five units subcutaneously with meals for diabetes mellitus. The order further documented that the insulin was not to be given if R46's blood sugar was less than 140 mg/dl (milligrams per deciliter). On 3/17/2021 at 12:58 PM, a review of the Resident's clinical record was conducted with Unit Manager A. The nurses' documentation on R46's March 2021 Medication Administration Record [REDACTED]. -3/4/2021 blood sugar of 90 mg/dl -3/7/2021 blood sugar of 81 mg/dl -3/8/2021 blood sugar of 110 mg/dl -3/9/2021 blood sugar of 137 mg/dl Additionally, on 3/5/2021 related to the 5:00 PM Insulin [MEDICATION NAME] administration, the Resident's blood sugar was 84 mg/dl and rapid-acting insulin was given. A review of the nurses notes with Unit Manager A revealed no documentation that the rapid-acting insulin was not given at the above referenced dates and times. On 3/17/2021 at 2:08 PM, Nurse B was interviewed. Nurse B obtained the blood sugars on 3/7/2021 of 81 mg/dl and 205 mg/dl related to the 8:00 AM and 11:30 AM insulin administrations, respectively. When queried about the meaning of her documentation on R46's MAR, related to the 8:00 AM and 11:30 AM rapid-acting insulin administration, she stated her documentation meant the medication was administered. Nurse B added, If it wasn't administered, I would put that it was held. On 3/17/2021 at 2:16 PM, when the Director of Nursing (DON) was queried if there was a nurse's note which indicated the rapid-acting insulin was held on 3/7/2021, she said, No. The DON added that the nurse's documentation indicated the medication was given. When queried if that was a concern related to the rapid-acting insulin, the DON said, Yes, because medication was given when it was indicated to be held per parameter. On 3/17/2021 at 3:50 PM, when the DON was queried if it was her expectation that nurses follow physician's orders, she said, Yes. On 3/17/2021 during the exit conference, the facility Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

This citation pertains to Facility Reported Intake (FRI) MI 346. Based on interviews and record reviews the facility failed to prevent misappropriation of resident's property for one of three residents (R#3) reviewed for abuse resulting in R#3's driver's license, social security card, and two of her credit cards being found at a facility staff member's house by the local Narcotics Team and Investigative Services (NTIS) department during the execution of search warrant. Findings include: According to the FRI ( facility reported incident) dated 8/13/20, the local NTIS department notified the Administrator that during the execution of search warrant at CNA Bs place of residence, Resident #3's driver's license, social security card, and two credit cards were found. CNA B' reported that she had picked them up off the floor after they fell out of R#3's person during assisting her to the bathroom and she forgot to return them. The local police department had confirmed that no activity had occurred on R#'s credit cards. During an interview with the Administrator on 9/3/20 at 9:00 AM she said the facility immediately conducted an internal investigation regarding the misappropriation of R#3's belongings upon receiving the information from NTIS. The facility concluded that CNA B had assisted R#3 to the bathroom on her last day of work. The Administrator said that CNA Bs employment had been terminated because she did not follow the facility's abuse policy regarding resident's personal belongings. The Administrator reported that a facility wide sweep had been conducted and no additional residents had reported missing belongings. According to R#3's medical record, she admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] indicated the resident has no cognition deficits, and requires one person assistance for ambulating and toileting. During an interview with R#3 on 9/3/20 at 10:15 AM she said she clearly remembers the day the CNA B had assisted her to the bathroom because she (CNA B) was not her 'usual CNA'. R#3 recalled that CNA B was taking an especially long time hanging around in her room after she had assisted her (R#3) on the toilet, and she heard her rummaging around over near her dresser. R#3 said she thought that CNA B was looking at her family pictures, which were arranged on that dresser along with some birthday gifts she had just received. R#3 said she keeps her purse in the bottom drawer of that dresser, and her wallet is kept in that purse. R#3 said that she did not have any of her identification cards on her person, she has always kept them in her purse. R#3 said she has never taken her purse to the bathroom, nor had she removed her driver's license, social security card, or credit cards from her wallet. Furthermore, her driver's license, social security card, and credit cards are kept in tight plastic sleeves in her wallet and would have never just fallen out. The Resident said that the theft of her belongings came to light on her birthday, and she feels the CNA targeted her because she knew her family had just given her birthday presents earlier in that week. R#3 said that her daughter gave her a $100.00 gift card to Walmart and another daughter had given her a $50.00 gift card to Red Lobster that are also missing and she knows that the CNA took those also. The Resident said she feels safe in this facility and feels justice has been served since the CNA will not be employed there any longer. R#3 also said, I hope she got a good meal at Red Lobster, and some things at Walmart, she must have needed it more than me.

