Every finding on record at Auburn Home in Waconia

Based on interview and document review, the facility failed to ensure physician-ordered monitoring for potential adverse effects related to antipsychotic medication use was completed when orthostatic blood pressures (BP) were not obtained as ordered for 1 of 3 residents (R7) reviewed for unnecessary psychotropic medication use.Findings included:R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had moderately impaired cognition, and diagnoses included chronic diastolic heart failure (a condition where the heart does not fill properly, which may affect blood flow), hypertension (high blood pressure), anxiety disorder, and depression. The MDS further identified R7 received antipsychotic, antianxiety, antidepressant, and diuretic medications.R7's physician orders, print date of 6/18/26 , identified an order for Olanzapine 5 milligrams (mg) by mouth two times daily for psychosis related to depression, with target behaviors including anxiety, apathy, and somatic symptoms (physical symptoms related to emotional distress) such as dizziness and nausea, initiated 4/3/25. R7's physician orders further identified an order to obtain monthly orthostatic blood pressures (lying, sitting, standing blood pressures) due to antianxiety, antidepressant, and antipsychotic medication use, initiated 1/28/25.R7's electronic health record (EHR) from January 2026 through May 2026 lacked evidence orthostatic blood pressures were obtained as ordered. The EHR failed to identify staff completed monitoring to assess R7 for potential medication-related adverse effects, including blood pressure changes associated with antipsychotic medication use.During an interview on 6/18/26 at 7:53 a.m., licensed practical nurse (LPN)-A stated nurses completed orthostatic blood pressures when the task appeared on the treatment administration record (TAR) indicating the monitoring was due.During an interview on 6/18/26 at 9:02 a.m., registered nurse case manager (RN)-A stated orthostatic blood pressures were completed for residents who received antipsychotic medications or had concerns related to orthostatic blood pressures. RN-A reviewed R7's EHR and verified the orthostatic blood pressure order was active, and the order type had not generated a task for nursing staff to document completion. RN-A confirmed orthostatic blood pressures had not been completed since the order was initiated on 1/28/25. RN-A stated monitoring orthostatic blood pressures was important to identify potential adverse effects from medications and blood pressure changes, which could increase a resident's risk for falls.During an interview on 6/18/26 at 9:16 a.m., director of nursing (DON) stated orthostatic blood pressure monitoring was important due to the potential for increased fall risk and adverse effects, including increased confusion and dizziness. DON stated physician-ordered monitoring should have been completed to assess residents for potential medication-related concerns.The facility's Psychotropic Medication Use policy, revised 3/1/25, identified guidelines for the safe and appropriate use of psychotropic medications to ensure effective treatment of mental health conditions while minimizing risks and adverse effects. The policy identified medications used to treat behaviors required a clinical indication and should be used at the lowest possible dose to achieve the desired therapeutic effect. The policy further identified medications used to treat behaviors should be monitored for effectiveness, risks, benefits, and potential adverse consequences.

Based on observation, interview, and document review, the facility failed to ensure staff implemented infection prevention and control practices when staff failed to wear required personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities for 1 of 1 resident (R4) reviewed for enhanced barrier precautions (EBP).Findings include:R4's significant change Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition, and diagnoses included benign prostatic hyperplasia (BPH; enlarged prostate which may affect the ability to empty the bladder), chronic obstructive pulmonary disease (COPD; chronic lung disease that affects breathing), severe protein-calorie malnutrition (lack of adequate nutrition which may affect the body's ability to heal and fight infections), and weakness (decreased strength which may affect mobility and ability to complete daily activities). The MDS further identified R4 required an indwelling urinary catheter (a tube inserted into the bladder to drain urine).R4's care plan, dated 6/18/26 identified R4 required an indwelling urinary catheter and EBP.During observation on 6/16/26 at 12:40 p.m., trained medication aide (TMA)-A and nursing assistant (NA)-A assisted R4 with a transfer from the wheelchair to bed utilizing a mechanical lift. TMA-A and NA-A provided hands-on, physical assistance during the transfer. However, TMA-A and NA-A had not worn gown or gloves while the transfer care was provided.During interview on 6/16/26 at 12:47 p.m., TMA-A stated R4 was on EBP due to an indwelling catheter, and staff were required to wear gowns and gloves when catheter cares were completed. TMA-A stated PPE was not worn during R4's transfer because staff had not provided catheter care.During observation on 6/16/26 at 4:39 p.m., NA-A and NA-B assisted R4 with a transfer utilizing a mechanical lift. NA-A and NA-B provided hands-on assistance during the transfer. NA-A rolled R4 side to side in bed to place the lift sling underneath R4, adjusted the bed, lowered the lift arm, and attached the sling to the lift. NA-A then applied gloves, picked up R4's catheter bag from the bed frame, and attached the catheter bag to the sling. After R4 was transferred into the wheelchair, staff removed the lift sling from underneath R4. However, NA-A and NA-B failed to wear a gown during the transfer, and only NA-A wore gloves while handling R4's catheter bag.During interview on 6/16/26 at 4:47 p.m., NA-A stated R4 was on precautions just for catheter and staff only needed to wear gown and gloves when providing catheter cares, such as emptying the catheter bag.During interview on 6/17/26 at 1:12 p.m., NA-B stated R4 was on precautions related to the catheter and staff were expected to wear gowns and gloves anytime they had contact with R4.During interview on 6/18/26 at 9:05 a.m., registered nurse case manager (RN)-A stated R4 was on EBP and staff were expected to wear a gown and gloves when any hands-on cares were provided. RN-A stated PPE use was important to prevent the spread of infection.During interview on 6/18/26 at 9:17 a.mm., the infection preventionist (IP) stated staff were expected to follow infection prevention practices, including appropriately donning and doffing PPE. The IP stated residents on EBP required staff to wear gowns and gloves during high-contact resident care activities. The IP confirmed transfers required PPE because staff had close physical contact with the resident.During interview on 6/18/26 at 9:20 a.m., the director of nursing (DON) stated staff were expected to wear gowns and gloves whenever they had close contact with residents on EBP. The DON stated personal cares and transfers required gowns and gloves to reduce the risk of spreading infection.The facility's Enhanced Barrier Precautions policy, reviewed 7/9/26, identified the facility would reduce the transmission of Centers for Disease Control and Prevention (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDROs) through the use of EBP. The policy identified EBP expanded the use of PPE, and required staff to wear gowns and gloves during high-contact resident care activities to reduce the risk of transferring MDROs to staff hands and clothing. The policy identified residents with wounds and/or indwelling medical devices, including urinary catheters, required EBP even if the resident was not known to have an infection or MDRO. The policy further identified gowns and gloves were required during high-contact resident care activities, including transferring, providing hygiene, toileting, and urinary catheter device care.

