Every finding on record at Miller's Merry Manor

Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred by a Hoyer (mechanical lift) for 1 of 2 residents randomly observed for transfers. (Resident 253) Findings include: The clinical record for Resident 253 was reviewed on 6/23/25 at 9:00 a.m. The diagnosis included, but was not limited to, lymphoma. The resident was admitted to the facility on [DATE]. A fall risk care plan, dated 6/7/25, indicated the resident was to be transferred by a mechanical Hoyer lift. A physician order, dated 6/8/25, indicated the resident was to be transferred by a mechanical Hoyer lift. A physical therapist evaluation, dated 6/9/25, indicated the resident's baseline was dependent with transferring from chair to bed. An observation was conducted of Resident 253 transferred from his chair to his bed utilizing a mechanical Hoyer lift with Certified Nurse Aide (CNA) 1 on 6/23/25 at 9:22 a.m. CNA 1 was observed pushing the mechanical lift inside the room. She then attached the straps from the Hoyer pad that was underneath the resident while he was sitting in his chair to the mechanical lift. After, CNA 1 pushed a button and raised the resident off the chair. She then turned the mechanical lift and pushed the lift to the bedside with the resident attached. The mechanical lift's legs were resistant to sliding under the bed. CNA 1 pushed and pulled the lift back and forth to position the legs of the lift under the bed. The resident at that time hollered out at CNA 1. CNA 1 then turned the mechanical lift around and positioned the lift in the middle of the room. The resident was suspended from the lift at that time. CNA 1 stated she would need assistance from another staff member. She then left the mechanical lift, stuck her head out of the resident's door and requested Occupational Therapist (OT) 5 to assist her with the transfer. OT 5 entered the room to assist. CNA 1 returned to the bed and lowered the mobility side bar. She indicated at that time, Resident 253's back was hitting the mobility side bar attached to the side of the bed during the first attempt to transfer him. She then returned back to the mechanical lift. OT 5 placed herself on the side of the lift assisting positioning of the resident's body as he was lowered to the bed. An interview was conducted with CNA 1 on 6/23/25 at 9:32 a.m. She indicated Resident 253 does transfer normally by mechanical lift with the assistance of one staff person. An interview was conducted with Resident 253 on 6/24/25 at 11:39 a.m. He indicated he was transferred sometimes with two staff members and sometimes with one staff member with the lift. An interview was conducted with OT 4 on 6/24/25 at 11:39 a.m. She indicated Resident 253 was evaluated by the therapy department as dependent with transfers. Residents that were dependent with transfers were transferred by mechanical Hoyer lift with two staff members. An interview was conducted with the Director of Nursing on 6/24/25 at 2:07 p.m. She indicated during the transfer of Resident 253; CNA 1 should not have left the resident suspended from the mechanical lift unattended. An interview was conducted with the Nurse Consultant (NC) on 6/24/25 at 2:34 p.m. She indicated the facility utilized a type of mechanical Hoyer lift that one staff member was required for transfers. She would provide the facility policy. A Joerns Hoyer lift policy was provided by the NC on 6/24/25 at 2:35 p.m. It indicated the following, .Policy: To safely transfer a resident from one surface to another via use of a mechanical lift. The hoyer stature lift may safely be used by one staff member if the resident can follow instructions or is cooperative with the transfer. If in doubt, a second staff member should be present during the transfer .Procedure .5. Adjust the stature cradle height and leg width. 6. Position the lift. 7. Connect hoyer sling to stature cradle. Attach sling clip to cradle lug. Pull clip down to secure. Feed green safe tab through the slot. 8. While explaining what you are doing, raise the resident using the pendant. 9. Ensure resident position and comfort and adjust as needed. 10. Adjust lifter height for safety during movement. 11. Move lift to end location. 12. Position resident for lowering. 13. Lower resident ensuring proper positioning to new location . A Joerns manufacture procedure manual was provided by the NC on 6/25/25 at 11:41 a.m. It indicated the following, .4. Safety Precautions .Always plan your lifting operations before commencing .7. Operating instructions .note: Before raising or lowering the patient, ensure you have planned your destination carefully . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia with behaviors of wandering for 1 of 2 residents reviewed for accidents. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 6/24/25 at 12:00 p.m. The diagnoses included, but were not limited to, dementia, paranoid personality disorder, and psychotic disorder with delusions. An Annual Minimum Data Set (MDS) assessment, dated 5/30/25, indicated Resident 1 was cognitively impaired. During an interview on 6/23/25 at 8:55 a.m., Resident 40 indicated there was a resident who got lost and wandered into his room at times. When this happened, he turned his call light on to have staff come to his room and assist the other resident back to her room. An interview was conducted with Qualified Medication Aide (QMA) 7 on 6/23/25 at 10:56 a.m. She indicated Resident 1 liked to wander into other residents' rooms, therefore staff redirected her into activities. During an interview with QMA 8 on 6/24/25 at 2:19 p.m., she indicated Resident 1 does wander into other residents' rooms, but staff always redirects her. On 6/24/25 at 2:24 p.m., an observation was conducted of Resident 1's bedroom door. It revealed a [NAME] hanging from the resident's door, but no other personalization specific to the resident. A placard with the resident's name was adjacent to the resident's door. An interview was conducted with Resident 37 on 6/24/25 at 3:19 p.m. He indicated Resident 1 had wandered into his room, and that she was not supposed to. During an interview with the Director of Nursing (DON) on 6/25/25 at 9:45 a.m., she indicated if residents were starting to have behaviors such as wandering, the facility staff would take the resident back into memory care to see how they get along with the other residents. If residents in memory care start to decline, such as needing a wheelchair, the facility transitions them out into the long-term care side of the facility. The DON indicated Certified Nurse Aides (CNAs) were to report new behaviors they observed to nursing staff, and management ran a report of residents who have been having increased behaviors. An interview was conducted with the DON on 6/25/25 at 3:37 p.m. She indicated she would consider wandering in and out of resident's rooms a behavior. The clinical record for Resident 1 did not include any physician's orders or care plans related to the behavior of wandering. Documentation of the resident wandering and/or interventions utilized could not be found in the clinical record. On 6/26/25 at 11:03 a.m., a random observation of Resident 22's room revealed a door guard with a stop sign had been placed in the entry way to the room. At that time, Resident 22 indicated staff had put up the door guard that morning because there was a resident who lives on the opposite end of the hall that liked to wander into their room. A Behavior Assessment and Management Policy, dated 2/18/19, was provided by the DON on 6/25/25 at 3:36 p.m. It indicated, .When a new behavior occurs that may present danger to the resident or others, interfere with activities of daily living, and/or cause the resident distress the nurse will document the episode on the assessment located in the EMR titled 'nursing-behavior assessment' . Interventions will be established in an effort to enhance staff approach to manage and assist in reducing or eliminating the problem behaviors . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed after doffing gloves for 1 of 1 resident reviewed for urinary catheter and 1 of 2 residents observed for blood sugar testing. (Resident B and Resident C) Findings include: 1. The clinical record for Resident B was reviewed on 6/23/25 at 8:45 a.m. The diagnoses included, but were not limited to, retention of urine and benign prostatic hyperplasia (BPH). A care plan, initiated 1/21/25, indicated Resident B required the use of a urinary catheter related to a diagnosis of benign prostatic hyperplasia (enlarged prostate) with neurogenic bladder. The goal was for his urinary catheter to be maintained per plan of care and for him to remain free from catheter related complications. The interventions included, but were not limited to, provide catheter care each shift and provide Enhanced Barrier Precautions (EBP). On 6/26/25 at 11:15 a.m., Licensed Practical Nurse (LPN) 2 was observed providing catheter care for Resident B. LPN 2 prepared the area and performed hand hygiene with alcohol-based hand gel. She donned a disposable gown and gloves. LPN 2 then provided catheter care. Upon completion of catheter care, LPN 2 emptied the basin of water and placed the soiled linen into a plastic bag. She held the plastic bag of soiled linen while she doffed her gloves and gown. LPN 2 did not perform hand hygiene after removing her soiled gloves and gown. She then opened the door of the room and stepped into the hallway. She opened the soiled utility linen closet and placed the soiled linen into the linen barrel, shut the door, and performed hand hygiene. 2. The clinical record for Resident C was reviewed on 6/25/25 at 10:00 a.m. The diagnoses included, but were not limited to, diabetes mellitus. An observation of glucometer testing (the testing of one's blood sugar) was conducted with LPN 6 on 6/25/25 at 10:32 a.m. LPN 6 performed hand hygiene upon arrival to the medication cart to gather Resident C's supplies. LPN 6 brought the resident's supplies to his location and performed hand hygiene. She then donned gloves and inserted testing strips into the glucometer, performed a finger stick on Resident C, and tested the resident's blood sugar. After the reading was completed, LPN 6 removed her gloves and wheeled the resident out of the room. LPN 6 then arrived at the medication cart and labeled the test strip container she had used and began disinfecting Resident C's glucometer. LPN 6 did not perform hand hygiene after removing her gloves or before exiting the room. During an interview with LPN 6 on 6/25/25 at 10:39 a.m., she indicated she sometimes disinfects the glucometers without gloves on while she was in the hall because staff were not allowed to wear gloves while in the hall. A Use of Medical Gloves Policy, dated 6/9/10, was provided by the Executive Director on 6/26/25 at 2:12 p.m. It indicated, . Gloves are worn to provide a protective barrier and prevent gross contamination of the hands when touching blood, body fluids, specimen collection, secretions, excretions, mucus membranes and non-intact skin .Guidelines: .D. Gloves should be removed and hands washed with soap and water immediately after glove removal .hand rub with alcohol gel may be used only if soap and water is not available upon removal of gloves . This citation relates to Complaint IN00457558. 3.1-18(l)

Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and reduce antibiotic resistance related to prescribing antibiotics without adequate indications for use based on the McGeer criteria and were able to treat the bacteria causing the infection for 1 of 1 resident reviewed for urinary catheters (Resident B). Findings include: The clinical record for Resident B was reviewed on 6/23/25 at 8:45 a.m. The diagnoses included, but were not limited to, retention of urine and benign prostatic hyperplasia (BPH). A care plan, initiated 1/21/25, indicated Resident B required the use of a urinary catheter related to a diagnosis of benign prostatic hyperplasia (enlarged prostate) with neurogenic bladder. The goal was for his urinary catheter to be maintained per plan of care and for him to remain free from catheter related complications. The interventions included, but were not limited to, provide catheter care each shift and document any catheter related complications in the electronic medical record and update the physician as needed. A Significant Change of Status Minimum Data Set assessment, completed 3/15/25, indicated Resident B was cognitively intact and had an indwelling urinary catheter. A General Note, dated 4/8/25 at 12:55 p.m., indicated Resident B was noted to have a sediment present in his urine. An order was received to perform a point of care urine dipstick. The test was performed with an abnormally large amount of leukocytes (type of white blood cell) and was positive for nitrates. The physician was informed, and an order was received to perform a urinalysis with culture and sensitivity. The urine sample was obtained, and the lab was notified. The physician was waiting for the urinalysis results to prescribe an antibiotic. A physician's progress note, dated 4/14/25 at 5:54 p.m., indicated Resident B was seen due to an abnormal urinalysis and positive urine culture. His urine test was completed, on 4/12/25, and showed growth of Pseudomonas aeruginosa (type of bacteria) greater than 100,000 CFU/mL (Colony Forming Units per milliliter; metric used to quantify the number of viable bacteria present in the sample). He would be started on Keflex 250 milligrams (mg) twice daily for a week. The urinalysis with culture and sensitivity, dated 4/12/25 and reviewed on 4/14/25, indicated the organism present in the urine was Pseudomonas aeruginosa. Keflex was not listed on the sensitivity report as a treatment option for the organism. The clinical record did not contain an Initial Nursing-Infection assessment when treatment for the positive urine culture started on 4/14/25. A Follow-Up Nursing - Infection assessment, dated 4/14/25 at 11:36 p.m., indicated Resident B was receiving the antibiotic Keflex 250 mg twice daily for seven days to treat a urinary tract infection. The constitutional criteria indicated the resident did not have a fever, leukocytosis (high white blood cell count), an acute change in mental status, or an acute decline in functional abilities. The April 2025 Medication Administration Record indicated he had received Keflex 250 mg twice daily for seven days. A Practitioner's visit note, dated 5/12/25 at 5:48 p.m., indicated Resident B was seen due to abnormal labs. Resident B's white blood cells were elevated. Due to leukocytosis, a urinalysis with culture and sensitivity was ordered to rule out a urinary tract infection. A General Note, dated 5/19/25 at 1:32 p.m., indicated the physician had received and reviewed Resident B's urinalysis with culture and sensitivity and a new order was received for Cipro (antibiotic) 250 mg to be given twice a day for seven days. The urinalysis with culture and sensitivity results, dated 5/17/25 and reviewed on 5/19/25, indicated the organism present in the urine was Pseudomonas aeruginosa. Cipro was listed on the sensitivity report as a treatment option for the organism. On 6/26/25 at 1:45 p.m., the Antibiotic Stewardship tracking binder was observed. The Infection Surveillance Data Collection Form for April 2025 indicated that Resident B had a catheter-associated urinary tract infection (CAUTI) with signs and symptoms starting on 4/14/25. The May 2025 Surveillance Data Collection Form indicated Resident B had an ongoing CAUTI, which started on 4/14/25, that was treated and then returned. The organism listed E-Coli (type of bacteria). During an interview on 6/26/25 at 2:50 p.m., the Infection Preventionist (IP) indicated she was unsure why the physician had chosen to treat the 4/14/25 urinalysis results with the antibiotic Keflex, as it was not on the sensitivity report. The IP had not spoken with the physician about the use of Keflex, instead of another antibiotic that was listed as a treatment option. The signs and symptoms of the infection should have been documented in the nurse's notes. The IP was unsure why she had listed the organism as E-Coli instead of Pseudomonas aeruginosa on the May 2025 Infection Surveillance Data Collection Form. She would see if she could find more information about what signs or symptoms that Resident B may have displayed in April 2025. The facility used McGeer's criteria for determining true infections. On 6/24/25 at 8:30 a.m., the Executive Director provided the Antibiotic Stewardship Policy, dated 3/29/24, that indicated, .The facility's Infection Control Program has defined standards outlining specific clinical criteria for identification of infections, action plans to administer when infections occur and surveillance program that aggressively monitors and implements procedures to treat and prevent further outbreaks. One of these procedures includes judicial and appropriate use of antimicrobial agents. McGeer criteria for defining infections will be the standard for determining infections .

