Every finding on record at Mill Creek Nursing & Rehabilitation

Based on observation and interview, the facility failed to ensure thickener and flour were properly stored. This had the potential to affect three residents (#23, #33, and #73) that received pureed diets and 14 residents on mechanical diets. Facility census was 71. Findings include: A tour of the kitchen on 02/09/25 at 8:21 A.M. revealed two large square containers with the lids off. The containers were located on the bottom shelf of a table that held the immersion blender. One container was labeled flour and one was labeled thickener. No food was being blended or prepared at the time. On 02/09/25 at 8:55 A.M. Dietary Manager #210 verified the containers with flour and thickener were not properly covered.

Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible. This affected two residents (Resident #17 and #66) of two residents reviewed for call light accessibility. The census was 71. Findings Include: 1. Record review revealed Resident #17 was admitted on [DATE] to the facility with diagnoses that included but not limited to hypertensive heart disease, polyarthritis, and general anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had moderately impaired cognition and required supervision of activities of daily living. Review of care plans dated 08/25/22 revealed Resident #17 had a potential risk for falls related to decreased mobility and incontinent of bowel and bladder. Interventions included but not limited to encourage and remind to ask for assistance and have commonly used articles within easy reach. Observation of Resident #17 on 02/09/25 at 10:16 A.M. revealed Resident #17 was in her wheelchair. There were two call lights in Resident #17's private room. The one call light was coming off the wall and the button to that call light was on the floor. The other call light was a soft touch pad and was hanging on the wall. Observation revealed both call lights were not within reach. This was verified by Medical Records #205. 2. Record review revealed Resident #66 was admitted on [DATE] and a readmitted [DATE] to the facility with diagnoses that included but not limited to atherosclerosis, Alzheimer's disease, and general anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had severely impaired cognition and required moderate assistance for activities of daily living. Review of care plans dated 08/12/24 revealed Resident #66 had a potential risk for falls related to decreased mobility and history of falls. Interventions included but not limited to encourage soft touch call light with glow tape and have commonly used articles within easy reach. Observation on 02/09/25 at 9:50 A.M. revealed that Resident #66 was lying in her bed, her soft touch pad was sitting on the nightstand, and her telephone was off the hook on the floor and under the bed. This was verified by the Assistant Director of Nursing #208 on 02/09/25 at 9:52 A.M.

Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to ensure oxygen was administered per physician orders and failed to ensure oxygen tubing was dated when initiated/changed. This affected two (#23 and #31) of eight residents reviewed for oxygen administration. The facility identified eight residents who received oxygen therapy. The facility census was 71. Findings include: 1. Review of the medical records for resident #23 revealed an admitted [DATE] with the following but not limited to diagnoses of: respiratory failure, Parkinson's disease, dysphagia, and pneumonia. Resident #23 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of 15 noted on 01/10/24. Resident #23 required assistance with activities of daily living (ADLs) tasks including medication administration and the use of a wheelchair for mobility. Review of Resident #23's physician orders dated 02/09/25 revealed an order for oxygen continuous at two to four liters per minute via per nasal cannula to maintain saturation above 90% (normal above 90%). There were no orders for nasal cannula (oxygen tubing) maintenance/care Further review of the medical record revealed on 02/09/25 at 5:10 P.M. the resident was receiving oxygen via nasal cannula at 2 LPM and his oxygen saturation was 99%. On 02/10/25 it was documented under vital signs that Resident #23 was receiving oxygen via nasal cannula at 2 LPM via NC. An observation on 02/09/25 at 10:59 A.M. revealed Resident #23 was seated in his wheelchair in his room with oxygen via nasal cannula being administered at a rate of 1 LPM. No date was noted on the oxygen tubing. Resident #23 was resting with his eyes closed and no respiratory distress was noted. An observation on 02/10/25 at 9:10 A.M. revealed Resident #23 was in bed, resting with eyes closed, with oxygen via nasal cannula at a rate of 1 LPM. An interview on 02/10/25 at 9:13 A.M. with Registered Nurse (RN) #76 confirmed Resident #23's oxygen was running at a rate of 1 LPM when the order read to administer the oxygen at 2-4 LPM. Also confirmed with RN #76 that there was no order in the electronic medical record (EMR) to change the oxygen tubing/nasal cannula. 2. Review of the medical record of Resident #31 revealed an admitted [DATE], with diagnosis including but not limited to chronic respiratory failure with hypoxia, unspecified asthma, and chronic atrial fibrillation. Resident #31 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Further review of the medical record revealed on 11/22/24 under progress notes it was noted that Resident #31 was placed on 2 liters of oxygen after her oxygen level was 87% on room air. There were no orders written for oxygen, or notification to the physician documented. On 12/8/24 at 9:22 P.M. it was documented in the EMR under vitals Resident #31 was on oxygen via nasal cannula with an oxygen saturation of 94%,. On 12/09/24 at 11:10 P.M. it was documented under the vitals that Resident #31 was on oxygen via nasal cannula with an oxygen concentration of 93%, with no flow rate or progress note was noted in the EMR. Further review of the medical record revealed no evidence the physician was notified of Resident #31's shortness of breath and/or low oxygen saturation levels. Observation on 02/09/25 at 2:06 P.M. in the room of Resident #31 revealed an oxygen concentrator with tubing connected to the oxygen concentrator and a humidifier containing water also connected, next to the residents recliner chair plugged into the wall. The oxygen tubing was not dated. When asked by this writer if Resident #31 used oxygen the resident stated Yes I do when I am feeling short of breath. Interview with the Director of Nursing (DON) at 8:50 A.M. on 02/12/25 revealed the facility's policy is after someone is placed on oxygen, they are to update the doctor and place an order in the electronic medical record. The. DON also verified the above findings in regard to Resident #31 not having orders for oxygen including when to change the tubing. Review of the facility policy titled, Oxygen Administration, dated 07/30/24, revealed , Oxygen tubing and mask/cannula may be changed weekly and as needed if it becomes contaminated or soiled. Oxygen is administered under the orders of a physician.