Based on interview and document review the facility failed to ensure a physician performed an initial comprehensive assessment within 30 days after admission for 1 of 3 residents (R3), failed to ensure physician visits every 30 days after admission for 90 days for 1 of 3 residents (R3) and failed to ensure physician visits every 60 days after the initial 90 days for 3 of 3 residents (R1, R2, R3). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted [DATE]. R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility.R1's progress notes dated 7/21/25 at 3:31 a.m., indicated discharge on [DATE].R1's provider visits for 2025 included nurse practitioner (NP) visits monthly from January to July, except March. The medical record lacked evidence of any physician visits to date in 2025.R2's quarterly MDS dated [DATE], indicated R2 admitted [DATE]. R2 had intact cognition with diagnoses that included heart failure, chronic lung disease, diabetes, impaired kidney function, and asthma. R2 required a walk or wheelchair for mobility, substantial/maximum assistance from the staff for mobility, and was unable to walk independently.R2's progress notes dated 9/20/25 at 1:34 a.m., indicated discharge on [DATE]. R2's provider visits records indicated visits by a NP every month in 2025, except February and August, and lacked indication of a physician visits in 2025.R3's admission MDS dated [DATE], indicated admission to the facility on 6/13/25, severe cognitive impairment with diagnoses that included impaired kidney function, malnutrition, asthma for which R3 required oxygen therapy. R3 required a walker or wheelchair for mobility, partial/moderate assistance (helper does less than half the effort), and was able to walk with supervision.R3's provider visits included an initial admission visit on 6/26/25, performed by the NP, and a provider visit on 8/26/25, also performed by the NP. The electronic medical record lacked indication R3 was seen by a physician for the initial assessment, every 30 days after admission, or for an assessment in July by any provider.During an interview on 9/24/25 at 3:05 p.m., the director of nursing (DON) stated the expectation was for residents to see a physician every 60 day after admission, and an NP could alternate visits with the physician. The DON acknowledged, I know we have been having problems with that.During an interview on 9/25/25 at 10:44 a.m., the NP-A stated she emailed the scheduler and DON and informed them physician visits did not occur on schedule, and R1 needed another provider as his provider did not round in the facility. The NP acknowledged R1, R2, and R3 had no physician visits in 2025, and she had performed the admission visit for R3 instead of a physician.During an interview on 9/25/25 at 11:43 a.m., the administrator stated a physician should perform an admission visit and then visit every 30 days for 90 days. A physician then performs visits every 60 days but could alternate those visits with a NP. The administrator stated she was not aware the physician visits were not occurring per regulation.The Physician Visit Schedule policy dated 7/29/25, indicated all individuals will be seen by their physician or physician extender in accordance with the standards set in their regulatory service line.

Based on interview and document review the facility delayed the transfer to the hospital after a change of condition, 1 of 3 residents (R1) who had a change in condition. R1's change of condition was identified at approximately 12:45 a.m. and was sent to the hospital at 3:30.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1 had chronic pain rated typically at 3 on a scale of 0-10. R1's progress notes dated 7/21/25 at 12:47 a.m., indicated R1 was nauseated, vomited green fluid, was short of breath, had blood pressure of 72/32 and then 87/57, pain in the right upper quadrant rated as 7 on a scale of 0-10 (severe pain), and a fever of 100.3 degrees Fahrenheit. The progress note indicated on-call administrative staff was notified, and staff left a voice message for the nurse practitioner (NP) were notified, but the progress note lacked indication R1's family was notified. R1's progress notes dated 7/21/25 at 3:31 a.m., indicated R1's condition had not improved, R1 was sent to the hospital. R1's progress notes dated 7/21/25 at 3:31 a.m., indicated R1's condition had not improved, R1 was sent to the hospital, and R1's family was notified, nearly 3 hours after R1's change in condition. R1's pain assessments indicated two pain assessments in the previous 90 days. On 7/20/25 at 11:31 p.m., R1 reported pain rated as a 6 on a scale of 0-10 (moderate to moderately strong), and on 7/21/25 at 12:28 a.m., a 7 on a scale of 0-10. R1's orders and Medication Administration Record (MAR) indicated the following:-7/20/25 at 6:51 p.m. administered gabapentin (used to treat nerve pain) oral capsule, give one capsule by mouth as needed for leg pain, dated 1/2/25.-7/20/25 at 11:31 p.m. administered acetaminophen (pain and fever-reducing medication) 500 milligrams (mg), administer 2 tablets by mouth every 6 hours as needed for pain, fever, dated 9/24/24.-7/20/25 at 11:31 p.m. administered albuterol sulfate (used to treat breathing problems) inhalation solution 108 micrograms (mcg)/actuation (ACT) (puff), give 1 puff every 4 hours as needed for spasm of lung air passages, dated 9/24/24. -7/20/25 at 11:36 p.m. administered Zofran (used to treat nausea) oral tablet 4 mg, give one tablet my mouth every 6 hours as needed for nausea, dated 10/21/24. During an interview on 9/23/25 at 2:48 p.m., registered nurse (RN)-A stated R1 was very sick on 7/21/25 in the early morning and had a blood pressure of 72/32 millimeters/mercury (mm/Hg) (blood pressure (BP) lower than 90/60 can reduce oxygen and nutrients a brain receives, leading to brain damage) and decided to call the on-call provider to report R1's condition, and left a message for the NP and on-call facility administrative staff, but not R1's family. The RN-A acknowledged she did not call the daughter right away, even though she was worried about R1's condition. R1's low blood pressure was what concerned her enough to want to call the on-call provider. During an interview on 9/23/25 at 3:14 p.m., nursing assistant (NA)-A stated he worked the night R1 was sent to the hospital. R1 reported pain to NA-A, and asked NA-A to get a nurse. The NA-A stated he told the RN about R1's request for a nurse and then took R1's vital signs at the RN's request, which showed a low BP, low oxygen saturation, and with rapid respirations. R1 vomited black fluid, and the nurse eventually called for an ambulance. NA-A stated when the emergency medical service (EMS) staff arrived one commented the vomit appeared to have blood in it, and thought R1 had a GI bleed. NA-A thought it took about 3 hours to send R1 to the hospital, because the RN was very busy that night. During an interview on 9/24/25 at 1:18 p.m., RN-C stated the nurses were allowed to call 911 when a resident needs emergency assistance and then notify the on-call administrative staff and provider afterwards. RN-C stated R1 should have been sent to the hospital right away, and with a fever, pain, and vomiting, R1 would not have felt very well. RN-C would have expected the nurse to use their judgement to send him to the hospital immediately. During an interview on 9/24/25 at 2:03 p.m., RN-D stated RN-A called her when R1 was not feeling well, and RN-D advised RN-A to send R1 to the hospital and was not aware RN-A waited three hours to send R1. RN-D stated she was not aware no further assessments were done in the three hours while RN-A waited to send R1 to the hospital but would have expected continuous assessments until R1 went to the hospital. If she did not send him in right away, it was a delay in care. He should have gone right away. It was an emergency. During an interview on 9/24/25 at 3:05 p.m., the director of nursing (DON) stated she was not aware RN-A did not send R1 to the hospital immediately and would question why RN-A didn't send R1 immediately, and why R1 was sent to the hospital by non-emergency transport. The expectation would have been to assess every 30 minutes or more often with vital signs, until R1 was sent to the hospital. The DON acknowledged no further assessments were documented on 7/21/25 between 12:47 a.m., and 3:31 a.m., but stated further assessment should have occurred. The DON further acknowledged R1 was in pain and should have been sent to the hospital sooner to alleviate the pain. During an interview on 9/24/25 at 3:46 p.m., the nurse practitioner (NP)-A stated if RN-A was told to send R1 to the hospital, R1 should have been sent immediately. The NP-A stated she reviewed the hospital records, and R1 would not have been saved if he had been sent to the hospital right away but could have had comfort cares much sooner; R1 was in pain and did not need to be. During an interview on 9/24/25 at 4:21 p.m., the medical director (MD)-A stated it was certainly possible sending R1 to the hospital could have made a difference for him, and staff should have called an ambulance to send R1 to the hospital right away. The (MD)-A stated she would have expected assessment in between the two documented assessments by the nurse to know how the resident's condition was progressing, and the incident should be reviewed by the facility. The Change of Condition and Provider Notification policy dated 7/29/25, indicated a change in condition is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. A change in condition shall be reviewed by a registered nurse. The primary care provider or on-call provider will be contacted. As applicable, the individual representative will be notified. The individual with a change in condition will be monitored as appropriate.