Based on observation, interview, and record review, the facility failed to ensure staff accurately identified and monitored skin impairment for a cognitively impaired, dependent resident at risk to develop pressure injuries, failed to ensure interventions for effective pressure relief, and to promote healing, were implemented when an area of concern on the resident's skin was reported to a nurse, and failed to ensure care and services were provided to prevent the pressure injury from deteriorating for 1 of 2 residents reviewed for skin integrity (Resident 50). This deficient practice resulted in Resident 50 developing a facility-acquired stage three (full thickness tissue loss) pressure injury. Findings include: The clinical record for Resident 50 was reviewed on 6/11/24 at 3:00 p.m. The resident's admitting diagnoses included, but were not limited to, adult failure to thrive, moderated protein-calorie malnutrition, and Alzheimer's disease. He was admitted to the facility on [DATE]. A Braden Scale Assessment (assessment to predict pressure ulcer risk), completed 2/8/24, indicated he was at high risk for pressure ulcer development due to decreased mobility, having occasional moisture of the skin, and being bed and chair fast. A care plan, initiated 2/8/24, indicated that Resident 50 was at risk for skin breakdown due to urinary and fecal incontinence, impaired mobility, decreased functional ability, and previously healed wounds to the left buttock and palm of hand. The goal was to provide preventative measures in an attempt to avoid skin breakdown. The interventions included, but were not limited to, monitor skin daily during care, initiated 2/8/24, notify physician and family of any change in skin integrity, initiated 2/8/24, and skin assessment at least weekly by nurse, initiated 2/8/24. A Quarterly MDS (Minimum Data Set) Assessment, completed 6/5/24, indicated his cognition was severely impaired, he required maximal assistance of staff for toileting, bathing, dressing, turning in bed, and transfers. He was totally incontinent of bowel and bladder. He did not have a pressure ulcer and was at risk of developing pressure ulcers. Weekly skin assessments were completed by LPN (Licensed Practical Nurse) 5 on 5/26/24, 6/2/24, and 6/9/24 which indicated he did not have any new skin breakdown or pressure ulcer. A physician's order, dated 6/10/24, indicated to cleanse wound on right buttock with normal saline, pat dry, apply Medi honey (wound treatment gel) and alginate (wound dressing) into the wound bed, apply skin prep to surrounding area and cover with a bordered foam dressing daily and as needed for soiling or dislodgement. A Pressure Injury Assessment, dated 6/11/24, indicated the pressure injury was originally noted on 6/10/24 and located on lower right buttock and was a stage 3 that was new and acquired in-house. The wound bed exhibited 1-25% necrosis (dead tissue). Ecchymosis (bruised/ discolored) surrounding wound. There was light drainage and no odor. The physician and family were notified of the pressure injury. On 6/14/24 at 2:04 p.m., Resident 50's right buttock wound was observed with the DON (Director of Nursing) and the WN (Wound Nurse). Resident 50 was resting on a low air loss mattress. The dressing was removed, and the wound was approximately the size of a silver dollar. The wound bed had necrotic tissue which was light brown and soft in appearance. There was a thin line of pink colored tissue surrounding the wound bed and the skin surrounding the wound was flesh tone. The WN completed the dressing as ordered by the physician. During an interview on 6/14/24 at 2:04 p.m., the DON and the WN indicated there was necrotic tissue present in the wound bed of the pressure ulcer on the right buttock. The DON and WN had been informed of the pressure ulcer when it was about this size. They were unsure as to why it was not found or reported earlier. The staff could have assumed it was the moisture associated skin damage which had been treated on the left hip and healed in May 2024 and thought they knew about the area. During an interview on 6/14/24 at 2:15 p.m., CNA (Certified Nursing Assistant) 3 indicated she had cared for Resident 50 about a week ago and had noticed an area on his right buttock. CNA 3 had informed LPN (Licensed Practical Nurse) 4. During an interview on 6/14/24 at 2:20 p.m., LPN 4 indicated she had not been told about any skin concerns until the WN informed after the WN had found the wound on the right buttock. LPN 4 was not aware of any skin issues prior to being told by the WN. During an interview on 6/14/24 at 2:53 p.m., LPN 5 indicated she had completed the weekly skin assessment during the night shift on 6/9/24. She had not seen any new skin areas. There was one skin area that was being treated on his left buttock. She did not recall a skin area on Resident 50's right buttock. She did not always turn the lights on all the way, which could have affected it. LPN 5 had not been informed of any new skin areas by the nursing staff during her shift. During an interview on 6/14/24 at 03:47 p.m., the DON indicated that a low air loss mattress had been obtained for Resident 50 the day the pressure ulcer on his right buttock was found. Resident 50 was receiving barrier cream to the area prior to the pressure ulcer being found. On 6/14/24 at 3:20 p.m., the Executive Director provided the Skin Management Program policy, dated 8/14/2014, which read .It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin alterations unless the individual's condition demonstrates that the development is clinically unavoidable .A comprehensive head to toe skin assessment [inspection] will be completed by a licensed nurse upon admission/ return, and at least weekly thereafter . Residents who received assistance with bathing and/or peri-care will be observed daily by nursing staff and any notation of red areas, open areas, skin tears, bruises, rashes, abrasions, excoriations or other alterations will be reported to the licensed nurse for further assessment . Notification/ communication will occur with the resident/ sponsor and physician when there is a change in condition and /or change in treatment plan .Nursing staff will communicate changes via the 24 hour condition report . DON or designee will be alerted to all new skin alterations via the EMR [sic] dashboard and the 24 hr. report and will oversee that all assessment and documentation is completed 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to timely complete a Significant Change of Status MDS (Minimum Data Set) Assessment for a resident receiving hospice services and to ensure a Minimum Data Set (MDS) Assessment was accurately completed for dental issues for 1 of 1 resident reviewed for Resident Assessment (Resident 45) and 1 of 1 resident reviewed for dental (Resident 16). Findings include: 1. The clinical record for Resident 45 was reviewed on 6/13/24 at 10:00 a.m. The Resident's diagnoses included, but were not limited to, lung cancer and failure to thrive. He was admitted to the facility on [DATE]. A physician's order, dated 4/17/24, indicated that Resident 45 was admitted to hospice services. The clinical record did not contain a Significant Change of Status MDS that had been completed within 14 days of the hospice admission. During an interview on 6/13/24 at 11:44 a.m., the MDSC (Minimum Data Set Coordinator) indicated that a Significant Change of Status MDS should have been completed when Resident 45 began receiving hospice care. The facility used the RAI (Resident Assessment Instrument) Manual as the policy for completing the MDS. 34850 2. The clinical record for Resident 16 was reviewed on 6/11/23 at 1:40 p.m. Resident 16's diagnosis included, but was not limited to, chronic obstructive pulmonary disorder. The MDS assessments dated 12/5/23 and 6/6/24 indicated Resident 16 was not edentulous. An observation was made of Resident 16 on 6/11/24 at 1:48 p.m. The resident was observed in bed. The resident was observed with no teeth. The resident indicated he had been edentulous for over [AGE] years. A dental visit for Resident 16 was provided by the Social Services Director on 6/13/24 at 10:57 a.m. It indicated the resident was edentulous and not a good candidate for dentures. An interview was conducted with the MDS Coordinator on 6/13/24 at 2:27 p.m. She indicated the resident does not have teeth. She had updated the resident's medical record to reflect the resident does not have teeth. The Long-Term Care Facility Resident Assessment Instrument 3.0 User 's Manual, Version 1.18.11 October 2023 read . If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA) .

Based on observation, interview, and record review, the facility failed to use gloves and perform hand hygiene when providing care to a resident whose leg was bleeding in the common area of the unit for 1 of 1 resident randomly observed. (Resident 40) Findings include: The clinical record for Resident 40 was reviewed on 6/11/24 at 1:40 p.m. Her diagnosis included, but were not limited to, Alzheimer's disease. She resided on the memory care unit of the facility. An observation of Resident 40 and interview with CNA (Certified Nursing Assistant) 1 was conducted on 6/11/24 at 1:41 p.m. Resident 40 was sitting down on the couch in the television area located in the middle of the unit. Resident 40 pulled her right pant leg up to her knee and began scratching her leg. There was blood dripping down Resident 40's right leg near the inner side of her calf area. CNA (Certified Nursing Assistant) 1 was sitting at the nurse's desk and informed of the blood on Resident 40's right leg. CNA 1 indicated she would inform the nurse. CNA 1 got up from the nurse's desk, came over to Resident 40 at the couch, and bent down with tissue paper and a pair of gloves in her hands. CNA 1 used the tissue paper with her bare right hand to wipe the blood from Resident 40's right leg and did not put on the gloves she had in her left hand. After wiping, she folded the tissue paper in half, walked down the hall to the unit exit doors, punched the code into the keypad to exit the unit, and exited the unit. CNA 1 did not wash her hands after she wiped the blood from Resident 40's leg and prior to exiting the unit. An interview was conducted with the DON (Director of Nursing) on 6/11/24 at 3:45 p.m. She indicated after speaking with staff about the above observation, she thought there was an infection control issue regarding glove use and hand hygiene. The Hand Washing and Hand Asepsis policy was provided by the ED (Executive Director) on 6/12/24 at 11:40 a.m. It read, To provide protection for resident and staff when performing direct care procedure. To ensure that hands remain clean so as to assist in maintenance of a clean environment and assist in the prevention of and the transmission of disease and infection. This facility follows the recommendations for handwash and hand hygiene recommended by the CDC (Centers for Disease Control ) SPECIFIC TIMES HANDS MUST BE WASHED: .Before and after direct resident contact. The Use of Medical Gloves policy was provided by the ED on 6/12/24 at 3:50 a.m. It read, Medical glove use by HCW's [health care workers] is recommended for two main reasons: 1) to reduce the risk of contaminating the HCW's hands with blood and other body fluids, 2) to reduce the risk of the germ dissemination to the environment and the transmission from the HCW's to the patient and vice versa, as well as from one patient to another. Gloves are worn to provide a protective barrier and prevent gross [sic] contamination of the hands when touching blood, body fluids, specimen collection, secretions, excretions, mucus [sic] membranes and non-intact skin .Gloves should be removed and hands washed with soap and water immediately after glove removal. (Hand washing with soap and water is highly recommended when gloves are removed because of a tear or puncture and the HCW has had contact with blood or another body fluid, hand rub with alcohol gel may be used only if soap and water is not available upon removal of gloves.) 3.1-18(b)(1) 3.1-18(l)

Based on interview and record review, the facility failed to take prompt efforts to resolve an oral grievance from a resident regarding missing clothing items for 1 of 1 residents reviewed for personal property. (Resident 6) Finding include: The clinical record for Resident 6 was reviewed on 5/17/23 at 4:29 p.m. Resident 6's diagnoses included, but not limited to, diabetes type II, hypertension, non-pressure chronic ulcer of the left foot, cardiomegaly (enlarged heart), and chronic kidney disease. The quarterly MDS (Minimum Data Set) dated 3/31/23 indicated, Resident 6 was cognitively intact and could make daily healthcare decisions for himself. An admission MDS dated [DATE] indicated, his preferences for how important it was for him to: choose what clothes to wear, to take care of his personal belongings or things; and importance of having a place to lock his things up to keep them safe was very important Resident 6's care plan dated 12/30/22 indicated, He had expressed during the assessment process that it was important to him to take care of his personal belongings. Some interventions were to discuss with the resident regarding placement of items in room, assistance with securing items as needed, and to ensure family/friend was invited to care plan meetings. An interview with Resident 6 was conducted on 5/16/23 at 9:23 a.m. Resident 6 indicated, a week ago his [NAME] kit (containing his soap, shower wash and shampoo) went missing from the top of his bedside night stand along with a can of orange soda. Additionally, he indicated about three months ago, when he had moved from one room to his present room, his clothing had gone missing. He stated he was missing 10 pairs of underwear, pants, shirts, and a jogging suit. He stated that now he and his roommate will not leave the room unattended for fear that more of their items would be taken. An interview with ED (Executive Director) was conducted on 5/17/23 at 11:53 a.m. ED indicated, the facility did not have any grievance forms from Resident 6 within the last year. An interview with Resident 6's family member (FM 7) conducted on 5/17/23 at 2:38 p.m. indicated, her father had been moved from one room to his present room and when they moved him, his clothing did not get moved with him. She stated, he had told his nurse as well as the oncoming shift's nurse of the fact that he was missing his clothing. He was told by the nurses that they must have been left in his closet in his old room and would check to see if they were still there but, when they did check, his clothing was not there. The nurses then told Resident 6 that perhaps laundry had taken them. FM 7 indicated, she was unable to visit her dad for a couple weeks after his room move but when she did visit, she noticed that her dad's outfit was unclean and he was now wearing incontinence briefs. When she asked him about his appearance, he told her that his clothing was still missing which included all of his underwear so he had to wear the incontinent briefs as underwear. FM 7 stated, on that day, she went and spoke with his nurse who indicated, they would have to look into it. FM 7 indicated, she had received a phone call from the facility regarding his lost clothes. FM 7 indicated, the person who called her identified themselves as the business office manager and told her the facility was unable to locate his clothing and because they were not labeled with his name, that there was nothing they could do about it. FM 7 indicated, the person who called her also asked if she had a receipt for the missing clothing, but FM 7 no longer had the receipt. FM 7 indicated, her dad was missing 2 ten packs of underwear, 2 jogging suits, and some tops and bottoms from Wal-mart. Additionally, she stated that even his orthotic inserts he had for his shoe was missing. An interview with Social Services Director (SSD) conducted on 5/17/23 at 3:27 p.m. indicated, she was not made aware of Resident 6 missing clothing items, a can of orange soda, or his [NAME] kit. A Grievance Procedure policy was received on 5/17/23 at 11:35 a.m. from ED. The policy indicated, the facility strives to address all resident concerns and complaints immediately to the satisfaction of the resident and/ or family. Residents and families are encouraged to speak to any staff whenever their expectations of care and service are not met so immediate action can be taken .Miller's Merry Manor will investigate, act upon and resolve to the best of our ability any resident or family concern/grievance that cannot be immediately resolved .Procedure .Resident may verbally file a grievance with any staff member or may request a specific staff member to speak to .Any alleged violations involving neglect, abuse .and/or misappropriation of resident property will be reported immediately to the administrator .Follow up with the involved party will be completed until the concern is resolved to the satisfaction of the resident and/or involved party and documented on the form .Staff will be trained upon hire and throughout employment on how to receive grievance voiced by residents and/or family members. 3.1-7(a) 3.1-7(b)

Based on observation, interview and record review, the facility failed to ensure a humidifier was provided for a resident using oxygen therapy for 1 of 1 resident reviewed for oxygen. (Resident 21) Findings include: The clinical record for Resident 21 was reviewed on 5/16/23 at 9:44 a.m. The diagnoses included, but were not limited to, chronic pain, obstructive sleep apena, chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD). A respiratory care plan for Resident 21 dated 12/8/22 indicated the staff was to administer oxygen, medications and treatments as ordered. A physician order dated 12/8/23 indicated .Check oxygen flow rate: tank level; tube patency; portable/concentrator function; humidifier level every 4 hr. A physician order dated 12/11/22 indicated the staff was to change humidifier and clean concentrator filter every Sunday on night shift. A physician order dated 12/8/23 indicated Resident 21 was to receive 4 liters of continuous oxygen. An observation was made of Resident 21 on 5/16/23 at 9:44 a.m. The resident was observed with a nasal cannula in his nose and oxygen was running through it. Resident 21 indicated at that time, the staff do not always replace the humidifier on the concentrator of the oxygen unit. His nose gets dry. It feels good when he does have it. The humidifier bottle was observed empty. An observation was made of Resident 21 on 5/17/23 at 11:35 a.m. The resident's oxygen concentrator was observed with an empty humidifier bottle. The resident indicated at that time, the staff had not changed out the humidifier. An interview was conducted with License Practical Nurse (LPN) 5 on 5/17/23 at 11:45 a.m. She indicated she was Resident 21's nurse that day. The humidifier was changed every Sunday night. She was unsure why it had not been done. 3.1-47(6)