This citation pertains to intake #s MI 178 and MI 502. Based on interview and record review, the facility failed to ensure proper supervision and implementation of fall safety devices for two (#s [AGE]1, [AGE]2) of four sampled residents reviewed for accident hazards, resulting in falls while being assisted by staff during surface to surface transfers causing pain and the potential for further injury. Findings include: Complainants reported to the State agency that falls occurred while being assisted by staff. Resident #[AGE]1- On 2/25/20 at 10 AM, the resident's clinical record and Incident/Accident (I/A) Reports were reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted the resident had minimal cognitive impairment, required extensive two-person assistance with transfers and mobility and had impaired range of motion on one side of the body. The Nursing Comprehensive evaluation dated 1/31/20 noted that on admission, the resident had a history of [REDACTED]. The resident was prescribed a brace to the right lower extremity to be worn during transfers and dycem (anti-skid pad) to the wheelchair seat. An I/A Report dated 2/6/20 noted: Resident was being transferred from wheelchair to toilet, lost footing and 'slid off' cushion of wheelchair to sitting position on floor holding onto grab bar. There was no noted injury. The report noted that there were three nurse aides assisting the resident when the fall occurred including aides Confidential Witness (CW) C and D. Initial interventions to prevent future falls in the I/A Report included Ensure proper amount of assistance present to ensure resident is steady on feet during transfer. At 10:20 AM, when queried by phone about the fall, CW-D said that she was not providing assistance and was not present when the fall occurred. The second aide was not available for comment by phone or in person. CW-C said during a phone interview that she was the resident's assigned aide on 2/6/20 and was transferring the resident alone without assistance. When asked what happened, CW-C said, She had back problems. I told her to stand straight up. The wheelchair slid back. She was extensive one-person assist. She didn't stand straight up. She was not straight and started sliding. When asked what extensive assistance meant, CW-C said, It means she can stand straight up but I'm doing most of the work. When asked, CW-C could not explain how the wheelchair slid back if the brakes were locked as she said they were. The resident's At Risk for Future Falls care plan initiated 1/31/20, did not note how much assistance the resident required. The Kardex (care guide specifically used by nurse aides) noted: Requires extensive x 2 (two-person) assistance with bed mobility, transfers.Patient has impaired range of motion to right upper extremity and right lower extremity. At 1 PM, when asked why the I/A report erroneously noted that there were three staff assisting the resident when she fell , the Director of Nursing (DON) said, Well, I can only go by what the report said. When informed that CW-D said she was not present and CW-C said she was transferring the resident alone, the DON did not respond why the proper assistance was not provided. Resident #[AGE]2- On 2/25/20 at 10:30 AM, the resident's clinical record and I/A Reports were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted minimal cognitive impairment, limited range of motion to right lower extremity and extensive two-person assistance required for transfers and mobility. The Nursing Comprehensive evaluation dated 12/24/19 noted that on admission, the resident had a history of [REDACTED]. On 12/24/19, orders were written: Right knee immobilizer to right leg at all times; No weight bearing to the right leg. An I/A Report dated 12/24/19, on the date of admission, noted: The resident was transferring with assistance from two nurse aides (CW-A and CW-B) from the wheelchair to bed, lost her balance and had to be lowered to the floor onto buttocks. There was no noted injury. (The resident said however, that aides dropped her on the floor the day she got to the facility and sustained pain to her tailbone.) At 10:50 AM, when asked what happened, CW-B said that she was assisting assigned aide CW-A with the transfer by standing in front of the resident, who was standing with a walker, while CW-A was behind the resident and the resident fell . When asked if a fall safety device, such as a gait belt, was in use, CW-B said, You're supposed to use a gait belt for transfers and that she and CW-A didn't have one. At 2 PM, when queried, the DON said that gait belts were supposed to be used during transfers. When told that it was not used when the fall occurred, the DON looked at the I/A report and said, According to the report, a gait assist device was used. I assume it was a gait belt. However, at 2:22 PM when interviewed by phone, CW-A said, I was supposed to use one but the gait belt wasn't on me at the time. The resident's Kardex noted: Resident required extensive assist x 2 with transfer using a sliding board on the left. No weight bearing right lower extremity. (A sliding board is used when a standing transfer is not safe and serves as a bridge between the two surfaces that a person can slide across to transfer.) There was no mention in the Kardex of using a gait belt. The resident was discharged on [DATE]. The resident's At Risk for Future Falls care plan created 12/24/19 and revised on 2/25/20, the day of the survey and after the resident's discharge, did not note how much assistance the resident required or to use a gait belt or sliding board for safety. On 2/25/20 at 6 PM, per review of the facility's policies on Fall Management dated 8/2016, Transfer From Bed To Wheelchair and Gait Belt Use dated 6/14/19: -The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices.as appropriate to minimize the risk for falls. -For a resident with diminished or absent lower-body sensation or one-sided weakness, immobility, or injury, transfer from a bed to a wheelchair may require partial support to full assistance-initially by at least two persons.If necessary, place a gait belt over the patient's clothes around the waist, with the buckle or velcro fasteners secured in the front. -A gait belt is a safety device made of cloth or plastic that buckles securely around the patient's waist. The device provides a secure grasping surface to aid with patient transfer and ambulation. Common for patients who are at risk for falling, a gait belt can help safely lower a patient to the ground if the patient begins to fall or loses balance during transfer or ambulation.