Based on interview and document review, the facility failed to timely update the family member (FM) of a change in condition for 1 of 3 residents (R1) to allow family to be involved in decisions for the resident's end of life care.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1's progress notes dated 7/21/25 at 12:47 a.m., indicated R1 was nauseated, vomited green fluid, was short of breath, had blood pressure of 72/32 and then 87/57, pain in the right upper quadrant rated as 7 on a scale of 0-10, and a fever of 100.3 degrees Fahrenheit. The on-call administrative staff was notified, and staff left a voice message for the nurse practitioner (NP) were notified, but the progress note lacked indication R1's family was notified. R1's progress notes dated 7/21/25 at 3:31 a.m., indicated R1's condition had not improved, R1 was sent to the hospital, and R1's family was notified, three hours after R1's change in condition. During an interview on 9/23/25 at 2:48 p.m., registered nurse (RN)-A stated R1 was very sick on 7/21/25 in the early morning and had a blood pressure of 72/32 millimeters/mercury (mm/Hg) (blood pressure (BP) lower than 90/60 can reduce oxygen and nutrients a brain receives, leading to brain damage) and the on-call provider was called to report R1's condition, and left a message for the NP and on-call facility administrative staff, but not R1's family. The RN-A acknowledged she did not call the daughter right away, even though she was worried about R1's condition, and further acknowledged R1's low blood pressure was what concerned her enough to want to call the on-call provider. During an interview on 9/23/25 at 4:04 p.m., RN-B stated R1 was sick, and the low blood pressure indicated R1 may have been dying, and the family should have been notified right away so family could be with R1. During an interview on 9/24/25 at 1:18 p.m., RN-C stated R1's family should have been notified when the change of condition occurred, on 7/21/25 around 12:47 a.m. During an interview 9/24/25 at 3:05 p.m., the director of nursing (DON) stated with R1's condition, family should have been notified right away. R1's daughter was involved in R1's care and would have wanted to know when he was not doing well. During an interview on 9/24/25 at 3:36 p.m., the nurse practitioner (NP)-A stated R1's family should have been notified right away when his condition changed, [R1]'s daughter liked to know what was going on with him. The Change of Condition and Provider Notification policy dated 7/29/25, indicated a change in condition is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. A change in condition shall be reviewed by a registered nurse. The primary care provider or on-call provider will be contacted. As applicable, the individual representative will be notified. The individual with a change in condition will be monitored as appropriate.

Based on interview and document review, the facility failed to ensure the comprehensive care plan was updated to include interventions to address constipation and a bowel program for 1 of 3 residents (R1), who had periods of three or four days between documented bowel movements. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1's orders dated 9/24/24, indicated senna-docusate (medication used to relieve constipation, also known as MiraLAX) oral tablet 8.6 milligram (mg), give 2 tablets by mouth in the morning for constipation and give 2 tablets by mouth as needed for constipation, up to 2 times a day. Further, R1's orders dated 9/24/24, indicated polyethylene glycol (a laxative used to treat occasional or chronic constipation), give one packet as needed for constipation, once a day. R1's July medication administration record indicated neither senna-docusate nor polyethylene glycol were administered in July. R1's bowel movement (BM) records indicated a small BM on 7/12/25, a medium BM on 716/25, with no BMs recorded between 7/12/25 and 7/16/25. R1's progress notes lacked mention of assessment for constipation, or intervention after no BM for four days. R1's care plan was reviewed and lacked a focus area or interventions for constipation. During an interview on 9/24/25 at 12:06 p.m., licensed practical nurse (LPN)-A stated constipation interventions should be on a resident's care plan to direct staff on how to manage it. During an interview on 9/24/25 at 3:05 p.m., the director of nursing (DON) stated if a resident had a diagnosis and history of constipation, and was prescribed medications for constipation, there was an expectation to have a care plan to manage constipation. The DON acknowledged R1's care plan did not have a focus area for constipation. The Bowel and Bladder Management policy dated 7/29/25, indicated staff will assess residents for past and present bowel patterns which may include medication review, medical diagnosis, and/or diet. Staff will adopt a person-centered interdisciplinary care plan and implement interventions/approaches to bowel management to meet the goals of the individual and review the care plan at least quarterly. Staff will review individuals that do not have a recorded BM within the past 3 days and provide appropriate intervention.

Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented to reflect the resident's current wishes which affected 1 of 16 residents (R29) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R29 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R29's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R29's wishes of do not resuscitate (DNR). The three ring household binder and staff report form identified R29's wishes of CPR. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:35 p.m. The IJ was removed on [DATE], at 12:33 p.m., when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had moderately impaired cognition and had diagnoses which included atrial fibrillation (irregular heart rhythm), anemia, coronary artery disease (narrowing or blockage of the coronary arteries). R29 was dependent on staff for activities of daily living (ADLs) which included bed mobility, toileting, and transfers. R29's current POLST signed by family member (FM)-A on [DATE], identified R29's wishes were DNR. The POLST was scanned into his EHR and signed by his medical provider on [DATE]. Review of R29's electronic health record (EHR) on [DATE] at 5:29 p.m., identified R9 wanted DNR. R29's care plan lacked documentation on resuscitation status. Review of a facility report form undated, located at the nurses station and carried by each nurse and nursing assistant identified R29 wanted CPR. Review of the household three ring binder located at the nurses station identified R29's POLST signed [DATE], R29 wanted CPR. During an interview on [DATE] at 6:31 p.m., FM-A stated he had signed the POLST on [DATE], identifying that R29's wishes were to be DNR. During an interview on [DATE] at 7:08 p.m., registered nurse (RN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the report form and would have proceeded accordingly. During an interview on [DATE] at 11:47 a.m., licensed practical nurse (LPN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the report form located in her pocket and would have proceeded accordingly. LPN-A verified R29's report sheet identified R29 wanted CPR. During an interview on [DATE] at 11:49 a.m., RN-B indicated in the event a resident did not have a pulse or respirations, she would refer to the three ring binder at the nurses desk and would have proceeded accordingly. RN-B verified R29's POLST in the binder identified R29 wanted CPR. RN-B verified there was a discrepancy between R29's EHR and the POLST in the binder and report form. During an interview on [DATE] at 12:18 p.m., RN-C indicated in the event a resident did not have a pulse or respirations, she would refer to the three ring binder at the nurses desk and would have proceeded accordingly. RN-C verified R29's POLST in the binder identified R29 wanted CPR. RN-C verified there was a discrepancy between R29's EHR and the POLST in the binder and report form. During a interview on [DATE] at 2:15 p.m., DON stated a POLST was completed with all residents or resident representatives upon admission and was effective upon admission. DON confirmed there was a discrepancy with R29's EHR, the report form and three ring binder which identified R29 was a full code and did not match his current wishes of being DNR. DON confirmed in the event R29 did not have a pulse or respirations, CPR would have been initiated against R29's wishes. DON indicated she would expect staff to follow the POLST, resident wishes and the facility policy. Review of a facility policy titled Code Status Policy and Procedure, undated, identified the facility would follow a policy regarding a resident's right to request, refuse, and/or discontinue medical treatment and to formulate an advance directive. Identified the POLST would have been documented in the EHR and the household three ring binder. Further identified the code status would have been reviewed with Care Conferences at least quarterly and documented in the medical record. The IJ was removed on [DATE] at 12:33 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form and the electronic health records were updated to ensure resident's wishes for advance directives, were accurate on [DATE]. -R29's three ring binder was updated to match the current POLST and the code status for all residents was removed from the report form. -All current licensed staff were educated on the policy for advance directives, updating the POLST, the EHR, and the three ring binder to reflect the resident's wishes on [DATE], as evidenced by the education sent to all nursing staff via email on [DATE] and interviews. -A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift on [DATE], by notification of required education via phone/text. All staff would sign off once education had been completed. -The advance directive policy was reviewed and determined no changes were required.

