Every finding on record at Barrett Care Center Inc

Based on observation, interview, and document review, the facility failed to follow the policy following a report of an allegation of a suspicion of a crime and/or neglect of duty of residents, when an allegation of illicit substance use while on duty by 1 of 1 staff (licensed practical nurse (LPN-A) occurred and immediately suspend LPN-A pending the investigation. Findings include: Review of the 3/23/26, complainant report to the SA identified on 3/22/26, nursing assistant (NA)-A witnessed licensed practical nurse (LPN)-A smoking what appeared to be methamphetamine and contacted the charge nurse on duty (RN-B) and the director of nursing (DON). NA-A was told by the DON that there was no proof. NA-A then sent a video and picture (unknown route) of LPN-A allegedly smoking methamphetamine, however, the DON did not reply to that communication. The administrator was notified around 2:30 p.m., on 3/22/26 and only responded to NA-A, thank you. NA-A also contacted the sheriff's office to report the incident while LPN-A was still working his shift. NA-A was concerned for vulnerable adults that LPN-A was caring for and was advised to contact the SA. There was no mention NA-A had advised the sheriff's office she had photo and video evidence supporting her claim. Review of the 1/1/26, facility Employee Handbook identified all employees were responsible for helping to prevent and eliminate conditions which may cause accidents to residents, employees, or visitors. Staff were to report concerns to their department manager. Failure by a licensed personnel member (registered nurse, licensed practical nurse, certified nursing assistant) to meet professional obligations may result in mandatory reporting to the appropriate licensing board under state law and facility policy. The facility prohibited retaliation against any employee who, in good faith, reported misconduct, safety concerns, or violations of the Vulnerable Adult Act, or who participated in any investigation. There was no mention in the handbook about use of illicit substances being prohibited in the handbook. Interview on 7/21/26 at 4:00 p.m., with the administrator identified that she had seen the video that NA-A had sent to the DON. She stated, you could not even tell who it was. it was unclear. The facility had completed an investigation. She did not have the video when asked to view it, but the DON had it on her phone. Per the facility policy, staff could not video another employee without their permission and the employee who made the complaint, was no longer employed at the facility. The administrator felt the employee left when she did not get the maintenance position she had applied for. She confirmed LPN-A was the nurse that NA-A made the complaint about. She reported an investigation had been completed, and she had called and spoke to LPN-A that day, and the DON had spoke to the other nurse on duty (RN-B). RN-B had reported to the DON nothing was going on or different about LPN-A. A copy of the investigation the facility completed was requested. Interview on 7/21/26 at 4:15 p.m., with DON identified she no longer had the video as that was back in March 2026. The DON reported there were no incidents that day while LPN-A was working, no medication errors or anything. The facility did not drug test their employees, so they did not have LPN-A complete a drug test following the allegation. She revealed that NA-A was very upset that she did not get a position she had applied for, and things had just become different, and she was more disgruntled after not getting the maintenance position she had wanted. Review of 3/22/26, facility investigation identified the administrator had received a call from the DON at 1:55 p.m., informing her that she had been notified via phone from RN-B that NA-A allegedly had seen LPN-A out in the parking lot, on his break, in his car smoking something that was potentially drugs. NA-A reported LPN-A had taken excessive breaks that day. NA-A had sent the DON a video of LPN-A in the car smoking. The DON spoke to RN-B regarding the reported allegation, and RN-B had reported that she did not think LPN-A was intoxicated or impaired at all. The administrator spoke to NA-A at 2:49 p.m. and received a video of the incident stating the DON had not responded to her report, and she wanted to be sure it had been reported to the administrator. At that time, the administrator responded to NA-A she would follow up on the incident and thanked her for bringing it to her attention. The administrator identified she had spoken to LPN-A and he did not appear intoxicated to her. She had asked him about how he was feeling, and about his breaks being excessive. LPN-A responded he did not feel his breaks had been excessive and assured her that he would keep a better eye on the timing of his breaks. He also reported feeling fine and he was doing his job. The investigation identified the video was shown to the pharmacist, and he stated that the video was very difficult to see, and it could potentially be a medical device in the video. The pharmacist agreed with the administrator and DON that the video was unclear who was in the vehicle and what was being smoked. The administrator noted in the investigation per the facility policy, that videotaping of a fellow employee without their knowledge while on break was prohibited. The allegation was unsubstantiated based on the information provided. There was no mention the administrator had performed a thorough investigation consisting of asking residents if their cares were delayed or not completed, if the facility had reviewed any medical records to identify potential neglect, medication errors, etc while LPN-A was working that day. There was also no mention in the investigation that the administrator had interviewed other staff or families about the concerns or had interviewed NA-A in depth about her concerns. There was also no indication if a suspicion of alleged drug use occurred, that the facility had reviewed their controlled medications to identify if potential diversion had taken place nor was there evidence they had called law enforcement (LE) for them to conduct an investigation or view the evidence supplied by NA-A, or had immediately suspended LPN-A while the investigation occurred. Interview on 7/22/26 at 9:01 a.m., with NA-A identified on 3/22/26, RN-B and LPN-A were the nurses on duty for the shift. LPN-A had spent a lot of time in his car, and NA-A, along with another unidentified staff, had been keeping track of LPN-A taking breaks. LPN-A had only been in the building for approximately 2 of NA-A's 8-hour shift. LPN-A was seen smoking in his car from some kind of a pipe. NA-A reported she had a picture and a video, and you could see that it was a long glass pipe he was lighting from the bottom. She stated from what she found on google search, she believed it was a methamphetamine pipe. She reported there was another NA that had witnessed LPN-A, who also thought the same thing. NA-A reported she had followed the chain-of-command and reported her concern to the RN-B. RN-B called and reported the concern to the DON but nothing was done. LPN-A remained at work. NA-A stated she shared the video with the facility and then was told there was no way to prove what he was doing, and it was probably a vape that he was smoking. The next day that she had worked, the DON told her to come to her office and when NA-A asked what it was about, the DON had replied she would be told once in the office. NA-A had asked for a witness to be present, and the DON had RN-B join. NA-A also asked if she could record the conversation and was told she was not allowed to record. The DON was reported to have yelled at her saying she was just spreading rumors and ruining the reputation of other employees. Once she started to scream at her, she walked out of the office. She then asked RN-B to write what happened in that meeting and RN-B refused. NA-A said LPN-A worked his entire shift that day. NA-A stated she had reported LPN-A because LPN-A was responsible for taking care of vulnerable adults and passing their medication, and she was worried if he was under the influence, that he could mess up. She further revealed that she had told LPN-A earlier that day on 3/22/26, about a resident who reported abdominal pain, and LPN-A replied to NA-A it was probably just gas pain and never checked on that resident. Throughout the shift, LPN-A would pass some medications, and then go out and sit in his car. This was not unusual for LPN-A though, and that was why NA-A said they were keeping track of how much he was out in his car, so that they could report back to the DON as it was a common occurrence. NA then stated she had the picture and video of LPN-A and would share it with the SA surveyors. Review of the video NA-A provided showed a male, (LPN-A) sitting in a car, slumped over to his right side. LPN-A then sat upright and was observed to be wearing a gray or blue jacket/sweatshirt type clothing with white writing on it, holding an object to his mouth in his left hand that had a long cylinder-shaped stem pipe-like object, that had a round sphere-like ball at the end and was shiny in appearance. The still picture NA-A provided showed LPN-A holding this pipe-like object grasped in his left hand, wearing the same clothing. LPN-A had on glasses and had short hair in both the video and the still picture. Review of LPN-A's personnel file identified LPN-A had satisfactory reviews in 2021 and 2023. In 2024, LPN-A has satisfactory in all but one column labeled, reports to work on time/attendance which was noted to need improvement. LPN-A's 2026 review, performed on 3/23/26, one day after the incident, identified he was satisfactory with work performance, however there was a note Reminder to watch breaks, be ready to work by 2 (often coming in a few minutes after). No disciplinary action was noted in his file. No 2025 employee review was submitted. Interview on 7/22/26 at 9:49 a.m., with RN-B identified she had worked on 3/22/26. RN-B reported during morning break LPN-A was out in his car and gone for quite some time. over an hour. RN-B had looked outside and seen LPN-A sitting in his car smoking some type of pipe. RN-B stated she then called her supervisor (the DON) and reported this and told her there was another employee (NA-A) who thought he was smoking something like a drug. The supervisor said, we could not assume [it was illegal substances]. She reported she did not notice any impairment in LPN-A herself upon his return. LPN-A does go out to his car a lot and that was not unusual for him. LPN-A tended to take more breaks than anyone else. It was frustrating when he takes excessive breaks because she ended up covering any (resident) behaviors, alarms, or anything else that happens on his assigned hall when he was not there to do his part. LPN-A would often go out to his car to smoke or sleep. RN-B had not witnessed any concerns with LPN-A that day and she reported she had kept an eye on him the entire shift to make sure he was doing everything he was supposed to be doing. RN-B said she never felt like LPN-A was impaired and did not observe signs of impairment. RN-B had not noted how she assessed LPN-A for signs of potential impairment. RN-B made no mention if she had been advised to perform any tasks to ensure resident safety had occurred while LPN-A was outside the facility in the parking lot, or if she should have performed any other procedures, or that the DON was going to come to the facility on 3/22/26 (Sunday) to immediately perform investigative tasks or follow facility policy by immediately suspending LPN-A, pending an investigation. Interview on 7/22/26 at 12:52 p.m., with the consulting pharmacist (RPh) identified he had been shown the video and reported it was very grainy. The video was of a male in his car, and he looked like he was leaning down using some kind of inhalation [device]. The question posed (to him) was, could this person be smoking a crack pipe? In his opinion, usually with that type of pipe you would see visual smoke. He was unable to determine if the male was or wasn't using a pipe. He reported his first impression was that this person may be using an albuterol inhaler or Symbicort for something like asthma. The pharmacist was unable to recall if he was at the facility when he reviewed the video or if it had been sent the video to review. He reported he was asked to give his opinion, and his first reaction was that this was not proof of anything, this was just someone inhaling something. When asked specifically by the facility if it looked like methamphetamine, the answer was unlikely because you would have seen a flame and a cloud of smoke. It was not clear what experience and/or training RPh had in identifying illicit substance use/abuse or specific paraphernalia used. Interview on 7/22/26 at 11:09 a.m., with local police department dispatch identified that they had received a call at 4:44 p.m. on 3/22/26, for a report of an employee who was suspected of smoking a pipe. The deputy assigned reported that he recalled the individual was not at the facility by the time he got the report (unknown time). He was unaware of any video or picture of the event but would have liked to have had that information at the time of the incident. The hard part about the situation was a person can have all the drugs in their system that they want, but he would have had to have physical evidence and probable cause to search the individual. As he recalled, he heard about the incident after the fact, so there was not really anything he could do about it. The courts would consider the video now as stale evidence at this point. Interview on 7/22/26 at 1:52 p.m., with DON and assistant director of nursing (ADON) identified the DON stated when asked if the facility was to report an allegation of a suspicion of a crime to law enforcement, that she would need to review the regulation and the policy. The ADON stated in review of the video that was sent to the facility, management was not able to confirm the video had taken place on the property. The DON reported the RN on duty at the time (RN-B) assessed LPN-A. He did not appear to be impaired, so she felt there was no suspicion of a crime. She revealed LPN-A was a smoker and had a history of taking excessive breaks. The ADON then stated, was it even legal that she recorded him? The DON reported the facility did not report to law enforcement or make a SA report, as they felt they did not have suspicion of LPN-A committing a crime. She reported she did not suspend LPN-A, but they did start an investigation at the time. The video was not provided when the concern was first brought to the DON's attention. the video came later that day (3/22/26). NA-A did not believe RN-B did anything after she reported it to her, so that was when NA-A sent the video to the DON. The DON reported in their interpretation of the report and video, they did not feel the report warranted a call to the police or notification to the SA, but the matter was investigated. The DON again stated that RN-B assessed LPN-A and determined he was not impaired so there was not suspicion of a crime that needed to be reported. The DON did confirm an allegation could be considered suspicion however, LPN-A was assessed and had no impairment so there was no need to call the police. The DON and ADON made no mention of any specific training RN-B had to identify illicit drug use and/or impairment from use for appropriate assessment. LPN-A's timecard was requested for 3/22/26, but not provided by the end of survey. Follow-up email was sent 7/23/26 requesting that information again. Review of the 1/1/26, Employee Handbook identified absence from duty was related to call-in's, however excessive breaks were not mentioned. Use of camera phones for the purpose of photographing residents without their consent was strictly prohibited. There was no such prohibition on taking pictures of staff in outdoor spaces. The facility was to make timely and thorough investigations of all reports and allegations of abuse (and neglect). All members of staff were responsible for helping prevent and eliminate conditions which may cause accidents to residents. Supervisors were to use a progressive process on dealing with work habits that required corrective action. They were to have an employee conference, notice of concern, then a final notice of performance improvement, followed by termination of employment. All staff were mandatory reporters. There was no mention of potential drug use by staff in the employee hand book. Review of the current, undated Abuse Prevention Policy and Plan identified it was the policy of the facility to protect residents who, because of physical or mental disability were dependent on institutional services and were particularly vulnerable to abuse and neglect, to provide safe living environments for vulnerable adults, and assist persons charged with care to provide safe environments. All reports were to be investigated. The facility policy was to orientate, maintain, and follow the abuse prevention plan at all times. A report was required when a mandated reported has reason to believe that a vulnerable adult is being, or has been maltreated (abuse, neglect, financial exploitation, et. Al). Residents of the facility had the right to be free from all types of abuse including verbal, sexual, physical, and mental abuse, corporal punishment, mistreatment, neglect/deprivation, injuries of unknown source (unexplained injuries), misappropriation of resident property, and involuntary seclusion. Definitions included in the policy were:Neglect was defined as a failure of the facility, its employees or service providers, to provide goods and services necessary to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Willful was defined as an individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Depravation of goods and services was defined as depriving residents of services that are necessary to provide care but choosing not to do it. The policy further noted signs of actual physical neglect included inadequate provision of care and a caregiver that was indifferent to residents' personal care and needs. Staff were to report incidents, findings, and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy. Investigating abuse would be done by the charge nurse, DON, SSD and/or the administrator. The interview was to consist of:Interview person(s) reporting the abuse.Interview any witnesses that may have knowledge of the abuse (or neglect).Interview resident (as appropriate).Interview employees of any accused abuse (or neglect).Interview staff persons having contact with resident during the shift of alleged abuseInterview with resident roommates (if applicable), family and visitors.In the case of abuse, an appropriate report form was to be completed, and the information recorded in the resident's medical chart.Alleged or suspected cases of abuse (or neglect) that are reported, the Administrator, Social Services Designee or Director of Nursing was to notify the following agencies of the incident:Minnesota Department of Health.Resident Representative.Law Enforcement.During the investigation, accused employees were to be reassigned to non-resident contact duties or suspended with or without pay until the investigation has been completed. Reporting abuse (or neglect) was to be done immediately upon discovery. Initial reports of abuse (or neglect) were to be reported to MDH, via a secure web site, immediately (not later than 2 hours) of discovery of the incident after forming the suspicion of abuse (or neglect).