Based on interview and record review, the facility failed to address a resident's pain utilizing nonpharmacological interventions for 1 of 1 residents reviewed for pain. (Resident 21) Findings include: The clinical record for Resident 21 was reviewed on 5/16/23 at 9:44 a.m. The diagnoses included, but were not limited to, chronic pain, obstructive sleep apena, chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD). A pain care plan for Resident 21 dated 12/9/22 indicated the goal was for the resident's pain would be at a tolerable level. The interventions were the following: .Assess pain using the 0-10 scale [1 being the least amount of pain and 10 being the most amount of pain]. , Instruct resident to take pain medication before pain becomes severe to achieve better pain control, . Administer pain medication as per MD orders and note the effectiveness, Document/Report complaints & non-verbal signs of pain . A physician order dated 5/11/23 indicated Resident 21 was to receive Biofreeze on both knees four times a day for pain. A physician order dated 4/14/23 indicated Resident 21 was to receive 325 milligrams of Tylenol for pain management three times a day. The May 2023 Medication Administration Record (MAR) indicated the following days and shifts the resident indicated he was in pain, and the pain severity level: 5/1/23 = a.m., - pain level of 6, mid day - pain level of 6, night - pain level 3, 5/2/23 = a.m., - pain level of 6, mid day - pain level of 7, night - pain level 3, 5/3/23 = a.m., - pain level of 6, mid day - pain level of 6, night, 5/4/23 = a.m., - pain level of 6, mid day - pain level of 5, night - pain level 2, 5/5/23 = a.m., - pain level of 7, mid day - pain level of 6, night - pain level 2, 5/7/23 = a.m., - pain level of 2, 5/8/23 = a.m., - pain level of 8, mid day - pain level of 6, night - pain level 1, 5/9/23 = a.m., - pain level of 7, mid day - pain level of 6, 5/10/23 = a.m., - pain level of 8, mid day - pain level of 6, night - pain level 2, 5/11/23 = a.m., - pain level of 7, mid day - pain level of 6, night - pain level 1, 5/12/23 = night - pain level 2, 5/15/23 = a.m., - pain level of 6, mid day - pain level of 8, 5/16/23 = a.m., - pain level of 7, mid day - pain level of 8, 5/17/23 = a.m., - pain level of 7, mid day - pain level of 6, and 5/18/23 = a.m. - pain level of 9 An interview was conducted with Resident 21 on 5/16/23 at 9:41 a.m. He indicated he has pain in his lower extremities. The staff give him Tylenol to address his pain, but it does not relieve his pain. The resident reported at that time, his pain in his lower legs were at a pain severity of a 9. The resident's clinical record did not indicate nonpharmacological interventions were provided to address a resident's pain. An interview was conducted with License Practical Nurse (LPN) 5 on 5/17/23 at 11:45 a.m. She indicated the resident does complain about his pain in his legs. The resident receives Tylenol and Biofreeze topically for pain management. The resident was not compliant with wearing his CPAP [Continuous Positive Airway Pressure] during the times of sleeping, so the medical provider can not order any additional stronger pain medications due to the concern with affecting the resident's breathing. An interview was conducted with the Director of Nursing on 5/17/23 at 3:33 p.m. She indicated the staff should be offering, providing and documenting nonpharmacologiccal interventions to address Resident 21's pain. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide appropriate dementia care services to 1 of 6 residents reviewed for dementia care. (Resident 24) Findings include: The clinical record for Resident 24 was reviewed on 5/16/23 at 9:20 a.m. Her diagnoses included, but were not limited to, Alzheimer's disease and dementia. The undated memory care functional maintenance plan indicated, Late state dementia. Cognition is severely impaired. Lack awareness on the effects that actions have on objects or other people. Able to use simple communication. Needs to feel stable. Can perform gross motor movements and is mobile (may be able to sit, stand, walk). Maximum assistance with all activities of daily living to prevent falls and wandering. The cognition care plan, last reviewed 4/18/23, indicated interventions were to ensure staff explain procedures at initiation of each interaction with resident and allow time to process and to gently redirect activities when resident makes inappropriate actions. An observation of the memory care unit was made on 5/16/23 at 9:24 a.m. Resident 24 was sitting at a table in the dining room. She had an abrasion above her left eye. There was a Christmas tree in the television lounge area of the unit, decorated in red, white, and blue holiday decorations. The decorations were bows, [NAME], and stars that did not include any hooks or sharp objects. The 5/13/23, 4:30 p.m. nursing occurrence initial assessment, written by LPN (Licensed Practical Nurse) 8, indicated Resident 24 had a fall with injury in the hallway by the television lounge. The type of injury sustained was a bruise/hematoma and abrasion. It read, resident pulled decorations of [sic] the tree in the lounge writer tried to get decorations from resident then resident started to walk in a fast pace went to help resident to slow down when resident was approached the resident jerked away and fell to the floor assisted resident up in chair noticed resident's nose was bleeding from the right nostril applied a gauze had moderate amount of bleeding before it stopped has abrasion above left eye and a red bruise under left eye. The 5/15/23 nurse practitioner note read, Plan: s/p [status post] witnessed fall. Neuro [neurological] check at baseline. Remains ambulatory w/o [without] assistive. Abrasion x [times] 2 above L [left] eye and at corner of L [left] eye. Will add bacitracin. Fall precautions. Encourage safe and supportive environment. The 5/15/23 post occurrence IDT (Interdisciplinary Team) & fall risk assessment indicated the root cause was, as resident was being approached by staff, she jerked away causing her to lose her balance and fall to the floor. The IDT recommendations were, staff education, if resident has something in her hands to go ahead and allow her to keep it until she puts it down. Don't try and take it away from her, unless it will cause someone or herself harm. An interview was conducted with the SSD (Social Services Director) on 5/18/23 at 10:25 a.m. She indicated she was part of the 5/15/23 IDT review of Resident 24's fall. The facility did not currently have a memory care director for the unit. She would have let Resident 24 take the decorations and retrieve them later. An interview was conducted with the DON (Director of Nursing) on 5/18/23 at 10:34 a.m. She indicated she was not present in the facility when Resident 24 fell . Resident 24 was really upset about it. It was hard to redirect her. My fix was let her have the decorations, and we'll redirect her later. It wasn't worth Resident 24 getting upset or causing her any distress. An interview was conducted with LPN 8 on 5/18/23 at 10:56 a.m. She indicated she worked the memory care unit of the facility over the weekend and there was an incident with Resident 24. LPN 8 was standing in the common area across from the television lounge when she saw Resident 24 rip a piece of [NAME] off the tree. LPN 8 did not want the tree to fall on Resident 24. Resident 24 began walking in a fast pace away from the tree, and LPN 8 was going to try and get her to sit down. When LPN 8 approached her, it startled Resident 24. Resident 24 started fighting me, grabbing at me. LPN 8 was trying to calm her down, but Resident 24 jerked away. I was hanging onto her in like a hug, but not a tight hug. Afterwards, LPN 8 thought she should have just left it alone, as the decorations weren't that important. By the time LPN 8 got to Resident 24, she was already away from the tree, so she should have just left it alone. LPN 8 thought Resident 24 hit her head on the floor, because when she got up, there was blood coming from her nose. LPN 8 was the only staff member on the unit at the time, as the CNA (Certified Nursing Assistant) on duty was on break. The Specialty Unit Responding to Feelings policy was provided by the DON on 5/18/23 at 2:03 p.m. It read, Things Not To Do: a. Don't argue with the person. This always makes the situation worse. Furthermore, it is important to remember that a person with dementia no longer has the ability to be rational or logical to the extent you do. b. Don't order the person around. Few of us like to [sic] bossed around and the person with dementia is no exception. Even when your words are not understood, your tone of voice will be. c. Don't tell the person what he or she can't do. State directions positively instead of negatively. Instead of 'You can't go outside now,' try 'Let's sit down here and look at these pictures.' The Specialty Unit Communication Techniques for Alzheimer's Residents policy was provided by the DON on 5/18/23 at 2:03 p.m. It read, Approach from the front and at eye level Most importantly, 'BE PATIENT AND CONVEY LOVE WITH EACH INTERACTION.' The Specialty Unit Behaviors-What Can We Do? policy was provided by the DON on 5/18/23 at 2:03 p.m. It read, First and foremost, determine who the problem is a problem for. Is it endangering the resident or another resident? Or is it simply annoying you? Is it socially unacceptable? Is it altering the function of the unit or disrupting anyone in any way? .Resisting care-This is often a result of improper approach. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was free of unnecessary mediations with antibiotic usage for 1 of 1 residents reviewed for antibiotic medications. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 5/16/23 at 10:00 a.m. The diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease (COPD). A physician order dated 6/4/22 indicated Resident 1 was to receive 250 milligrams of Azithromycin once a day every Monday, Wednesday and Friday for prevention. The June 2022 Infection Surveillance Data Collection Form indicated Resident 1's signs and symptoms of the resident's infection was cough and COPD. This was an ongoing prophylactic antibiotic. It did not meet criteria for antibiotic usage. A physician order dated 10/14/22 indicated Resident 1 was to receive 300 milligrams of Cefdinir daily until 10/18/22. Stop Azithromycin while taking Cefdinir. Azithromycin will resume after the completion of Cefdinir. The October 2022 Infection Surveillance Data Collection Form indicated Resident 1's signs and symptoms of the resident's infection was COPD exacerbation. The October 2022 Medication Administration Record (MAR) indicated Resident 1 had received Azithromycin antibiotic on Mondays, Wednesdays, and Fridays 10/3/22 through 10/31/22. The Azithromycin medication had not been stopped on 10/15/22, 10/16/22, 10/17/22, and 10/18/22 as ordered. An interview was conducted with Director of Nursing (DON) on 5/18/23 at 2:03 p.m. She indicated the resident does see an outside physician that ordered the prophylactic antibiotic. Normally, the Infection Preventionist would notify the Medical Director (MD) about the prophylactic antibiotic order. The MD would then contact the outside physician/specialist to clarify if it was truly necessary to start a prophylatic antibiotic. She was unable to find documentation the discussion had taken place. Resident 1 has been on the prophylactic a long time and continues receiving Azithromycin Mondays, Wednesdays and Fridays. The residents that have used prophylactic antibiotics are not normally kept on them as long as Resident 1 has been on the preventive antibiotic. Resident 1 had received the Azithromycin and the Cefdinir antibiotics at the same time in October 2022. The Azithromycin had not been stopped on 10/14/22 as ordered. 3.1-48(a)(2)(4)

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 4 residents observed during medication pass. There were 25 opportunities with 2 errors resulting in an 8% medications error rate. The errors involved 1 resident (Resident 3) in the sample of 4. Findings include: The clinical record for Resident 3 was reviewed on 5/19/23. Resident 3's diagnoses included, but not limited to, chronic obstructive pulmonary disease (COPD), diabetes type II,, and Alzheimer's disease. A physician's order dated 11/2/22 indicated, to give Resident 3 one 2.5 mg(milligram) of Zyprexa (antipsychotic) ODT (orally disintegrating tablet) every Wednesday for dementia with delusions. A physician's order dated 11/3/22 indicated to give Resident 3 one 5 mg Zyprexa tablet ODT on Monday, Tuesday, Thursday, Friday, Saturday, and Sunday and an order for Flovent 110 mcg (micrograms). An observation of LPN (licensed Practical Nurse) 6 was conducted on 5/18/23 at 9:29 a.m. LPN 6 was administering Resident 3's medications which included, but not limited to, the Zyprexa and Flovent. The box for the Flovent indicated, to rinse the patients mouth with water and to spit the water out after administering the Flovent. LPN 3 took all the oral medications, including the Zyprexa ODT tablet, and placed them into a plastic sleeve and crushed the medications. She placed the crushed medications into vanilla pudding and administered them to the resident. After taking the crushed oral medications, Resident 3 then inhaled her dose of Flovent and took a sip of water. Resident 3 did not rinse and spit after the inhaler and she swallowed the Zyprexa tablet instead of letting it disintegrate in her mouth. An interview with Pharmacist 2 was conducted on 5/18/23 at 10:30 a.m. Pharmacist 2 indicated, Zyprexa ODT should not be administered when crushed and swallowed as that will affect the absorption of the medication. An interview with DON (Director of Nursing) conducted on 5/18/23 at 2:12 p.m. indicated, when administering an inhaled medication which indicated a need to rinse and spit after taking the medication, it would not suffice to only take a sip of water and the resident should have been instructed to rinse then spit out the water. A Medication Administration Procedure policy was received 5/19/23 at 10:19 a.m. from DON. The policy indicated, Altering of medication: Ensure that there is a physician's order stating it is acceptable to crush tablets of open medication capsules and give with food substance. If a medication should not be crushed or altered contact physician for al alternate medication or liquid equivalent. 3.1-48(c)(1) 3.1-48(c)(2)