Based on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This deficient practice had the potential to affect all 32 residents residing in the facility. Findings include: During an interview on 4/1/25 at 2:22 p.m., the director of nursing (DON), stated the IP resigned on 2/1/25, and the DON and two nurse managers assumed the infection control role at that time. The DON confirmed the nurse managers and herself were not enrolled in the Centers for Disease Control (CDC) infection preventionist course or any other specialized IP training. The DON added the facility was in the process of hiring a new IP. During an interview on 4/1/25 at 2:30 p.m., RN-B verified she was new to the infection preventionist role and has had no training at this time. RN-B stated the IP role was split between herself, RN-A, and DON. During an interview on 4/1/25 at 2:42 p.m., the administrator stated she was aware the facility currently had no trained infection preventionist. A facility policy titled, Infection Control Policy, revised 2/2023, included the early detection, prevention and management of infections are accomplished through effective oversight of the Infection Prevention and Control program that must include at a minimum, the following elements: To recognize and manage infections at the time of the resident's admission to the facility and throughout the stay; to follow recognized infection prevention and control practice while providing care that includes transmission based precautions and isolation; to provide program oversight including planning, organizing, implementing, operating, and monitoring; to maintain all of the elements of the program and ensuring the facility's interdisciplinary teams is involved in infection prevention and control practices; to develop and revise policies, procedures, and practices that promote consistent adherence to evidence-based infection control practices; to plan organize, implement, operate and maintain all the program elements; to define roles and responsibilities during routine implementation of practice and during unusual occurrences or times of potential risk of spread of infection or outbreak; to define and manage resident and employee health initiatives. The infection Prevention and Control Program components include the establishment of surveillance standards and frequency, the development of the education component including the training in infection prevention and control practices that ensures compliance with facility requirements as well as State and Federal regulations.

Based on interview and document review the facility failed to establish a process for antibiotic review in order to determine appropriate indications for use of an antibiotic for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnoses of chronic heart failure, chronic kidney disease, atrial fibrillation. The MDS further identified R15 required supervision with setup help for activities of daily living (ADL's). R15's physician's orders and oncology notes were requested and not received. R15's medication administration record (MAR) dated 3/2025, included the following medication but lacked diagnoses or ongoing need for use: -Bactrim DS 800-160 milligrams (mg). Give one tablet by mouth in the morning every Monday, Wednesday, Friday for due to high dose of steroids. Bactrim order initiated 1/15/25. During an interview on on 4/2/25 at 12:58 p.m., RN-B verified R15 had been receiving Bactrim DS 800-160 mg since 1/15/25 and the medication had not been reviewed for antibiotic stewardship at this time. During an interview on 4/2/25 at 1:48 p.m., pharmacy consultant (PC) stated the facility is new to work with him starting three months ago. PC verified R15 was on Bactrim DS 800-160 mg and R15 had been receiving the medication since 1/15/25. PC stated the facility had not established an antibiotic stewardship program with him yet to review antibiotics monthly during his visit. PC confirmed antibiotics would only be used as ordered by a physician and would not be used long term unless indicated. During an interview on 4/2/25 at 1:50 p.m., nurse practitioner (NP) stated Bactrim DS 800-160 mg was not identified on R15's medication list on file at the clinic. NP verified if the Bactrim order was on the current medication file it would have been reviewed at each physician visit to determine if the medication could be discontinued. NP confirmed the expectation of the facility would be to review antibiotics monthly and since R15's steroid use had been decreased over the past few months the Bactrim should have been discontinued. NP verified that was important to review and discontinue antibiotics for a resident to prevent antibiotic resistance and appropriate antibiotic use. During an interview on 4/2/25 at 2:18 p.m., director of nursing (DON) verified R15 was receiving Bactrim DS 800-160 mg three times a week since 1/15/25. DON confirmed R15 was not being monitored or reviewed for antibiotic stewardship use monthly with the pharmacist or on the facility antibiotic tracking system. The facility did not currently have an infection preventionist (IP) to track and monitor unnecessary antibiotic use. DON verified the expectation of the facility was to monitor each resident receiving antibiotics at least monthly to promote the appropriate use of antibiotics and reduce possible adverse events associated with antibiotic use. A facility policy on medication administration and unnecessary medication use was requested and not received. A facility policy titled Antibiotic Stewardship Program reviewed 2/2020, identified the policy to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The medical director, nursing team and consultant pharmacist would be responsible for promoting the program. The IP was responsible for overseeing the antibiotic stewarship program.