Based on observation, interview, and document review, the facility failed to report an allegation of a suspicion of a crime and/or neglect of duty of residents to the State Agency (SA) and Law Enforcement when an allegation of illicit substance use while on duty by 1 of 1 staff (licensed practical nurse (LPN-A) was reported to management. Findings include: Review of the 3/23/26, complainant report to the SA identified on 3/22/26, nursing assistant (NA)-A witnessed licensed practical nurse (LPN)-A smoking what appeared to be methamphetamine and contacted the charge nurse on duty (RN-B) and the director of nursing (DON). NA-A was told by the DON that there was no proof. NA-A then sent a video and picture (unknown route) of LPN-A allegedly smoking methamphetamine, however, the DON did not reply to that communication. The administrator was notified around 2:30 p.m., on 3/22/26 and only responded to NA-A, thank you. NA-A also contacted the sheriff's office to report the incident while LPN-A was still working his shift. NA-A was concerned for vulnerable adults that LPN-A was caring for and was advised to contact the SA. There was no mention NA-A had advised the sheriff's office she had photo and video evidence supporting her claim. Review of the 1/1/26, facility Employee Handbook identified all employees were responsible for helping to prevent and eliminate conditions which may cause accidents to residents, employees, or visitors. Staff were to report concerns to their department manager. Failure by a licensed personnel member (registered nurse, licensed practical nurse, certified nursing assistant) to meet professional obligations may result in mandatory reporting to the appropriate licensing board under state law and facility policy. The facility prohibited retaliation against any employee who, in good faith, reported misconduct, safety concerns, or violations of the Vulnerable Adult Act, or who participated in any investigation. There was no mention in the handbook about use of illicit substances being prohibited in the handbook. Interview on 7/21/26 at 4:00 p.m., with the administrator identified that she had seen the video that NA-A had sent to the DON. She stated, you could not even tell who it was. it was unclear. The facility had completed an investigation. She did not have the video when asked to view it, but the DON had it on her phone. Per the facility policy, staff could not video another employee without their permission and the employee who made the complaint, was no longer employed at the facility. The administrator felt the employee left when she did not get the maintenance position she had applied for. She confirmed LPN-A was the nurse that NA-A made the complaint about. She reported an investigation had been completed, and she had called and spoke to LPN-A that day, and the DON had spoke to the other nurse on duty (RN-B). RN-B had reported to the DON nothing was going on or different about LPN-A. A copy of the investigation the facility completed was requested. Interview on 7/21/26 at 4:15 p.m., with DON identified she no longer had the video as that was back in March 2026. The DON reported there were no incidents that day while LPN-A was working, no medication errors or anything. The facility did not drug test their employees, so they did not have LPN-A complete a drug test following the allegation. She revealed that NA-A was very upset that she did not get a position she had applied for, and things had just become different, and she was more disgruntled after not getting the maintenance position she had wanted. Review of 3/22/26, facility investigation identified the administrator had received a call from the DON at 1:55 p.m., informing her that she had been notified via phone from RN-B that NA-A allegedly had seen LPN-A out in the parking lot, on his break, in his car smoking something that was potentially drugs. NA-A reported LPN-A had taken excessive breaks that day. NA-A had sent the DON a video of LPN-A in the car smoking. The DON spoke to RN-B regarding the reported allegation, and RN-B had reported that she did not think LPN-A was intoxicated or impaired at all. The administrator spoke to NA-A at 2:49 p.m. and received a video of the incident stating the DON had not responded to her report, and she wanted to be sure it had been reported to the administrator. At that time, the administrator responded to NA-A she would follow up on the incident and thanked her for bringing it to her attention. The administrator identified she had spoken to LPN-A and he did not appear intoxicated to her. She had asked him about how he was feeling, and about his breaks being excessive. LPN-A responded he did not feel his breaks had been excessive and assured her that he would keep a better eye on the timing of his breaks. He also reported feeling fine and he was doing his job. The investigation identified the video was shown to the pharmacist, and he stated that the video was very difficult to see, and it could potentially be a medical device in the video. The pharmacist agreed with the administrator and DON that the video was unclear who was in the vehicle and what was being smoked. The administrator noted in the investigation per the facility policy, that videotaping of a fellow employee without their knowledge while on break was prohibited. The allegation was unsubstantiated based on the information provided. There was no mention the administrator had performed a thorough investigation consisting of asking residents if their cares were delayed or not completed, if the facility had reviewed any medical records to identify potential neglect, medication errors, etc while LPN-A was working that day. There was also no mention in the investigation that the administrator had interviewed other staff or families about the concerns or had interviewed NA-A in depth about her concerns. There was also no indication if a suspicion of alleged drug use occurred, that the facility had reviewed their controlled medications to identify if potential diversion had taken place nor was there evidence they had called law enforcement (LE) for them to conduct an investigation or view the evidence supplied by NA-A, or had immediately suspended LPN-A while the investigation occurred. Interview on 7/22/26 at 9:01 a.m., with NA-A identified on 3/22/26, RN-B and LPN-A were the nurses on duty for the shift. LPN-A had spent a lot of time in his car, and NA-A, along with another unidentified staff, had been keeping track of LPN-A taking breaks. LPN-A had only been in the building for approximately 2 of NA-A's 8-hour shift. LPN-A was seen smoking in his car from some kind of a pipe. NA-A reported she had a picture and a video, and you could see that it was a long glass pipe he was lighting from the bottom. She stated from what she found on google search, she believed it was a methamphetamine pipe. She reported there was another NA that had witnessed LPN-A, who also thought the same thing. NA-A reported she had followed the chain-of-command and reported her concern to the RN-B. RN-B called and reported the concern to the DON but nothing was done. LPN-A remained at work. NA-A stated she shared the video with the facility and then was told there was no way to prove what he was doing, and it was probably a vape that he was smoking. The next day that she had worked, the DON told her to come to her office and when NA-A asked what it was about, the DON had replied she would be told once in the office. NA-A had asked for a witness to be present, and the DON had RN-B join. NA-A also asked if she could record the conversation and was told she was not allowed to record. The DON was reported to have yelled at her saying she was just spreading rumors and ruining the reputation of other employees. Once she started to scream at her, she walked out of the office. She then asked RN-B to write what happened in that meeting and RN-B refused. NA-A said LPN-A worked his entire shift that day. NA-A stated she had reported LPN-A because LPN-A was responsible for taking care of vulnerable adults and passing their medication, and she was worried if he was under the influence, that he could mess up. She further revealed that she had told LPN-A earlier that day on 3/22/26, about a resident who reported abdominal pain, and LPN-A replied to NA-A it was probably just gas pain and never checked on that resident. Throughout the shift, LPN-A would pass some medications, and then go out and sit in his car. This was not unusual for LPN-A though, and that was why NA-A said they were keeping track of how much he was out in his car, so that they could report back to the DON as it was a common occurrence. NA-A then stated she had the picture and video of LPN-A and would share it with the SA surveyors. Review of the video NA-A provided showed a male, (LPN-A) sitting in a car, slumped over to his right side. LPN-A then sat upright and was observed to be wearing a gray or blue jacket/sweatshirt type clothing with white writing on it, holding an object to his mouth in his left hand that had a long cylinder-shaped stem pipe-like object, that had a round sphere-like ball at the end and was shiny in appearance. The still picture NA-A provided showed LPN-A holding this pipe-like object grasped in his left hand, wearing the same clothing. LPN-A had on glasses and had short hair in both the video and the still picture. Review of LPN-A's personnel file identified LPN-A had satisfactory reviews in 2021 and 2023. In 2024, LPN-A has satisfactory in all but one column labeled, reports to work on time/attendance which was noted to need improvement. LPN-A's 2026 review, performed on 3/23/26, one day after the incident, identified he was satisfactory with work performance, however there was a note Reminder to watch breaks, be ready to work by 2 (often coming in a few minutes after). No disciplinary action was noted in his file. No 2025 employee review was submitted. Interview on 7/22/26 at 9:49 a.m., with RN-B identified she had worked on 3/22/26. RN-B reported during morning break LPN-A was out in his car and gone for quite some time. over an hour. RN-B had looked outside and seen LPN-A sitting in his car smoking some type of pipe. RN-B stated she then called her supervisor (the DON) and reported this and told her there was another employee (NA-A) who thought he was smoking something like a drug. The supervisor said, we could not assume [it was illegal substances]. She reported she did not notice any impairment in LPN-A herself upon his return. LPN-A does go out to his car a lot and that was not unusual for him. LPN-A tended to take more breaks than anyone else. It was frustrating when he takes excessive breaks because she ended up covering any (resident) behaviors, alarms, or anything else that happens on his assigned hall when he was not there to do his part. LPN-A would often go out to his car to smoke or sleep. RN-B had not witnessed any concerns with LPN-A that day and she reported she had kept an eye on him the entire shift to make sure he was doing everything he was supposed to be doing. RN-B said she never felt like LPN-A was impaired and did not observe signs of impairment. RN-B had not noted how she assessed LPN-A for signs of potential impairment. RN-B made no mention if she had been advised to perform any tasks to ensure resident safety had occurred while LPN-A was outside the facility in the parking lot, or if she should have performed any other procedures, or that the DON was going to come to the facility on 3/22/26 (Sunday) to immediately perform investigative tasks or follow facility policy by immediately suspending LPN-A, pending an investigation. Interview on 7/22/26 at 12:52 p.m., with the consulting pharmacist (RPh) identified he had been shown the video and reported it was very grainy. The video was of a male in his car, and he looked like he was leaning down using some kind of inhalation [device]. The question posed (to him) was, could this person be smoking a crack pipe? In his opinion, usually with that type of pipe you would see visual smoke. He was unable to determine if the male was or wasn't using a pipe. He reported his first impression was that this person may be using an albuterol inhaler or Symbicort for something like asthma. The pharmacist was unable to recall if he was at the facility when he reviewed the video or if it had been sent the video to review. He reported he was asked to give his opinion, and his first reaction was that this was not proof of anything, this was just someone inhaling something. When asked specifically by the facility if it looked like methamphetamine, the answer was unlikely because you would have seen a flame and a cloud of smoke. It was not clear what experience and/or training RPh had in identifying illicit substance use/abuse or specific paraphernalia used. Interview on 7/22/26 at 11:09 a.m., with local police department dispatch identified that they had received a call at 4:44 p.m. on 3/22/26, for a report of an employee who was suspected of smoking a pipe. The deputy assigned reported that he recalled the individual was not at the facility by the time he got the report (unknown time). He was unaware of any video or picture of the event but would have liked to have had that information at the time of the incident. The hard part about the situation was a person can have all the drugs in their system that they want, but he would have had to have physical evidence and probable cause to search the individual. As he recalled, he heard about the incident after the fact, so there was not really anything he could do about it. The courts would consider the video now as stale evidence at this point. Interview on 7/22/26 at 1:52 p.m., with DON and assistant director of nursing (ADON) identified the DON stated when asked if the facility was to report an allegation of a suspicion of a crime to law enforcement, that she would need to review the regulation and the policy. The ADON stated in review of the video that was sent to the facility, management was not able to confirm the video had taken place on the property. The DON reported the RN on duty at the time (RN-B) assessed LPN-A. He did not appear to be impaired, so she felt there was no suspicion of a crime. She revealed LPN-A was a smoker and had a history of taking excessive breaks. The ADON then stated, was it even legal that she recorded him? The DON reported the facility did not report to law enforcement or make a SA report, as they felt they did not have suspicion of LPN-A committing a crime. She reported she did not suspend LPN-A, but they did start an investigation at the time. The video was not provided when the concern was first brought to the DON's attention. the video came later that day (3/22/26). NA-A did not believe RN-B did anything after she reported it to her, so that was when NA-A sent the video to the DON. The DON reported in their interpretation of the report and video, they did not feel the report warranted a call to the police or notification to the SA, but the matter was investigated. The DON again stated that RN-B assessed LPN-A and determined he was not impaired so there was not suspicion of a crime that needed to be reported. The DON did confirm an allegation could be considered suspicion however, LPN-A was assessed and had no impairment so there was no need to call the police. The DON and ADON made no mention of any specific training RN-B had to identify illicit drug use and/or impairment from use for appropriate assessment. LPN-A's timecard was requested for 3/22/26, but not provided by the end of survey. Follow-up email was sent 7/23/26 requesting that information again. Review of the 1/1/26, Employee Handbook identified absence from duty was related to call-in's, however excessive breaks were not mentioned. Use of camera phones for the purpose of photographing residents without their consent was strictly prohibited. There was no such prohibition on taking pictures of staff in outdoor spaces. The facility was to make timely and thorough investigations of all reports and allegations of abuse (and neglect). All members of staff were responsible for helping prevent and eliminate conditions which may cause accidents to residents. Supervisors were to use a progressive process on dealing with work habits that required corrective action. They were to have an employee conference, notice of concern, then a final notice of performance improvement, followed by termination of employment. All staff were mandatory reporters. There was no mention of potential drug use by staff in the employee hand book. Review of the current, undated Abuse Prevention Policy and Plan identified it was the policy of the facility to protect residents who, because of physical or mental disability were dependent on institutional services and were particularly vulnerable to abuse and neglect, to provide safe living environments for vulnerable adults, and assist persons charged with care to provide safe environments. All reports were to be investigated. The facility policy was to orientate, maintain, and follow the abuse prevention plan at all times. A report was required when a mandated reported has reason to believe that a vulnerable adult is being, or has been maltreated (abuse, neglect, financial exploitation, et. Al). Residents of the facility had the right to be free from all types of abuse including verbal, sexual, physical, and mental abuse, corporal punishment, mistreatment, neglect/deprivation, injuries of unknown source (unexplained injuries), misappropriation of resident property, and involuntary seclusion. Definitions included in the policy were:Neglect was defined as a failure of the facility, its employees or service providers, to provide goods and services necessary to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Willful was defined as an individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Depravation of goods and services was defined as depriving residents of services that are necessary to provide care but choosing not to do it. The policy further noted signs of actual physical neglect included inadequate provision of care and a caregiver that was indifferent to residents' personal care and needs. Staff were to report incidents, findings, and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy. Investigating abuse would be done by the charge nurse, DON, SSD and/or the administrator. The interview was to consist of:Interview person(s) reporting the abuse.Interview any witnesses that may have knowledge of the abuse (or neglect).Interview resident (as appropriate).Interview employees of any accused abuse (or neglect).Interview staff persons having contact with resident during the shift of alleged abuseInterview with resident roommates (if applicable), family and visitors.In the case of abuse, an appropriate report form was to be completed, and the information recorded in the resident's medical chart.Alleged or suspected cases of abuse (or neglect) that are reported, the Administrator, Social Services Designee or Director of Nursing was to notify the following agencies of the incident:Minnesota Department of Health.Resident Representative.Law Enforcement.During the investigation, accused employees were to be reassigned to non-resident contact duties or suspended with or without pay until the investigation has been completed. Reporting abuse (or neglect) was to be done immediately upon discovery. Initial reports of abuse (or neglect) were to be reported to MDH, via a secure web site, immediately (not later than 2 hours) of discovery of the incident after forming the suspicion of abuse (or neglect).