Based on observation, record review, and interview, the facility failed to honor Resident #185's food preferences. This affected one (Resident #185) of four residents reviewed for food and nutrition. Facility census was 71. Findings include: Review of the medical record revealed Resident #185 was admitted on [DATE] with diagnoses that included urinary tract infection, asthma, and type 2 diabetes. The Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #185 was cognitively intact. The MDS also revealed Resident #185 received a regular diet. The care plan dated 01/28/25 revealed Resident #185 had the potential for alteration in nutrition and hydration. Interventions included to honor food/beverage preferences as able and provide the diet as ordered. A physician order dated 02/03/25 revealed Resident #185 was ordered a low concentrated sweets diet and regular texture. Observation on 02/11/25 at 11:20 A.M. revealed Resident #185's meal ticket had spinach and greens listed as dislikes. Dietary Personnel #231 placed a bowl of collard greens on Resident #185's meal tray. When questioned about Resident #185's dislikes, Dietary Personnel #231 stated Resident #185 did not have to eat the collard greens and could ask for something else when Resident #185's tray was delivered. Resident #185's meal tray, with the collard greens still on the meal tray, was loaded onto the cart to be delivered. On 02/11/25 at 11:22 A.M. Dietary Manager #210 verified food preferences were to be honored. Dietary Manager #210 instructed the dietary staff to replace the collard greens with a salad on Resident #185's meal tray. Interview on 02/11/25 at 1:18 P.M. Resident #185 verified they did not like spinach, greens, or collard greens.

Based on review of a Self-Reported Incident (SRI) of neglect, staff interview, and review of the facility policy, the facility failed to follow their policy to protect the residents following an allegation of neglect involving two (#42 and #54) residents. The facility census was 62. Findings include: Review of the SRI dated 12/23/19 revealed the facility reported a allegation of neglect to the Ohio Department of Health. A written statement from State tested Nursing Assistant (STNA) #250 documented on 12/22/19 during dinner, STNA # 265 was asked to answer call lights on the 100 Hall. STNA #250 was overheard by STNA#265 telling Resident # 42 and Resident #54 I can't help you. I have my own residents to care for. The written statement noted STNA # 250 reported the incident to the nurse on duty and nothing was done. STNA #250 documented she felt STNA #265 was neglecting the residents and not providing adequate care. The SRI noted the written statement was placed under the the Director of Nursing (DON)'s door on 12/22/19. STNA #265 worked the remainder of the 2:00 P.M. to 10:00 P.M. shift and was not suspended until 12/23/19. The SRI file contained interviews with Resident #42 and #54 revealing no concerns. There were no interviews with the other residents or staff. Interview with the Administrator on 12/28/19 at 5:00 P.M. he verified he was aware of the neglect allegation on 12/22/19 however, he did not feel it was an allegation of neglect. He stated STNA #250 and #265 were friends and were having some kind of a disagreement. He verified the facility received a call on 12/23/19 of an allegation of neglect involving Resident #42 and #54, which was the same information contained in STNA #250 written document. The Administrator verified STNA #265 was not suspended until 12/23/19. Review of the facility policy titledAbuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, indicated under Section D-1 b indicated if the staff member was accused or suspected of abuse, neglect, exploitation, and misappropriation of resident property, the facility should remove the staff member from the facility pending the outcome of the investigation. This deficiency substantiates Complaint Number OH 009.

Based on review of a Self-Reported Incident (SRI) of neglect, staff interview, and review of the facility policy, the facility failed to protect the residents following an allegation of neglect involving two (#42 and #54) residents. The facility census was 62. Findings include: Review of the SRI dated 12/23/19 revealed the facility reported a allegation of neglect to the Ohio Department of Health. A written statement from State tested Nursing Assistant (STNA) #250 documented on 12/22/19 during dinner, STNA # 265 was asked to answer call lights on the 100 Hall. STNA #250 was overheard by STNA#265 telling Resident # 42 and Resident #54 I can't help you. I have my own residents to care for. The written statement noted STNA # 250 reported the incident to the nurse on duty and nothing was done. STNA #250 documented she felt STNA #265 was neglecting the residents and not providing adequate care. The SRI noted the written statement was placed under the the Director of Nursing (DON)'s door on 12/22/19. STNA #265 worked the remainder of the 2:00 P.M. to 10:00 P.M. shift and was not suspended until 12/23/19. The SRI file contained interviews with Resident #42 and #54 revealing no concerns. There were no interviews with the other residents or staff. Interview with the Administrator on 12/28/19 at 5:00 P.M. he verified he was aware of the neglect allegation on 12/22/19 however, he did not feel it was an allegation of neglect. He stated STNA #250 and #265 were friends and were having some kind of a disagreement. He verified the facility received a call on 12/23/19 of an allegation of neglect involving Resident #42 and #54, which was the same information contained in STNA #250 written document. The Administrator verified STNA #265 was not suspended until 12/23/19. Review of the facility policy titledAbuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, indicated under Section D-1 b indicated if the staff member was accused or suspected of abuse, neglect, exploitation, and misappropriation of resident property, the facility should remove the staff member from the facility pending the outcome of the investigation. This deficiency substantiates Complaint Number OH 009.