Based on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for for 1 of 4 residents (R25) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure safe delivery of beverages during the dining observation. This deficient practice had the potential to affect all 32 residents who resided in the facility. Findings Include: PPE: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition with diagnoses of dystonia (movement disorder characterized by uncontrollable muscle contractions), neurogenic bladder (nerves that control bladder function are damaged), hypertension (elevated blood pressure), urinary tract infection, anxiety, depression, chronic pain. Identified R25 was independent with bed mobility, transfers and toileting, setup help only for eating and had an indwelling catheter (a hollow, flexible tube inserted through the urethra into the bladder to drain urine into an external collection bag). R25's care plan revised on 1/28/25, identified R25 required an indwelling catheter and staff were to change catheter per physician orders. R25's care plan lacked documentation for use of EBP. R25's annual Care Area Assessment (CAA) dated 1/24/25, identified R25 required an indwelling catheter. R25's CAA lacked documentation for use of EBP. R25's physician order summary report dated 12/13/24, identified R25 had an indwelling catheter that was to be changed by the facility staff on the first Monday of each month. During an observation and interview on 4/1/25 at 9:06 a.m., nursing assistant (NA)-D was in R25's bathroom assisting R25 to get dressed for the day. NA-D washed hands, put on gloves and changed R25's overnight catheter drainage bag to a leg bag for use during the day. NA-D removed her gloves and washed hands. NA-D stated she was unaware R25 was on EBP. Surveyor had NA-D verify R25 had an EBP sign and PPE bin outside of R25's room and that a gown and gloves should have been worn during high contact cares while changing R25's catheter bag and assisting R25 to get dressed. NA-D stated the facility use of EBP was pretty new, unsure of exact date, and NA-D stated she had not had much training on when to use PPE with EBP. HAND HYGIENE: During an observation on 4/1/25 at 4:41 p.m., NA-E placed a clothing protector around a resident's neck and chest area and hooked the snap at the back of the residents neck area. NA-E continued this process for two more residents and touched each residents skin while the snaps were hooked around the resident's neck. NA-E proceeded to the kitchenette area, opened the refrigerator, poured five glasses of milk or juice, picked up each glass holding the top rim and delivered the glass to a resident table. NA-E removed a water pitcher from the fridge, poured multiple glasses of water, carried three glasses at a time holding them by the top rim and placed on a table. NA-E poured three glasses of milk, held top rim of each glass and delivered to a resident table. NA-E opened a cupboard door, took out four glasses and set on counter. NA-E poured four more glasses of juice or milk, held onto top rim with her hand and delivered to a resident table. During an interview on 4/1/25 at 4:52 p.m., NA-E confirmed she placed clothing protectors on residents, touched cupboard doors, refrigerator door handle, did not wash her hands, and was unaware she was touching the top rim of the glasses during dining service. NA-E stated she had not received any training on how to handle food and utensils. NA-E stated by touching the top rim of the glasses it could pass germs to residents and they could become ill. During an interview on 4/2/25 at 11:44 a.m., director of nursing (DON) verified R25 was in EBP and had an indwelling catheter. DON confirmed staff had not received EBP and PPE use training except for the information that was posted on the EBP signs on a resident door. DON verified the expectation of staff was to wear PPE gown and gloves when performing high contact cares with a resident to prevent infection and the spread of infection to other residents and staff. In addition, DON verified the expectation of staff was to hold the bottom of a glass and to not touch the top rim where a resident would place their mouth to prevent infection and the spread of germs. A facility policy titled Infection Control: Essential Principles, undated, identified transmission based precautions including: contact, droplet, airborne. The policy lacked documentation on EBP and use of PPE. A facility policy titled Hand Hygiene Policy and Procedure, undated, identified employees were to follow current Centers for Disease Control and Prevention (CDC) hand hygiene recommendations. All employees were responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. Compliance with proper hand hygiene procedures before and after resident contact was an expectation of all healthcare disciplines. A facility policy titled Infection Control: Essential Principles, undated, identified hand hygiene was the single most important practice to reduce the transmission of infections in healthcare settings and was an essential element of standard precautions. In addition, the policy identified hand hygiene would be completed before and after preparing food. A facility policy on handling food and utensils was requested and not received.

Based on observation, interview and document review, the facility failed to ensure food items were properly labeled and dated after packaging was opened and were disposed of after the expiration date to prevent cross contamination. In addition, the facility failed to maintain a clean and sanitary kitchen area. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings Include: During an initial tour of the kitchen and kitchenettes on 3/31/25 at 2:10 p.m., with dietary manager (DM)-A, the following areas of concern were identified: -walk in refrigerator; one large metal pan of fruit crisp, and a tray of fruit cups were covered and not dated. DM-A indicated they should have been dated and applied dated stickers to each item. -stainless steel cupboards had smears, spots and fingerprints inside and outside the doors. The stainless-steel counter below and across the Robot Coupe on the counter multiple various size crumbs were noted. DM-A indicated they did not use the Robot Coupe at this time. -Elm/Island Pantry kitchenette fridge had some multiple irregular shaped spills and crumbs. It also had a sandwich in clear bags dated 3/24, and a clear plastic container covered with clear wrap unmarked dated 1/22. DM-A indicated he thought the container held Caesar dressing, and thought the date marked was the date it was opened and stated he would get rid of that, and DM-A put the sandwich marked 3/24 in the garbage. DM-A stated items should not be kept more than three days. -Elm kitchenette refrigerator had multiple irregular shaped spills and crumbs on shelves and bottom front area inside covering a few inches. One container of Boost supplement opened and not dated. Ten small dishes with pistachio pudding, uncovered and undated. DM-A confirmed the Boost should have been dated when opened, and the puddings should have been covered and dated. DM-A confirmed the above findings and indicated his expectation was for refrigerators to be cleaned daily or at least every other day. -Lake kitchenette refrigerator had a few irregular shaped thick sticky spills and crumbs on top shelf and spills and crumbs on the bottom front area inside. One sandwich in bag undated, a tomato slice in a small sandwich bag with a large amount of pink liquid dated 3/27, and a small sandwich bag of lettuce undated. In addition, a clear plastic container of butter, with written instructions on container to discard 3/24, and an undated, approximately one-half pound of butter, loosely wrapped in its paper wrapping. DM-A threw all items away. DM-A indicated he was working on getting dietary staff trained, and had a meeting scheduled 4/8/25. During a follow up interview on 4/1/25 at 3:33 p.m., DM-A confirmed the above findings. The stainless-steel cupboards in the kitchen had been cleaned on the outside, but DM-A confirmed they still were not cleaned on the inside, as spots, smears and fingerprints remained. DM-A indicated they should all be wiped down, as well as the refrigerators. DM-A was unable to locate a cleaning schedule for the main kitchen but located a handwritten cleaning schedule for the kitchenettes. DM-A stated it was important to keep the kitchen clean for the integrity of the food and not to invite rodents or pests. DM-A indicated it was important to date foods and to throw items as needed so they were not serving foods that could cause foodborne illness to the residents. Review of the facility policy titled Food Dating And Storage, undated, noted it was to ensure the service of safe potentially hazardous foods/ times and temperatures control for food and safety. The policy instructions included the following: -cover with non-absorbent lid or material, use of zip lock baggies or seal food containers. -date the food product the day put into container. -discard any unused food after five days. -food service director or cook in charge will dispose of food after five days. -condiments in such as dressing, mayo, and frosting have a 30 day shelved life when stored in original containers. -Foods that do not have to be disposed of in five days are foods that have use by, Best by or sell by date located on food products. -always check packages for instructions on when to discard. If different from above, follow package guidelines.

Based on observation, interview, and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R18, R16, R19, and R7) reviewed for grievances. Findings include: On 3/31/25 at 11:00 a.m., a resident council meeting was held with four residents which included R18, R16, R19, and R7. During the resident council meeting, all four residents indicated they were unaware of how to file a grievance. During an observation on 3/31/25 at 12:00 p.m., the surveyor could not locate grievance forms throughout the facility. During a joint interview on 4/1/25 at 12:35 p.m., the administrator and director of nursing (DON) both confirmed the grievances were kept in the social service office. During an interview on 3/31/25 at 2:38 p.m., social services director (SSD) confirmed there were grievances in her office and was unable to locate grievances that were posted in prominent locations for the residents or resident representatives to file grievances anonymously. During an interview on 4/1/25 at 3:46 p.m., registered nurse (RN)-A confirmed that grievance forms were kept in the social service office and unaware if there were grievances posted in prominent locations for the residents or resident representatives to file grievances anonymously. Review of facility form titled Grievance, Complaint and Non-Retaliation Policy, dated 1/2522, stated If an informal resolution could not be found, the resident would be offered the opportunity to file a formal complaint utilizing a grievance report form. The resident may file a grievance orally to an employee. The employee was to complete the grievance report form with the resident's oral report. The resident could file a grievance anonymously. The grievance would be forwarded to the grievance official for review within a reasonably expected timeframe. The grievance official would work with the resident, the resident's representative, the department manager, and the director of nursing and Social Services to work toward an acceptable solution. The facility Grievance policy updated 1/25/22, lacked documentation on how grievances could be filed anonymously or how to obtain a grievance form other than talking to staff.