Based on observation, interview, and document review, the facility failed to thoroughly investigate an allegation of a suspicion of a crime and/or neglect of duty of residents by 1 of 1 staff (licensed practical nurse (LPN-A) who was reported to have used illicit substances while on duty. Findings include: Review of the 3/23/26, complainant report to the SA identified on 3/22/26, nursing assistant (NA)-A witnessed licensed practical nurse (LPN)-A smoking what appeared to be methamphetamine and contacted the charge nurse on duty (RN-B) and the director of nursing (DON). NA-A was told by the DON that there was no proof. NA-A then sent a video and picture (unknown route) of LPN-A allegedly smoking methamphetamine, however, the DON did not reply to that communication. The administrator was notified around 2:30 p.m., on 3/22/26 and only responded to NA-A, thank you. NA-A also contacted the sheriff's office to report the incident while LPN-A was still working his shift. NA-A was concerned for vulnerable adults that LPN-A was caring for and was advised to contact the SA. There was no mention NA-A had advised the sheriff's office she had photo and video evidence supporting her claim. Review of the 1/1/26, facility Employee Handbook identified all employees were responsible for helping to prevent and eliminate conditions which may cause accidents to residents, employees, or visitors. Staff were to report concerns to their department manager. Failure by a licensed personnel member (registered nurse, licensed practical nurse, certified nursing assistant) to meet professional obligations may result in mandatory reporting to the appropriate licensing board under state law and facility policy. The facility prohibited retaliation against any employee who, in good faith, reported misconduct, safety concerns, or violations of the Vulnerable Adult Act, or who participated in any investigation. There was no mention in the handbook about use of illicit substances being prohibited in the handbook. Interview on 7/21/26 at 4:00 p.m., with the administrator identified that she had seen the video that NA-A had sent to the DON. She stated, you could not even tell who it was. it was unclear. The facility had completed an investigation. She did not have the video when asked to view it, but the DON had it on her phone. Per the facility policy, staff could not video another employee without their permission and the employee who made the complaint, was no longer employed at the facility. The administrator felt the employee left when she did not get the maintenance position she had applied for. She confirmed LPN-A was the nurse that NA-A made the complaint about. She reported an investigation had been completed, and she had called and spoke to LPN-A that day, and the DON had spoke to the other nurse on duty (RN-B). RN-B had reported to the DON nothing was going on or different about LPN-A. A copy of the investigation the facility completed was requested. Interview on 7/21/26 at 4:15 p.m., with DON identified she no longer had the video as that was back in March 2026. The DON reported there were no incidents that day while LPN-A was working, no medication errors or anything. The facility did not drug test their employees, so they did not have LPN-A complete a drug test following the allegation. She revealed that NA-A was very upset that she did not get a position she had applied for, and things had just become different, and she was more disgruntled after not getting the maintenance position she had wanted. Review of 3/22/26, facility investigation identified the administrator had received a call from the DON at 1:55 p.m., informing her that she had been notified via phone from RN-B that NA-A allegedly had seen LPN-A out in the parking lot, on his break, in his car smoking something that was potentially drugs. NA-A reported LPN-A had taken excessive breaks that day. NA-A had sent the DON a video of LPN-A in the car smoking. The DON spoke to RN-B regarding the reported allegation, and RN-B had reported that she did not think LPN-A was intoxicated or impaired at all. The administrator spoke to NA-A at 2:49 p.m. and received a video of the incident stating the DON had not responded to her report, and she wanted to be sure it had been reported to the administrator. At that time, the administrator responded to NA-A she would follow up on the incident and thanked her for bringing it to her attention. The administrator identified she had spoken to LPN-A and he did not appear intoxicated to her. She had asked him about how he was feeling, and about his breaks being excessive. LPN-A responded he did not feel his breaks had been excessive and assured her that he would keep a better eye on the timing of his breaks. He also reported feeling fine and he was doing his job. The investigation identified the video was shown to the pharmacist, and he stated that the video was very difficult to see, and it could potentially be a medical device in the video. The pharmacist agreed with the administrator and DON that the video was unclear who was in the vehicle and what was being smoked. The administrator noted in the investigation per the facility policy, that videotaping of a fellow employee without their knowledge while on break was prohibited. The allegation was unsubstantiated based on the information provided. There was no mention the administrator had performed a thorough investigation consisting of asking residents if their cares were delayed or not completed, if the facility had reviewed any medical records to identify potential neglect, medication errors, etc while LPN-A was working that day. There was also no mention in the investigation that the administrator had interviewed other staff or families about the concerns or had interviewed NA-A in depth about her concerns. There was also no indication if a suspicion of alleged drug use occurred, that the facility had reviewed their controlled medications to identify if potential diversion had taken place nor was there evidence they had called law enforcement (LE) for them to conduct an investigation or view the evidence supplied by NA-A, or had immediately suspended LPN-A while the investigation occurred. Interview on 7/22/26 at 9:01 a.m., with NA-A identified on 3/22/26, RN-B and LPN-A were the nurses on duty for the shift. LPN-A had spent a lot of time in his car, and NA-A, along with another unidentified staff, had been keeping track of LPN-A taking breaks. LPN-A had only been in the building for approximately 2 of NA-A's 8-hour shift. LPN-A was seen smoking in his car from some kind of a pipe. NA-A reported she had a picture and a video, and you could see that it was a long glass pipe he was lighting from the bottom. She stated from what she found on google search, she believed it was a methamphetamine pipe. She reported there was another NA that had witnessed LPN-A, who also thought the same thing. NA-A reported she had followed the chain-of-command and reported her concern to the RN-B. RN-B called and reported the concern to the DON but nothing was done. LPN-A remained at work. NA-A stated she shared the video with the facility and then was told there was no way to prove what he was doing, and it was probably a vape that he was smoking. The next day that she had worked, the DON told her to come to her office and when NA-A asked what it was about, the DON had replied she would be told once in the office. NA-A had asked for a witness to be present, and the DON had RN-B join. NA-A also asked if she could record the conversation and was told she was not allowed to record. The DON was reported to have yelled at her saying she was just spreading rumors and ruining the reputation of other employees. Once she started to scream at her, she walked out of the office. She then asked RN-B to write what happened in that meeting and RN-B refused. NA-A said LPN-A worked his entire shift that day. NA-A stated she had reported LPN-A because LPN-A was responsible for taking care of vulnerable adults and passing their medication, and she was worried if he was under the influence, that he could mess up. She further revealed that she had told LPN-A earlier that day on 3/22/26, about a resident who reported abdominal pain, and LPN-A replied to NA-A it was probably just gas pain and never checked on that resident. Throughout the shift, LPN-A would pass some medications, and then go out and sit in his car. This was not unusual for LPN-A though, and that was why NA-A said they were keeping track of how much he was out in his car, so that they could report back to the DON as it was a common occurrence. NA then stated she had the picture and video of LPN-A and would share it with the SA surveyors. Review of the video NA-A provided showed a male, (LPN-A) sitting in a car, slumped over to his right side. LPN-A then sat upright and was observed to be wearing a gray or blue jacket/sweatshirt type clothing with white writing on it, holding an object to his mouth in his left hand that had a long cylinder-shaped stem pipe-like object, that had a round sphere-like ball at the end and was shiny in appearance. The still picture NA-A provided showed LPN-A holding this pipe-like object grasped in his left hand, wearing the same clothing. LPN-A had on glasses and had short hair in both the video and the still picture. Review of LPN-A's personnel file identified LPN-A had satisfactory reviews in 2021 and 2023. In 2024, LPN-A has satisfactory in all but one column labeled, reports to work on time/attendance which was noted to need improvement. LPN-A's 2026 review, performed on 3/23/26, one day after the incident, identified he was satisfactory with work performance, however there was a note Reminder to watch breaks, be ready to work by 2 (often coming in a few minutes after). No disciplinary action was noted in his file. No 2025 employee review was submitted. Interview on 7/22/26 at 9:49 a.m., with RN-B identified she had worked on 3/22/26. RN-B reported during morning break LPN-A was out in his car and gone for quite some time. over an hour. RN-B had looked outside and seen LPN-A sitting in his car smoking some type of pipe. RN-B stated she then called her supervisor (the DON) and reported this and told her there was another employee (NA-A) who thought he was smoking something like a drug. The supervisor said, we could not assume [it was illegal substances]. She reported she did not notice any impairment in LPN-A herself upon his return. LPN-A does go out to his car a lot and that was not unusual for him. LPN-A tended to take more breaks than anyone else. It was frustrating when he takes excessive breaks because she ended up covering any (resident) behaviors, alarms, or anything else that happens on his assigned hall when he was not there to do his part. LPN-A would often go out to his car to smoke or sleep. RN-B had not witnessed any concerns with LPN-A that day and she reported she had kept an eye on him the entire shift to make sure he was doing everything he was supposed to be doing. RN-B said she never felt like LPN-A was impaired and did not observe signs of impairment. RN-B had not noted how she assessed LPN-A for signs of potential impairment. RN-B made no mention if she had been advised to perform any tasks to ensure resident safety had occurred while LPN-A was outside the facility in the parking lot, or if she should have performed any other procedures, or that the DON was going to come to the facility on 3/22/26 (Sunday) to immediately perform investigative tasks or follow facility policy by immediately suspending LPN-A, pending an investigation. Interview on 7/22/26 at 12:52 p.m., with the consulting pharmacist (RPh) identified he had been shown the video and reported it was very grainy. The video was of a male in his car, and he looked like he was leaning down using some kind of inhalation [device]. The question posed (to him) was, could this person be smoking a crack pipe? In his opinion, usually with that type of pipe you would see visual smoke. He was unable to determine if the male was or wasn't using a pipe. He reported his first impression was that this person may be using an albuterol inhaler or Symbicort for something like asthma. The pharmacist was unable to recall if he was at the facility when he reviewed the video or if it had been sent the video to review. He reported he was asked to give his opinion, and his first reaction was that this was not proof of anything, this was just someone inhaling something. When asked specifically by the facility if it looked like methamphetamine, the answer was unlikely because you would have seen a flame and a cloud of smoke. It was not clear what experience and/or training RPh had in identifying illicit substance use/abuse or specific paraphernalia used. Interview on 7/22/26 at 11:09 a.m., with local police department dispatch identified that they had received a call at 4:44 p.m. on 3/22/26, for a report of an employee who was suspected of smoking a pipe. The deputy assigned reported that he recalled the individual was not at the facility by the time he got the report (unknown time). He was unaware of any video or picture of the event but would have liked to have had that information at the time of the incident. The hard part about the situation was a person can have all the drugs in their system that they want, but he would have had to have physical evidence and probable cause to search the individual. As he recalled, he heard about the incident after the fact, so there was not really anything he could do about it. The courts would consider the video now as stale evidence at this point. Interview on 7/22/26 at 1:52 p.m., with DON and assistant director of nursing (ADON) identified the DON stated when asked if the facility was to report an allegation of a suspicion of a crime to law enforcement, that she would need to review the regulation and the policy. The ADON stated in review of the video that was sent to the facility, management was not able to confirm the video had taken place on the property. The DON reported the RN on duty at the time (RN-B) assessed LPN-A. He did not appear to be impaired, so she felt there was no suspicion of a crime. She revealed LPN-A was a smoker and had a history of taking excessive breaks. The ADON then stated, was it even legal that she recorded him? The DON reported the facility did not report to law enforcement or make a SA report, as they felt they did not have suspicion of LPN-A committing a crime. She reported she did not suspend LPN-A, but they did start an investigation at the time. The video was not provided when the concern was first brought to the DON's attention. the video came later that day (3/22/26). NA-A did not believe RN-B did anything after she reported it to her, so that was when NA-A sent the video to the DON. The DON reported in their interpretation of the report and video, they did not feel the report warranted a call to the police or notification to the SA, but the matter was investigated. The DON again stated that RN-B assessed LPN-A and determined he was not impaired so there was not suspicion of a crime that needed to be reported. The DON did confirm an allegation could be considered suspicion however, LPN-A was assessed and had no impairment so there was no need to call the police. The DON and ADON made no mention of any specific training RN-B had to identify illicit drug use and/or impairment from use for appropriate assessment. LPN-A's timecard was requested for 3/22/26, but not provided by the end of survey. Follow-up email was sent 7/23/26 requesting that information again. Review of the 1/1/26, Employee Handbook identified absence from duty was related to call-in's, however excessive breaks were not mentioned. Use of camera phones for the purpose of photographing residents without their consent was strictly prohibited. There was no such prohibition on taking pictures of staff in outdoor spaces. The facility was to make timely and thorough investigations of all reports and allegations of abuse (and neglect). All members of staff were responsible for helping prevent and eliminate conditions which may cause accidents to residents. Supervisors were to use a progressive process on dealing with work habits that required corrective action. They were to have an employee conference, notice of concern, then a final notice of performance improvement, followed by termination of employment. All staff were mandatory reporters. There was no mention of potential drug use by staff in the employee hand book. Review of the current, undated Abuse Prevention Policy and Plan identified it was the policy of the facility to protect residents who, because of physical or mental disability were dependent on institutional services and were particularly vulnerable to abuse and neglect, to provide safe living environments for vulnerable adults, and assist persons charged with care to provide safe environments. All reports were to be investigated. The facility policy was to orientate, maintain, and follow the abuse prevention plan at all times. A report was required when a mandated reported has reason to believe that a vulnerable adult is being, or has been maltreated (abuse, neglect, financial exploitation, et. Al). Residents of the facility had the right to be free from all types of abuse including verbal, sexual, physical, and mental abuse, corporal punishment, mistreatment, neglect/deprivation, injuries of unknown source (unexplained injuries), misappropriation of resident property, and involuntary seclusion. Definitions included in the policy were:Neglect was defined as a failure of the facility, its employees or service providers, to provide goods and services necessary to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Willful was defined as an individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Depravation of goods and services was defined as depriving residents of services that are necessary to provide care but choosing not to do it. The policy further noted signs of actual physical neglect included inadequate provision of care and a caregiver that was indifferent to residents' personal care and needs. Staff were to report incidents, findings, and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy. Investigating abuse would be done by the charge nurse, DON, SSD and/or the administrator. The interview was to consist of:Interview person(s) reporting the abuse.Interview any witnesses that may have knowledge of the abuse (or neglect).Interview resident (as appropriate).Interview employees of any accused abuse (or neglect).Interview staff persons having contact with resident during the shift of alleged abuseInterview with resident roommates (if applicable), family and visitors.In the case of abuse, an appropriate report form was to be completed, and the information recorded in the resident's medical chart.Alleged or suspected cases of abuse (or neglect) that are reported, the Administrator, Social Services Designee or Director of Nursing was to notify the following agencies of the incident:Minnesota Department of Health.Resident Representative.Law Enforcement.During the investigation, accused employees were to be reassigned to non-resident contact duties or suspended with or without pay until the investigation has been completed. Reporting abuse (or neglect) was to be done immediately upon discovery. Initial reports of abuse (or neglect) were to be reported to MDH, via a secure web site, immediately (not later than 2 hours) of discovery of the incident after forming the suspicion of abuse (or neglect).

