Chippewa Manor Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 3 of 4 residents (R) reviewed for pressure injuries (PI) (R48, R47, and R51) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R48 and R47 are being cited at (actual harm/isolated). R51 is being cited at (potential for minimal harm/isolated). R48 and R47 were at risk for PI development. The facility failed to provide adequate interventions to prevent PI development, and did not complete comprehensive weekly assessment with staging of the PI. The facility did not complete weekly comprehensive skin assessments, obtain physician orders for wound treatments, and implement interventions to promote skin integrity and healing for R51. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) for one of five residents (R7) reviewed for MDS.R7 expired in the facility on [DATE] with hospice services. R7's Minimum Data Set (MDS) assessment for a death in the facility was not submitted to the CMS System. On [DATE], Surveyor requested the facility's policy related to MDS assessments; the facility did not provide Surveyor with this policy. Per CMS requirements, within 14 days after a facility completes a resident's assessment, the facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including a resident's death. On [DATE] at 8:34 AM, Surveyor interviewed Registered Nurse (RN) F. RN F also acts as the MDS coordinator. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 residents (R51) reviewed for dialysis. The facility failed to provide ongoing assessment of R51's condition and monitoring for complications before and after dialysis treatments. On 03/23/26 at 3:30 PM, Director of Nursing (DON) B reported the facility did not have a policy. On 03/24/26, DON B provided Surveyor with a policy titled Hemodialysis Policy and Procedure. DON B stated the policy was created on 03/24/26. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 5 out of 5 residents (R). (R29, R10, R24, R37, and R7) Laundry aide (LA) D did not sanitize hands in between delivering clean linens to R29, R10, R24, R37, and R7.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's representative or Ombudsman was notified in writing, in a language and manner they understand, of the resident transfer for 1 of 1 resident (R) investigated. (R10)

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's representative was provided notice of the resident's bed hold upon transfer for 1 of 1 resident (R) investigated. (R10)

Inspectors wroteBased on observation, record review and interview, the facility did not ensure all drugs and biologicals were securely stored for 2 of 2 residents (R) (R2 and R246) and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments.

Inspectors wroteBased on interview and record review, the facility failed to assess resident (R) 28 using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 12 residents reviewed. The facility did not complete a quarterly Minimum Data Set (MDS) assessment for R28 with a frequency of not less than three months.

Inspectors wroteBased on interview and record review, the facility failed to ensure that written notification required for facility-initiated transfers was given to the residents or resident representatives for two (R31 and R16) of two residents reviewed for hospitalization in the sample of 14. The facility failed to have a system in place to ensure that residents or resident representatives were given written notices upon transfers. This had the potential to affect all 35 residents that reside in the facility. The facility did not notify the resident's representatives in writing of a transfer to the hospital for Resident (R)31 and R16. Findings Include: Example 1 Record review of R31's past hospitalizations showed that on 08/12/23, R31 was transferred to the hospital for an extended stay. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that written bed hold notice required for facility-initiated transfers was given to the residents or resident representatives for two (R16 and R31) of two residents reviewed for hospitalization in the sample of 14. The facility failed to have a system in place to ensure that residents or resident representatives were given written bed hold notices upon transfers. This had the potential to affect all 35 residents that reside in the facility. The facility did not notify the residents' representatives in writing of the bed hold policy at the time of transfer or within 24 hours of transfer to the hospital for Resident (R)31 and R16. This is evidenced by: Example 1 Review of R16's medical record revealed R16 was transferred to the hospital on [DATE], 04/12/23, and 07/02/23. [...]

Inspectors wroteBased on observations and interview, the facility did not ensure the posted nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 35 residents in the building. The facility's Nursing Staff sheet postings were not posted daily. Evidenced by: Division of Quality Assurance (DQA) memo 12-020 titled Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift . The information that is posted must include the following . 1. Facility name. 2. The current date. 3. [...]