Based on review of resident medical records, staff interview, and review of the facility policy, the facility failed to revise care plans with new [DIAGNOSES REDACTED].#59 and #32) of 16 residents reviewed for care plans. The census was 62. Findings include: 1. Review of Resident #59's medical record revealed she admitted to the facility 06/15/18. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 11/08/19, revealed Resident #59 had a severe cognitive impairment and required extensive assistance from staff for activities of daily living. Review of a nursing progress note dated 11/25/19 revealed Resident #59 was difficult to arouse, would not verbally respond to sternal rub and had frequent twitching of her arms noted. Her physician was notified of her change of condition and she was sent to the emergency room for evaluation and treatment. Review of a nursing note dated 11/27/19 revealed Resident #59 readmitted to the facility with a primary [DIAGNOSES REDACTED]. Review of hospital documentation titled Continuity of Care, dated 11/27/19, revealed Resident #59 had a new onset of [MEDICAL CONDITION] on 11/25/19. Review of Resident #59's current care plan revealed no care plan had been developed for the resident's onset of [MEDICAL CONDITION] upon return from the hospital on [DATE]. Interview on 12/28/19 at 12:09 P.M., with MDS Registered Nurse (MDS RN) #28 confirmed Resident #59 returned to the facility 11/27/19 with a new [DIAGNOSES REDACTED].#28 confirmed a care plan had not been developed for Resident #59's new condition of [MEDICAL CONDITION]. Review of a facility policy titled Documentation: Care Plan, last revised (MONTH) 2006, revealed the interdisciplinary team (IDT) would develop, maintain, and modify the nursing component of the plan of care. The policy revealed the care plan was reviewed and revised at least quarterly with the MDS, and on an as needed basis as changes occurred in the resident's regimen. 2. Resident #32 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 07/31/19, revealed Resident # 32 had no cognitive deficits. She required extensive assistance of two staff for mobility activities of daily living (ADL) and toileting. The assessment indicated she was occasionally incontinent of bladder and always continent of bowel with no toileting plan. Review of a Certified Nurse Practitioner (CNP) progress note, dated 10/26/19, documented the resident had [MEDICAL CONDITION]. Review of the quarterly MDS assessment, dated 10/31/19, revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel with no toileting plan. Review of the (MONTH) 2019 monthly physician orders revealed an order to straight catheterize the resident for [MEDICAL CONDITION] if she did not void for eight hours and alert the physician. The order was initiated on 09/17/19. Review of the plan of care, updated 10/31/19, revealed the resident had an alteration in elimination related to occasional bladder incontinence. The care plan did not identify the resident was to be straight catheterized if unable to void for eight hours. Interview on 12/28/19 at 1:00 P.M., RN #120 and Cooperate RN #113 verified the plan of care did not address [MEDICAL CONDITION] with the need for intermittent catheterization.

Based on medical record review, resident interview, and staff interview, the facility failed to follow the physician order [REDACTED]. Finding include: Review of Resident #36's medical record revealed she admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #36 had a moderate cognitive impairment and required limited assistance with toilet use. Review of a physician's progress note dated [DATE] revealed Resident #36 stated she was having more frequent stools but not frank diarrhea. Review of Resident #36's bowel documentation revealed loose stools occurred twice on [DATE], on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] twice, [DATE], and [DATE]. Review of Resident #36's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the medical record revealed the physician had not been notified of the continued loose stools of Resident #36. Interview on [DATE] at 11:20 [NAME]M., Resident #36 stated she had loose bowels since she admitted . She revealed the had briefly given her something for the diarrhea but that she was no longer receiving anything to help. She stated she used a commode to remain continent with her loose bowels. She stated she was still having loose bowels. Interview on [DATE] at 1:39 P.M., State tested Nurse Aide (STNA) #65 stated Resident #36 had loose bowels. She stated if she noticed loose stools she would document it in the medical record and inform the nurse. Interview on [DATE] at 1:41 P.M., Registered Nurse (RN) #51 confirmed Resident #36 had been prescribed a seven day order on [DATE] for [MEDICATION NAME] for diarrhea as needed for seven days, ending on [DATE]. RN #51 confirmed Resident #36 only received her as needed anti-diarrheal once, on [DATE], but had documented loose stools [DATE], [DATE], and [DATE] without the medication being administered. She confirmed Resident #36 continued having documented loose stools once her anti-diarrheal order had expired and there was no evidence the physician had been notified for further intervention for Resident #36's loose stools.