Based on interview and document review, the facility failed to analyze the data from the employee illnesses tracking to determine a potential outbreak of Norovirus when 3 of 4 employees (nursing assistant (NA)-B, licensed practical nurse (LPN)-A, assistant director of nursing (ADON)) were out ill with diarrhea and emesis who returned to work within 24 hours. Additionally, the facility failed to have a system in place to monitor resident room refrigerators for cleanliness, expired food, and appropriate temperatures for safe storage of food for 10 of 10 residents (R1, R5, R6, R9, R10, R11, R12, R19, R26, and R135) with in-room refrigerators. The deficient practices has the ability to affect all 35 residents. Findings include: EMPLOYEE SURVEILLANCE Review of the 2024-2025 Norovirus Information for Long-term Care Facilities, located at, https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf, identified Norovirus common symptoms as diarrhea, vomiting, nausea, abdominal pain, low-grade fever, headache, body aches. Monitor for staff illness and restrict ill staff/volunteers from patient care and food handling duties until 72 hours after their vomiting/diarrhea has ended. Review of Staff Illness surveillance for the month of March 2025, identified: 1) 3/18/25, LPN-A called in with signs/symptoms (s/s) of diarrhea and vomiting. NA-A returned to work on 3/19/25, the next day. 2) 3/24/25, NA-B called in with s/s of diarrhea, vomiting, and body aches. NA-B returned to work on 3/25/25, the next day. 3) 3/25/25, NA-A called in with s/s of diarrhea, vomiting, and sore throat. NA-A returned to work on 4/4/25, 9 days later. 4) 3/27/25, the assistant director of nursing (ADON) called in with s/s diarrhea and vomiting. The ADON returned to work on 3/28/25, the next day. Review of Resident illness surveillance for the month of March 2025, identified no residents with gastrointestinal (GI) symptoms. Interview on 6/24/25 at 2:38 p.m., with the director of nursing (DON) identified that the charge nurse determined if a staff could return to work. The charge nurse assessed the staff and made that determination prior to the staff working. When asked about the body aches, diarrhea, and vomiting symptom, if those could potentially be the symptoms of norovirus, the DON said she would need to review the policy. When asked about following the facility return to work policy the DON responded stated she would need to review the policy. Interview on 6/24/25 at 2:43 p.m., with ADON when asked if staff with s/s of diarrhea and vomiting, potential s/s of norovirus should have returned to work within 24 hours. She replied that the charge nurse had to assess staff and clear them to return to work. When asked about the facility return to work policy, which identified if symptoms are consistent with norovirus infection, employees should stay home for a minimum of 48 hours after symptom resolution. She reported she thought her s/s were more food poisoning. She identified she had reviewed the staff surveillance and determined that no staff had worked the same shift and there had been no correlation or pattern noted. She would provide documentation of the review for March employee call-ins. On 6/25/25, the ADON provided the first quarter 2025, infection control report brought forth to the QAPI meeting which identified for the month of March items reviewed in bullet points as: 1) Preparing for COVID booster clinic in April. 2) Educated on policy for employee emesis. 3) Identified 50% of infections were on the north end of the building. 4) Noted GI signs and symptoms in staff, potential trend, reviewed staff members/dates, but not noted to be correlated with each other. The infection control report lacked documentation of analysis of how the March GI staff illness were determined to not be correlated. Review of the 4/24/25, first quarter QAPI meeting minutes provided by QAPI coordinator. Included the infection control report brought forth to the QAPI meeting by infection preventionist (IP) and ADON which identified for the month of March items reviewed in bullet points as: 1) Preparing for COVID booster clinic in April. 2) There had been a noted trend of limited documentation of infections noted in chart besides on the MAR. This made it hard to paint a clear picture of what the signs and symptoms were, when they started, or how the specific signs and symptoms had improved or not. 3) Should consider monitoring all wounds for signs and symptoms of infection. 4) Educated on policy for employee emesis. 5) Identified 50% of infections were on the north end of the building. There was no notation of the information provided by the ADON, in March 2025, on GI signs and symptoms in staff, potential trend, with no correlation noted in the report provided by QAPI coordinator. Interview on 6/24/25 at 12:40 p.m., with administrator identified that the charge nurse assessed an employee and had to clear the employee before they were allowed to return to work. The charge nurse had access to the staff illness form which identified the employee reason for call in and symptoms. The administer declined to confirm she would expect staff to follow the facility policy on return-to-work criteria. Review of undated, Employee Illnesses and Return to Work Criteria policy identified if symptoms are consistent with norovirus infection, employees should stay home for a minimum of 48 hours after symptom resolve. The policy identified that the IP would monitor staff illness log monthly or periodically for actions to be taken when trends are noted to prevent spread of infection. The policy lacked any mention that the IP should be monitoring staff illness on an ongoing basis to prevent potential outbreaks. REFRIDGERATORS Observation and interview on 6/25/25 at 4:30 p.m , of R1's room where there was a small refrigerator larger than a dorm styled one, with multiple bottles of water stacked inside. There was a thermometer located inside the refrigerator but no sign of a temperature log within the room. R1 reported he was unsure if anyone cleaned his refrigerator or if anyone monitored the temperature of the refrigerator. He reported he only kept water in the refrigerator as he like cold water. Observation on 6/25/25 at 4:40 p.m., of R12's room where there was a small dorm style refrigerator. Inside the refrigerator was 3 individual containers of applesauce and a thermometer. There was no sign of a temperature log within the room. Observation and interview on 6/25/25 at 4:43 p.m., of R19's room where there was a small dorm style refrigerator. Inside the refrigerator was a can of soda and a thermometer. There was no sign of a temperature log within the room. R19 was unsure if anyone cleaned the refrigerator or if anyone checked the temperature of the refrigerator, he had not seen anyone ever do that. Observation on 6/23/25 at 2:00 p.m., the following was observed: 1.) R5's had a small refrigerator with a freezer located in her room. The freezer had ice cream bars and a small container of sherbet. The freezer had 1-2 inches of frost built up around the top and the freezer door was difficult to close. The refrigerator had a container of yogurt and 2 containers of apple juice. On the bottom shelf was 4 glass flower vases that had a unknown green and black substance dried on the inside of them. The bottom shelves had a pink stick substance with dirt/dust particles noted on the inner shelves and sides of the refrigerator. There was no thermometer located in the refrigerator or freezer. 2.) R6 had a small refrigerator with a freezer in her room. The refrigerator contained jelly, pop, fruit juice, fruit cups, and chocolate bars. The thermometer read 41 degrees. The freezer did not have a thermometer. 3.) R9 had a small refrigerator with a freezer located in his room, the freezer contained 2 frozen Ribeye steaks. The freezer did not have a thermometer. The refrigerator contained jelly and summer sausage. The refrigerator had a thermometer that read 39 degrees. 4.) R10 had a small refrigerator with a freezer located in her room. The refrigerator contained Gatorade, yogurt, and ranch dressing. A thermometer was in the refrigerator that read 39 degrees. The freezer did not have a thermometer. 5.) R26 had a refrigerator inside her room, the refrigerator had ranch dressing and cheese inside. There was no thermometer observed in the refrigerator or freezer. None of the refrigerators were observed to have a log present for monitoring temperature, nor was there any dating on food items to ensure food was discarded appropriately to prevent food-borne illness. Observation on 6/23/25 at 7:06 p.m., of R11's room fridge identified a small thermometer positioned on bottom floor of the fridge with a temperature of 39 degrees. The fridge appeared clean and had several unopened cans of Coca-Cola soda that was stored. Observation and interview on 6/24/25 at 4:51 p.m., of R135's room fridge identified a small thermometer that was placed on the second shelf of the fridge with a temperature of 39 degrees. Family member (FM)-A grabbed a small plastic container of carrots and with a date of 5/16/25 on the lid. FM-A opened the lid and identified small white fuzzy coat surrounding the outside of the carrots. FM-A stated to R135 that R135's carrots were expired. R135 replied, throw it away. FM-A discarded the item. FM-A discovered a four-ounce container of blueberry yogurt with an expiration date of 6/10/25. FM-A had informed R135, the yogurt may not be safe to eat. R135 stated none of the employees come in and check the food products in R135's fridge and was not aware what the normal temperature of R135's fridge should be for R135's food to stay cold when stored. Neither R11 and R135's room had no evidence temperatures were logged or recorded daily to ensure food remained at safe temperatures. Interview on 6/24/25 at 7:50 a.m., with housekeeper (HK)-A identified they do not have a schedule for checking refrigerators temps or cleaning but she says she does check them maybe every couple weeks Interview on 6/24/25 at 8:00 p.m., with the administrator identified she agreed with the above findings, and thought housekeeping was monitoring the resident refrigerators and had a process to ientify when food shoud be discarded, however, when she had spoken to the supervisor, she was told they had not been logging any temps or signing off the resident refrigerators had been cleaned or checked for expired foods. Interview on 6/25/25 at 8:15 a.m., with the housekeeping supervisor they check the refrigerators every Thursday and if there is old food in the fridge, they ask the resident if they can throw it away. If the resident says no, they leave the expired food in the refrigerator and go back and ask on another day. She identified she had no logs to show when the refrigerators were checked and had not audited to ensure the task was being completed. Review of the undated Resident Refrigerator policy was one paragraph as follows: Refrigerators and freezers will be examined by staff on bath day. The staff will make sure fridge looks clean and that there is no old food. The refrigerators will be thoroughly cleaned, old food thrown and wiped down when resident discharges form the facility. The policy made no mention of how the facility would monitor temperatures of resident refrigerators or freezers to ensure food could be safely stored.