Based on interview and record review, the facility failed to provide a speech evaluation, as ordered by the physician, for a resident requesting a diet upgrade for 1 of 1 resident reviewed for nutrition (Resident 48). Findings include: The clinical record for Resident 48 was reviewed on 5/16/23 at 8:32 a.m. The Resident's diagnosis included, but was not limited to, dysphagia (trouble swallowing). A physician's order, dated 8/14/2020, indicated he was to receive a mechanical soft and no added salt diet. A care plan, initiated 8/25/2020, indicated he was at nutritional risk related to being on a mechanically altered and therapeutic diet. He was non-compliant with diet and would eat foods that the family provided, such as pork rinds. He had experienced weight fluctuations. The goal was for him to consume meals of foods and beverages that he selected and for him to be served his diet as ordered. The interventions, initiated 7/14/2020, were to serve his diet as ordered, have him select his own menu, and monitor weight and intake. A Speech Therapy Discharge Summary, dated 5/6/21, indicated that he was able to follow safety strategies for safe swallowing with 75% accuracy with moderate verbal cues. He was educated that a mechanical soft diet was the safest to decrease aspiration (food going into lungs) risk. A physician's order, dated 1/19/23, indicated speech therapy was to evaluate and treat as indicated. The order was discontinued on 1/25/23. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/13/23, indicated he had moderately impaired cognition. On 5/16/23 at 8:32 a.m., Resident 48 was observed sitting in his wheelchair in his room. There was a box of individual potato chips bags on his bed. He indicated he wanted to eat hamburgers, but the facility would not give them to him. During an interview on 5/18/23 at 9:24 a.m., Resident 48 indicated he had not been seen by speech therapy. He often requested hamburgers and was told he could not have them because he couldn't swallow. He had not has a swallowing test since he had been at the facility. During an interview on 5/18/23 at 9:30 a.m , the Dietary Manager indicated that Resident 48 frequently asked for hamburgers. He was offered mechanical soft (ground up) hamburger on a bun but refused them. He was not safe to have a regular hamburger because he ate so fast. During an interview on 5/18/23 at 9:54 a.m., the Therapy Coordinator indicated there was no documentation that a speech eval was completed in January 2023. During an interview on 5/18/23 at 11:10 a.m., ST (Speech Therapist) 4 indicated she had screened him in March 2023 and felt he was on the appropriated diet. She was not sure if Resident 48 would be safe to eat a hamburger, it would have to be cooked right so that it was tender. He may be able to if it were cut in half or quarters, but she had not evaluated him, so she could not recommend he received hamburgers that were not mechanically altered. In order to upgrade Resident 48's diet so that he could have hamburger which were not mechanically altered, ST 4 would need to evaluate him and try the hamburger to see if he tolerated it. A Modified Barium Swallow test would be helpful to determine his swallowing ability. During an interview on 5/18/23 at 11:49 a.m., the DON (Director of Nursing) indicated Resident 48 had an order for speech therapy in January 2023. The order had not been properly communicated to the therapy department and had not been completed. Resident 48 frequently ate things like pork rinds, chips, and candy bars. To her knowledge, Resident 48 had not been treated for aspiration pneumonia during his time at the facility. On 5/18/23 at 2:05 p.m., the DON provided the New Order policy last updated 3/23/18, which read . To ensure physician orders are transcribed correctly and carried out per plan by a licensed nurse .Make a progress note to indicate that physician order was obtained and why. Use the note titled 'Communication of new or changed plan of care/ orders' to ensure that appropriate notification is completed . 3.1-23(a)(1)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by not ensuring: a urinary catheter bag was off of the floor for 1 of 1 residents reviewed for urinary catheter (Resident 14 ); medication cups, water cups, and plastic sleeves which are used to crush medications in were not handled in a manner to prevent staff from placing fingers and/or fingernails inside the cup or a disposable plastic pouch for 2 of 4 residents observed during medication administration (Residents 36, 56, and 3 ); and not performing proper hand hygiene prior to donning and doffing of gloves for 1 of 4 residents reviewed for medication administration (Resident 33) Findings include: 1. An observation of Resident 14 was conducted on 5/16/23 at 10:11 a.m. The bottom of Resident 14's urinary catheter bag was touching the bedside mat which was on the floor next to his bed. An observation of Resident 14 was conducted on 5/17/23 at 9:31 a.m. Resident 14 was sitting in his wheelchair and the bottom of his urinary catheter bag was on the floor under his wheelchair. A physician's order dated 8/7/21 indicated, to ensure Resident 14's catheter bag was below his waist, covered, and tubing is not touching the floor. Resident 14's most recent care plan was reviewed on 5/17/23. It indicated, Resident 14 required a urinary catheter related to bladder retention. Some of the interventions included, to maintain the urinary bag below bladder level to facilitate urine flow and to provide measures to prevent excessive pulling/tension on catheter tubing. A Foley Catheter Care & Maintenance policy was received on 5/17/23 at 11:35 a.m. from ED (Executive Director). The policy indicated, Placement of Catheter Tubing Procedure .When in bed of wheel chair .position tubing with no tension .ensure bag or tubing is not touching floor. 2. a. An observation of LPN (Licensed Practical Nurse) 5 administering medications to Resident 36 was conducted on 5/18/23 at 9:01 a.m. When LPN 5 went to grab a plastic medication cup to dispense the resident's medications into she grabbed the medication cup by placing her index finger inside the cup and her thumb on the outside of the cup in a pinching manner. Also, when she went to grab a cup to place water in for the resident to take their medications she grabbed the cup by its rim which is were the resident's mouth would touch when drinking from the cup. b. An observation of LPN 5 administering medications to Resident 56 was conducted on 5/18/23 at 9:16 a.m. When LPN 5 went to grab a plastic medication cup to dispense the resident's medications into she grabbed the medication cup by placing her index finger inside the cup and her thumb on the outside of the cup in a pinching manner. Also, when she went to grab a cup to place water in for the resident to take their medications she grabbed the cup by its rim which is were the resident's mouth would touch when drinking from the cup. c. An observation of LPN 6 administering medications to Resident 3 was conducted on 5/18/23 at 9:29 a.m. LPN 6 dispensed Resident 3's pills into a medication cup then grabbed a disposable plastic pouch used to crush medications in and placed her fingernail inside of the pouch to open the plastic pouch up so she could pour the tablets into the pouch. She then placed the plastic pouch into the crushing tool. After the pills were sufficiently crushed, she again placed her fingernail into the pouch to open it up so she could pour the contents of the pouch into a medication cup. 3. An observation of LPN 5 administering insulin to Resident 33 was conducted on 5/18/23 at 12:04 p.m. After performing the blood glucose check on Resident 33, LPN 5 walked out of the resident's room, removed her gloves, and preceded to draw up the Humalog to administer to the resident. LPN 5 did not perform hand hygiene after doffing her gloves. After drawing up the required amount of Humalog, she proceeded into Resident 33's room. She donned a pair of gloves and administered the medication. LPN 5 did not perform hand hygiene prior to donning her gloves. After administering the insulin, LPN 5 exited Resident 33's room, disposed of the syringe, and removed her gloves. She did not perform hand hygiene after leaving the room and doffing her gloves. An interview with DON (Director of Nursing) was conducted on 5/18/23 at 2:12 p.m. DON indicated, all medication and/or water cups should be handled so that the part of the cup the resident places their lips on is not contaminated and/or touched nor should fingers or fingernails be placed inside of a medication and/or water cup as well as the disposable plastic pouch used to crush medications. A Use of Medical Gloves policy was received on 5/19/23 at 10:19 a.m. from DON. The policy indicated, Gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms form a resident or a fomite (any substance that absorbed and transmits infectious material) can transmit these microorganisms to another resident .hands should be washed initially prior to putting on the gloves .Gloves should be removed and hands washed with soap and water immediately after glove removal. 3.1-18(a) 3.1-18(l)

Based on interview and record review, the facility failed to track and monitor antibiotic usage to ensure resident's did not receive prophylactic antibiotics for 1 of 1 residents reviewed for antibiotic medications. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 5/16/23 at 10:00 a.m. The diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease (COPD). A physician order dated 6/4/22 indicated Resident 1 was to receive 250 milligrams of Azithromycin once a day every Monday, Wednesday and Friday for prevention. The June 2022 Infection Surveillance Data Collection Form indicated Resident 1's signs and symptoms of the resident's infection was cough and COPD. This was an ongoing prophylactic antibiotic. The form indicated it did not meet criteria for antibiotic usage. The July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, and May 2023 Infection Surveillance Data Collection Forms did not include tracking or monitoring of Resident 1's Azithromycin antibiotic. A physician order dated 10/14/22 indicated Resident 1 was to receive 300 milligrams of Cefdinir daily until 10/18/22. Stop Azithromycin while taking Cefdinir. Azithromycin will resume after the completion of Cefdinir. The October 2022 Infection Surveillance Data Collection Form indicated Resident 1's signs and symptoms of the resident's infection was COPD exacerbation. An interview was conducted with Director of Nursing (DON) on 5/18/23 at 2:03 p.m. She indicated she was handling the antibiotic stewardship program due to the Infection Preventionist (IP) was on leave. The facility uses Mcgreers to determine if a resident's infection meets the criteria to treat with an antibiotic. If the resident's infection does not meet utilizing labs/x-rays and signs and symptoms the antibiotic was not normally started or if it was started discontinued. Resident 1 does have an outside physician that ordered the Azithromycin antibiotic to be used as a preventive for infection. In the cases, of outside providers ordering prophylactic antibiotics to residents; once aware the IP would notify the Medical Director (MD). The MD would address with the outside physician/specialist about the usage of the prophylactic antibiotic to determine if it was necessary to start. She was unable to provide documentation the discussion took place with Resident 1's outside physician/specialist. The IP should have been tracking and monitoring Resident 1's antibiotic. The resident's antibiotic usage should have been documented on July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, and May 2023 infection surveillance forms. The Infection Control Surveillance Program policy was provided by the Executive Director on 5/16/23 at 10:35 a.m. It indicated .1. Purpose: .To establish an infection control and prevention process for residents residing in the facility .Surveillance components will include Investigation, Clinical records and documentation, on-site monitoring, data analysis, reporting, implementation of program changes as needed. 2. Procedure A. The Initial Infection Assessment located in the electronic medical record (EMR) will be completed by the Charge Nurse when a resident is placed on an antibiotic. B. Daily Infection Assessments will be completed while a resident is receiving an antibiotic or presenting with infection systems. This documentation is completed via a daily infection assessment or the daily Medicare documentation assessment. C. During the course of treatment, and while the resident is receiving an antibiotic the Infection Control Coordinator will review the EMR for Infection Assessments and monitor for appropriate treatment and management of the infection or condition of warranting the use of antibiotics and treatment. D. Each resident be tracked by the Infection Control Coordinator until the course of treatment and symptoms have resolved. This tracking may include reviewing culture reports, progress notes, AM meeting attendance, chart review, walking rounds or direct observations and interview of residents/staff. E. At the end of each month, the Infection Control Coordinator will collect information contained in the infection assessments, and the list this information classified into either a true infection or symptoms requiring treatment per physician or provider assessment and clinical judgement .Individual and group action plans will be developed based upon information from this data collection. 3. Documenting Surveillance data A. Information on the line/listing form will include - I. Resident name. II. Signs and symptoms information. III. Infection type, IV. Date signs/symptoms were first noted. V. Any culture or x-ray results. VI. Antibiotic/Antimicrobial name and dosage. VII. Antibiotic/Antimicrobial start and stop date. VIII. Isolation type of required. IX. Verification of true infection/meets infection criteria definition. B. To determine if data is a true infection - a complete review of the infection criteria guideline must be completed . The Antibiotic Stewardship program was provided by Executive Director on 5/16/23 at 10:35 a.m. It indicated .It is the policy of the Miller's Health Systems, Inc. to utilize an Antimicrobial and Antibiotic Stewardship Program based upon the guidance and recommendations of the CDC [The Centers for Disease Control and Prevention and within CMS [The Centers for Medicare & Medicaid Services] proposed guidelines .On a monthly basis, antibiotic/antimicrobial use will be reviewed by the Consultant Pharmacist, ICPO [Infection Control and Prevention Officer], DON and Medical Director. Results of this review will then be presented to the QAPI [Quality Assurance and Performance Improvement] meeting as appropriate. If this review finds that a particular clinician is prescribing antibiotics outside of the appropriate use indicators, the Pharmacy Consultant or Medical Director at his/her discretion may inform the associate clinical of the need for further compliance need. Continued non-compliance may result in a need to alter provider privileges in the facility. Any discrepancies of the review will also be included in the QAPI program log and interventions initiated to demonstrate a good faith effort to correct inappropriate use of antibiotics .

Based on interview and record review, the facility failed to timely complete and transmit discharge tracking forms for 5 of 17 resident reviewed for Minimum Data Set Assessments (Resident 12, 23, 53, 59, and 60). Findings include: 1. Resident 23 was discharged from the facility on 12/19/22. The clinical record did not contain a discharge tracking record that had been transmitted to CMS (Center for Medicare and Services). 2. Resident 60 was discharged from the facility on 1/19/23. The clinical record did not contain a discharge tracking record that had been transmitted to CMS. 3. Resident 59 was discharged from the facility on 1/24/23. The clinical record did not contain a discharge tracking record that had been transmitted to CMS. 4. Resident 12 was discharged from the facility on 1/26/23. The clinical record did not contain a discharge tracking record that had been transmitted to CMS. 5. Resident 53 was discharged from the facility on 1/26/23. The clinical record did not contain a discharge tracking record that had been transmitted to CMS. During an interview on 5/18/23 at 10:53 a.m., the Minimum Data Set Coordinator indicated the discharge tracking forms should have been completed in the clinical record and transmitted to CMS timely. The facility used the Resident Assessment Instrument Manual as the policy for completing MDS Assessments. The current Resident Assessment Instrument Manual was retrieved from the CMS website on 5/19/23 and read .09. Discharge Assessment-Return Not Anticipated . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days . Must be complete . within 14 days after the discharge date .Must be submitted within 14 days after the MDS completion date .

Based on observation, interview, and record review, the facility failed to ensure a resident was provided nutritional supplements as ordered for 1 of 3 residents reviewed for weight loss. (Resident C) Findings include: The clinical record for Resident C was reviewed on 10/17/22 at 11 a.m. Resident C's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's quarterly MDS (Minimum Data Set) dated 9/5/22 indicated, he required extensive assistance of two persons for bed mobility, transfers, and bathing; and extensive assistance of one person for eating. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's September and October enteral and oral supplement administration record were reviewed on 10/17/22 at 12:19 p.m. The administration record indicated, on the following dates and shifts, Resident C had not received his Ensure Plus supplements and/or Magic Cup supplement: Ensure Plus: 9/1/22--morning, mid-day, evening 9/2/22--morning, mid-day, evening 9/5/22--morning and mid-day 9/6/22--morning, mid-day, evening 9/8/22--morning, mid-day, evening 9/9/22--morning, mid-day, evening 9/12/22--morning, mid-day, evening 9/13/22-morning, mid-day, evening 9/14/22--morning and mid-day 9/15/22--morning, mid-day, evening 9/16/22--morning and mid-day 9/19/22--morning, mid-day, evening 9/20/22--morning, mid-day, evening 9/22/22--morning, mid-day, evening 9/23/22--morning, mid-day, evening 9/26/22--morning, mid-day, evening 9/27/22--morning, mid-day, evening 9/28/22--morning and mid-day 9/29/22--morning, mid-day, evening 10/4/22--morning and mid-day 10/7/22--11 p.m. 10/8/22--6 a.m. and 11 p.m. 10/9/22--6 a.m. and 11 p.m. 10/10/22--6 a.m. 10/11/22--5 p.m. 10/12/22--5 p.m. and 11 p.m. 10/13/22--6 a.m. and 5 p.m. 10/14/22--11 a.m., 5 p.m. and 11 p.m. 10/15/22--6 a.m. and 11 p.m. 10/16/22--6 a.m. and 11 p.m. Magic cup: 9/1/22 9/2/22 9/6/22 9/8/22 9/9/22 9/12/22 9/13/22 9/15/22 9/19/22 9/20/22 9/22/22 9/23/22 9/26/22 9/27/22 9/29/22 10/10/22 10/11/22 10/12/22 10/13/22 10/14/22 An observation of Resident C in the dining room during lunch service was conducted on 10/17/22 at 12:41 p.m. The dining room was very noisy and Resident C was in his Broda chair at a table. Resident C had consumed his house shakes, the magic cup remained unopened, and only bites of food were consumed. There was no evidence of an Ensure Plus supplement given at lunch meal. An interview with Dietary Manager (DM) was conducted on 10/17/22 at 2:59 p.m. She indicated, the magic cups are distributed to the units and kept in the unit refrigerators for the evening shift and the Ensure Plus supplements were in the unit refrigerators and were to be distributed by the nursing staff when needed. She further indicated, the facility had not experienced any issues with obtaining an adequate supply of Magic cups or Ensure Plus. Resident C's clinical record indicated, his weights were: 6/8/22--67.6 pounds 7/2/22--60.5 pounds 8/1/22--64 pounds 9/5/22--60.6 pounds 10/6/22--59 pounds A RD (Registered Dietician) narrative note dated 9/22/22 at 2:09 p.m. indicated, Resident C had a weight loss of 5.3% in 30 days and 10.4% in 90 days. His intake was less than 50% of most meals on regular diet. His nutrition interventions included, but not limited to, super pudding at lunch and supper, 8 ounces of house supplement at meals, Ensure plus three times a day and Magic cup every evening shift. Under additional comments, it indicated, [Resident C's name] sometimes stops eating when distracted by noises and his is a picky eater who drinks better than he eats. The plan of action was changes were recommended which included, but not limited to, suggest trial locations for Resident C's meals to determine the environment in which he ate best. A RD narrative note dated 10/5/22 at 11:04 a.m. indicated, Resident C had a stage 2 pressure injury to inner left elbow, his weight loss was 5.3% in 30 days and 10.4% in 90 days. Recommendations included, but not limited to, offer additional supplement of Ensure Plus when he was awake during the night. A Weight Management Program policy was received on 10/17/22 at 3:13 p.m. from DON (Director of Nursing). The policy indicated, Alternative will be offered if less than 50% is consumed at meals .Hospice residents and/or palliative care residents shall be assessed by the IDT[sic, interdisciplinary team] team to determine the continued benefit for obtaining routine weights . This Federal tag relates to complaint IN 853. 3.1-46