Based on interview and document review, the facility failed to provide timely notification to a provider for change in condition related to falls for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit and at risk for falling related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23 required supervision or assist to transfer on and off toilet. R23 required supervision with transfers. Review of progress notes from 11/12/24 to 3/31/25, revealed the following: R23's progress note dated 11/12/24 at 2:27 a.m., identified R23's emergency contact was called and informed of R23's fall last night and health status. R23's progress notes lacked documentation of a fall on 11/11/24. R23's progress note dated 1/28/25 at 8:50 a.m., identified R23 was found on the floor laying next to the bed with wheelchair wheels against his back. Staff helped pick R23 up from the floor and took R23 to the bathroom. R23 slipped out of the wheelchair in front of the toilet. Staff picked R23 up and placed R23 on the toilet. R23's progress note dated 2/24/25 at 14:43 p.m., identified R23 was found on the floor in front of the toilet. Staff assisted R23 into wheelchair and then onto the toilet. A follow up note at 4:16 p.m., identified R23's guardian was updated on R23's fall. R23's progress note dated 3/31/25 at 10:18 a.m., R23 was found on the floor in the bathroom. Staff reminded R23 to use the call light before transfers, vitals obtained. R23's progress note dated 3/31/25 at 10:23 a.m., R23 again found sitting on floor in front of toilet. Vitals obtained and diabetic shoes put on for better traction. R23's progress notes lacked documentation the provider had been notified. During an interview on 4/1/25 at 11:47 a.m., licensed practical nurse (LPN)-A stated R23 had a history of falls. LPN-A stated staff were to supervise R23 with toileting and assist as needed. LPN-A stated staff were expected to report a fall, ensure the resident was safe, call provider if suspected injury, complete an incident report and update provider and representative. During an interview on 4/1/25 at 11:49 a.m., RN-B confirmed staff were expected to ensure a resident was safe after a fall, complete an incident/investigation report, update provider and resident representative. A voicemail was left for R23's guardian on 4/2/25 at 2:07 p.m., with no return call. During an interview on 4/2/25 at 2:22 p.m., DON verified R23 had a history of falls. DON confirmed the provider had not been updated on the above falls for R23. DON stated expectations of staff were to ensure resident was safe and not injured after a fall, complete an incident/investigation report and update provider and resident representative. DON confirmed that was important to prevent further falls and ensure the provider and representative were notified. A facility policy titled Accident: Managing Resident Falls, reviewed 7/10/24, identified a fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface. The policy identified a licensed nurse would be notified and evaluate the condition of the resident. Staff were to notify resident representative. Staff were to notify the provider if injury suspected or noted, head strike and on anticoagulants. The policy lacked documentation that a provider would be notified of a fall regardless of injury.

Based on interview and document review, the facility failed to investigate a bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right hip/buttock area measuring approximately 20 centimeter (cm) by 15 cm and a smaller red bruise to the left hip measuring approximately five cm by five cm. R23 stated he did not know how he obtained the bruises. R23's nursing progress note dated 1/18/25 at 2:30 p.m., stated R23 had a four cm by ten cm medium purple contusion on lower sacral (buttock) area. R23 stated he did not recall a injury. Origin unknown. An investigation into causative factors and analysis of R23's bruises was requested and was not received. During an interview on 4/1/25 at 11:47 a.m., licensed practical nurse (LPN)-A stated she was unaware of R23 having any bruises. LPN-A stated she would report to the registered nurse (RN) any bruises or injury of unknown origin and update the doctor. During an interview on 4/1/25 at 11:49 a.m., RN-B stated she was unaware of R23 having any bruises. RN-B stated she would report to the director of nursing (DON) any bruises or injury of unknown origin and complete an investigation report. A voicemail was left for R23's guardian on 4/2/25 at 2:07 p.m., with no return call. During an interview on 4/2/25 at 2:22 p.m., DON stated she was unaware of R23 having any bruises. DON confirmed an investigation had not been completed. DON verified the expectation of staff was to complete an incident report, update the doctor and resident representative and follow up with an investigation report. DON stated it was important for resident safety and to ensure no further bruising or deterioration occurred. During an interview on 4/2/25 at 2:37 p.m., administrator stated she was unaware R23 had any bruises. Administrator confirmed an investigation had not been completed. A facility policy on reporting and investigation was requested and not received.