Based on observation, interview, and document review, the facility failed to follow manufacturer's instructions and label liquid gabapentin (used to treat seizures) solution with an open and discard date for 1 of 1 resident (R24) reviewed for medication storage for 1 of 1 medication rooms. Findings include: Observation on [DATE] at 7:15 p.m., identified 1 of 1 medication room fridge had a opened bottle of liquid gabapentin with R24's name on the label had no open or discard date on the bottle. R24's current, undated diagnoses sheet identified R24 had dementia, anxiety, and idiopathic peripheral autonomic neuropathy (nerve damage that affects body functions, such as the heart rate, blood pressure, digestion and temperature). R24's [DATE], medication administration report (MAR) identified R24 was to receive gabapentin 250 milligram (mg)/ 5 milliliter (ml), give 2 mls by mouth daily, 2 mls equals 100mg and gabapentin 250 mg/5 ml, give 6 mls by mouth daily, 6 mls equals 300mg can be given in water for anxiety. Interview on [DATE] at 7:22 p.m., with licensed practical nurse (LPN)-A identified R24's solution bottle had no open date or discard date on the label. LPN-A identified R24 medication bottle last up to 90 days, once the seal had been broken. Interview on [DATE] at 7:39 p.m., with registered nurse (RN)-B had initially opened the bottle to administer the medication to R24 during his shift, however, RN-B forgot to label the bottle before returning it to the medication fridge. RN-B identified R24's medication was delivered to the facility on [DATE], however, RN-B could not provide documentation to support when the medication was delivered. Observation and interview on [DATE] at 3:08 p.m., with director of nursing (DON) confirmed R24's solution bottle had no open or discard date on the label. The local pharmacy was called for instructions to identify when R24's solution bottle was to be expired. The pharmacy directed the facility to use the manufacture's label on the bottle, as directed. When asked if there was supporting documentation of when the pharmacy was notified, the DON could not provide documentation of when the call was placed. Interview on [DATE] at 3:55 p.m., with licensed pharmacist would expect medications to be labeled with an open or discard date to identify medication use before it expired. Interview on [DATE] at 4:02 p.m., with local pharmacy identified R24's gabapentin solution bottle had a highlighted bold date of [DATE]. The date listed on the bottle was when the medication was prepared and was to be used within one year before it expired. Interview on [DATE] at 11:02 a.m., with registered nurse (RN)-A identified the local pharmacy was contacted during the survey to find out when R24's medication was to be expired. RN-A would expect nursing staff to label medications with an open or discard date, when used. Review of [DATE], Labeling of Medications policy identified the facility was to have procedures in place to ensure medications was properly labeled in accordance with state and federal regulations.

Based on interview and document review, the facility failed to ensure resident trust account statements were provide on at least a quarterly basis for 1 of 1 residents (R8) reviewed for personal fund accounts. Findings include: R8's quarterly minimum data set (MDS) dated [DATE], indicate R8 was cognitively intact. During interview on 8/14/24 at 12:52 p.m., R8 stated she did not receive any kind of statements from the facility. R8 stated she made her own decisions, but her daughter took care of the bills. R8 then called her daughter on speaker phone and asked if she received any financial statements from the facility. R8's daughter stated she received monthly billing statements, however, she did not receive a statement for R8's personal funds account. During interview on 8/14/24 at 1:11 p.m., business office manager (BM) stated the facility had a separate account set up for personal funds. BM stated bank statements were sent to her and she would balance each personal account against the bank statements. BM stated she used an excel spreadsheet to track resident personal fund accounts and cognitive residents who wanted to know their balance could ask her for that information. BM went on to state if a resident requested a statement, she would print it but did not routinely provide personal account statements to residents or families. Facility policy Resident Personal Funds indicated to comply with regulations regarding the management of resident personal funds the facility will set as a fiduciary of the residents' funds and hold, safeguard, manage, and account for the personal funds of the residents' funds. The policy further indicated records of receipts, disbursements, balances, and notices would be open to the resident or guardian or Department of Health upon request. The policy lacked information on frequency of issuing statements.

Based on observation, interview and document review the facility failed to ensure proper handwashing and glove usage was implemented for 1 of 1 resident (R16) observed for wound cares. Findings include: R16's face sheet dated 8/14/24, identified diagnoses including hereditary spastic paraplegia (genetic inability to move limbs/body), neuromuscular dysfunction of the bladder (bladder dysfunction-requires catheterization), weakness, and dementia. R16's quarterly minimum data set (MDS) dated [DATE], identified R16 had moderate cognitive impairment, and was completely dependent for mobility and self-cares. R16's Order Summary Report dated 8/15/24, indicated wound care orders for a stage three pressure ulcer to the coccyx (lower back-area just above buttocks) which stated the following: Cleanse with wound cleaner, apply skin prep to peri wound and apply a foam bordered dressing 3x (3 times) a week and as needed (PRN). On 8/14/24 at 11:48 a.m., registered nurse (RN)-B completed a dressing change on R16's wound site. RN-B was wearing gloves and removed the soiled dressing from R16's wound. RN-B did not change gloves or perform hand hygiene. RN-B proceeded to apply wound cleaner and cleaned the wound with soiled gloves. After cleansing of the wound, RN-B removed gloves and preformed hand hygiene. RN-B placed the new dressing. RN-B removed gloves, however, did not preform hand hygiene. The wound was covered. RN-B turned R16 on to their back and placed a clean split gauze over R16's super pubic catheter site (open area in the pelvic skin that allows for the catheter to pass to the bladder instead of through the urethra) prior to performing hand hygiene or donning gloves On 8/14/24 at 12:06 p.m., nursing assistant (NA)-A, who had been assisting RN-B with R16 dressing change, removed their gown and gloves. NA-A exited the room with the resident and assisted R16 to the dining room to eat lunch, however NA-A did not preform hand hygiene after providing resident cares. On 8/14/24 at 12:07 p.m., RN-B stated staff were expected to wash hands when entering or exiting a room, taking off gloves, hands are visibly soiled, and doing cares. RN-B stated they had not worn gloves because the tape used to secure the gauze stuck to the gloves. RN-B stated they should have completed hand hygiene every time gloves were removed. On 8/14/24 at 12:09 p.m., NA-A stated they were expected to wash hands when entering or exiting a room, taking off gloves, and doing cares. NA-A stated they had brought the resident to the dining room and had washed their hands after exiting the dining room. NA-A confirmed they should have washed their hands prior to exiting the resident's room. On 8/14/24 at 12:34 p.m., the infection preventionist (RN)-A stated staff were expected to wash their hands after cares, taking off gloves, during dressing changes, and when hands were visibly soiled. RN-A confirmed during dressing changes, after removing gloves, and when leaving the resident's room, hand hygiene should have been completed to prevent the spread of infection. On 8/15/24 at 09:49 a.m., the director of nursing (DON) (O)-A expected staff to preform hand hygiene before and after cares, and when visibly soiled. The DON confirmed hand hygiene should have been completed after removing the soiled dressings during a dressing change and before moving to a different site to prevent the spread of infection. Further, hand hygiene should have been performed prior to exiting a resident's room. The undated Standard Precaution-Hand Hygiene Policy indicated the following: Hand hygiene should be preformed during the, but not limited to the following situations: -Coming on duty -When hands are visibly soiled -Before and after: Direct resident contact Performing invasive procedures Entering isolation settings Eating or handling food Assisting residents with meals Assisting resident with personal cares Inserting indwelling catheters Handing catheters and invasive devices Changing a dressing Assisting a resident with toileting

Based on interview and document review the facility failed to ensure that the facility assessment was reviewed and updated annually. This had the potential to affect all 33 residents who resided in the facility. Findings include: Review of the 9/1/20, Facility Assessment identified there was no indication that the facility assessment had been reviewed annually or as necessary to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Interview on 3/24/22 at 4:04 p.m., with administrator confirmed the facility assessment had not been reviewed or updated since 2020. She revealed the facility assessment should have been reviewed, but with COVID, that review had been missed.