Based on interview and record review, the facility failed to document thorough and accurate clinical records in accordance with accepted professional standards and practices for two (#s [AGE]1 and [AGE]2) of four sampled residents reviewed for clinical information, resulting in the potential for further compromise in safety and well-being from on-going inappropriate or unmet care occurring without detection, due to incomplete and erroneous information made available to care givers. Findings include: Resident #[AGE]1- On 2/25/20 at 10 AM, the resident's clinical record and Incident/Accident (I/A) Reports were reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted the resident had minimal cognitive impairment, required extensive two-person assistance with transfers and mobility and had impaired range of motion on one side of the body. The Kardex (care guide specifically used by nurse aides) noted: Requires extensive x 2 (two-person) assistance with bed mobility, transfers.Patient has impaired range of motion to right upper extremity and right lower extremity. An I/A Report dated 2/6/20 noted, the resident was being transferred from wheelchair to toilet with three nurse aides assisting, including aides Confidential Witness (CW) C and D when a fall occurred. However, at 10:20 AM when queried by phone about the fall, CW-D said that she was not providing assistance and was not present at all when the fall occurred. The second aide was not available for comment by phone or in person. CW-C said during a phone interview that she was transferring the resident alone without assistance. The I/A report was signed by the Director of Nursing (DON) on [DATE], indicating that it was accurate and complete. When asked why the I/A report erroneously noted that there were three staff assisting the resident, but CW-D said she was not present and CW-C said she was transferring the resident alone, the DON said, Well, I can only go by what the report said. Resident #[AGE]2- On 2/25/20 at 10:30 AM, the resident's clinical record and I/A Reports were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted minimal cognitive impairment, limited range of motion to right lower extremity and extensive two-person assistance required for transfers and mobility. An I/A Report dated 12/24/19, on the date of admission, noted: The resident was transferring with assistance from nurse aides CW-A and CW-B from the wheelchair to bed and had to be lowered to the floor onto buttocks. (However, the resident said aides dropped her on the floor the day she got to the facility and sustained pain to her tailbone.) At 10:50 AM, when asked what happened, CW-B said that she was assisting aide CW-A with the transfer when the resident fell . When asked if a fall safety device, such as a gait belt, was in use (a belt that goes around the resident's waist used for grasping and safely lowering a person to the floor if falling), CW-B said, You're supposed to use a gait belt for transfers and that she and CW-A didn't have one. At 2 PM, when queried, the DON said that gait belts were supposed to be used during transfers. When told that it was not used when the fall occurred, the DON looked at the I/A report signed by her on 12/26/19, indicating that it was accurate and complete, and said, According to the report, a gait assist device was used. I assume it was a gait belt. However, at 2:22 PM when interviewed by phone, CW-A said, I was supposed to use one but the gait belt wasn't on me at the time. The resident's Kardex noted: Resident required extensive assist x 2 with transfer using a sliding board on the left. No weight bearing right lower extremity. (A sliding board is used when a standing transfer is not safe and serves as a bridge between the two surfaces that a person can slide across to transfer.) However, the resident's At Risk for Future Falls care plan, created on 12/24/19, was incomplete as it did not identify how much assistance the resident required or to use a gait belt or a sliding board for safety. Also, the care plan was noted as having been revised on 2/25/20, the day of the survey, and five weeks after the resident's discharge on 1/20/20. The I/A report and Post Fall Evaluation (part of the I/A report) did not mention the sliding board as an intervention to prevent future falls or to reduce repetition of falls.

Based on observation, interview and record review, the facility failed to implement its' policy for one (#14) of 26 sampled residents reviewed for concerns/grievances, resulting in staff not documenting, investigating and resolving in a timely manner, a complaint voiced by the resident regarding lack of care assistance. Findings include: On 7/30/19 at 2:45 PM, resident #14 was observed sitting in a wheelchair in the hallway propelling herself to an activity. When asked if she was receiving the care she needed at the facility, the resident gave the following account: I was in the hospital recently for a week. I was in the dining room and next thing I knew, I was in the hospital. I don't know what happened. A few weeks ago, I had a really big bowel movement. It went all over the place. I was covered with it. I couldn't help it. It just came out and was on the floor. An (nurse) aide came in the room and gave me a towel and took me in the bathroom. She left and didn't help me. It (stool) was all around here (motioning to buttocks, hips and thighs). I really needed a shower. I am weaker and can't do as much as I could before I went to the hospital. They (staff) are used to me being able to do more for myself like I used to. When asked if she told anyone of the concern, the resident said, I told (restorative aide A) when it happened. I didn't tell (nurse unit manager E) because I think she was on vacation. She said that no one had spoken to her or followed-up about it. The resident became tearful as she was explaining the situation. During an interview on 7/31/19 at 1:44 PM, staff A said, I got to work about 7:30 (AM) and was passing by, so I ducked my head in to say hello. She (resident #14) was very upset. This was about two to three weeks ago. It had just happened around the