Based on interview and record review, the facility failed to protect residents from physical abuse for 3 of 3 residents reviewed for abuse, resulting in emergency room visits, a pelvic fracture, and emotional distress. (Residents B, N, and W) Findings include: The clinical record for Resident W was reviewed on 10/3/22 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was readmitted to the facility on [DATE] after an inpatient psychiatric stay. The clinical record for Resident N was reviewed on 10/3/22 at 11:03 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident B was reviewed on 10/3/22 at 2:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigative file into a 3/29/22 incident between Resident W and Resident N was provided by the Administrator on 10/3/22 at 11:03 a.m. The Nursing Occurrence Initial Assessment for Resident W indicated Resident W took his house slipper off and hit Resident N in the right arm. The undated CNA (Certified Nursing Assistant) 5 statement, via interview by the previous Administrator, was included in the investigative file. It read, I was walking [name of Resident N] when [name of Resident W] came up to us. I was trying to walk [name of Resident N] to him [sic] room. When [name of Resident W] came up and I asked what he needed. I was still walking [name of Resident N] and out [name of Resident W] took his shoe off and hit [name of Resident N] in the arm. I asked [name of Resident W] to head to his room. He had no problem heading to his room. Residents were separated at this time. The 4/4/22 follow up report, included in the investigative file, indicated the residents were immediately separated and 15 minute checks had been discontinued. One to one (1:1) supervision was being provided to Resident W. Neither resident was able to recall the events. Resident W was administered as needed medication which worked to calm him. The facility was looking for alternative placement for Resident W. The investigative file into a 4/4/22 injury of unknown origin for Resident N was provided by the Administrator on 10/3/22 at 11:03 a.m. The 4/4/22 Nursing Occurrence Initial Assessment for Resident N, included in the file, read, CNA [name of CNA 6] reported resident with a swollen and split lib [sic.] This nurse assessed a swollen lower lip with dried close area that likely had bled some time ago. The 1:1 supervision logs for Resident W were provided by the NC (Nurse Consultant) on 10/4/22 at 2:40 p.m. They indicated he was placed on 1:1 supervision on 4/4/22 at 5:00 p.m. An interview was conducted with the Administrator on 10/5/22 at 10:30 a.m. She indicated he was placed on 1:1 supervision on 4/4/22 because, at the time, it was suspected Resident W may have been involved in Resident N's swollen, bloody lip. The 4/12/22 follow up report to the 4/4/22 incident, included in the investigative file, indicated the facility was unable to determine the root cause of injury to Resident N's lip. Resident N wore a facemask for [CONDITION(S)] (continuous positive airway pressure) while sleeping or napping, and his daughter believed that he may have bit his lip. The 4/5/22 psychological NP (nurse practitioner) note indicated Resident W was being sent out to a local hospital with unpredictable, severe verbal, physical agitation, wandering, and high risk for elopement. The 4/6/22 nurse's note indicated he returned from the hospital and was placed on 1:1 supervision upon return. The investigative file into a 4/22/22 incident between Resident W and Resident B was provided by the Administrator on 10/3/22 at 11:03 a.m. The 4/22/22 Nursing Occurrence Initial Assessment for Resident W, included in the investigative file, read, Resident had encounter with another dementia resident and pushed her down and she fell to the floor. The 4/22/22 Occurrence Investigation for Resident B, included in the investigative file, read, Resident was in the hallway near the dining room and other resident pushed her and she fell on the floor. CNA 7 was present at the time. Resident W pushed Resident B. Resident B was sent to the hospital. There was no statement or interview statement of CNA 7 in the investigative file and she was unavailable for interview. The 4/28/22 follow up incident report to the 4/22/22 incident indicated it had been concluded that Resident W could have pushed Resident B out of his room, causing her to lose her balance and fall to the floor. After Resident B was sent to the emergency room for further evaluation, she returned with no initial findings. The following 2 days, Resident B complained of pain in her pelvic region and was transferred to the emergency roiagnom on [DATE] for further evaluation where a pelvic fracture was identified. Resident W remained on 1:1 supervision since the 4/22/22 incident and was being evaluated for transfer to another location. The 4/24/22 hospital notes for Resident B read, .presented to the [name of hospital] emergency department with a chief complaint of leg pain. Patient was nonverbal with limited interaction with stimuli. Collateral information was obtained from nursing home [name and title of LPN-Licensed Practical Nurse 8.] Discussed patient having a fall that occurred on 04/22 and was sent to the ED [emergency department] for workup. Patient was then discharged back to facility given no acute fracture seen on x-ray imaging at that time. Patient continued to endorse pain to right buttocks and right hip. Patient able to communicate in small phrases and guttural noises Assessment/Plan: .Pelvic Fracture Initial fall 4/22, 4/24 CT pelvis demonstrates nondisplaced fractures involving the lateral superior aspect of the right superior pubic ramus and nondisplaced fracture of the mid inferior right pubic ramus. Patient facility continued to endorse pain to right buttock and right hip .Fracture likely inoperable given age. The 4/26/22 psychological NP note for Resident W read, .was notified yest [yesterday] that he has been physically aggressive toward female peer. No triggers, so random. Staff have been seeking in pt [patient] psyche. No one will take him. Two inpatient psychiatric facility locations felt Resident W was too aggressive for their units at this time. They discussed the process for a state hospital to which staff were reaching out. Plan: 1. No med [medication] changes 2. Cont [Continue with one on one, wander gd [guard,] new room [ROOM NUMBER]. See next wk [week] if here. On 10/4/22 at 2:40 p.m., the NC provided a timeline of Resident W's stay at the facility. It indicated he was on 1:1 supervision from 4/23/22 through his discharge on 6/6/22. The investigative file into a 6/5/22 incident between Resident W and Resident N in the hallway was provided by the Administrator on 10/3/22 at 11:03 a.m. The file included a 6/5/22 written statement from QMA (Qualified Medication Aide) 9 that read, I [name of QMA 9] got up to check on resident. I then seen [name of Resident W] put his hand down. [Name of Resident W] has just got done hitting [name of Resident N] in the eye because his eye was bleeding. I then got the CNA to help me break it up but then [name of Resident W] came walking up to me saying [name of Resident N] was talking crazy. I then notified the nurses and they came. The file included a 6/6/22 interview statement with QMA 9, conducted by the NC. It read, [Name of Resident N] had been out wandering the hall way which he does normally. She reports she could hear someone talking (cussing 'what did you say mother f*****?'). She responded coming from the med cart which was parked near the nurses station. [Name of Resident N] was at the end of the hall near [name of Resident Y's] room where [name of Resident W and Resident N] were near each other. [Name of QMA 9] never seen physical contact but seen blood under [name of Resident N's] right eye. The residents were immediately separated. [Name of QMA 9] states when [Name of Resident W] was asked what happened he said 'He was talking crazy' [Name of QMA 9] then alerted the charge nurse [name of LPN 10] to come and assess. The file included an undated written statement from CNA 10. It read, On 6/5 QMA came to come get me to help break up fight between [name of Residents W and N] and when I came around the corner where they were they were hitting each other until [name of Resident N] walked away. We then kept them separated until the nurse came. QMA 9 and CNA 10 were unavailable for interview. An interview was conducted with the MCC (Memory Care Coordinator) on 10/4/22 at 12:22 p.m. She indicated 1:1 supervision meant the aide assigned would do everything for the resident all day and was not assigned to any other residents. The aide assigned was to remain by the resident. She was uncertain how the 6/5/22 incident between Resident W and Resident N occurred. An interview was conducted with the NC, DON (Director of Nursing,) and Administrator on 10/5/22 at 10:30 a.m. The NC indicated Resident W was assigned to receive 1:1 supervision from 4/23/22 through his 6/6/22 discharge from the facility. CNA 10 was assigned to provide 1:1 supervision on 6/5/22 and was uncertain who specifically was providing 1:1 supervision at the exact time of the 6/5/22 incident. They'd tried to get a hold of CNA 10, but were unsuccessful, as she was agency staff. The NC and Administrator agreed, based on QMA 9 and CNA 10's statements that it seemed as though QMA 9 left Residents W and N in the hallway to retrieve help from CNA 10 and upon return the residents were physically hitting each other. The Abuse Prohibition, Reporting, and Investigation policy was provided by the Administrator on 10/3/22 at 11:00 a.m. It read, It is the policy of [name of facility] that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion Physical Abuse-A willful act against a resident by another resident, staff, or other individuals. Examples: hitting,, beating, slapping, punching, shoving, spitting, striking with an object, pulling/twisting, squeezing, pinching, scratching, tripping, biting, burning, using overly hot/cold water, and/or improper restraints. This Federal Tag relates to Complaint IN 572. 3.1-27(a)(1)

Based on interview and record review, the facility failed to timely address a resident's change of condition for 1 of 3 residents reviewed for hospitalization . This resulted in delayed hospitalization for a resident exhibiting signs and symptoms of a stroke. (Resident D) Findings include: The clinical record for Resident D was reviewed on 10/3/22 at 11:15 a.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted on [DATE]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident D was cognitively impaired. A care plan dated 4/12/22 indicated Pain: I [Resident D] have potential: for pain/discomfort related to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Notify MD [medical doctor] as needed . A care plan dated 4/22/22 indicated Cognition: I have cognitive impairments related to: having notable variations of cognition from day to day or throughout the day due to my medical condition .Interventions .Give resident two choices when presenting decisions .Notify physician as needed. Observe and report changes in cognitive status. An interview was conducted with Family Member (FM) 2 on 10/3/22 at 3:42 p.m. She indicated during a phone conversation with Resident D on the evening of 7/25/22 at approximately 6:30 p.m.; she had noticed the resident was talking gibberish. Resident D was not making any sense when she was talking. Prior to the conversation that day, the resident was able to speak and answer questions. FM 2 called the facility and had spoken to Resident D's nurse, License Practical Nurse (LPN) 1. At that time, she informed LPN 1, Resident D was showing signs of having another stroke and wanted her to be sent to the hospital. She then went to the facility. The resident had not been transferred to the hospital. FM 2 went to the resident's room and observed Resident D in a lot of pain due to a headache, and she felt something was wrong with the resident. She notified LPN 1 and asked again for the resident to be transferred to the hospital for evaluation. The staff did not show any urgency with sending the resident out. Resident D was transferred to the hospital. She did have another stroke. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A change of condition document dated 7/25/22 at 6:37 p.m., indicated Resident D had .Pain (uncontrolled), per [FM 2]: slurred speech, altered mental status. This started on 7/25/22 Since this started it has gotten: [marked with a checkmark] stayed the same .Vital signs: 137/91 [blood pressure] pulse: 82 RR: [respirations] 18, Temp [temperature] 98.2 .Resident Evaluation: Mental Status Evaluation (compared to baseline; .) [marked with a checkmark] Increased confusion or disorientation .Pain Evaluation. Does the resident have pain? [marked with a checkmark] yes. The pain? [marked with a checkmark] worsening of chronic pain. Intensity of pain (rate on a scale 1-10 with 10 being the worse): [documented as an] 8 Neurological Evaluation: .Describe symptoms or signs per daughter: slurred speech .Review and notify: primary care clinician notified: [no documentation noted] . Resident D's clinical record did not indicate the medical provider was notified of the resident's change of condition at 6:30 p.m. A transfer to hospital document completed by LPN 1 dated 7/25/22 at 9:00 p.m., indicated medical provider notified.Reason for transfer: .extreme headache with no relief with pain meds [medications] - [FM2] requesting her to go .usual mental status: A&O [alert and oriented] . An interview was conducted with LPN 1 on 10/3/22 at 2:18 p.m. She indicated Resident D did have a complaint of a headache on 7/25/22, but she was positive with COVID-19. Headaches are a symptom with COVID-19. She had administered Tylenol to the resident, but it was ineffective. She was not familiar with Resident D. The resident's change of condition was based on what FM 2 had reported to her during a phone call. LPN 2 had not notified the medical provider at that time as she should have. An interview was conducted with Physician 3 on 10/4/22 at 10:16 a.m. She indicate LPN 1 should not have delayed notifying her office of Resident D's change of condition. The hospital records dated 7/25/22 at 9:42 p.m., indicated Resident D had complaints of severe headache. Resident D was in .ED [emergency department] for evaluation of increase in speech difficulty onset about 3 hours ago today. Pt [patient] has associate headache and she describes it as worst headache ever. Per medics these are the same symptoms and pt described in her last prior stroke. Pt has right sided deficits from the prior stroke. LKN [last known normal] was at 18:30 [6:30 p.m.] today. history is limited due to Altered Mental Status .Review of systems .Neurological: Positive for speech difficulty and headaches .Triage Vital Signs - Temp: 98.2 F [Fahrenheit], Pulse: 100, Resp: 29, BP: 132/94, SpO2 [oxygen saturations]: 98 % .Physical Exam: .Comments: Holding head and saying pain .Doesn't answer questions appropriately, just says pain .MEDICAL DECISION MAKING: Patient .presenting to the emergency department today for evaluation of possible stroke-like symptoms. Patient normally is able to communicate but had increasing [CONDITION(S)] [disorder how to communicate] at her facility with increased rightsided deficits more than normal. She does have a history of a hemorrhagic stroke previously. Patient also complaining of a headache. Patient was evaluated immediately upon arrival as a potential code stroke. Given patient is 3 hours from onset of her symptoms I did initiate code stroke to evaluate for large vessel occlusion [blockage]. She is not a tPA [tissue [MEDICATION(S)] activator] candidate secondary to history of hemorrhagic [CONDITION(S)] .Case discussed with the hospitalist service and patient accepted for admission for further evaluation and care. Patient admitted in stable condition .presents to hospital with complaints of [CONDITION(S)] and headache. Headache started earlier today. Patient is describing this as the worst headache ever. It is sharp, stabbing, frontal and nonradiating. Notes some expressive [CONDITION(S)] as well that started about 630. She knows what she wants to say, but is having a hard time putting the words together. Patient has a history of a hemorrhagic stroke in 03/2022 and she reports symptoms are similar to that episode. Patient does have baseline right-sided weakness from the previous stroke.Date of Discharge: July 31, 2022 .Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Consults: neurology .MRI significant for subacute infarct [stroke] in the left medial temporoparietal lobe .[part of the brain] Patient also was found to have [CONDITION(S)] [blood clot] in the right upper extremity, .Patient was discharged to [name of rehabilitation facility] . A Physician & Family Notification of Change of Condition policy was provided by the Director of Nursing on 10/3/22 at 4:00 p.m. It indicated .Physician & Family Notification of Condition Changes: 1. Purpose A. To keep the physician, resident and family appraised of all condition changes .3. Procedure: A. Telephone I. Telephone notification is required for all emergencies, all condition changes .II. Notify the physician of any change in condition that may or may not warrant a change in the treatment plan. III. Notify the primary physician during regular office hours and the on-call or alternate physician during closed office hours or when the physician is not available. IV. Document the information reported to the physician in the nurses notes including the time and date of notification. be thorough and explicit . This federal tag relates to Complaint IN 910. 3.1-37(a)