Based on observation and interview, the facility failed to ensure proper containment of garbage in the outside dumpsters to prevent harboring pests and rodents. This had the potential to affect all 40 residents residing in the facility. Findings include: On 2/18/20, at 12:09 p.m. during a tour of the facility kitchen area with dietary manager (DM)-A present, the facility's two dumpsters located in the back of the building were observed. Both dumpster's lids were open, and several black and white garbage bags were observed, overflowing two to four feet on top of both dumpsters. DM-A confirmed the dumpsters were overflowing, and indicated the facility garbage containers were emptied weekly, and were scheduled to be emptied the next day. On 2/18/20, at 3:57 p.m. Administrator confirmed the facility had two dumpsters that were emptied weekly and were scheduled to be emptied the next morning. Administrator confirmed the dumpsters were very full and indicated the facility had this problem in the past, at times. Administrator indicated if the dumpsters were overfilled, it was because the back side of the dumpster was not being utilized, and confirmed the entire dumpster was overfilled at present. Administrator confirmed the dumpster lids were unable to be closed when the dumpsters were that full. On [DATE], at 1:52 p.m. maintenance director (MD)-A confirmed the dumpsters had been overflowing with garbage the day before. MD-A indicated during the winter, the first layer of garbage bags would get frozen into the bottom of the dumpsters, so they were not emptied all of the way. MD-A indicated this had caused the dumpsters to become overfull occasionally during the winter, but felt this did not occur in the summer months. The facility policy titled Barrett Care Center Policy To Remove Garbage dated 2012, identified that garbage was kept in dumpsters in back of building, and garbage would be removed once weekly. The policy did not address how the dumpsters were to be maintained, and what to do when full before the next scheduled garbage pick up.

Based on observation, interview and record review, the facility failed to maintain hot water temperatures within safe parameters in the facility for 16 of 40(R21, R12, R6, R17, R39, R26, R241, R38, R5, R3, R22, R35, R16, R36, R1, R14) residents identified with cognitive impairment and used the bathroom faucets independently. Findings include: On 2/18/20, at 5:23 p.m. during a tour of the building with maintenance director(MD)-A present, using the facility thermometer, water temperatures were checked and confirmed as follows: -room [ROOM NUMBER] hot water temperature was 129 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 127 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 130 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 124 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 122 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 133 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 132 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 132 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 132 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 131 Fahrenheit. -room [ROOM NUMBER] hot water temperature was 130 Fahrenheit. On 2/18/20, at 5:40 p.m. MD-A indicated the hot water temperature was supposed to be between 105 and 115 Fahrenheit. MD-A indicated the facility's usual practice was to check hot water temperatures in resident's bathrooms one to two times per week. MD-A indicated they had noticed the last couple of times the hot water temperatures were going higher, so they had a plumber out who checked their system. MD-A indicated the plumber was at the facility the first part of February and planned to rebuild the hot water valve mixer, but was waiting for parts. MD-A indicated he generally checked the water temperatures in the morning, when residents were being provided baths, which could affect the water temperatures. On 2/18/20, at 6:40 p.m. nursing assistant (NA)-B identified she was aware of some residents who had cognitive impairment who were able to use the bathroom faucets independently. NA-B identified R14, R16 and R35. On 2/18/20, at 6:58 p.m. director of nursing (DON) stated she was not aware of any residents who had [MEDICAL CONDITION] hot water in the facility. DON confirmed she was aware there were residents who had cognitive impairment, who were able to use the bathroom sinks independently in the facility and indicated she would provide a list those residents. Review of the list provided by the facility titled Residents Who Are Cognitively Impaired And Can Use The Bathroom Sinks By Themselves, undated, included R21, R12, R6, R17, R39, R26, R241, R38, R5, R3, R22, R35, R16, R36, R1, and R14. Review of facility incident reports from 4/11/19, to 2/18/20, revealed there had been no reports of [MEDICAL CONDITION] hot water in the faclity. On [DATE], at 1:57 p.m. Administrator indicated she expected the hot water temperature to be kept between 105-115 degrees. Administrator indicated the usual facility practice was to take water temperatures on a regular basis, and that the plumber was available when the facility needed. The facility policy titled Barrett Care Center Policy For Water Temperatures, dated 2012, identified the facility would maintain temperatures for water between 105-115 degrees. The policy further identified the water temperatures would be checked regularly by maintenance to assure temperatures were maintained per regulations. If water temperatures were found to be out of range the temperature would be adjusted to maintain a minimum and maximum temperature and plumber may be called to assist in regulating temperature.

Based on observation, interview and document review, the facility failed to ensure a clean, safe environment for 1 of 1 residents (R9) who utilized a wheelchair which was in disrepair. Findings include: R9's quarterly Minimum Data Set ((MDS) dated [DATE], revealed R9 had moderate cognitive impairment, and had [DIAGNOSES REDACTED]. The MDS indicated R9 required extensive assistance from 1-2 staff with activities of daily living (ADL)s including bed mobility, transfers, dressing, toileting and personal hygiene. R9's care plan dated [DATE], included various inverventions for care and instructed staff to provide extensive assistance with ADL's including transfers, toileting, repositioning, and bed mobility. The care plan indicated R9 required the use of a wheelchair or cane to mobilize on and off the unit with staff assistance. On 2/18/2020, at 3:46 p.m. R9's was observed in his recliner in his room seated. R9's wheelchair was positioned at the foot of the bed, and the left arm rest was observed to be wrapped with a beige colored 4 inch wide bandage, which covered the area of the arm rest assembly. Two pieces of blue tape, approximately 3 inches long by 2 inches wide, were affixed to the beige bandage. R9 indicated he used the wheelchair to get to the restroom and to wheel around the facility. R9 stated the arm rest had been falling off and staff wrapped it in ace wrap for padding. On [DATE]20, at 1:56 p.m. maintenance director (MD) stated he was not aware of any concerns with R9's wheelchair. MD indicated the usual practice was for nursing staff to communicate things that required repair in a communication notebook at the nurses desk and he checked it daily. MD reviewed the maintenance communication notebook and confirmed the repair log lacked documentation of R9's damaged wheelchair arm. MD stated if the issue was not able to be repaired he would expect staff to get the resident a different chair. On [DATE]20, at 2:10 p.m. the MD inspected R9's wheelchair and verified the left arm rest of R9's wheelchair was missing and the metal bar where the arm rest should be was missing and had been wrapped with an ace bandage and taped into place. MD stated he could feel the bolts used to mount the arm rest through the ace bandage wrapping. The MD stated the wheelchair arm rest needed to be repaired and a new arm rest put on. MD stated the ace bandage was not an acceptable repair, and he would expect staff to have notified him immediately of the damage so a repair could be made. On [DATE]20, at 2:13 p.m. nursing assistant (NA)-C stated she was aware R9's left wheelchair arm was broken and wrapped in an ace bandage and indicated it had been that way for a while for about a month. NA-C stated she had not communicated the damage in the maintenance communication book, and stated it should have been reported so a repair could be made. On [DATE]20, at 2:25 p.m. NA-D stated she was aware R9's left wheelchair arm was broken and wrapped in an ace bandage. NA-D stated she had not reported it or put a note in the maintenance communication book because she thought everyone knew about it. On [DATE]20, at 3:27 p.m. the director of nurses (DON) stated she had not been notified of any damage on R9's left wheelchair arm rest being missing and wrapped in an ace bandage. The DON indicated the ace wrap was not an acceptable repair and expected staff to notify maintenance in the communication book so it could be repaired. The DON indicated the broken arm rest and ace bandage repair could have caused skin break down or injury. The DON stated she expected all staff that had observed the broken left arm rest to have reported it immediately or removed it from service until the wheelchair arm could be repaired/replaced. A review of the facility provided undated document titled Occupational Safety and Health Act (OSHA) - Safe Medical Devices and Lockout/Tagout, instructed staff to alert maintenance and remove equipment in the facility that is not in good working order or repair until the item can be replaced or fixed. Additionally, the document instructed staff to ensure all items including wheelchairs, lifts, slings and lift sheets were working well prior to use.

Based on observation, interview, and document review, the facility failed to ensure a system for accurate reconciliation to prevent potential loss of diversion of controlled drugs for 1 of 2 residents (R6) who was received controlled medications in the facility. Findings include: On 2/18/20 at 5:54 p.m. a review of the north medication cart of controlled drugs was conducted with registered nurse (RN)-D. RN-D unlocked the metal lid of the bottom drawer of the medication cart and a white bottle containing a blue liquid was noted to be partially full and was labeled [MEDICATION NAME] [MED] with R6's name on it. - R6's bottle of [MEDICATION NAME] [MED] 100 milligrams (mg)/5 milliliters (ml) solution, was labeled with instructions to give 0.25 -0.5 ml by mouth every 4 hours as needed. RN-D verified the bottle had 14 ml remaining in the bottle. At the time, RN-D verified the red bound narcotic log book count indicated 2 staff had counted the [MEDICATION NAME] [MED] last on [DATE] at 9:40 p.m. and listed the present amount of [MEDICATION NAME] should of been 18 ml (a 4 ml discrepancy). On 2/18/20 at 6:33 p.m. RN-D indicated staff were to count at the beginning of the shift and the end of every shift to ensure an accurate narcotic count. RN-D indicated staff coming on the shift would review the red bound book, while the other licensed staff member going off shift would review the narcotic medications and verify the count given by the other licensed staff. RN-D verified she did not review the narcotic amount present while she verified the count with the other staff member. She indicated she only reviewed the red bound book when reconciling the narcotics and did not realize the amount was off. RN-D indicated she had counted narcotics with staff at the beginning of her shift that day and confirmed there was no documentation to verify the count had been completed since [DATE]. RN-D indicated she should be looking at the narcotic medications while counting to verify the count was accurate. On [DATE] at 2:08 p.m. RN-C confirmed the above findings and indicated because of the multi-dose vial, the reconciliation needed to be kept up more frequently to keep the count more accurate. RN-C indicated staff were to count the narcotics every shift and make adjustments for gains and losses with multi-dose vials. On [DATE] at 2:27 p.m. consulting pharmacist (CP) indicated he completed spot checks of controlled medications on his monthly visits. CP confirmed facility policy and indicated he would expect the facility staff to reconcile the count of narcotics with two nurses each shift to prevent any diversion. CP indicated staff would need re-education, both nurses should be looking at the controlled medication to make sure the count was accurate, signing off the count was accurate and he stated you should know what you are signing off on. On 2/20/20 at 2:20 p.m. director of nursing (DON) confirmed the above findings and indicated she would expect staff to identify and report any discrepancies to her or either RN-C when first noted. The DON indicated staff should be checking the narcotics with every shift change and would expect staff to follow the facility policy. Review of the facility policy titled, Policy ad Procedure for Narcotic Accountability dated 9/26/18, all scheduled two, three, four and five narcotics are to have a count entered on the MAR indicated [REDACTED]. The policy directed any count discrepancy must be reported to the DON and the administrator and a paper incident report filled out. All reasonable efforts will be made to reconcile all reported discrepancies. An investigation will then be conducted to determine further actions necessary. Reports will be made as per state regulations/law.

Based on interview and document review, the facility failed to update the care plan for 1 of 1 resident (R3) who received hospice services. Findings include: Review of R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 had long and short term memory impairment, and had [DIAGNOSES REDACTED]. The MDS required extensive staff assistance for all other areas of daily living (ADL) and indicated R3 did not walk. The MDS identified R3 received hospice services. R3's care plan revised 7/31/18, identified R3's terminal prognosis with orders for Hospice services. The care plan identified the facility would work cooperatively with the hospice team to ensure R3's spiritual, emotional, intellectual, physical and social needs were met and hospice would work with nursing staff to provide maximum comfort for R3. However, the care plan lacked specific directions for assistance from hospice services and lacked direction for hospice nursing visit, nursing assistant or chaplain visits. On 4/10/19, at 2:45 p.m. licensed practical (LPN)-A indicated a hospice aid came to the facility on Wednesdays. The aid asked facility nursing staff what cares R3 needed and would then assist R3 with the needed dressing, bathing or other cares. With review of R3's chart, LPN-A verified R3's record lacked a hospice care plan. On 4/10/19, at 2:53 p.m. the registered nurse (RN)/ MDS coordinator (MDSC) indicated the usual facility protocol for hospice patients included a facility care plan which included a note regarding hospice services along with a full hospice care plan filed under the hospice tab in the resident's paper chart. With review of R3's paper chart a hospice care plan was not found. The RN/MDSC verified R3 did not have a completed hospice care plan. On 4/10/19, at 3:13 p.m. the director of nursing (DON) verified a hospice care plan was expected to be in the paper chart for residents who received hospice services. The requested facility policy was not provided.