change of shift (between the midnight and day shifts). She said she had a large BM (bowel movement) and it went on the floor. The aide came in and cleaned up the floor, but left and did not help her. She said she had BM all over her. I think it was about her dignity. I told a nurse about it. I don't remember which one. When asked if the facility had concern forms and if she had written one about the complaint or had given one to the resident, staff A said, We have concern forms. I did not write one up because I told the nurse about it. Staff A said she did not know if there was a follow-up with the resident by nursing staff, when asked. At 2:49 PM, the resident's clinical record was reviewed and revealed according to the minimum (MDS) data set [DATE]: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/16/19, the resident was found in the dining room with altered mental status, was transported to the hospital and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 8/01/19 at 12:30 PM, nurse unit manager [NAME] said she was just made aware of the concern on 7/31/19 and that she may have been off or on vacation when the incident occurred. She indicated that a concern form should have been written by staff A. At 2:30 PM, the Director of Nursing said she was just made aware of the resident's concern and did not respond why a concern form was not written by staff A or if one should have been. On 8/2/19 at 8 AM, per review of the facility's 'Resident, Family, Employee, and Visitor Assistance Form' dated 9/2013: Please give our facility an opportunity to address your concern by completing this form Expect a response within 3-5 business days. The form asked for information about your concern with fields in which to document the facility response, action to be taken and facility follow-up. The facility's Care Program policy dated 11/2017 noted: Purpose-To ensure that the facility actively resolves any concerns/grievances submitted orally or in writing to the facility's staff All concerns/grievances are investigated, resolved, and documented If a resident has a concern, a staff member should encourage and assist the resident to file a written concern/grievance with the facility If the facility receives a concern/grievance orally, staff should document the concern using the Resident Concern Form Staff receiving the concern/grievance should acknowledge receipt of concern and immediately address the concern if possible and document the resolution will have 5-7 days following receipt of the concern to complete the investigation and document his/her conclusions The Administrator will review the findings will contact the resident as soon as possible

Based on interview and record review, the facility failed to ensure residents received their 60-day physician's visit for two (#17, #71) residents reviewed for frequency of physician's visits resulting in the failure to provide medical supervision and the potential for unobserved change of condition. Findings include: Resident #17 (R17) was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #71 (R71) was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 8/1/19 at 10:50 AM, the Director of Nursing (DON) was interviewed regarding the provision of physician services in the facility. The DON stated that MD 'B' no longer worked in the facility. She added, He retired 4/30/19. (MD 'C'), who started around the end of (MONTH) (2019) took over most of his residents. When queried if she was aware of any interruptions in the timeliness of physician visits, the DON said, Not to my knowledge. The DON added, (MD 'C') had a list of residents that needed to be seen and was confident that he could see them. When the DON was queried about her expectations for physician visits, she stated Medicaid residents are to be seen every 60 days. A Mid-level (provider such as a Nurse Practitioner or Physician Assistant) can visit the residents every other visit. Short-term rehab residents are to be seen shortly after admission and then as needed or at least every 30 days. The DON added, I would expect the physician, or his extender, would visit the resident more often if requested. When queried about the purpose of the visit frequency, the DON said, To establish a baseline for that resident. To get to know them so they know that resident and any variance afterwards. On 8/1/19 beginning at 11:00 AM, when the medical records of R17 and R71 were reviewed with the DON to determine the frequency that they received visits and examinations by their physician, the following was revealed: --R17's physician, Medical Doctor (MD) 'B', saw and examined her during 2019 on 1/2/19, 1/7/19, 1/14/19, 1/21/19, 1/29/19, and 2/16/19. R17 was next examined on 6/11/19 by her new physician, MD 'C'. --R71's physician, MD 'B', saw and examined her during 2019 on 1/17/19 and 2/16/19. R71 was next examined on 6/11/19 by her new physician, MD 'C'. When queried about the way a physician documents their visit and evaluations/assessments, the DON stated the visit would be documented in the electronic medical record in the progress notes. When queried if R17 and R71 should have received a 60-day visit by their physician, the DON said, That's my understanding. When queried if that was done, the DON said, I don't see a physician's note for that time frame. When queried when R17 and R71 should have received their sixty-day physician visit, the DON said, Around (MONTH) 2019. The DON provided documentation that R17 and R71 had been seen by other medical providers during 2019 such as a Podiatrist, Urologist, Orthopedic Surgeon, Cardiologist, and Wound Care Nurse Practitioner. When queried if any of these medical providers were responsible for the care of R17 and R71 in the facility, the DON said, No. A facility policy titled, Physician Services, released (MONTH) 2013, was reviewed and revealed the following: -Each resident must be seen by their physician at least every 30 days for the first 90 days after admission, and then every 60 days thereafter. -Physician services mean those services provided by physicians responsible for the care of individual residents in the facility.