Based on observation, interview, and document review, the facility failed to provide assistance with routine grooming care which included facial hair removal for 3 of 3 residents (R7, R12, R3) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 as being cognitively intact, and diagnoses which included heart failure, asthma, macular degeneration (vision loss), and dysphagia (difficulty swallowing). R7 required moderate assistance for personal hygiene which included washing and drying face, shaving, and combing hair. R7's care plan revised on 11/4/24, identified R7 requires moderate assistance with personal hygiene. During an observation on 3/31/25 at 4:28 p.m., R7 had .25 centimeters (cm) of hair growth on the cheeks, chin, neck, and upper lips. During an observation on 4/1/25 at 8:11 a.m., R7 was sitting at the breakfast table and continued to have 0.25 cm of hair growth on their face and neck. During an observation on 4/1/25 at 3:50 p.m., R7 was sitting in his room and continued to have 0.25 cm of hair growth on his face and neck. During an interview on 3/31/25 at 4:28 p.m., R7 stated that he would like to be shaved daily. During an interview on 4/1/25 at 4:00 p.m., nursing assistant (NA)-A indicated he was unsure how often R7 would like to be shaved. NA-A reported it was his second shift at the facility and was unaware of how often residents were to be shaved but would assume it would be on a resident's bath day. During an interview on 4/2/25 at 7:18 a.m., NA-B indicated she was unaware of how often R7 would like to be shaved. NA-B indicated residents should have been offered to be shaved on their bath day. NA-B reported it was her first shift at the facility. During an interview on 4/2/25 at 8:01 a.m., NA-C indicated R7 needed assistance with ADLs. NA-C reported R7 was shaved on his bath day and would need to request if he wants to be shaved in addition to once a week. During an interview on 4/1/25 at 4:11 p.m., registered nurse (RN)-A indicated it was her expectation residents were shaved every morning. RN-A verified that R7 had facial hair and should have been offered assistance with grooming. R12 R12's significant change MDS dated [DATE], identified R12 as severely cognitively impaired with diagnoses which included dementia, muscle weakness, and peripheral vascular disease (a progressive disorder of the blood vessels). Identified R12 required maximal assistance for personal hygiene which included washing their face, shaving, and combing their hair. R12's care plan revised on 10/11/24, identified R12 required physical assistance with ADLS and mobility on more than a daily basis. During an observation on 3/31/25 at 4:40 p.m., R12 had one cm of hair growth on the face, upper lip, cheeks, and neck. During an observation on 4/1/25 at 8:11 a.m., R12 was sitting at the breakfast table dressed. R12 had not been shaved and continued to have one cm of facial hair on the face and neck. During an observation on 4/1/25 at 3:49 p.m., R12 was in his room and continued to have one cm of facial hair on his face and neck. During an interview on 3/31/25 at 4:40 p.m., R12 indicated he would like to be shaved daily. During an interview on 4/1/25 at 4:00 p.m., nursing assistant (NA)-A indicated he was unaware of how often R12 liked to be shaved. NA-A reported it was his second shift at the facility and was unaware of how often residents were to be shaved but would assume it would be on a resident's bath day. During an interview on 4/2/25 at 7:18 a.m., NA-B indicated she was unaware of how often R12 would like to be shaved. NA-B indicated residents should have been offered the resident's bath day once a week. NA-B reported it was her first shift at the facility. During an interview on 4/1/25 at 4:11 p.m., RN-A indicated it was her expectation residents were shaved every morning. RN-A went into R12's room and verified that R12 had facial hair around one cm. long. R12 told RN-A he wanted his beard shaved today. During an interview on 4/2/25 at 8:01 a.m., NA-C indicated R12 required assistance with ADLs and was shaved on his bath day. R3 R3 admission MDS dated [DATE], identified R3 as severely cognitively impaired with a diagnosis that included Parkinson ' s (brain disorder that causes problems with movement, balance, and coordination), dementia, and diabetes (a disease that affects how the body uses blood sugars). Identified R3 as being on hospice and needing supervision or touching assistance for combing hair, shaving, washing face and hands. R3 care plan revised on 2/19/25, identified R3 required supervision or touching assistance for personal care. During an observation on 3/31/25 at 3:00 p.m., R3 was sleeping in his room and noted to have two cm of facial hair on cheeks, chin, and neck. During an observation on 4/1/25 at 8:13 a.m., R3 was sitting at the breakfast table sleeping. R3 was dressed and continued to have two cm length of facial hair on face and neck. During an observation on 4/1/25 at 3:27 p.m., R3 was sitting in his bedroom in his wheelchair sleeping. R3 continued to have two cm length of facial hair on the face and neck. During an interview on 3/31/25 at 3:00 p.m., with power of attorney (POA) indicated R3 would like to be shaved daily. R3 shaved daily when living at home and having facial hair would bother him. During an interview on 4/1/25 at 4:00 p.m., nursing assistant (NA)-A indicated he was unaware of how often R3 liked to be shaved. NA-A reported it was his second shift at the facility and was unaware of how often residents were to be shaved but would assume it would be on a resident's bath day. During an interview on 4/2/25 at 7:18 a.m., NA-B indicated she was unaware of how often R3 would like to be shaved. NA-B indicated residents were offered to be shaved on the resident's bath day once a week. NA-B reported it was her first shift at the facility. During an interview on 4/1/25 at 4:11 p.m., RN-A went into R3's room and verified that R12 had facial hair around two cm in length of facial hair. During an interview on 4/2/25 at 8:01 a.m., NA-C indicated R3 required assistance with ADLs and was shaved on his bath day. During an interview on 4/2/25 at 9:02 a.m., director of nursing (DON) indicated residents were shaved on their bath day which was normally once a week. DON was unaware if residents were asked what their preference was with shaving on admission. The DON was unsure if their preference on how often they would like to be shaved was included in the care plan. The DON expectation would be to ask residents what their preference was for shaving and placing the resident's preference in the care plan. A policy for grooming and/or ADL care was requested and non was provided.

Based on interview and document review, the facility failed to comprehensively assess and monitor a bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right hip/buttock area measuring approximately 20 centimeter (cm) by 15 cm and a smaller red bruise to the left hip measuring approximately five cm by five cm. R23 stated he did not know how he obtained the bruises. R23's nursing progress note dated 1/18/25 at 2:30 p.m., stated R23 had a four cm by ten cm medium purple contusion on lower sacral (buttock) area. R23 stated he did not recall a injury. Origin unknown. R23's nursing progress note dated 3/11/25 at 2:11 p.m., stated R23 had a large bruise on lower back- football size. R23 stated the bruise was from hitting the arm of the wheelchair. R23's progress notes lacked comprehensive assessments and monitoring of the large bruises. An investigation into causative factors and analysis of R23's bruises was requested and was not received. During an interview on 4/1/25 at 11:47 a.m., licensed practical nurse (LPN)-A stated she was unaware of R23 having any bruises. LPN-A stated she would report to the registered nurse (RN) any bruises or injury of unknown origin and update the doctor. During an interview on 4/1/25 at 11:49 a.m., RN-B stated she was unaware of R23 having any bruises. RN-B stated she would report to the director of nursing (DON) any bruises or injury of unknown origin and complete a comprehensive assessment and investigation report. RN-B verified a comprehensive assessment and monitoring of R23's bruises had not been completed. A voicemail was left for R23's guardian on 4/2/25 at 2:07 p.m., with no return call. During an interview on 4/2/25 at 2:22 p.m., DON stated she was unaware of R23 having any bruises. DON verified the expectation of staff was to complete an incident report, update the doctor and resident representative and follow up with an investigation report. DON confirmed a comprehensive assessment and monitoring of R23's bruises had not been completed. DON stated assessments and ongoing monitoring was important for resident safety and to ensure no further bruising or deterioration occurred. A facility policy on comprehensive assessments was requested and not received.