Based on medical record review and staff interview the facility failed to follow physician's orders to intermittent catheterize a resident if there was no urine output for an eight hour period for one (#32) of one resident reviewed for urinary catheterization. The facility identified one resident as requiring intermittent catheterization. The facility census was 62. Findings include: Resident #32 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had no cognitive deficits. She required extensive assistance of two staff for mobility activities of daily living (ADL) and toileting. The assessment indicated she was occasionally incontinent of bladder and always continent of bowel with no toileting plan. Review of a Certified Nurse Practitioner progress note dated 10/26/19 documented the resident had [MEDICAL CONDITION]. Review of the quarterly MDS assessment darted 10/31/19 revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel with no toileting plan. Review of the (MONTH) 2019 monthly physician orders revealed an order to straight catheterize the resident for [MEDICAL CONDITION] if she did not void for eight hours and alert the physician. The order was initiated on 09/17/19. Review of State tested Nursing (STNA) documentation for bowel and bladder elimination revealed on 12/16/19 Resident #32 was continent of urine at 1:19 P.M. and 11:23 P.M. with no other evidence of urinary output documented. On 12/17/19 the resident was continent of urine at 10:29 [NAME]M. and 10:09 P.M. with no other evidence of urinary output documented. On 12/18/19 the resident was continent of urine at 1:26 P.M. and 10:00 P.M. with no other evidence of urinary output documented. On 12/19/19 the resident was continent of urine at 12.56 [NAME]M. and incontinent of urine 11:43 AM and 11:29 P.M. with no other evidence of urinary output documented. On 12/20/19 the resident was continent of urine at 12:55 [NAME]M. and incontinent of urine at 11:23 P.M. with no other evidence of urinary output documented. On 12/21/19 the resident was continent of urine at 12:04 AM, at 1:25 P.M. the resident did not void, and at 11:12 P.M. was continent of urine with no other evidence of urinary output documented. On 12/22/19 the resident was continent of urine at 1:22 PM and 11:12 P.M. with no other evidence of urinary output documented. On 12/23/19 the resident was incontinent of urine at 9:11 [NAME]M. and continent of urine at 11:59 P.M. with no other evidence of urinary output documented. On 12/24/19 the resident was continent of urine at 1:29 P.M. and 7:43 P.M. with no other evidence of urinary output documented. On 12/25/19 the resident was incontinent of urine at 1:46 P.M. and at 7:09 P.M. was continent of urine with no other evidence of urinary output documented. On 12/26/19 the resident was continent of urine 2:40 [NAME]M., 11:27 [NAME]M. and 11:41 P.M. with no other evidence of urinary output documented. There was no evidence Resident #36 was catheterized when she went greater than eight hours without voiding. Interview on 12/28/19 at 1:30 P.M., Registered Nurse (RN) #120 verified Resident #32 had a physician order was to catheterize the resident if she did not void every eight hours. She stated the information found in the STNA Tasks section of the electronic record possibly did not track all the resident's episodes of urinating. The nurses relied on the the STNAs to verbally tell them at the end of their shift if the resident did not void.

Based on record review and staff interview, the facility failed to ensure residents representative was notified of residents leaving the facility for modified [MEDICATION NAME] swallow (MBS). This affected two (#1 and $41) of three residents reviewed for swallowing evaluations. The facility identified three residents whom went out for MBS. The census was 61. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].>Review of the Minimum Data Set (MDS) for Resident #41 dated 11/29/19 revealed she was severely cognitively impaired. In the area of swallowing she was assessed as having coughing or choking during meals or when swallowing medications and has complaints of difficulty or pain when swallowing. Review of the progress notes dated 10/17/19 at 9:28 [NAME]M. revealed the facility sent a signed order for MBS to local facility and they were awaiting a call back with appointment. Review of progress notes dated 10/18/19 at 4:00 P.M. revealed the resident returned from MBS. Suggestion was for puree and thin liquids. Certified Nurse Practitioner updated and received orders to follow orders from speech therapist. Continue puree and nectar thick liquids. The progress notes were absent of notifications to family of the resident leaving or returning to the facility. 2. Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #1 was cognitively impaired. Review of the physician's orders [REDACTED]. Further review of the progress notes for Resident #1 revealed they were absent of any notification to the family regarding the resident going to have a MBS. Interview on 11/27/19 at 12:30 P.M. with the Administrator verified staff were unable to produce any documentation the families of Residents (#1, and 4#1) were notified of leaving the facility for the MBS. Interview on 11/27/19 at 12:45 P.M with Transportation State tested Nursing Assistant (STNA) #1 verified the form had an area to indicated if families were notified. She verified she did not do the notifications, it was written on a paper which was used during transporting residents to appointments. The nurses write on the form if the family was notified and also verbally tell her if the families were notified, but the paper was thrown away after transport. This deficiency substantiates Complaint Number OH 490.