Linked to intake MI 778 Based on interview and record review the facility failed to notify the Physician in a timely manner of a suspected injury, effecting one Resident #400(R#400) out of one resident sampled from a total of 29 residents during an annual survey. Resulting in the potential of delay medical treatment of [REDACTED]. Findings Include: On 5/1/18 , a record review of R#400 revealed admission to facility on 10/6/17 with [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS) R#400 had intact cognition and was extensive assist with Activities of Daily Living (ADLs). R#400 was discharged to hospital on [DATE] at 12:52 p.m. 5/1/18, record review of Nurses Notes dated 11/14/17 at 1:44 a.m.- Resident was observed on the floor at 0055. X-ray ordered stat (Now) to right hip/pelvis area r/t(related to) pain. will notify Physician and family in morning. Radiology Report dated 11/14/17 at 9:30 a.m. revealed, Conclusion- acute comminuted right intertrochanteric femur fracture (break in upper part of hip). On 5/2/18 at 8:45 a.m., Interview with Director of Nursing (DON), When asked if Nursing staff suspect an injury of a resident should they call the physician and report their findings, DON states, Yes, when any injury is suspected a nurse should call the Physician. When asked if it should be reported immediately, DON states, Yes. On 5/2/18 at 9:35 a.m., Interview with NurseA, When asked if Physician B was notified of suspected injury to R#400 at time of incident, Nurse A states No. When asked if an order for [REDACTED]. When asked if after the incident was he/she inserviced on the proper protocol of contacting a Physician when there is a suspected injury, Nurse A states, Yes. When asked if Physician B should have been called as soon as possible after the incident, Nurse A states Yes. On 5/2/18 at 10:50 a.m., Interview with Physician B, when asked in the event a Patient is suspected of having an injury is it your expectation that the Nurse will call and make you aware of the suspected injury, Physician B, states Yes, I am available all the time, and when I am not available I have someone to cover for me. On 5/2/18, record review of Fall Management policy revised on 8/2016, #8- The licensed nurse will notify the attending Physician and the responsible party of the fall, and document the notification in the medical record.

Based on interview and record review the facility failed to monitor a medication that has a Narrow Therapeutic Index (NTI-a medication in which the therapeutic dose is very close to the toxic dose, [MEDICATION NAME]-for treatment and prevention of [MEDICAL CONDITION])) for one sampled resident (#78) out of 26 residents reviewed for medication monitoring from a total sample of 29, resulting in the potential for undetected subtherapeutic or toxic drug levels. Findings include: Resident #78 FTag Direct Cite On 05/01/18 at 11:00 am, record review revealed that R#78 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated the resident cognition was severely impaired and required extensive assistance from staff for all activities of daily living. Review of a physician order [REDACTED]. Review of the care plan titled, At risk for injury/complications related to resident with past medical history of [REDACTED]. Report results/any subtherapeutic or toxic results to physician. Follow up as indicated/ordered. Review of a laboratory result dated 10/17/16 (18 months prior to the survey) revealed a [MEDICATION NAME] level of 3.1 (reference range is between 10.0-20.0 milligram (mg)/milliliter (ml). There were no other [MEDICATION NAME] level results in R#78's clinical record. Review of the Pharmacy Medication Regimen Reviews dated 2/28/18, 3/31/18, and 4/11/18 revealed no recommendation from the pharmacist to monitor R#78's [MEDICATION NAME] (a drug with a NTI) blood level. On 05/02/18 12:03 PM, During an interview with the facility's Director of Nursing (DON) and Unit Manager, Nurse C they were asked about the blood level [MEDICATION NAME] monitoring for R#78. The DON said that in a (nursing reference book) there was no suggested times on monitoring the drug level for [MEDICATION NAME]. The DON went on to say there was no time frame for the monitoring component for [MEDICATION NAME] on the manufactures web site. Nurse C stated, Therapeutic [MEDICATION NAME] levels are drawn closest to the time when the patient is having signs and symptoms. Per the DON she stated, We have no policy on when to draw levels. The physician determines that. The physician doesn't want to subject the resident to unnecessary blood level checks so we draw the levels when symptoms are present. The DON said that she spoke with the pharmacist and he (the pharmacist) said that the resident had not had any symptoms, so a [MEDICATION NAME] level was not indicated. On 5/2/18 at 3:30 PM, the DON provided a laboratory result dated 5/2/18 (same day) documenting [MEDICATION NAME] level <2.5 (reference range 10.0-20.0 mg/ml). We still need to call the physician and report this result to him.

Based on interview and record review, the facility failed to ensure documented evidence that care plan reviews were completed with the interdisciplinary team which included the Physician, nurse aide, and/or a member of the food and nutrition support staff for 14 of 21 sampled Residents (#s 801, 803, 805, 808, 809, 810, 812, 813, 814, 815, 816, 817, 818, and 821) reviewed for care conferences in a total sample of 21, resulting in the potential lack of opportunity for the Residents, Legal Representatives, and/or family members to participate in discussion of treatment options and decisions which pertained to their care. Findings include: Resident #803 On 3/7/17 at 1:30 p.m., review of R#803's face sheet record documented the Resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS) assessment dated [DATE], R#803 was severely cognitively impaired, and required moderate to extensive assistance with most activities of daily living (ADL). Review of R#803's Interdisciplinary Care Conference documentation dated 1/11/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #808 On 3/7/17 at 2:45 p.m., review of R#808's face sheet record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], R#808 was cognitively intact, and required moderate to extensive assistance with most ADLs. Review of R#808's Interdisciplinary Care Conference documentation dated 1/12/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #810 On 3/7/17 at 3:30 p.m., review of R#810's face sheet record documented the Resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], R#810 was severely cognitively impaired, and required moderate to extensive assistance with most ADLs. Review of R#810's Interdisciplinary Care Conference documentation dated 1/12/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #814 On 3/8/17 at 1:00 p.m., review of R#814's face sheet record documented the Resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, R#814 