Based on interview and record review, the facility failed to re-evaluate a treatment plan to determine whether the current treatment needed to be modified in which a pressure injury deemed to have worsened and later resulted in hospitalization for 1 of 3 residents reviewed for pressure injuries. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/17/19 at 11:10 a.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, dated 1/11/19, noted Resident B to require extensive assistance with 2 staff person for bed mobility, transfers, and toileting. Resident B also required extensive assistance with 1 staff person for personal hygiene. A nurses note, dated 1/21/19, indicated the following, .Skin assessed related to new skin assessment completed on 1/20/19. Area to coccyx measuring 2.5 cm (centimeters) by 1.8 cm is red, area blanches, top layer of skin appears to be sheared. Foam dressing applied to protect skin Resident B was hospitalized from [DATE] to 1/24/19. Hospital records for that time period indicated, on 1/21/19, a stage 2 pressure injury was noted to Resident B's coccyx. The area measured 3 cm in length by 2.5 cm in width by 0.1 cm in depth. The notes indicated a foam dressing was continuing to be utilized at that time by the hospital. A physician order, dated 1/25/19, indicated the following, .Coccyx: Cleanse with wound cleanser; pat dry; apply [MEDICATION NAME] (type of foam dressing). Change Q (every) day & PRN (as needed) A Pressure Injury assessment, dated 1/29/19, indicated the area to Resident B's coccyx is a stage 3 pressure injury measuring 5.4 cm in length by 5.9 cm in width and 0.2 cm of depth. The wound was noted with 75% granulation (healing surface of a wound) and 25% tan slough (dead tissue, usually cream or yellow in color that could impede healing). A Pressure Injury assessment, dated 2/5/19, noted a stage 3 to Resident B's coccyx and was noted as healing. A Pressure Injury assessment, dated 2/12/19, noted a stage 3 to Resident B's coccyx and was noted as healing. A Pressure Injury assessment, dated 2/19/19, noted a stage 3 to Resident B's coccyx and was noted to not change compared to the previous week assessment. A Pressure Injury assessment, dated 2/26/19, noted a stage 3 to Resident B's coccyx and was noted to not change compared to the previous week assessment. The wound was noted with 75% granulation tissue and 25% tan slough tissue. A Pressure Injury assessment, dated 3/5/19, noted a stage 3 to Resident B's coccyx that was noted to be non-healing with 50% granulation tissue and 50% slough tissue. There was no indication a change of treatment was initiated due to the status of non-healing to the pressure injury. A Pressure Injury assessment, dated 3/12/19, noted Resident B's coccyx to be non-healing and unstageable with 25% granulation tissue and 75% soft black necrotic tissue (dead tissue). There was a slight odor noted to the wound at the time of this assessment. There was no indication a change of treatment was initiated due to the status of non-healing to the pressure injury. A Pressure Injury assessment, dated 3/19/19, noted Resident B's coccyx to continue as non-healing and listed as an unstageable pressure injury. The wound consisted of 80% soft black necrotic tissue, 10% tan slough and 10% granulation tissue. There was a moderate amount of odor present. A physician order, dated 3/18/19, noted the following, .Cleansed area to coccyx with wound cleaner, pat dry, apply Dakins 0.25% moistened kerlix/rolled gauze to wound bed, cover with ABD (abdominal) pad, and secure. Change drsg (dressing) BID (twice daily) and PRN (as needed) A physician order, dated 3/22/19, noted advanced wound care to evaluate and treat Resident B's pressure injury as indicated. An interview conducted with the Director of Nursing (DON), on 6/17/19 at 3:30 p.m., indicated Resident B was declining in her condition and he was approaching the care of her pressure injury from the perception of her continuing to decline. There was an odor noted on 3/19/19 and that was when the Dakins treatment was initiated. He further indicated he is not wound care certified. Resident B was sent to the hospital on [DATE] after a fall incident. Hospital records were reviewed from the 3/22/19 hospital stay regarding Resident B. A Emergency Department (ED) note, dated 3/23/19 at 3:00 a.m., indicated the following, .Sacral decubitus ulcer with packing and malodorous (smelling very unpleasant) discharge .After discussion with the family joint decision made to admit for MRI and wound care A History of Physical note, dated 3/23/19 at 5:28 a.m., indicated the following, .Plan: She does appear to have a large infected sacral decubitus ulcer with purulence (pus like) and it appears quite deep .Will obtain wound culture A Orthopaedic (sic) Surgery Consult, dated 3/26/19, indicated the following, .advanced stage decubitus ulcer noted over sacrum .raising concern for osteo[DIAGNOSES REDACTED] .CT (computer tomography) .Impression .1. Sacral decubitus ulcer with gas extending to the cortical surface at the S5 level with focal cortical erosion, imaging findings are findings are concerning for focal osteo[DIAGNOSES REDACTED] A Palliative Care note, dated 3/26/19, indicated the following, .We assessed patient and plastics (plastic surgeon) stated they would not offer surgery/flap (skin flap). The also stated they would not debride the sacral wound. We discussed the care at length and agreed we felt patient was most appropriate for comfort, and that she would never recover enough for the wound to heal or any surgical procedure to become appropriate A Discharge Summary, dated 3/27/19, indicated the following, .Unfortunately patient passed away today. Given severe malnutrition and indolent chronic sacral OM (osteo[DIAGNOSES REDACTED]) not amenable to treatment, patient's health declined over the past 24 hours .Secondary Discharge Diagnosis .Sacral pressure ulcer with osteo[DIAGNOSES REDACTED] An interview conducted with the DON, on 6/17/19 at 4:55 p.m., indicated there were multiple discussions with the family in regards to comfort care and hospice services. The family did not want to pursue with comfort measures when it was brought up by the facility staff. He indicated if anything could have been done differently he would have referred Resident B to the wound center for wound care and treatment when the wound went from a stage 3 to an unstageable pressure injury. He noted he was trying to approach the care for the pressure injury from a comfort care stand point. He doesn't disagree with the treatment choice but, possibly, the timeliness of referring the wound center. An interview conducted with Nurse Practitioner 4, on 6/18/19 at 10:35 a.m., indicated weekly meetings are conducted at the facility to discuss wounds and any treatment changes that should occur. Resident B was, overall, declining and the wound deteriorating was not surprising to her. She indicated there, possibly, were other items of treatment that could have been used. The treatment could have, possibly, been changed a week or so prior when there was a noted decline in the status of the wound. If there is slough noted at 25% and it continued to stay that way there would not be a reason to change the treatment to her. A policy titled Skin Management Program, dated 8/14/14, was provided by the DON on 6/17/19 at 4:50 p.m. The policy indicated the following, .Communication: .I. Notification/communication will occur with the resident/sponsor and physician when there is a change in condition and/or a change in treatment plan .Documentation .III. Physician will make note of wound progress/regress and unavoidability if applicable at routine visits. Wound nurse will keep physician up to date with progress/regress as needed .Quality Assurance Review: .I. Pressure ulcers, stasis ulcers, arterial ulcers, diabetic ulcers, surgical incisions w/ (with) complications [MEDICAL CONDITION] than 1st degree will be assessed and monitored by the designated wound nurse(s) of the facility. Wound nurse(s) will monitor/assess for progression or regression of healing and treatments will be re-evaluated to ensure appropriateness This federal tag relates to Complaint IN 354. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to properly utilize a mechanical lift device during transfer of a resident resulting in a fall with emergency room visit for 1 of 4 residents reviewed for accidents. (Resident #D) Findings include: The clinical record for Resident #D was reviewed on 8/13/15 at 10:30 a.m. The [DIAGNOSES REDACTED]. The 5/2/15 Quarterly MDS (minimum data set) assessment indicated Resident #D had a BIMS (brief interview for mental status) score of 5, indicating she's cognitively impaired. The assessment indicated she required extensive assistance of 2 persons for transfers. An interview was conducted with LPN #10 on 8/13/15 at 11:45 a.m. She indicated Resident #D had one fall in the last 30 days with injury. She indicated Resident #D slid out of the (name brand of mechanical lift device) sling in the shower room, while staff was putting her back in her chair. She indicated Resident #D had to get a staple in the back of her head. The 8/6/15, 11:40 a.m., Nursing-Occurrence Initial Assessment indicated, Location of occurrence: shower room .Fall with injury .CNA was transferring resident from shower chair to (name brand of specialized chair for elderly and /or disabled) chair with (sic) resident slid out of bottom of (name brand of mechanical lift device) sling onto floor hitting head. Bleeding noted to post skull with pressure held until bleeding stopped. Ice applied to laceration. Abrasion also noted to right side underarm Describe all injuries noted and include measurement: Back of head -0.5 x 0.5 cm laceration to back of head, Other-abrasion to right side underarm. The 8/6/15,11:55 a.m. late entry nurses note indicated, addendum to occurrence initial assessment: res (resident) slid from (name brand of mechanical lift device) sling while transferring from shower bed to (name brand of specialized chair for elderly and /or disabled) chair. 0.5 cm x 0.5 cm laceration to posterior scalp, pressure applied to stop bleeding, then ice applied. no active bleeding at time of EMS (Emergency Medical Services) pick up. abrasion of partial thickness under R (right) arm on side approx (approximately) 4 cm x 3.5 cm, pink, no bleeding. no loss of consciousness. The 8/6/15, 11:40 a.m. Occurrence Investigation was provided by the ADON (Assistant Director of Nursing) on 8/17/15 at 2:10 p.m. It indicated, What was the resident doing or attempting to do at time of fall/occurrence? transferring resident from shower bed to (name brand of specialized chair for elderly and /or disabled) chair .Equipment involved: (name brand of mechanical lift device) .Name of staff present and/or assisting resident at time: CNA (Name of CNA #3), home health CNA .If staff assisting, was the skill performed correctly according to the resident's plan of care? No .(name brand of mechanical lift device) sling not placed properly .Go to site of occurrence and evaluate space/equipment to determine what adjustments can be made (explain if changes made): educate staff on (name brand of mechanical lift device) use .Resident interview: unable .Witness interview: CNA stated resident slid out of bottom of (name brand of mechanical lift device) sling onto floor and hit back of head. Small amount of bleeding. Abrasion - pink partial thickness, no bleeding 4 cm x 3 cm approx. An interview was conducted with CNA #3 and the DON (Director of Nursing) on 8/17/15 at 11:18 a.m. CNA #3 indicated she and the home health aide for Resident #D, who was not a facility employee, gave Resident #D a shower. After they were finished showering her, she slid out of the sling. CNA #3 indicated they were transferring her from the shower bed to her chair. CNA #3 indicated they placed her in the (name brand of mechanical lift device) sling the normal way. CNA #3 indicated they hooked her up from the bottom, but didn't hook her between her legs like they were supposed to, rather from side to side. CNA #3 indicated Resident #D went down on her bottom. CNA #3 indicated if they had hooked Resident #D between her legs, it would have prevented her from sliding onto her bottom. CNA #3 indicated she used that particular (name brand of mechanical lift device) lift prior to Resident #D's 8/6/15 fall from the (name brand of mechanical lift device) lift, but not that particular sling. CNA #3 indicated they should have used a full body sling, but used a mesh sling. CNA #3 indicated she didn't recognize, at the time, that they used the wrong kind of sling with her. CNA #3 indicated Resident #D's home health aide informed her she could help with the shower, so she (CNA #3) thought she (Resident #D's home health aide) could, but had never helped her before. The DON indicated she didn't think the type of sling used caused the problem, rather the way the sling was positioned. The DON indicated the mesh sling could be used, it just needed to be positioned correctly. The DON further indicated the type of sling used was a split leg sling, not a mesh sling. The DON indicated Resident #D's home health aide was not a Certified Nursing Assistant, and moving forward, 2 facility employees needed to assist with (name brand of mechanical lift device) lift transfers. The 8/6/15 statement written by CNA #3 was provided by the Administrator on 8/17/15 at 11:45 a.m. It indicated, I (Name of CNA #3) gave (Name of Resident #D) a shower on Thursday Aug (August) 6. I had a home health aid (sic) in the shower room with me who also help (sic) with her shower. We transfer (sic) her on the shower bed to clean her up. We got her all cleaned up. We placed a new (name brand of mechanical lift device) pad under her to transfer her back to her chair (sic) the lift that we used stoped (sic) on us about half way in the air so we tried to lift her manuly (sic) and that's when she came out (sic) the (name brand of mechanical lift device) paid (sic) and fell to the floor. She hit her head on the bottom of the machine and their (sic) was blood coming from the back of her head. We laid (sic) her down flat on the ground and put a pillow under her head and then I left the room to get the nurse so she could come in and check her out (sic) she took her blood pressure and looked at the back of her head (sic) then the nurse asked me to go and get therapy so they could help us get her back in the chair (sic) they came in got her up and we took her to her room (sic) after that I left the room. the home health aid (sic) was still there with her until (sic) she went out to the hospital. An interview was conducted with the DON and CNA #3 on 8/17/15 at 12:35 p.m., to clarify CNA #3's earlier interview (at 8/17/15, 11:18 a.m.) when compared to her 8/6/15 written statement. CNA #3 indicated the (name brand of mechanical lift device) did not stop. It went as high as it could go, but it wasn't high enough to get her off the shower bed. CNA #3 indicated she was unaware of that at the time. CNA #3 indicated she thought it was as high as it could go, so they lifted her manually. She indicated that is what she would do with residents when the (name brand of mechanical lift device) lift went as high as it could go. CNA #3 indicated if the sling used for Resident #D was hooked up to the right color to correspond with the height necessary to go, the sling would have gone higher. CNA #3 indicated she knew something about the color and height, but not really. CNA #3 indicated she worked at the facility for 2 years, and didn't find out about the colors on the sling until after Resident #D's fall from the (name brand of mechanical lift device) on 8/6/15. CNA #3 indicated she did not know exactly how the colored straps were used to assist with utilization of the (name brand of mechanical lift device) lift. CNA #3 indicated the problem was not affixing the sling to the lift appropriately. The DON indicated the resident should have been lowered, the situation reassessed, and Resident #D should have never been manually lifted. The DON indicated the root cause of Resident's D's fall was improper positioning of the sling. The 8/6/15 11:59 a.m. EMS (Emergency Medical Services) Notes indicated, dispatched to below ECF location for neuro/head injury. UOA (Upon our arrival), found (age and gender of Resident #D) sitting in recliner style wheelchair. Pt is awake and continually stating 'don't drop me.' ECF staff states that pt was in (name brand of mechanical lift device) Lift attempting to be moved to shower when pt 'slipped out' of lift. Pt fell to ground and landed on posterior. Pt then fell back striking head. ECF denies LOC. Attempt made to place C-collar on pt per protocol, but pt would not tolerate collar. Pt