Based on medical record review, review of an employee education/training document, review of hospital notes, review of an incident follow-up report, staff interviews and policy review, the facility failed to implement fall interventions. This resulted in actual harm for Resident #46 when staff left her alone and unsupervised during toileting. The resident attempted to leave the bathroom and fell sustaining fractures to the hip and pelvis requiring hospitalization . Additionally, the facility failed to implement fall interventions for Resident #21 who required a floor mat while in bed. This affected two (#46, #21) of two residents reviewed for falls. The facility census was 61. Findings include 1. Review of the medical record revealed Resident #46 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the significant change assessment dated [DATE] revealed Resident #46 had cognitive impairment. Resident #46 required the extensive assistance of two staff members for bed mobility, transfers and toileting. Review of the fall care plan initiated 11/29/14 revealed Resident #46 was at risk for falls with potential for injury related to a history of falls, unsteady gait, debilitation/weakness, impaired balance secondary to neurological impairment. The resident was at risk for spontaneous fracture related to [MEDICAL CONDITION]. A fall intervention added on 04/27/17, revealed do not leave alone in the bathroom. Review of a nursing progress note dated 07/27/18 at 8:45 P.M. revealed the resident was found on the floor on her right side. The resident complained of pain and rated her pain as a ten on a scale of zero to ten with ten indicating severe pain. Review of a physician order [REDACTED].#46 to the emergency room for evaluation. Review of the emergency room (ER) computed tomography (CT) scan results dated 07/28/18 revealed Resident #46 had a moderately comminuted [MEDICAL CONDITION] acetabulum (surface of the pelvis) with involvement of both the anterior and posterior columns. There was a minimally displaced fractured of the right inferior pubic ramus. A nondisplaced component of the fracture extended to involve the right iliac ala. The fracture appeared to be most consistent with an anterior with posterior hemi [MEDICATION NAME] acetabular fracture. Further review of the ER note revealed Resident #46 required transfer to an emergency room in another city for evaluation and treatment. Review of a nursing progress note dated 07/28/18 at 12:08 A.M. revealed Resident #46 had a right [MEDICAL CONDITION] and would not return to the facility tonight. Review of CT scan results dated 07/28/18, from the second ER, revealed Resident #46 had a right acetabular fracture involving the anterior and posterior columns with a [MEDICATION NAME] component. The fracture extended superiorly into the right ilium. Also, the resident had a minimally displaced inferior right pubic ramus fracture. Review of an Employee Education/Training Document dated 07/28/18 and signed by State tested Nursing Assistant (STNA) #116 revealed a resident was left on the toilet alone. She fell and sustained a [MEDICAL CONDITION]. STNA #116 was educated to review care plans for new safety items before each shift. Review of an incident follow-up report dated 07/30/18 revealed Resident #46 was found on the floor outside her bathroom doorway. Resident #46 attempted to transfer self from the toilet and fell . Review of a hospital discharge note dated 08/01/18 revealed Resident #46 had a left acetabular fracture and a right pubic ramus fracture from a fall. Review of a nursing progress note dated 08/01/18 at 3:39 P.M. revealed Resident #46 returned to the facility with a primary [DIAGNOSES REDACTED]. Interview on 10/24/18 at 9:57 A.M. with the Director of Nursing (DON) revealed she could review the fall incident report and investigation but she could not provide a copy of the fall incident report and investigation. The DON revealed STNA #116 assisted Resident #46 to the bathroom on 07/27/18. The DON revealed Resident #46 indicated she needed to have a bowel movement and it would take a while. STNA #116 left Resident #46 on the toilet and went to answer another call light. STNA #116 returned to the bathroom and Resident #46 was not done. STNA #116 told Resident #46 to put on the bathroom light when she was done. The DON revealed STNA #116 went to answer another call light. STNA #116 heard a noise in Resident #46's room. STNA #116 found Resident #46 on the floor at the bathroom door. The DON revealed Resident #46 stated she was done waiting The DON revealed Resident #46 was not to be left alone in the bathroom. The DON revealed STNA #116 was educated to review care plans. Telephone interview on 10/24/18 at 12:06 P.M. with STNA #116 revealed she assisted Resident #46 to the toilet and left to assist another resident. STNA #116 checked on Resident #46 and she was not done so STNA #116 left again to assist another resident. STNA #116 revealed she heard a noise and found Resident #46 lying outside of the bathroom door on the floor. STNA #116 revealed she was not aware Resident #46 was not allowed to be left alone in the bathroom. STNA #116 stated the intervention for the resident not to be alone in the bathroom, was not added to the care plan until after the resident fell and fractured her hip. Telephone interview on 10/24/18 at 2:28 P.M. with Licensed Practical Nurse (LPN) #200 revealed STNA #116 called her to Resident #46's room. LPN #200 revealed Resident #46 was observed on the floor with pain in the right hip. LPN #200 revealed the physician ordered Resident #46 to be sent to the emergency room . LPN #200 revealed STNA #116 indicated she had helped Resident #46 to the bathroom and assumed the resident would wait for her. LPN #200 revealed Resident #46 got impatient and transferred herself off the toilet. LPN #200 revealed she was unaware of the fall intervention requiring Resident #46 not to be left alone in the bathroom. LPN #200 revealed she thought the intervention was added to the care plan after the fall on 07/27/18. Review of the Fall Management policy dated 10/17/16 revealed the interdisciplinary plan of care would be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had significant confusion, forgetfulness and memory loss. Further review of the MDS revealed Resident #21 needed extensive assistance from two staff for all activities of daily living, transfers, and repositioning. Review of the care plan dated 11/22/17 revealed Resident #21 to be a fall risk and interventions were listed of bed/chair alarm, proper non-skid footwear, clutter-free environment, and mat to floor beside bed on each side. Observation on 10/24/18 at 2:03 P.M. revealed Resident #21 was asleep in bed with a bed alarm in place. Only one floor mat was in place on the floor in front of the bed. A second floor mat was observed upright and horizontal against the side of the bed closest to the window. Interview on 10/24/18 at 2:04 P.M. with STNA #70 verified both floor mats should be laid on each side of Resident #21's bed while Resident #21 was in bed. STNA #70 indicated staff had recently mopped, but the floor was observed dry at the time of the interview.

Based on medical record review, review of the shower schedule, review of shower report sheets, review of nursing progress notes and staff and resident interviews, the facility failed to ensure residents received assistance with scheduled showers. This affected one (#13) of one resident reviewed for showers. The facility census was 61. Findings include Medical record review revealed Resident #13 had an admitted d of 04/29/18. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. Further review of the MDS assessment revealed Resident #13 required the physical assistance of one staff member for bathing. Review of the shower schedule revealed Resident #13 had scheduled showers twice a week on Wednesdays and Saturdays. Review of shower documentation sheets and nursing aide shower task documentation from 09/01/18 through 10/21/18 revealed Resident #13 had not received showers on 09/29/18, 10/06/18 and 10/17/18. Review of the nursing progress notes from 09/29/18 through 10/17/18 revealed no documentation Resident #13 had refused showers on 09/29/18, 10/06/18 and 10/17/18. Interview on 10/22/18 at 10:02 A.M. with Resident #13 revealed she had not received her showers two times per week. Interview on 10/24/18 at 3:00 P.M., the Director of Nursing (DON) verified Resident #13 had not received scheduled showers on 09/29/18, 10/06/18 and 10/17/18.