was moderately cognitively impaired, and required minimal assistance with most ADLs. Review of R#814's Interdisciplinary Care Conference documentation dated 2/22/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. On 3/8/17 at 3:30 p.m., the Administrator was asked about the facility's process for conducting care planning reviews which included the Physician, and nurse aide, and reported, We have nursing, dietary, activities, social work and therapy. We don't have Physicians. It's hard enough to get them in to sign orders. They can't stay five hours for care conferences. The Administrator was informed of the concerns regarding lack of documented evidence to identify the Physician and nurse aide inclusion in the care plan reviews and at that time was asked to provide documentation regarding the facility's process to address this. There was no further documentation provided by the end of the survey. Resident #802 On 3/7/17 at 2:30 p.m., review of Resident #802's face sheet record documented the Resident was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission minimum data set (MDS) assessment dated [DATE], Resident #802 was cognitively intact, and required moderate to extensive assistance with most activities of daily living (ADL). Review of Resident #802's Interdisciplinary Care Conference documentation dated 3/1/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #812 On 3/7/17 at 2:50 p.m., review of Resident #812's face sheet record documented the Resident was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly minimum data set (MDS) assessment dated [DATE], Resident #812 was cognitively intact, and required moderate to extensive assistance with most activities of daily living (ADL). Review of Resident #812's Interdisciplinary Care Conference documentation dated 2/2/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #805 On 3/8/2017 at 1:29 p.m., record review of Resident #805's face sheet record documented the resident was admitted initially on 05/14/2016 then readmitted on [DATE], with the following [DIAGNOSES REDACTED].O.P.D.-lung disease). According to the admission Minimum Data Set ((MDS) dated [DATE] resident is cognitively intact and needs minimal assist with most activities of daily living (ADL). Review of Resident #805's Interdisciplinary Care Conference documentation dated 2/17/17 and supporting progress notes revealed there was no documented evidence that the Physician or Nurse Aide were involved in the review of the Resident's care plan interventions Resident#809 On 3/8/2017 at 2:14 p.m., record review of Resident #809's face sheet record documented the resident was admitted on ,[DATE].2016 with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set ((MDS) dated [DATE] Resident #809 is cognitively intact. Review of Resident #809's Interdisciplinary Care Conference documentation dated 2/9/17 and supporting progress notes revealed there was no documented evidence that the Physician or Nurse Aide were involved in the review of the Resident's care plan interventions Resident #815 On 3/8/2017 at 2:21 p.m., record review of Resident # 815 face sheet record documented the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Date Set ((MDS) dated [DATE] Resident #815 was cognitively impaired. Review of Resident #815's Interdisciplinary Care Conference documentation dated 12/28/16 and supporting progress notes revealed there was no documented evidence that the Physician or Nurse Aide were involved in the review of the Resident's care plan interventions Resident #821 On 03/09/2017 at 10:28 a.m., record review of Resident # 821's face sheet record documented the resident was admitted on [DATE], then readmitted on [DATE] with the following [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set ((MDS) dated [DATE] Resident #821 was cognitively intact. Review of Resident #821's Interdisciplinary Care Conference documentation dated 12/28/16 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were involved in the review of the Resident's care plan interventions. Resident #801 On 3/8/17 at 8:30 a.m., review of R#801's face sheet record documented the Resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS) assessment dated [DATE], R#801 was severely cognitively impaired, and required total extensive assistance with all activities of daily living (ADL). Review of R#801's Interdisciplinary Care Conference documentation dated 12/21/16 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were not involved in the review of the Resident's care plan interventions. Resident #816 On 3/9/17 at 9:25 a.m., review of R#816's face sheet record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the initial minimum data set (MDS) assessment dated [DATE], R#816 was cognitively intact, and required minimum to extensive assistance with ADLs. Review of R#816's Interdisciplinary Care Conference documentation dated 3/1/17 and supporting progress notes revealed there was no documented evidence that the Physician or nurse aide were not involved in the review of the Resident's care plan interventions. #813 On 3/8/17 at 10:30 A.M., review of the Admission Face sheet for resident #813 documented the resident was admitted to the facility 9/9/16, with [DIAGNOSES REDACTED]. According to the Minimum (MDS) data set [DATE], resident #813 was independent in cognitive skills for decision making required supervision with set up assistance with eating, and one person assistance for bed mobility, transfers and toileting Review of resident #813's Interdisciplinary Care Conference documentation dated 12/29/16, and supporting progress notes there was no evidence that the Certified Nurse Aide and Physician were involved in the review and/or development of the resident's care plan interventions. #817 On 3/9/17 at 10:00 A.M., review of the Admission Face sheet for resident #817 documented the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE], documented resident #817 was independent in cognitive skills for decision making and required one person physical assistance for all activities of daily living . Review of resident #817's Interdisciplinary Care Conference dated 12/22/2016, and corresponding Progress Notes revealed there was no evidence that the physician and and Certified Nurse Aide were involved in the review of the resident's care plan interventions. #818 On 3/8/17 at 3:50 P.M., review of the Admission Face sheet for resident #818 documented the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the minimum Data Set ((MDS) dated [DATE], documented resident #818 was independent in cognitive skills for decision making and required one person physical assistance for activities of daily living. Review of resident #818's Interdisciplinary Care Conference documentation dated 1/9/2017, and supporting Progress Notes revealed there was no documented evidence that the physician or Certified Nurse Aide was involved in the review of the resident's care plan interventions.