has small hematoma to rear, base of skull approx 1 inch by 1 inch in size with no discoloration. Pt is not bleeding at this time. Pt is not oriented at this time, however, ECF states pt is at norm at this time. The 8/6/15 Hospital Records for Resident #D indicated, Fall .pt (patient) from ecf (extended care facility), (Name of facility), was in (name brand of mechanical lift device) lift and fell backwards out of lift, landed on bottom and then hit head posterior head on ground, staff state no LOC (loss of consciousness), during triage, no active bleeding, no wound seen on posterior head, normal mentation per staff and L (left) sided weakness as per normal for staff Number of [DIAGNOSES REDACTED]. will have (Name of Physician Assistant), PA, repair the laceration Pt is to return in 7 days for staple removal. Clinical impression: 1. Scalp contusion 2. Laceration of scalp, initial encounter 3. Back contusion, unspecified laterality, initial encounter Procedures: The 1 cm posterior scalp wound area was prepped and draped in a sterile fashion. The wound area was not anesthetized The wound was explored with the following results No foreign bodies found. The wound was then copiously irrigated with sterile saline per nursing staff. The wound was repaired with 1 staple (sic) was used. The wound was dressed and antibiotic ointment was applied. The patient underwent the procedure with no complications. An interview was conducted with Family Member #4, daughter and POA (power of attorney) of Resident #D, on 8/17/15 at 2:19 p.m. She indicated the home health aide present during Resident #D's fall was hired by her to visit and spend time with Resident #D. She indicated Resident #D was terrified of the (name brand of mechanical lift device) lift, since the her 8/6/15 fall. She indicated the psychiatric nurse who sees Resident #D spoke with her last week about starting an anti-anxiety medication. She indicated Resident #D's fear was valid and the anti-anxiety medication wouldn't take away the fear. She indicated her mother yelled, 'No, no' the last time she observed her mother getting ready to be put into the (name brand of mechanical lift device) lift. She indicated Resident #D's reaction to the (name brand of mechanical lift device) lift was 'since the fall.' An interview was conducted with Family Member #4 on 8/20/15 at 10:09 a.m. She indicated Resident #D's yelling and screaming has been 'intensified' since her 8/6/15 fall, and was not fearful of care prior to the fall. She indicated she visited 5-6 times weekly, usually in the evenings. An observation of Resident #D being transferred via (name brand of mechanical lift device) Lift was made on 8/18/15 at 11:05 a.m. Resident #D was heard yelling out prior to entering the room for the observation. RN #5 knocked on the door. CNA #2 answered the door and indicated she was providing care. Resident #D was lying in bed. She appeared calm. The (name brand of mechanical lift device) Lift was located next to Resident #D's bed. The ADON touched Resident #D's blouse to straighten it. Resident #D began yelling out again. Resident #D was placed into the (name brand of mechanical lift device) Lift. When lowering Resident #D into her chair, she began yelling oh, oh, oh very loudly and fearfully. She then stated, You didn't tell me, you didn't tell me. Resident #D stopped yelling once she was in the chair. Staff began repositioning her in her chair, and Resident #D began yelling No, no. The ADON asked Resident #D if she was okay. Resident #D yelled, No, no. An interview was conducted with CNA #2 on 8/18/15 at 1:31 p.m. She indicated Resident #D's behavior during her transfer was pretty typical for her. CNA #2 indicated she worked at the facility for 8 months and cared for Resident #D approximately 6 days a week. She indicated Resident #D didn't say 'no, no' all the time, just since the 8/6/15 fall. She indicated Resident #D was hesitant for people to touch her, and was 'just real scared now since the fall, real nervous.' She indicated, since the fall, Resident #D slept more, didn't like to get up as much, seemed more depressed, poked her lip out, and didn't like to get up for meals. She indicated Resident #D used to like to get her nails done before the fall, but now her companion did her nails. She indicated Resident #D didn't drink as much since the fall. She indicated since the fall, Resident #D told her she's hurting more often than she used to tell her. CNA #2 indicated staff have to take more time, be more gentle, and reassure her more, since the fall. CNA #2 indicated, in her opinion, there was no reason Resident #D should have fallen out of the (name brand of mechanical lift device) Lift. CNA #2 indicated Resident #D's visiting companion never helped her transfer Resident #D before. The 8/14/15 psychiatric notes, written by CNS (Clinical Nurse Specialist) #6, indicated, cont (continues) vocal agit (agitation), esp (especially) (symbol for with) hands on care (symbol for with) anxious fearful statements .Per DON -she still yells, screams out, makes such fearful statements (symbol for with) direct hands on care i.e. 'don't hurt me' 'Don't look @ my (expletive)' imp (impression): still yells out, fearful (symbol for with) care, anxious (symbol for with) care . The psychiatric notes, written by CNS #6, from prior visits on 6/8/15, 5/15/15, 2/17/15, and 12/12/14 indicate vocal agitation and calling/yelling out, but do not indicate anxious, fearful statements or fearful/anxious with care. An interview was conducted with CNS #6 on 8/18/15 at 2:06 p.m. She indicated she was unsure if Resident #D would remember her fall on 8/6/15, due to her dementia. She indicated there were certain events people with dementia do remember and get stuck on. She indicated she did not think Resident #D had the ability to process her fall, because of her dementia. She indicated it was a change for Resident #D to be fearful and anxious with care, as referenced in her 8/14/15 visit note, but patients change with dementia and go through different phases. A care plan for tactile defensiveness was initiated for Resident #D on 8/13/15. Resident #D's visiting companion was unavailable for interview. The 6/12/15 Mechanical Lift Transfers Policy was provided by the DON on 8/17/15 at 12:00 p.m. It indicated, Purpose 1. To move a resident safely and with as little physical effort as possible Two staff members (minimal) -during the transfer itself. Procedure: .6. Position resident per manufacturers instructions. 7. Attach and secure lifting straps per manufacturer's guidelines 9. Check lifting straps to make sure they are properly positioned. 10. Begin lifting resident per manufacturer's instructions. 11. When the resident has been lifted clear off the bed, position residents feet off the bed and move them over to the chair or seating device. An undated Use of Mechanical Lift & Full Body Sling policy was provided by the DON on 8/17/15 at 12:00 p.m. It indicated, Always have two Miller's employees that have been trained on the use of the lift! .Choose appropriate sling for the patient. See guide attached to lift and/or CNA assignment sheet. Be aware there are different types of slings, if you are unfamiliar with a sling, do not use it! .Attach straps to the lift swivel bar; verify the same color strap is used on both sides. Colors used top to bottom can be different, depending on what position you need the patient in. If transferring into chair, use closer straps at top and further straps at bottom; if transferring to bed, use closest straps for top and bottom.* .When ready, lift patient up from surface. The patient must clear the surface by 2-3*, if you cannot clear the surface you must lower the patient back down to the surface and stop the procedure and get your supervisor for further instruction *This information obtained from the Owner's Operator and Maintenance Manual: Patient Slings Part No 91 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to properly utilize a mechanical lift device during transfer of a resident resulting in a fall with emergency room visit for 1 of 4 residents reviewed for accidents. (Resident #D) Findings include: The clinical record for Resident #D was reviewed on 8/13/15 at 10:30 a.m. The [DIAGNOSES REDACTED]. The 5/2/15 Quarterly MDS (minimum data set) assessment indicated Resident #D had a BIMS (brief interview for mental status) score of 5, indicating she's cognitively impaired. The assessment indicated she required extensive assistance of 2 persons for transfers. An interview was conducted with LPN #10 on 8/13/15 at 11:45 a.m. She indicated Resident #D had one fall in the last 30 days with injury. She indicated Resident #D slid out of the (name brand of mechanical lift device) sling in the shower room, while staff was putting her back in her chair. She indicated Resident #D had to get a staple in the back of her head. The 8/6/15, 11:40 a.m., Nursing-Occurrence Initial Assessment indicated, Location of occurrence: shower room .Fall with injury .CNA was transferring resident from shower chair to (name brand of specialized chair for elderly and /or disabled) chair with (sic) resident slid out of bottom of (name brand of mechanical lift device) sling onto floor hitting head. Bleeding noted to post skull with pressure held until bleeding stopped. Ice applied to laceration. Abrasion also noted to right side underarm Describe all injuries noted and include measurement: Back of head -0.5 x 0.5 cm laceration to back of head, Other-abrasion to right side underarm. The 8/6/15,11:55 a.m. late entry nurses note indicated, addendum to occurrence initial assessment: res (resident) slid from (name brand of mechanical lift device) sling while transferring from shower bed to (name brand of specialized chair for elderly and /or disabled) chair. 0.5 cm x 0.5 cm laceration to posterior scalp, pressure applied to stop bleeding, then ice applied. no active bleeding at time of EMS (Emergency Medical Services) pick up. abrasion of partial thickness under R (right) arm on side approx (approximately) 4 cm x 3.5 cm, pink, no bleeding. no loss of consciousness. The 8/6/15, 11:40 a.m. Occurrence Investigation was provided by the ADON (Assistant Director of Nursing) on 8/17/15 at 2:10 p.m. It indicated, What was the resident doing or attempting to do at time of fall/occurrence? transferring resident from shower bed to (name brand of specialized chair for elderly and /or disabled) chair .Equipment involved: (name brand of mechanical lift device) .Name of staff present and/or assisting resident at time: CNA (Name of CNA #3), home health CNA .If staff assisting, was the skill performed correctly according to the resident's plan of care? No .(name brand of mechanical lift device) sling not placed properly .Go to site of occurrence and evaluate space/equipment to determine what adjustments can be made (explain if changes made): educate staff on (name brand of mechanical lift device) use .Resident interview: unable .Witness interview: CNA stated resident slid out of bottom of (name brand of mechanical lift device) sling onto floor and hit back of head. Small amount of bleeding. Abrasion - pink partial thickness, no bleeding 4 cm x 3 cm approx. An interview was conducted with CNA #3 and the DON (Director of Nursing) on 8/17/15 at 11:18 a.m. CNA #3 indicated she and the home health aide for Resident #D, who was not a facility employee, gave Resident #D a shower. After they were finished showering her, she slid out of the sling. CNA #3 indicated they were transferring her from the shower bed to her chair. CNA #3 indicated they placed her in the (name brand of mechanical lift device) sling the normal way. CNA #3 indicated they hooked her up from the bottom, but didn't hook her between her legs like they were supposed to, rather from side to side. CNA #3 indicated Resident #D went down on her bottom. CNA #3 indicated if they had hooked Resident #D between her legs, it would have prevented her from sliding onto her bottom. CNA #3 indicated she used that particular (name brand of mechanical lift device) lift prior to Resident #D's 8/6/15 fall from the (name brand of mechanical lift device) lift, but not that particular sling. CNA #3 indicated they should have used a full body sling, but used a mesh sling. CNA #3 indicated she didn't recognize, at the time, that they used the wrong kind of sling with her. CNA #3 indicated Resident #D's home health aide informed her she could help with the shower, so she (CNA #3) thought she (Resident #D's home health aide) could, but had never helped her before. The DON indicated she didn't think the type of sling used caused the problem, rather the way the sling was positioned. The DON indicated the mesh sling could be used, it just needed to be positioned correctly. The DON further indicated the type of sling used was a split leg sling, not a mesh sling. The DON indicated Resident #D's home health aide was not a Certified Nursing Assistant, and moving forward, 2 facility employees needed to assist with (name brand of mechanical lift device) lift transfers. The 8/6/15 statement written by CNA #3 was provided by the Administrator on 8/17/15 at 11:45 a.m. It indicated, I (Name of CNA #3) gave (Name of Resident #D) a shower on Thursday Aug (August) 6. I had a home health aid (sic) in the shower room with me who also help (sic) with her shower. We transfer (sic) her on the shower bed to clean her up. We got her all cleaned up. We placed a new (name brand of mechanical lift device) pad under her to transfer her back to her chair (sic) the lift that we used stoped (sic) on us about half way in the air so we tried to lift her manuly (sic) and that's when she came out (sic) the (name brand of mechanical lift device) paid (sic) and fell to the floor. She hit her head on the bottom of the machine and their (sic) was blood coming from the back of her head. We laid (sic) her down flat on the ground and put a pillow under her head and then I left the room to get the nurse so she could come in and check her out (sic) she took her blood pressure and looked at the back of her head (sic) then the nurse asked me to go and get therapy so they could help us get her back in the chair (sic) they came in got her up and we took her to her room (sic) after that I left the room. the home health aid (sic) was still there with her until (sic) she went out to the hospital. An interview was conducted with the DON and CNA #3 on 8/17/15 at 12:35 p.m., to clarify CNA #3's earlier interview (at 8/17/15, 11:18 a.m.) when compared to her 8/6/15 written statement. CNA #3 indicated the (name brand of mechanical lift device) did not stop. It went as high as it could go, but it wasn't high enough to get her off the shower bed. CNA #3 indicated she was unaware of that at the time. CNA #3 indicated she thought it was as high as it could go, so they lifted her manually. She indicated that is what she would do with residents when the (name brand of mechanical lift device) lift went as high as it could go. CNA #3 indicated if the sling used for Resident #D was hooked up to the right color to correspond with the height necessary to go, the sling would have gone higher. CNA #3 indicated she knew something about the color and height, but not really. CNA #3 indicated she worked at the facility for 2 years, and didn't find out about the colors on the sling until after Resident #D's fall from the (name brand of mechanical lift device) on 8/6/15. CNA #3 indicated she did not know exactly how the colored straps were used to assist with utilization of the (name brand of mechanical lift device) lift. CNA #3 indicated the problem was not affixing the sling to the lift appropriately. The DON indicated the resident should have been lowered, the situation reassessed, and Resident #D should have never been manually lifted. The DON indicated the root cause of Resident's D's fall was improper positioning of the sling. The 8/6/15 11:59 a.m. EMS (Emergency Medical Services) Notes indicated, dispatched to below ECF location for neuro/head injury. UOA (Upon our arrival), found (age and gender of Resident #D) sitting in recliner style wheelchair. Pt is awake and continually stating 'don't drop me.' ECF staff states that pt was in (name brand of mechanical lift device) Lift attempting to be moved to shower when pt 'slipped out' of lift. Pt fell to ground and landed on posterior. Pt then fell back striking head. ECF denies LOC. Attempt made to place C-collar on pt per protocol, but pt would not tolerate collar. Pt has small hematoma to rear, base of skull approx 1 inch by 1 inch in size with no discoloration. Pt is not bleeding at this time. Pt is not oriented at this time, however, ECF states pt is at norm at this time. The 8/6/15 Hospital Records for Resident #D indicated, Fall .pt (patient) from