Based on observation, interview and document review, the facility failed to provide a comprehensive assessment (fall scene investigation) and a review or adjustment of the current fall prevention interventions to prevent falls for 1 of 1 residents (R23) who had multiple falls within the facility reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit and at risk for falling related to impaired mobility, weakness, history of falls, and an intellectual disorder. R23 required supervision or assist to transfer on and off toilet. R23 required supervision with transfers. Staff were to monitor/document/report any changes. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: -On 11/7/24 at 8:31 a.m., identified R23 was found on the floor in the bathroom. R23 was reminded to use the call light and wait for assistance. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 11/12/24 at 2:27 p.m., identified R23's emergency contact was called and informed of R23's fall last night and health status. R23's progress notes lack documentation of a fall on 11/11/24 and a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 12/17/24 at 6:30 a.m., identified R23 stated he hit his head on the bathroom wall while self transferring from toilet to wheelchair. R23 was sent to the emergency department for evaluation. A follow up progress note on 12/17/24 at 12:03 p.m., identified R23 returned from the emergency department and presented with his usual mental and physical abilities. R23 had a contusion on the left knee and pain in the right hip, received Tylenol. No contusion present on R23's head. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 1/5/25 at 5:30 a.m., identified R23 was found on the floor next to the bed. R23 was assisted into the wheelchair and confirmed no injuries. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 1/27/25 at 7:04 p.m., identified R23 was on the floor with no injury noted. Staff reminded R23 to call for assistance. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 1/28/25 at 8:50 a.m., identified R23 was found on the floor laying next to the bed with wheelchair wheels against his back. Staff helped pick R23 up from the floor and took R23 to the bathroom. R23 then slipped out of the wheelchair in front of the toilet. Staff picked R23 up and placed R23 on the toilet. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 2/24/25 at 14:43 p.m., identified R23 was found on the floor in front of the toilet. Staff assisted R23 into wheelchair and then onto the toilet. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 3/6/25 at 14:40 p.m., identified R23 fell in the bathroom for the second time. After the second fall R23 stated his right knee hurt. The progress notes lacked documentation of a first fall on 3/6/25 and further lacked a fall scene investigation to evaluate the root cause of both falls and implement or change interventions on the plan of care. -On 3/31/25 at 10:18 a.m., R23 was found on the floor in the bathroom. Staff reminded R23 to use the call light before transfers, vitals obtained. The progress note lacked a fall scene investigation to evaluate the root cause of the fall and implement or change interventions on the plan of care. -On 3/31/25 at 10:23 a.m., R23 again found sitting on floor in front of toilet. Vitals obtained and diabetic shoes put on for better traction. The progress note lacked a fall scene investigation to evaluate the root cause of the fall. During an interview on 4/1/25 at 11:47 a.m., licensed practical nurse (LPN)-A stated R23 had a history of falls. LPN-A stated staff were to supervise R23 with toileting and assist as needed. LPN-A stated a falls assessment would be completed and an intervention put in place. During an interview on 4/1/25 at 11:49 a.m., RN-B confirmed the above falls occurred for R23. RN-B verified a falls assessment identified as a fall scene investigation was to be completed after each fall to identify the root cause of the fall and an intervention would be implemented on the care plan to prevent further falls. RN-B confirmed a fall scene investigation and new care plan interventions were not completed for the above falls. During an interview on 4/2/25 at 11:51 a.m., physical therapist (PT) verified R23 was receiving therapy for strengthening and falls. PT stated therapy was working with R23 on standing tolerance as R23 had many falls in the bathroom. PT confirmed R23 was not to be independent in the bathroom and to have staff assistance. During an interview on 4/2/25 at 2:22 p.m., DON verified R23 had a history of falls and verified the above falls occurred. DON confirmed a fall scene investigation and care plan interventions were note completed for the above falls. DON stated expectations of staff were to ensure resident was safe and not injured after a fall, complete a falls scene investigation to evaluate and implement or change interventions on the plan of care. DON confirmed that was important to prevent further falls and injury. A facility policy titled Accident: Managing Resident Falls, reviewed 7/10/24, identified a fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface. The policy identified a licensed nurse would be notified and evaluate the condition of the resident. The staff in conjunction with the interdisciplinary team (IDT), resident and or resident representative would implement the residents plan of care with interventions to reduce the risk of falls. Following a fall, staff would initiate a fall scene investigation to evaluate and implement or change interventions on the plan of care to minimize serious consequences of falling. Immediate interventions implemented or changed to prevent additional falls must be documented on the fall scene investigation form. IDT would review all falls and interventions implemented to further reduce the risk of additional falls.

Based on interview and document review, the facility failed to identify diagnoses or indications for use of medications for 1 of 6 residents (R15) reviewed for unnecessary medications. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnoses of chronic heart failure, chronic kidney disease, atrial fibrillation. Identified R15 required supervision with setup help for activities of daily living (ADL's). R15's physician's orders and oncology notes were requested and not received. R15's medication administration record (MAR) dated 3/2025, included the following medication but lacked diagnoses or ongoing need for use: -Bactrim DS 800-160 milligrams (mg). Give one tablet by mouth in the morning every Monday, Wednesday, Friday for due to high dose of steroids. Bactrim order initiated 1/15/25. During an interview on on 4/2/25 at 12:58 p.m., RN-B verified R15 had been receiving Bactrim DS 800-160 mg since 1/15/25, and the medication had not been reviewed for unnecessary medications at this time. During an interview on 4/2/25 at 1:48 p.m., pharmacy consultant (PC) stated the facility starting working with the facility three months ago. PC verified R15 was on Bactrim DS 800-160 mg and R15 had been receiving the medication since 1/15/25. PC stated the facility had not established an antibiotic stewardship program with him yet to review antibiotics monthly during his visit. PC confirmed antibiotics would only be used as ordered by a physician and would not be used long term unless indicated. During an interview on 4/2/25 at 1:50 p.m., nurse practitioner (NP) stated Bactrim DS 800-160 mg was not identified on R15's medication list on file at the clinic. NP verified if the Bactrim order was on the current medication file it would have been reviewed at each physician visit to determine if the medication could be discontinued. NP confirmed the expectation of the facility would be to review antibiotics monthly and since R15's steroid use had been decreased over the past few months the Bactrim should have been discontinued. NP verified that was important to review and discontinue unnecessary medications for a resident to prevent unnecessary medication use. During an interview on 4/2/25 at 2:18 p.m., director of nursing (DON) verified R15 was receiving Bactrim DS 800-160 mg three times a week since 1/15/25. DON confirmed R15 was not being monitored or reviewed for unnecessary medication use monthly with the pharmacist or on the facility antibiotic tracking system. The facility did not currently have an infection preventionist to track and monitor unnecessary antibiotic use. DON verified the expectation of the facility was to monitor each resident for unnecessary medications at least monthly to prevent unnecessary medication use. A facility policy on medication administration and unnecessary medication use was requested and not received. A facility policy titled Antibiotic Stewardship Program reviewed 2/2020, identified the policy to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The medical director, nursing team and consultant pharmacist would be responsible for promoting the program.

Based on interview and document review, the facility failed to report a bruise of unknown origin to the State Agency (SA) for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right hip/buttock area measuring approximately 20 centimeter (cm) by 15 cm and a smaller red bruise to the left hip measuring approximately five cm by five cm. R23 stated he did not know how he obtained the bruises. R23's nursing progress note dated 1/18/25 at 2:30 p.m., stated R23 had a four cm by ten cm medium purple contusion on lower sacral (buttock) area. R23 stated he did not recall a injury. Origin unknown. An investigation into causative factors and analysis of R23's bruises was requested and was not received. During an interview on 4/1/25 at 11:47 a.m., licensed practical nurse (LPN)-A stated she was unaware of R23 having any bruises. LPN-A stated she would report to the registered nurse (RN) any bruises or injury of unknown origin and update the doctor. During an interview on 4/1/25 at 11:49 a.m., RN-B stated she was unaware of R23 having any bruises. RN-B stated she would report to the director of nursing (DON) any bruises or injury of unknown origin and complete an investigation report. A voicemail was left for R23's guardian on 4/2/25 at 2:07 p.m., with no return call. During an interview on 4/2/25 at 2:22 p.m., DON stated she was unaware of R23 having any bruises. DON confirmed a report to the SA had not been filed and should have been. DON verified the expectation of staff was to complete an incident report, update the doctor and resident representative and follow up with an investigation report. DON stated that was important for resident safety and to ensure no further bruising or deterioration. During an interview on 4/2/25 at 2:37 p.m., administrator stated she was unaware R23 had any bruises. A facility policy on reporting was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure that three years of survey results and the plan of correction were readily accessible to residents or visitors. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings include: During an observation on 4/1/25 at 12:00 p.m., the survey results binder was located on a shelf in a sitting area by the front door. The binder contained the last survey results noted from 2/29/24. The binder lacked the plan of correction for the 2/29/24, survey results. The binder lacked the survey results and plan of correction from the 12/1/22, survey. During a co-interview on 4/1/25 at 12:35 p.m., the administrator and director of nursing (DON) confirmed the most recent survey results from 2/29/24, were in the binder without the plan of correction and the plan of correction should have been included in the binder. The administrator and DON verified their process was to keep the most recent survey results in the binder and not the past three years. A policy on survey inspection results was requested and one was not provided.