Based on observation, interview and record review the facility failed to assess and modify approaches for pain management for one sampled resident (#806) from a total of 17 residents reviewed for pain out of a total sample of 21 resulting in the resident experiencing prolonged periods of pain. Findings include: On 3/7/17 at 9:05 a.m. during the initial tour of the Pleasantview Nursing Unit, Resident #806 was asked about her care at the facility. The resident responded with noted facial wincing, It's just alright. I'm in (generalized) pain all the time, and I have to always ask for and wait for them (the facility nursing staff) to bring me my pain medication. I put the call light on and the aide will come in and ask me what I want. I tell them I want my pain medication and then I have to wait for the nurse to bring the pain medication. Sometimes the aide forgets to tell the nurse and I have to wait even longer. On 3/7/17 at 10:15 a.m., record review revealed that Resident #806 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] documented Resident #806's pain intensity at a 5 (Scale 1-10, 10 being the worst pain gets). The assessment documented that 2 was an acceptable level of pain for the resident. Review of the Nursing Re-admission assessment dated [DATE] documented Resident #806's pain intensity at an 8. The assessment documented that 3 was an acceptable level of pain for the resident. Review of the physician's orders [REDACTED].#806 documented a pain regime of [MEDICATION NAME] HCL ER (Extended release narcotic pain medication) 5 milligram (mg) oral tablet, extended release four tablets (20 mg) orally every 12 hours as needed (PRN) for pain. As well as [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) tablet 10-325 mg give one tablet by mouth every 6 hours as needed for pain. Review of the PRN Medication Administration sheets dated 3/1/17 through 3/6/17 documented that Resident #806 received [MEDICATION NAME] HCL ER 20 mg on the following dates and times; 3/1/17 at 8:54 p.m., for a pain intensity of 8, 3/2/17 at 8:58 a.m., for a pain intensity of 9, 3/2/17 at 9:01 p.m., for a pain intensity of 10, 3/3/17 at 9:08 a.m., for a pain intensity of 7, 3/3/17 at 9:08 p.m., for a pain intensity of 9, 3/4/17 at 9:31 a.m., for a pain intensity of 7, 3/4/17 at 9:38 p.m., for a pain intensity of 8, 3/5/17 at 9:39 a.m., for a pain intensity of 9, 3/5/17 at 9:35 p.m., for a pain intensity of 8, 3/6/17 at 11:01 a.m., for a pain intensity of 7. Review of the PRN Medication Administration sheets dated 3/1/17 through 3/6/17 documented that Resident #806 received [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg on the following dates and times; 3/1/17 at 6:31 p.m., for a pain intensity of 8, 3/2/17 at 4:34 a.m., for a pain intensity of 8, 3/2/17 at 10:27 a.m., for a pain intensity of 9, 3/2/17 at 5:32 p.m., for a pain intensity of 8, 3/2/17 at 11:29 p.m., for a pain intensity of 8, 3/3/17 at 4:30 a.m., for a pain intensity of 8, 3/3/17 at 4:10 p.m., for a pain intensity of 9, 3/4/17 at 1:51 a.m., for a pain intensity of 6, 3/4/17 at 3:22 p.m., for a pain intensity of 7, 3/5/17 at 5:28 a.m., for a pain intensity of 8, 3/5/17 at 2:37 p.m., for a pain intensity of 6, 3/6/17 at 1:02 p.m., for a pain intensity of 8. The Risk for Pain/Discomfort care plan dated 2/25/17 had an interventions of Administer [MEDICATION NAME] per physician's orders [REDACTED]. On 3/8/17 at 12:30 p.m., the facility's Director of Nursing and Unit Manager (Nurse A) were interviewed and asked about the pain medication assessment and approaches for Resident #806. The DON said that in the morning stand up meeting the Interdisciplinary Team Members (IDT) discuss issues like resident pain. The DON said that the nursing staff evaluate the effectiveness of the prescribed pain medication, and if the medication was ineffective then the patient's physician should be contacted. Nurse A said that she was aware that (Resident #806's) pain medications were ordered as needed. Nurse A went on to state, the attending physician recently visited the resident and discussed keeping the pain medication on an 'as needed basis'. Review of the progress notes dated 3/1/17 through 3/6/17 revealed a physician's visit note dated 3/5/17. There was no documentation regarding Resident #806's pain in the 3/5/17 physician's note. Both the DON and Nurse A were asked why a pain assessment was not conducted for Resident #806 who's pain levels remained at a 6 to 10 level for five consecutive days to which the DON responded, (Resident #806) was just admitted on [DATE] and we were still evaluating the effectiveness of the pain medication to do a formal assessment. On 3/8/17 at 1:00 p.m., Resident #806's Attending Physician was interviewed and asked about Resident #806's pain management. The physician said that he usually does not try and interrupt a residents medication regime but does want the resident to remain comfortable to the resident's satisfaction. On 3/9/17 at 11:30 a.m., review of the facility's policy titled, Pain Management dated 5/10, revised 8/16 documented, Pain is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent .The pain experience is very subjective; pain is whatever the resident says it is. A comprehensive evaluation of pain includes: history of pain, characteristics of pain, impact of pain on quality of life, factors such as activities, care or treatment that precipitate or exacerbate pain, factors that reduce pain, additional symptoms associated with pain, physical exam and the resident's goals for pain management and his/her satisfaction with the current level of pain control.