Based on interview and document review, the facility failed to maintain an on-going infection control program, which included comprehensive surveillance of resident infections to identify and analyze possible patterns of infection in the facility, including identification of any patterns in residents, locations or pathogens in real time to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 38 residents who resided in the facility. Findings include: Review of the facility's infection control surveillance program was conducted on 03/07/18, at 2:12 p.m. The infection logs included the following columns: date, resident name, signs/symptoms, culture/organism, treatment and date resolved. However, the logs failed to identify resident's room or unit location, location infection acquired, criteria met, date resolved, analysis of data or any follow up activities. Review of the Monthly Infection Reports from 5/17 through 3/18, included: -May (YEAR), infection log entries included ten residents and included date, resident's name, and signs/symptoms. The log listed various infections including skin/wound, upper respiratory, pneumonia, peritonitis and emesis. Six entries included antibiotic as a treatment. None of the entries listed on the infection log included the resident room number, if community or nursing home acquired or criteria met. In addition, the (MONTH) (YEAR) infection log included entries for (MONTH) (YEAR) and (MONTH) (YEAR). -June (YEAR), infection log entries included eight residents listed with various infections including skin/wound, upper respiratory, urinary tract, ear and emesis. One entry did not identify symptoms. Seven entries included antibiotic as a treatment. None of the entries listed the resident room number, location acquired, culture, organism identified, criteria met and date resolved. In addition, the (MONTH) (YEAR) infection log included one (MONTH) (YEAR) entry between two 6/1/17, entries. -July (YEAR), infection log entries included twelve residents listed with various infections including skin/wound, urinary tract, pneumonia, vomiting, and abnormal sputum. None of the entries listed the resident room number, criteria met and date resolved, did not consistently included acquired infection for resident. The logs also lacked inclusion of residents with infections not treated by antibiotics. -August (YEAR), infection log entries included nine residents listed with various infections and/or symptoms including skin/wound, flank pain, emesis, disarticulates and unknown. None of the entries listed the resident room number, criteria met, location infection acquired or date resolved. -September (YEAR), infection log entries included eight residents listed with various infections and/or symptoms listed including [MEDICAL CONDITION], wound, eye, [MEDICAL CONDITION], shortness of breath, cough and bad looking chest X-ray. One entry indicated a culture was performed, but no results listed. None of the entries listed the resident room number, criteria met, location infection acquired or date resolved. -October (YEAR), infection log entries included six residents listed with various infections and/or symptoms including urinary tract infections, elevated temperature and diarrhea. One entry identified a resident returned from the hospital with antibiotic treatment, but no infection identified. None of the entries listed the resident room number, criteria met, location infection acquired or date resolved. -November (YEAR), infection log entries included eight residents listed with various infections and/or symptoms including urinary tract infection, abscess tooth, elevated temperature, lethargy, crying out and eye discharge. None of the entries listed resident room number, criteria met, pathogen identified, location infection acquired or date resolved. -December (YEAR), infection log entries included sixteen residents listed with various infections and/or symptoms including skin, sore throat, lethargy, cough, shingles, diminished lung sounds, low-grade temperature, increased behaviors, pneumonia, wound e-coli, congestion and yellow phlegm. None of the entries listed resident room number, criteria met, location infection acquired or date resolved. -January (YEAR), infection log entries included six residents listed with infections and/or symptoms including urinary tract infection, low-grade temperature, confusion, rash, increased phlegm, chest x-ray and pneumonia. None of the entries listed resident room number, pathogen identified, criteria met, location infection acquired or date resolved. -February (YEAR), infection log entries included eight residents listed with infections and/or symptoms including increased white blood count, aspiration pneumonia, paronychia (nail disease), cough, lower respiratory infection/[MEDICAL CONDITIONS], exacerbated [MEDICAL CONDITIONS] and abscess of abdomen. None of the entries listed resident room number, pathogen identified, criteria met, location infection acquired or date resolved. -March (YEAR), infection log entry included one resident listed with infections and/or symptoms including pneumonia, kidney, dehydration and upper respiratory infection. The entry did not include pathogen identified, resident room number, criteria met, location infection acquired or date resolved. On 3/7/18, at 2:12 p.m. registered nurse (RN)-A confirmed she was the infection control nurse for the facility, stated she was new to the position and was currently taking on-line education courses for the infection preventionist position. RN-A reviewed the infection log entries with surveyor, and confirmed she had just made the (MONTH) entry prior to the review. RN-A confirmed she was the only one who made entries on the form and no one did tracking while she was gone. RN-A indicated they do not track resident locations, since she knew where the residents' rooms were and confirmed she only tracked residents who had infections treated by antibiotics. RN-A confirmed the facility currently had a resident on isolation precautions [MEDICAL CONDITION], but had not started to track the wound infections. RN-A stated she was aware the infection log tracking forms were not thorough. RN-A stated the infection control logs were completed and shared at quality assurance meetings. RN-A indicated she had just received training that day on what to do if a pattern was found with infections in the facility. RN-A indicated the facility was working on starting over their infection control program including the policy and procedures. On 3/7/18, at 2:56 p.m. the administrator confirmed RN-A just started in her role for the infection control program. The administrator stated the last RN in charge left in November. The administrator stated RN-A was still in training and stated the tracking form was reviewed and discussed quarterly at Quality Assurance meetings to see if a pattern was found. The administrator would neither confirm nor deny the infection control program was not fully functioning. The Surveillance for Healthcare-Associated Infections Barrett Care Center policy reviewed 8/30/17, included surveillance would include gathering of surveillance data, calculation of infection rates and interpretation of surveillance data. Multiple data listed to include as appropriate identifying information, including resident room number, unit, attending physician, pathogens, preventative measures and comments. The policy also instructed staff to analyze the data to identify trends.

Based on interview and document review, the facility failed to fully implement an antibiotic stewardship program. This deficient practice had the potential to affect all 38 residents who resided in the facility. Findings include: A review of the facility's infection control surveillance program was conducted on 03/07/18, at 2:12 p.m. which identified the facility lacked an antibiotic stewardship program. The infection control program lacked protocols for a facility-wide system to monitor the use of antibiotics which included (but not limited to) appropriate prescribing of antibiotics and periodic review of antibiotic use by physicians. The program also lacked protocols for review of signs and symptoms, labs, determination of appropriate antibiotic use and reporting of any patterns identified. On 3/07/18, 2:12 p.m. registered nurse (RN)-A confirmed she was the facility infection control nurse. RN-A indicated she was new to the position and was currently in training. RN-A confirmed the facility did not have an antibiotic stewardship program in place, but had begun some protocols. RN-A stated the nurses had a form with criteria to use prior to contacting the physician related to resident infections. RN-A indicated the facility had usually not obtained cultures prior to antibiotic use or received antibiotic sensitivity reports. RN-A stated she wanted to meet with the director of nursing, medical director and administrator to decide on what protocol the facility would use in the future for their antibiotic stewardship program. RN-A stated letters were sent out to families and physicians to provide education on antibiotic stewardship, but no further tracking or analysis of antibiotic use had been started. On 3/07/18, at 2:56 p.m. the administrator confirmed she was aware some pieces of the antibiotic stewardship program was missing. The administrator confirmed RN-A had just started the infection prevention program the first of the year and confirmed RN-A was still in training for the position. The administrator stated more education and re-education was needed for the facility staff and physicians. The administrator stated the facility had sent out letters to families and physicians with antibiotic stewardship education, but indicated she intended to send out letters again. The Antibiotic Stewardship Program (ASP) undated policy included, the(NAME)Care Center ASP included core elements of leadership, accountability, drug expertise, actions, tracking, reporting and education. The facility would review and discuss data and use an antibiotic use algorithm. The ASP would be a standing agenda item of the facility quality assurance quarterly meeting. The policy included monitoring, tracking and review of providers, pharmacy and lab reports and antibiotic resistance patterns.

Based on observation, interview, and document review, the facility failed to ensure a system for reconciliation of controlled medications to prevent potential loss or diversion for 1 of 1 medication storage rooms in the facility. Findings include: On 3/6/18, at 5:33 p.m. a medication storage room tour was conducted with registered nurse (RN)-B, below the counter of the medication storage room was a locked cabinet. RN-B obtained the key and unlocked the cabinet located under the counter. Inside the locked cabinet contained a white sheet of paper titled, Certificate Of The Inventory And Destruction Of Controlled Substances and three bottles of medications. The three bottles of medication were [MEDICATION NAME] (sedative) 2 milligrams (ml)/ milliliter (ml), which contained 26.5 ml left in the bottle, [MEDICATION NAME] (pain medication) 20 mg/ml, which contained 25 ml left in the bottle and [MEDICATION NAME] (pain medication) 5 mg which contained 73 tablets. The Certificate Of The Inventory And Destruction Of Controlled Substances sheet had columns listed on it to list the prescription (RX) number, drug name, strength, quantity, date, administrator/nurse and pharmacist. After review the Certificate it only listed RX number- 47, drug name-[MEDICATION NAME], strength-2 mg/ml, quantity-26.5 ml and the date was blank. The Certificate did not list the other two controlled medications [MEDICATION NAME] or [MEDICATION NAME]. On 3/6/18, at 6:03 p.m. RN-B stated the pharmacy came once a month to the facility to destroy controlled medications with another nurse and was just at the facility on 2/8/18. RN-B confirmed findings and indicated all controlled medications are to be logged on the Certificate, locked up in the cabinet until the pharmacy comes to destroy them with another nurse every month. RN-B stated her expectations of staff would be to fill out the Certificate and to log the controlled medication correctly. RN-B stated staff needed to log the controlled medications on the Certificate to track the controlled medications for accountability and to prevent diversion. RN-B stated the nursing staff were not always good about writing the controlled medications on the Certificate form to track On 3/8/18, at 1:34 p.m. the Administrator stated she expected staff to destroy medications with two staff members and follow the facility policy to prevent possible drug diversion. Review of the Destroying Medications policy revised on 9/2003, indicated the drug disposition record must contain as a minimum the following: residents name, date drug destroyed, name of the drug, strength, prescription number, issuing pharmacy, quantity destroyed, method of destruction, reason for destruction and signatures of witnesses.