ecf (extended care facility), (Name of facility), was in (name brand of mechanical lift device) lift and fell backwards out of lift, landed on bottom and then hit head posterior head on ground, staff state no LOC (loss of consciousness), during triage, no active bleeding, no wound seen on posterior head, normal mentation per staff and L (left) sided weakness as per normal for staff Number of [DIAGNOSES REDACTED]. will have (Name of Physician Assistant), PA, repair the laceration Pt is to return in 7 days for staple removal. Clinical impression: 1. Scalp contusion 2. Laceration of scalp, initial encounter 3. Back contusion, unspecified laterality, initial encounter Procedures: The 1 cm posterior scalp wound area was prepped and draped in a sterile fashion. The wound area was not anesthetized The wound was explored with the following results No foreign bodies found. The wound was then copiously irrigated with sterile saline per nursing staff. The wound was repaired with 1 staple (sic) was used. The wound was dressed and antibiotic ointment was applied. The patient underwent the procedure with no complications. An interview was conducted with Family Member #4, daughter and POA (power of attorney) of Resident #D, on 8/17/15 at 2:19 p.m. She indicated the home health aide present during Resident #D's fall was hired by her to visit and spend time with Resident #D. She indicated Resident #D was terrified of the (name brand of mechanical lift device) lift, since the her 8/6/15 fall. She indicated the psychiatric nurse who sees Resident #D spoke with her last week about starting an anti-anxiety medication. She indicated Resident #D's fear was valid and the anti-anxiety medication wouldn't take away the fear. She indicated her mother yelled, 'No, no' the last time she observed her mother getting ready to be put into the (name brand of mechanical lift device) lift. She indicated Resident #D's reaction to the (name brand of mechanical lift device) lift was 'since the fall.' An interview was conducted with Family Member #4 on 8/20/15 at 10:09 a.m. She indicated Resident #D's yelling and screaming has been 'intensified' since her 8/6/15 fall, and was not fearful of care prior to the fall. She indicated she visited 5-6 times weekly, usually in the evenings. An observation of Resident #D being transferred via (name brand of mechanical lift device) Lift was made on 8/18/15 at 11:05 a.m. Resident #D was heard yelling out prior to entering the room for the observation. RN #5 knocked on the door. CNA #2 answered the door and indicated she was providing care. Resident #D was lying in bed. She appeared calm. The (name brand of mechanical lift device) Lift was located next to Resident #D's bed. The ADON touched Resident #D's blouse to straighten it. Resident #D began yelling out again. Resident #D was placed into the (name brand of mechanical lift device) Lift. When lowering Resident #D into her chair, she began yelling oh, oh, oh very loudly and fearfully. She then stated, You didn't tell me, you didn't tell me. Resident #D stopped yelling once she was in the chair. Staff began repositioning her in her chair, and Resident #D began yelling No, no. The ADON asked Resident #D if she was okay. Resident #D yelled, No, no. An interview was conducted with CNA #2 on 8/18/15 at 1:31 p.m. She indicated Resident #D's behavior during her transfer was pretty typical for her. CNA #2 indicated she worked at the facility for 8 months and cared for Resident #D approximately 6 days a week. She indicated Resident #D didn't say 'no, no' all the time, just since the 8/6/15 fall. She indicated Resident #D was hesitant for people to touch her, and was 'just real scared now since the fall, real nervous.' She indicated, since the fall, Resident #D slept more, didn't like to get up as much, seemed more depressed, poked her lip out, and didn't like to get up for meals. She indicated Resident #D used to like to get her nails done before the fall, but now her companion did her nails. She indicated Resident #D didn't drink as much since the fall. She indicated since the fall, Resident #D told her she's hurting more often than she used to tell her. CNA #2 indicated staff have to take more time, be more gentle, and reassure her more, since the fall. CNA #2 indicated, in her opinion, there was no reason Resident #D should have fallen out of the (name brand of mechanical lift device) Lift. CNA #2 indicated Resident #D's visiting companion never helped her transfer Resident #D before. The 8/14/15 psychiatric notes, written by CNS (Clinical Nurse Specialist) #6, indicated, cont (continues) vocal agit (agitation), esp (especially) (symbol for with) hands on care (symbol for with) anxious fearful statements .Per DON -she still yells, screams out, makes such fearful statements (symbol for with) direct hands on care i.e. 'don't hurt me' 'Don't look @ my (expletive)' imp (impression): still yells out, fearful (symbol for with) care, anxious (symbol for with) care . The psychiatric notes, written by CNS #6, from prior visits on 6/8/15, 5/15/15, 2/17/15, and 12/12/14 indicate vocal agitation and calling/yelling out, but do not indicate anxious, fearful statements or fearful/anxious with care. An interview was conducted with CNS #6 on 8/18/15 at 2:06 p.m. She indicated she was unsure if Resident #D would remember her fall on 8/6/15, due to her dementia. She indicated there were certain events people with dementia do remember and get stuck on. She indicated she did not think Resident #D had the ability to process her fall, because of her dementia. She indicated it was a change for Resident #D to be fearful and anxious with care, as referenced in her 8/14/15 visit note, but patients change with dementia and go through different phases. A care plan for tactile defensiveness was initiated for Resident #D on 8/13/15. Resident #D's visiting companion was unavailable for interview. The 6/12/15 Mechanical Lift Transfers Policy was provided by the DON on 8/17/15 at 12:00 p.m. It indicated, Purpose 1. To move a resident safely and with as little physical effort as possible Two staff members (minimal) -during the transfer itself. Procedure: .6. Position resident per manufacturers instructions. 7. Attach and secure lifting straps per manufacturer's guidelines 9. Check lifting straps to make sure they are properly positioned. 10. Begin lifting resident per manufacturer's instructions. 11. When the resident has been lifted clear off the bed, position residents feet off the bed and move them over to the chair or seating device. An undated Use of Mechanical Lift & Full Body Sling policy was provided by the DON on 8/17/15 at 12:00 p.m. It indicated, Always have two Miller's employees that have been trained on the use of the lift! .Choose appropriate sling for the patient. See guide attached to lift and/or CNA assignment sheet. Be aware there are different types of slings, if you are unfamiliar with a sling, do not use it! .Attach straps to the lift swivel bar; verify the same color strap is used on both sides. Colors used top to bottom can be different, depending on what position you need the patient in. If transferring into chair, use closer straps at top and further straps at bottom; if transferring to bed, use closest straps for top and bottom.* .When ready, lift patient up from surface. The patient must clear the surface by 2-3*, if you cannot clear the surface you must lower the patient back down to the surface and stop the procedure and get your supervisor for further instruction *This information obtained from the Owner's Operator and Maintenance Manual: Patient Slings Part No 91 This Federal tag relates to complaint IN 773. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow up on a recommendation for an increase in a pain medication and timely address a resident's pain resulting in sleeplessness and varied participation and progress in therapy, and for 1 of 3 residents reviewed of 3 who met the criteria for pain. (Resident #9) Findings include: The clinical record for Resident #9 was reviewed on 7/1/14 at 10:30 a.m. The [DIAGNOSES REDACTED]. The July, 2014 physician's orders [REDACTED].#9 was prescribed the following medications for pain: duloxetine (antidepressant) 60 mg once daily effective 5/28/14, [MEDICATION NAME] topical 1% gel to be applied to left thigh 4 times daily effective 6/6/14, [MEDICATION NAME] 600 mg tab to be given 3 times daily effective 6/12/14, [MEDICATION NAME] with [MEDICATION NAME] 5-325 mg tab to be given every 4 hours as needed for moderate to severe pain effective 6/17/14, and [MEDICATION NAME] 37.5 mg with [MEDICATION NAME] 325 mg tab to be given every 6 hours as need for pain effective 4/3/14. The 4/2/14 pain care plan for Resident #9 indicated the goal was, "Pain will be controlled to acceptable level." Interventions indicated on the care plan were to monitor the effectiveness of pain medications, to notify M.D. as needed, and to acknowledge the presence of pain and discomfort, and to listen to the resident's concerns. An interview was conducted with Resident #9 on 6/26/14 at 1:18 p.m. regarding whether he had any discomfort such as pain, heaviness, burning, or hurting with no relief. Resident #9 indicated, "My right [MEDICAL CONDITION] the time. I need my pain meds (medications) adjusted. If I took the pain meds at the right time, I could walk back from therapy. During the night, I'm in so much pain, and they say it's in between times for me to take it, so I can't get it. I pray to God to take the pain away. It's driving me out of my skull. This has been going on for quite a while...." An interview was conducted with PTA (Physical Therapy Assistant) #3 on 7/2/14 at 9:56 a.m. regarding Resident #9's progress with therapy. He indicated, "It's been widely variable. With his wounds on his foot, he may not walk at all. Last week he didn't walk on it at all." The 4/2/14 Physical Therapy (PT) Plan of Care for Resident #9 indicated the long term goals were, "The patient will safely ambulate up/down 12 of (sic) steps with hand rail with independent (able to negotiate stairs without physical assistance and/or cues. No handrails, assistive device, or external support required.) to enter/exit home. The patient will complete all functional transfers with independent (able to transfer without physical assistance or verbal cues. No external support or assistive device required.) and ambulation x 300 feet with can with modified independence." The PT plan indicated the reason for referral was, "Recent hospitalization resulting in a decrease in strength, balance, endurance, safety, and mobility." The therapy necessity was, "Therapy necessary for improved strength, balance, endurance, safety, and mobility. Without therapy patient at risk for decreased functional..." The 6/25/14 PT Therapist Progress Note indicated, "Analysis of Functional Outcome/Clinical Impression: Patient has demonstrated inconsistent gains in therapy due to pain and fatigue....Impact on Burden of Care/Daily Life: complicating factors, including pain and increased fatigue may prevent the patient from achieving all established goals." The 4/2/14 Occupational Therapy Plan of Care indicated, "Patient is on medication for the following [DIAGNOSES REDACTED]." the therapy plan indicated the pain intensity on a scale of 0-10 was "2/10." The therapy plan indicated, "underlying Impairments: Activity Tolerance, Standing - (symbol for "about") 2 minutes Pain in B (both) legs....The patient actively participates in 2 minutes of graded therapeutic activities influenced by fatigue, pain, nausea and decreased functional activity tolerance." The 5/27/14 OT (Occupational Therapy) Therapist Note indicated, "Caregiver education continued with patient regarding attempting to complete with functional tasks and participating despite pain and fatigue. Remaining Functional Deficits/Underlying Impairments: Patient continues to have deficits in functional activity tolerance and standing tolerance which limit ability to safely and independently complete self care tasks." The 5/28/14 OT Therapist Progress & Updated Plan of Care note indicated, "Caregiver education continued with patient regarding attempting to complete with functional tasks and participating despite pain and fatigue....Remaining Functional Deficits/Underlying Impairments: Patient continues to have deficits in functional activity tolerance and standing tolerance which limit ability to safely and independently complete self care tasks." The 6/11/14 OT Therapist Progress note indicated, "Patient continue (sic) to present with c/o (complaints of) LE (lower extremity)/foot pain impacting standing tolerance/balance....Higher level challenges introduced this week in sustained UE (upper extremity) activity and standing time....Patient/Caregiver Training: Caregiver education continued with patient regarding importance of continued attempts at participation with functional tasks to improve safety and independence. Patient continues to c/o LE pain....Impact on Burden of Care/Daily Life: The patient's set backs in standing tolerance and functional activity tolerance due to LE pain, have caused in increase in burden of care for bathing, dressing and toileting." The 6/25/14 OT Therapist Progress note indicated, "Patient continues to have deficits in standing tolerance/balance and functional activity tolerance which limit ability to safely complete self care and functional transfer tasks." The June, 2014 PRN Pain Management Flow Sheet for Resident #9 was reviewed. It indicated prn [MEDICATION NAME] was only given four times between the hours of 7:00 a.m. and 9:00 a.m. when it would have been most effective during therapy, from 6/1/14 to 6/28/14. It indicated prn [MEDICATION NAME] was never given between 7:00 a.m. and 9:00 a.m., and only given three times between 6/1/14 and 6/28/14. An interview was conducted with Unit Manager #2 on 7/2/14 at 2:25 p.m. regarding Resident #9's pain during therapy. She indicated, "Therapy never told me about him having foot pain during his therapy. He usually goes to therapy right after breakfast, so around 8:45 a.m., maybe a little later. His [MEDICATION NAME] is only prn every 6 hours, so if he gets it in the middle of the night, he can't have it an hour before therapy for it be at it's most effective. He takes [MEDICATION NAME], but that's not really going to do much as far as pain." She indicated she did not know why Resident #9 was not on regularly scheduled pain medications. She offered no information regarding the prn [MEDICATION NAME] as an option prior to therapy. During an interview with PTA (Physical Therapy Assistant) #3 on 7/2/14 at 9:56 a.m., he indicated, "This week he went 150 feet. He's improving this week. At first he was improving, then not so much....He comes five times a week. He's never refused, always comes, and does something. As of right now he can bear weight, and can transfer with a stand by. When we started, he was a minimal assist, so he has improved. Right now, he's as good as he's been." The June, 2014 PRN Pain Management Flow Sheet for Resident #9 indicated on 6/29/14, Resident #9 received [MEDICATION NAME] at 7:30 a.m., [MEDICATION NAME] at 10:45 a.m., [MEDICATION NAME] at 2:30 p.m., [MEDICATION NAME] at 3:30 p.m., and [MEDICATION NAME] at 8:30 p.m. The 6/27/14 Wound Care Center note indicated Resident #9 had a stage 3 pressure ulcer on his right heel, an arterial ulcer midfoot, and [MEDICAL CONDITION] of native arteries of the extremities with gangrene. The note indicated, "My Reported Pain Level (Last Filed) Score 10-Excruciating (worst ever) Location Foot-right Comments pt (patient) states he takes pain medication as prescribed....Recommend increasing [MEDICATION NAME] to 900 mg PO (by mouth) TID (3 times daily) r/t (related to) pain 10/10." An interview was conducted with the DON (Director of Nursing) on 7/1/14 at 3:18 p.m. regarding whether the recommendation from the wound care center to increase [MEDICATION NAME] was addressed. She indicated she did not see an order to increase it or any information to suggest the recommendation was acknowledged. She indicated it was the nurse's responsibility to act on the recommendation. The nurse, she indicated as having been responsible, was Unit Manager #2. An interview was conducted with Unit Manager #2 on 7/1/14 at 3:35 p.m. She indicated, "I didn't see anything about a recommendation for increase in [MEDICATION NAME] to 900 mg TID." At this time, Unit Manager #2 reviewed the 6/27/14 wound care center notes for Resident #9, and stated, "No, I didn't see that." The Pain Management Program policy provided by the DON on 6/30/14 at 3:30 p.m. indicated, "It is the goal of this facility to assist residents in achieving their optimal level of comfort by providing an effective pain management program." 3.1-37(a)