Based on interview and record review the facility failed to provide a two day advance notice of Medicare non-coverage and notification of beneficiary right to appeal the decision to the Legal Guardian (LG) for one of three Residents (#501) reviewed for notice of non-coverage, from a total sample of three, resulting in Resident #501's LG not being able to exercise his rights to appeal the decision and the potential for financial hardship. Findings include: A medical record review was conducted on 5/12/15 at 11:30 a.m., and revealed that Resident #501 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #501 was covered under Medicare Part A benefits at the time of admission. An undated 'Notice of Medicare Non-Coverage' form was observed; however, it was not signed by the Resident or her LG. The notice identified Resident #501's last day of Medicare coverage, based on facility assessment, was 12/18/14. A handwritten note, dated 12/24/14 reads as follows; "12/24/14, bookkeeper notified of cut from Medicare, Resident unable to understand total. Sent denial to son." During an interview on 5/12/15 at 9:30 a.m., the Bookkeeper (staff 'B') said that she had notified Resident #501 of her change in Medicare coverage in person, but then later realized that Resident #501 was cognitively unable to understand what that meant in regards to payment amount. Staff 'B' said she then called Resident #501's LG and left a voice mail for him. Staff 'B' said she then mailed the letter of non-coverage to Resident #501's LG, but did not send it by certified mail to ensure the information was received and allowed for expedited appeal. During a telephone interview on 5/12/15 at 11:00 a.m., Resident #501's LG said that he did not receive any voice message, or letter regarding changes in Resident #501's Medicare coverage or change in the monthly payment amount until February 2015. Resident #501's LG said that he was unaware that he had a right to appeal that decision, or the process.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent a potential pressure sore in one (#702) sampled resident of six residents reviewed for pressure sores in a total sample of 23 residents, resulting in an unstageable (unable to determine depth) pressure sore. Findings Include: On 1/14/14 at 2:50 p.m., Resident #702 was observed sitting in a wheelchair in his room, visiting with his wife. Upon inquiry, Resident #702 stated "I have some pain in my back, legs, and feet...I like being up in the chair during the day." Pressure reducing boots were observed in place for both feet. On 1/14/14 at 3:00 p.m., a review of Resident #702's facility record revealed admission into the facility on [DATE] with discharge on 5/26/13, readmission on 9/3/13 with discharge on 9/23/13, readmission on 9/27/13 with discharge on 10/13/13, and readmission on 10/18/13. The readmission on 10/18/13 included [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status score of 8 (moderate cognitive impairment) and extensive assistance of two staff for bed mobility and transfers, with extensive assistance of one staff for dressing and personal hygiene/bathing. Functional range of motion in this assessment was identified as impairment on both sides for the upper and lower extremities. Additionally, a Braden Scale (a scale used for predicting pressure sore risk) score of 18 (at risk for the development of a pressure sore) on 10/25/13 was documented. During this same record review, a nursing note dated 11/12/13 at 2000 (8:00 p.m.) documented "Resident body audit completed, right heel noted with tender area, center measure 1 x 1 cm (centimeter), red in color surrounding tissue purple in color." A nursing note dated 11/14/13 at 1840 (6:40 p.m.) identified "Right heel with nonstageable pressure ulcer." A Wound/Skin Healing Record dated 11/12/13 documented an unstageable pressure ulcer over the right heel, with undeterminable depth, date of onset 11/12/13. On 1/15/14 at 10:00 a.m., Resident #702 was observed sitting in a wheelchair in his room. A wound observation of the right heel was conducted with Wound Care Nurse "D." The right heel was observed as reddened with no open areas. On 1/15/14 at 1:00 p.m., an additional record review was conducted and revealed the following: A care plan with a focus area "potential for alteration in skin integrity," dated as initiated on 9/17/13 and revised on 10/30/13, with no reference in the interventions to reducing pressure to heels while in the wheelchair. Another care plan with a focus area documented "has actual impaired skin...with unstageable to right heel..." was dated as initiated on 12/11/13, with no reference in the interventions to reducing pressure to heels while in the wheelchair. On 1/16/14 at 9:30 a.m., Resident #702 was observed sitting in a wheelchair in his room watching television. Upon inquiry, stated "I'm doing OK, had a good breakfast." On 1/16/14 at 1:30 p.m., Nurse Manager "C" was interviewed regarding the development of Resident #702's pressure sore over the right heel. Nurse Manager "C" stated: "I see we didn't care plan to off load any pressure on his heels when he is in the wheelchair." On 1/17/14 at 10:00 a.m., the facility's policy titled "Skin Management" dated as approved on 5/1/10, was reviewed and revealed the following: A policy statement which read "It is the policy of the facility that a resident does not develop pressure ulcers unless clinically unavoidable." Under the section titled "Practice Guidelines" was documented under #3: "Appropriate preventative measures will be implemented on residents identified at risk (score 18 or less on the Braden Scale) and the interventions documented on the care plan." ( ).