Based on medical record review, resident and staff interviews and policy review, the facility failed to follow-up with a physician and provide timely treatment for [REDACTED].#48) of two residents reviewed for urinary tract infections. The facility census was 61. Findings include Review of the medical record revealed Resident #48 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of skilled nursing progress notes dated 10/16/18 and 10/17/18 revealed Resident #48 had urinary frequency, discomfort and intermittent burning with urination. Review of a nursing progress note dated 10/17/18 at 5:31 P.M. revealed Resident #48 requested the antibiotic [MEDICATION NAME], stating she had taken the medication for years. The physician was in the facility and was notified of the resident's request and advised to monitor for symptoms of a urinary tract infection [MEDICAL CONDITION] at this time. Review of a nursing progress note dated 10/19/18 at 4:22 P.M. revealed the resident complained of burning during urination. The nurse practitioner was in the facility and ordered a urinalysis with a culture and sensitivity (UA C&S). Review of a skilled nursing progress note dated 10/20/18 at 2:55 A.M. revealed Resident #48 had discomfort with urination, and complained of burning with urination. The progress note indicated the ordered urine sample had been sent to the lab. Review of a skilled nursing progress note dated 10/21/18 at 4:11 A.M. revealed Resident #48 had discomfort with urination and complaints of burning with urination. Urinalysis culture and sensitivity results were indicative of a UTI. The physician was updated and awaiting new orders. Review of a skilled nursing progress note dated 10/22/18 at 1:46 A.M. revealed Resident #48 had discomfort with urination and urinary frequency. Resident #48 continued to complain of burning and frequency with urination. Review of a final laboratory report dated 10/22/18 at 8:38 A.M. revealed Resident #48 was positive for greater than 100,000 colony forming units (cfu) per milliliter (ml) of the bacteria Proteus Mirabilis. Further review of the laboratory results and nursing notes dated 10/22/18 revealed no documentation the physician was notified of the final laboratory results. Interview on 10/22/18 at 12:02 P.M. with Resident #48 revealed she had discomfort during urination. Resident #48 revealed she was still waiting to hear back from the physician. Review of a skilled nursing progress note dated 10/23/18 at 4:46 A.M. revealed Resident #48 had discomfort with urination and urinary frequency. Interview on 10/23/18 at 2:15 P.M. with the Director of Nursing (DON) revealed the laboratory notified physicians of laboratory results. Review of a physician order [REDACTED].M. revealed the resident was ordered [MEDICATION NAME] 100 milligrams (mg) daily for a chronic UTI. At 3:39 P.M. the resident was ordered [MEDICATION NAME] 200 mg three times a day for burning with urination. Review of a skilled nursing progress note dated 10/24/18 at 1:59 A.M. revealed Resident #48 continued with frequency and discomfort with urination. Review of the 10/2018 Medication Administration Record [REDACTED].M. Review of a nursing progress note dated 10/24/18 at 1:47 P.M. revealed the resident refused to get out of bed today. The resident stated, she just felt out of it. Interview on 10/25/18 at 11:18 A.M. with the DON revealed the nursing staff should have called and followed up sooner with the physician regarding the final laboratory results. Interview on 10/25/18 at 1:24 P.M. with Licensed Practical Nurse (LPN) #202 revealed the physician received laboratory reports directly from the lab. LPN #202 revealed nursing staff should also initial and fax the lab report to the physician. LPN #202 revealed nursing staff should call the physician if no response was received. LPN #202 further revealed nursing staff should document when the physician was notified. LPN #202 verified the final urinalysis lab report for Resident #48 was received by the facility at 9:01 A.M. on 10/22/18. LPN #202 verified there was no documentation nursing staff contacted or followed up with the physician regarding the results of the final urinalysis lab report. Review of the Diagnostic Testing policy revised 12/09/16 revealed the licensed nurse would receive and review the diagnostic test report and communicate the results to the ordering physician within 24 hours of receipt or per physician instruction. For results that fall outside of clinical reference ranges and require immediate attention, the physician would be notified upon receipt.

Based on record review, staff interview, and policy review the facility failed to ensure [MEDICAL TREATMENT] communication was maintained with [MEDICAL TREATMENT] staff. This affected one (#30) of one resident reviewed for [MEDICAL TREATMENT]. The facility identified four residents on [MEDICAL TREATMENT]. The facility census was 61. Findings include Record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of care plan for [MEDICAL TREATMENT] dated 09/28/18 revealed Resident #30 was to receive [MEDICAL TREATMENT] three times a week through the right upper chest central line. Communication intervention was outlined to be maintained with [MEDICAL TREATMENT] staff. Further record review revealed '[MEDICAL TREATMENT] Communication Sheet' dated 10/24/18 was blank where nursing facility was to complete and sign for any complaints, concerns, changes or lab draws for visit to [MEDICAL TREATMENT] center. Interview on 10/24/18 at 1:53 P.M. with Licensed Practical Nurse (LPN) #80 verified the [MEDICAL TREATMENT] form was blank and should have been completed on 10/24/18 at 5:00 A.M. prior to Resident #30 leaving the facility. LPN #80 indicated the floor nurse assigned to Resident #30 should have completed the form. Review on 10/24/18 of facility policy '[MEDICAL TREATMENT] Management' revealed the facility will assess, monitor for complications and provide adequate intervention in the management of those receiving [MEDICAL TREATMENT] based on physician orders [REDACTED]. Monitoring vital signs, weights, nutritional, and fluid needs or any restrictions, lab results, and who to notify with concerns noted could be included in facility care plan.

Based on medical record review, staff interview and policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an anti-anxiety medication. This affected one (#48) of five residents reviewed for unnecessary medications. The facility identified 15 residents receiving anti-anxiety medications. The facility census was 61. Findings include Review of the medical record revealed Resident #48 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care initiated on 09/21/18 revealed for staff to assess for non-drug approaches to deal with problem behaviors and implement as needed. Review of a physician order [REDACTED].#48 was ordered [MEDICATION NAME] 0.25 milligrams (mg)by mouth, as needed twice a day for anxiety. Review of the Medication Administration Record [REDACTED]. Review of the nursing progress notes and MAR from 09/26/18 through 10/24/18 revealed no documentation of attempted or refused non-pharmacological interventions prior to the administration of the 29 doses of [MEDICATION NAME] 0.25 mg. Interview on 10/24/18 at 5:54 P.M. with the Director of Nursing (DON) verified non-pharmacological interventions were not attempted prior to each administered dose of [MEDICATION NAME] for Resident #48 Interview on 10/25/18 at 1:24 P.M. with Licensed Practical Nurse (LPN) #202 revealed nursing staff should document when non-pharmacological interventions were attempted or document if non-pharmacological interventions were refused. Review of the Medication Monitoring policy dated 06/21/17 revealed non-pharmacological approaches, when clinically indicated, should be documented to reduce the need for or the dose of a medication.

Based on medical record review, staff interviews and policy review, the facility failed to notify and follow-up with a physician regarding results of a laboratory report. This affected one (#48) of five residents reviewed for laboratory testing. The facility census was 61. Findings include Review of the medical record revealed Resident #48 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nursing progress note dated 10/19/18 at 4:22 P.M. revealed the nurse practitioner was in the facility and Resident #48 complained of pain and burning during urination. A new physician order [REDACTED]. Review of a final urinalysis laboratory result report dated 10/22/18 at 8:38 A.M. revealed Resident #48 was positive for greater than 100,000 colony forming units (cfu) per milliliter (ml) of the bacteria Proteus Mirabilis. Further review of the laboratory results dated [DATE] revealed no documentation the physician was notified. Review of the nursing progress notes from 10/22/18 at 9:00 A.M. through 10/23/18 at 2:00 P.M. revealed no documentation nursing staff followed up with the physician regarding the final results of the urinalysis with culture and sensitivity laboratory report dated 10/22/18. Interviews on 10/22/18 at 12:02 P.M. with Resident #48 revealed she had discomfort during urination. Resident #48 revealed she was still waiting to hear back from the physician. Interview on 10/23/18 at 2:15 P.M. with the Director of Nursing (DON) revealed the laboratory notified physicians of laboratory results. Interview on 10/25/18 at 11:18 A.M. with the DON revealed the nursing staff should have called and followed up sooner with the physician regarding the final laboratory results. Interview on 10/25/18 at 1:24 P.M. with Licensed Practical Nurse (LPN) #202 revealed the physician received laboratory reports directly from the lab. LPN #202 revealed nursing staff should also initial and fax the lab report to the physician. LPN #202 revealed nursing staff should call the physician if no response was received. LPN #202 further revealed nursing staff should document when the physician was notified. LPN #202 verified the final urinalysis lab report for Resident #48 was received by the facility at 9:01 A.M. on 10/22/18. LPN #202 verified there was no documentation nursing staff contacted or followed up with the physician regarding the results of the final urinalysis lab report dated 10/22/18. Review of the Diagnostic Testing policy revised 12/09/16 revealed the licensed nurse would receive and review the diagnostic test report and communicate the results to the ordering physician within 24 hours of receipt or per physician instruction. For results that fall outside of clinical reference ranges and require immediate attention, the physician would be notified upon receipt.

Based on medical record review, observation, resident and staff interviews, and policy review the facility failed to implement care planned interventions of monitoring for side effects of medications. This affected one Resident (#35) of three reviewed for non-pressure related skin conditions. The facility census was 60. Findings include: Review of Resident #35's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired as indicated by a brief interview for mental status score of seven. Review of a physician order dated 08/19/15 revealed an order for [REDACTED].>Review of Resident #35's care plan revealed the resident was at risk for bruising related to the administration of blood thinning medication. Interventions included to provide medication as ordered, monitor for mediation side effects of bruising and internal bleeding and to notify the physician of abnormal findings. Review of the most recent Skin Grid Non-Pressure skin assessment dated [DATE] revealed the resident had a skin tear. The assessment did not document any bruising for Resident #35. Review of Resident #35's Shower/Bath Skin Sheets dated 07/26/17 and 08/09/17 revealed bruising on the fingertips of both hands, abdomen and right lower leg. Shower/Bath Skin Sheets dated 08/12/17 and 08/16/17 revealed there were no skin issues noted on these days, including any bruising to the back of the right hand. Review of nursing notes dated 07/15/17 to 08/15/17 revealed no documentation of bruising to Resident #35's right hand. Review of Resident #35's physician orders for 07/2017 and 08/2017 revealed no order to monitor bruising to the back of Resident #35's right hand. Observation on 08/14/17 at 3:33 P.M. revealed a dark purple bruise that covered the back of Resident #35's right hand. Interview with Registered Nurse (RN) #400 on 08/16/17 at 8:35 A.M. revealed RN #400 monitored wounds in the facility. RN #400 revealed all bruising was to be reported by staff when first noticed. Further interview revealed when bruising is reported, a physician order to monitor the bruising every shift until healed was put into place. Interview with Resident #35 on 08/16/17 at 10:12 A.M. revealed the bruise had been there for approximately one week. Resident #35 stated he/she did not remember having an accident and woke up one morning and the bruise was there. Interview with State tested Nursing Assistant (STNA) #200 on 08/16/17 at 10:55 A.M. revealed staff looked at residents skin each time they were given a shower and staff documented the findings on Shower/Bath Skin Sheets. STNA #200 stated he/she showered Resident #35 earlier this day and Resident #35 had bruising to the fingertips and abdomen. STNA #200 stated he/she did not notice any new skin conditions during the shower. STNA #200 did not mention bruising to the back of Resident #35's right hand. Interview with RN #410 on 08/16/17 at 1:57 P.M. revealed Resident #35 bruised easily and had bruising on the fingertips from checking his/her blood sugar levels and on the abdomen from insulin injections. RN #410 stated Resident #35 did not have any other skin conditions including any other bruising. Interview with the Director of Nursing on 08/16/17 at 2:15 P.M., verified the care plan was not followed to monitor the resident's skin for side effects of the blood thinning medication. Review of the facility policy titled Skin Assessment, dated 12/02/15, revealed it is the policy of the facility to provide necessary treatment and services to promote healing, prevent infection and prevent new skin abnormalities from developing. A skin evaluation was to be completed weekly and during activities of daily living care. Areas of alteration in skin were to be treated according to medical direction and ongoing monitoring of abnormal skin areas were to be performed and documented in the resident's medical record.

Based on medical record review, observation, resident and staff interviews and policy review the facility failed to assess and monitor residents with impaired skin integrity. This affected one Resident (#35) of three reviewed for non-pressure related skin conditions. The facility census was 60. Findings include: Review of Resident #35's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired as indicated by a brief interview for mental status score of seven. Review of the most recent Skin Grid Non-Pressure skin assessment dated [DATE] revealed the resident had a skin tear. The assessment did not document any bruising for Resident #35. Review of Resident #35's Shower/Bath Skin Sheets dated 07/26/17 and 08/09/17 revealed bruising on the fingertips of both hands, abdomen and right lower leg. Shower/Bath Skin Sheets dated 08/12/17 and 08/16/17 revealed there were no skin issues noted on these days, including any bruising to the back of the right hand. Review of nursing notes dated 07/15/17 to 08/15/17 revealed no documentation of bruising to Resident #35's right hand. Review of Resident #35's physician orders for 07/2017 and 08/2017 revealed no order to monitor bruising to the back of Resident #35's right hand. Observation on 08/14/2017 at 3:33 P.M. revealed a dark purple bruise that covered the back of Resident #35's right hand. Interview with Registered Nurse (RN) #400 on 08/16/17 at 8:35 A.M. revealed RN #400 monitored wounds in the facility. RN #400 revealed all bruising was to be reported by staff when first noticed. Further interview revealed when bruising is reported, a physician order to monitor the bruising every shift until healed was put into place. Interview with Resident #35 on 08/16/17 at 10:12 A.M. revealed the bruise had been there for approximately one week. Resident #35 stated he/she did not remember having an accident and woke up one morning and the bruise was there. Interview with State tested Nursing Assistant (STNA) #200 on 08/16/17 at 10:55 A.M. revealed staff looked at residents skin each time they were given a shower and staff documented the findings on Shower/Bath Skin Sheets. STNA #200 stated he/she showered Resident #35 earlier this day and Resident #35 had bruising to the fingertips and abdomen. STNA #200 stated he/she did not notice any new skin conditions during the shower. STNA #200 did not mention bruising to the back of Resident #35's right hand. Interview with (RN) #410 on 08/16/17 at 1:57 P.M. revealed Resident #35 bruised easily and had bruising on the fingertips from checking his/her blood sugar levels and on the abdomen from insulin injections. RN #410 stated Resident #35 did not have any other skin conditions including any other bruising. Interview with the Director of Nursing (DON) on 08/16/17 at 2:15 P.M. verified Resident #35 had a dark purple bruise covering the back of the right hand. The DON was unable to provide documentation of the bruising being reported and/or monitored by staff. The DON stated staff should have been aware the bruising was there and the bruising should have been reported and monitored by staff. Review of the facility policy titled Skin Assessment, dated 12/02/15, revealed it is the policy of the facility to provide necessary treatment and services to promote healing, prevent infection and prevent new skin abnormalities from developing. A skin evaluation was to be completed weekly and during activities of daily living care. Areas of alteration in skin were to be treated according to medical direction and ongoing monitoring of abnormal skin areas were to be performed and documented in the resident's medical record.

Based on record review, observation, staff interview and review of facility policy the facility failed to securely anchor an indwelling urinary catheter to prevent dislodgement. This affected one Resident (#105) of two residents reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. The facility census was 60. Findings include: Review of Resident #105's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #105's physician orders [REDACTED]. Review of Resident #105's care plan revealed the care plan addressed indwelling urinary catheter and to secure indwelling urinary catheter tubing to prevent accidental dislodgement. Review of Resident #105's nurse's note dated 08/14/17 revealed an STNA found Resident #105's indwelling urinary catheter to be dislodged. A nurse inserted the indwelling urinary catheter. Observation on 08/16/17 at 9:10 A.M. of Resident #105 revealed State tested Nursing Assistant (STNA's) #201 and #202 completed urinary catheter care for the resident. The resident's catheter tubing was noted to not be secured to her leg. Interview at the time of the observation with STNA's #201 and #202 stated Resident #105 usually had an urinary catheter anchor in place. Interview on 08/17/17 at 11:06 A.M. with Licensed Practical Nurse (LPN) #405 stated she had to reinsert Resident #105's indwelling urinary catheter the other day when it was found dislodged. LPN #405 stated she forgot to anchor the urinary catheter in place after re-insertion. Review of facility policy titled Catheter Care/Urinary dated 10/18/01 revealed the catheter should be secured utilizing a leg band.

Based on record review and staff interview, the facility failed to obtain physician ordered laboratory orders for one (#17) of five residents reviewed for laboratory services. The facility census was 60. Findings include: Record review for Resident #17 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #17 was readmitted to the facility on [DATE] from a hospitalization for an elevated potassium level. Review of physician orders [REDACTED]. There was no evidence in the record of these laboratory tests being obtained. Interview with Licensed Practical Nurse (LPN) #71 on 04/25/16 at 2:55 P.M. revealed the laboratory tests written on 4/25/16 had not been obtained as ordered. Interview with LPN #71 on 04/25/16 at 2:55 P.M. revealed the physician orders [REDACTED].