Based on observation, interview and document review, the facility failed to ensure identified preferences for food choices were honored for 1 of 1 residents (R34) reviewed for choices. Findings include: R34's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R34 was cognitively intact, had [DIAGNOSES REDACTED]. The MDS indicated R34 was able to understand others, express her ideas and wants with no difficulty, and was independent with eating after set up help from staff. During an interview on 3/6/18, at 1:22 p.m. R34 stated the food was crap, lacked seasoning; the vegetables were not cooked and were hard. R34 indicated she had talked to the dietary manager (DM) several times at care conferences about this issue. R34 stated the DM did not say anything when the subject was brought up at care conferences, except you must be eating your gaining weight. R34 stated she was on a regular diet and stated, I don't bother asking for something different, not worth saying. R34 stated this was what the facility cooked and you do not get a choice. R34 stated, I don't really eat anymore. I am a picky eater. R34 stated she had told them (facility staff) what her favorite foods are. R34 stated, They look at me like I'm crazy. R34 stated she liked steak, potatoes, coleslaw and raw carrots. R34 stated, All you get is cooked carrots and green beans with no seasoning. R34 stated the food for the holidays was good and stated, Why can't they make it that way all the time. R34 was observed on 3/6/18, at 6:17 p.m. during the supper meal. R34 was sitting in her wheelchair at the end of the dining room table by the window. R34 was eating her supper independently which consisted of macaroni and cheese, broccoli, fruit cocktail water and coffee. R34 ate everything except for her broccoli, which had not been touched. R34 was observed during the breakfast meal on 3/8/18, at 8:28 a.m. R34 was in her room sitting in a recliner by the window. Cook (C)-A knocked, entered R34's room to deliver her breakfast tray and sat it on the bedside table in front of her. C-A assisted R34 to put her clothing protector on, uncovered R34's drinks and set her breakfast up for her, which consisted of cream of wheat cereal, boiled egg, coffee, water and cranberry juice. C-A asked R34 if she needed anything else and R34 stated in a frustrated tone of voice I guess it is ok. C-A left the room and did not respond to R34's comment about the food that was served to her. After C-A left the room, R34 was asked how her breakfast was and she stated in frustrated voice I like grape juice, but whatever. R34 indicated that she prefers grape juice but it all depends on who was doing the trays for the day. R34 began to eat her breakfast independently in her room. Review of the Barret Care Center Menu from 3/5/18 to 3/11/18 only listed the main food entree served for the day. The menu did not list any other alternatives or food choices that were available. R34 menu card indicated R34 was on a small portion, no added salt diet. The menu card indicated R34 likes for breakfast: 4 ounces of cranberry juice and 4 ounces of grape juice, poached egg, one-quarter cup of cereal and coffee for supper: R34 liked green beans or corn only for cooked vegetables. The menu card also listed dislikes such as milk, peppers, mushrooms and tomatoes. R34's current care plan revised on 2/22/18, indicated R34 had potential nutritional problem related to MS, depression and disorder of cartilage. The care plan interventions included: assess likes and dislikes and alter menu to meet R34's needs and provide printed menu for R34 to make choices weekly and assist where necessary. R34's Care Conference Review Notes reviewed from 6/13/17 to 2/20/18 indicated a check mark was noted for review of current weights, diet orders and nutritional supplements. The Care Conference Notes indicated, R34 would eat in room most of the time, had meal replacement shakes she can have when desired and continued to gain weight and will use clothing protector for meals. The care conference notes lack any discussion of R34's food choices, preferences or concerns regarding the food. R34's dietary notes were reviewed from 6/20/17 to 2/20/18 and lacked any documentation regarding discussions with R34 about food choices, preferences or concerns regarding the food. R34's quarterly Nutritional assessment dated [DATE], indicated R34 was on a small portions, no added salt diet. The assessment indicated R43 ate in the dining room for evening meals and had room trays for breakfast and lunch. The assessment lacked any documentation about R34's food choices, preferences or concerns regarding food. On 3/8/18, at 8:16 a.m. R34 stated she did get a menu every week and if there was something on the menu she did not like, she got a bowl of cheerios. R34 indicated there was no other options on the menu to pick from and stated the dietary staff had not talked to her about alternatives foods. R34 stated she had been frustrated because she had brought it up (her concerns with the food) many times in care conferences and stated, They don't do anything, they say they will do it, but they don't. On 3/8/18, at 9:12 a.m. cook (C)-A stated R34 was independent with eating, will tell you if she needed something or help setting up. C-A stated R34 ate all of her food if she liked it and if she did not like it, she won't touch it. C-A stated R34 had a menu card they followed in the kitchen and stated R34 liked greens beans and corn. C-A stated R34 asked for a bowl of oatmeal if she did not like what was on the menu. C-A stated R34 had complained about the vegetables and stated they usually had green beans for her as the other choice. C-A stated they (the facility) did not serve an alternative meal right now because they had tried it in the past and it caused a lot of confusion with the residents not knowing what they wanted. On 3/8/18, at 9:21 a.m. the dietary manager (DM) stated she attended care conferences for R34 on a regular basis. The DM stated R34 did not like many vegetables and stated corn and green beans were her favorite. The DM stated R34 had voiced concerns about meals at care conferences in the past, but not at the last care conference. The DM stated R34 did have a menu in her room, and if R34 did not like what was being served, R34 was aware other choices were available which included, sandwiches, hamburger, or soup. The DM verified R34 had talked to her about the vegetables not being cooked; being hard and that she did not like them. The DM stated they had not come up with a resolution to fix the problem and stated R34, says never mind. The DM stated she had never asked R34 why she says never mind. The DM indicated she thought R34 was frustrated in general and indicated that she would be visiting with R34 in the future about these issues. Review of facility policy titled, Exercise Of Rights dated 11/16, indicated residents have the freedom of choice about how they wish to live their lives everyday lives and receive care, subject to out facility's rules and regulations affecting resident conduct and those regulations governing protection of the resident health and safety. Review of facility policy untitled and undated, indicated Barret Care Center (BCC) will offer an alternate meal equal to 3 ounces of protein at meals. Under number 1) alternate meal will consist of soup and sandwich unless otherwise posted, 2) BCC always has on hand other alternates such as: yogurt, cottage cheese, cheese, peanut butter and jelly, hot/dry cereals, Jell-O and beverages.

Based on interview and document review, the facility failed to ensure soiled laundry was handled in a manner to prevent the spread of infection through cross contamination. This practice had the potential to affect all residents currently residing in the facility, who had their laundry or linens processed in the facilities laundry department. Findings include: During tour of laundry area on 4/21/17, at 10:13 a.m. housekeeping/laundry aid (HLA) confirmed she routinely worked in the laundry department. The HLA indicated nursing staff placed the soiled linen/clothing in netted cinched laundry bags, staff send the soiled linen/clothing down the shoot and it ended up in a very large square laundry bin in the dirty linen area of the laundry room. HLA indicated the soiled linen/clothing was taken out of the netted cinched laundry bags, sorted into separate bins of whites, colors and category of clothing. HLA stated staff wore gloves to sort dirty linen and did not wear any protection to cover their uniforms. HLA stated I do not wear anything else to sort dirty laundry. The HLA indicated the only time she wore a cloth gown was when she handled red bagged infectious items which were sent out of the facility for laundering or when they go in a residents room that may be infectious and stated no other time do I wear a gown. HLA verified that she continued to wash, dry, fold and deliver the clean laundry to the residents rooms after sorting soiled linen/clothing. The HLA confirmed there was a potential for contamination of residents and themselves. On 4/21/17, at 10:21 a.m. housekeeping/laundry supervisor (HLS) confirmed staff did not wear any gowns while sorting dirty linen and indicated they only wear cloth gowns when working with red bag items. The HLS indicated staff would wear gloves and a mask if needed and stated so we don't wear gowns when sorting, we wear gloves only, but not always gowns. The HLS confirmed there was a potential for contamination of residents and themselves and stated it could be touching our clothing, no guarantee that its not. The HLS indicated staff could spread dirt on clean linen, carts of clothes and could be infectious or contaminated and stated this is not the best practice and should be wearing gowns when sorting dirty laundry. Review of the facility policy titled, Laundry and Bedding, Soiled, revised on August 2009, indicated soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen and anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment such as gowns if soiling of clothing is likely.

Based on interview and document review, the facility failed to immediately notify the State Agency (SA) of an allegation of potential neglect/abuse for 1 of 3 residents (R50) reviewed for abuse prohibition. Findings include: R50's quarterly Minimum Data Set ((MDS) dated [DATE], identified R50 had [DIAGNOSES REDACTED]. R50's care plan revised 4/11/17, identified R50 had impaired cognitive function/dementia or impaired thought process r/t (related to) Dementia. (R50) needs supervision with all decision making. (R50) is at risk for possible abuse/neglect as a vulnerable adult r/t cognitive impairment. All staff to monitor for signs or symptoms of abuse neglect and report per policy. R50's incident form #617 dated 2/20/17, at 10:39 a.m. indicated R50 had approached staff to look at R50's abdomen. The report indicated bruising extended from one side of R50's abdomen to the other and described it as going all the way down into her groin area. The form indicated R50 complained of pain in the area, had a difficult time coming up with the words to describe it. When questioned regarding the bruise, R50 was not sure, however; denied falling into anything or hitting anything. The printed computerized form had a hand written review dated 2/21/17, which indicated R50 was questioned if she recalled any sudden stops in a vehicle due to a recent outing and the bruising in an area a seatbelt may have been. R50 could not recall. The review also indicated R50 had a recent injury and had leaned onto the bathroom sink. Review of the progress notes identified an entry dated 2/21/17, at 16:00 (4:00 p.m.). The note identified the following: INCIDENT: Bruise that goes from LT (left) to Rt (right) on lower abd (abdomen) and down into her pelvis area. CAUSE: (R50) was unable to tell what happened. Could be from when she was sick and leaned up into bathroom sink. (R50) went out to an appt. (appointment) and had been wearing a seat belt. If there was a sudden stop in the car. INTERVENTION: unable to give one due to not knowing where the bruise came from. R50's incident was not reported to the state agency, nor was there a comprehensive investigation including interviews of anyone other than R50 and investigation of the suspicion the bruise was caused by a seatbelt during a recent out-of-facility appointment. On 4/19/17, at 2:55 p.m. the director of nursing (DON) verified the incident regarding R50's bruise was accurate with the bruise extending across the abdomen from one hip to the other hip and down into the groin area. The DON verified a report had not been made to the state agency regarding this bruising. The DON indicated the bruise was in an area that a seat belt could have been. On 4/20/17, at 3:35 p.m. the administrator indicated the usual facility protocol for resident incidents was, staff notified the DON, administrator or social services designee. The DON and/or administrator then reviewed the incidents and made the determination of whether or not to report it to the state agency. The administrator indicated the procedure to identify a reportable incident was determined by using a decision tree form from their provider organization revised 11/16. The administrator indicated the decision tree directed the incident was not reportable if the injury could be explained by the resident. The administrator stated, they could tell me if there was abuse or not. Although R50 was identified to be cognitively impaired and unable to explain the injury, the administrator would not agree the bruising could not be explained. On 4/21/17, at 10:00 a.m. licensed practical nurse (LPN)-A verified the incident report was accurate. R50 had a bruise which extended across the abdomen from one side to another and down into the groin. LPN-A indicated R50 was unable to remember or explain how the injury occurred. LPN-A identified the usual procedure for this and all injuries was to write an incident report, notify the doctor, family, and administrator. The administrator then decided what was to be reported and made the report if needed. The facility form titled Vulnerable Adults and Reporting and the Prevention of Abuse updated 11/16. Identified the following: * All residents are considered Vulnerable Adults * This is because they may have cognitive and physical impairments which prevent them from making their own decisions, recognizing safety hazards, being able to defend themselves from harm and being able to report abuse of any kind. The facility form titled Abuse Prevention Plan revised 11/28/16, identified residnets had the right to be free from all types of abuse including injuries of unknown source (unexplained injuries). The plan also listed examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. The list included; welts or bruises/suspicious bruising and /or extensive bruising.

Based on interview and document review, the facility failed to failed to operationalize their abuse prevention policy for 1 of 3 residents (R50) reviewed for abuse prohibition. Findings include: The facility form titled Vulnerable Adults and Reporting and the Prevention of Abuse updated 11/16. Identified the following: * All residents are considered Vulnerable Adults * This is because they may have cognitive and physical impairments which prevent them from making their own decisions, recognizing safety hazards, being able to defend themselves from harm and being able to report abuse of any kind. The facility form titled Abuse Prevention Plan revised 11/28/16, identified residnets had the right to be free from all types of abuse including injuries of unknown source (unexplained injuries). The plan also listed examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. The list included; welts or bruises/suspicious bruising and /or extensive bruising. R50's quarterly Minimum Data Set ((MDS) dated [DATE], identified R50 had [DIAGNOSES REDACTED]. R50's care plan revised 4/11/17, identified R50 had impaired cognitive function/dementia or impaired thought process r/t (related to) Dementia. (R50) needs supervision with all decision making. (R50) is at risk for possible abuse/neglect as a vulnerable adult r/t cognitive impairment. All staff to monitor for signs or symptoms of abuse neglect and report per policy. R50's incident form #617 dated 2/20/17, at 10:39 a.m. indicated R50 had approached staff to look at R50's abdomen. The report indicated bruising extended from one side of R50's abdomen to the other and described it as going all the way down into her groin area. The form indicated R50 complained of pain in the area, had a difficult time coming up with the words to describe it. When questioned regarding the bruise, R50 was not sure, however; denied falling into anything or hitting anything. The printed computerized form had a hand written review dated 2/21/17, which indicated R50 was questioned if she recalled any sudden stops in a vehicle due to a recent outing and the bruising in an area a seatbelt may have been. R50 could not recall. The review also indicated R50 had a recent injury and had leaned onto the bathroom sink. Review of the progress notes identified an entry dated 2/21/17, at 16:00 (4:00 p.m.). The note identified the following: INCIDENT: Bruise that goes from LT (left) to Rt (right) on lower abd (abdomen) and down into her pelvis area. CAUSE: (R50) was unable to tell what happened. Could be from when she was sick and leaned up into bathroom sink. (R50) went out to an appt. (appointment) and had been wearing a seat belt. If there was a sudden stop in the car. INTERVENTION: unable to give one due to not knowing where the bruise came from. R50's incident was not reported to the state agency, nor was there a comprehensive investigation including interviews of anyone other than R50 and investigation of the suspicion the bruise was caused by a seatbelt during a recent out-of-facility appointment. On 4/19/17, at 2:55 p.m. the director of nursing (DON) verified the incident regarding R50's bruise was accurate with the bruise extending across the abdomen from one hip to the other hip and down into the groin area. The DON verified a report had not been made to the state agency regarding this bruising. The DON indicated the bruise was in an area that a seat belt could have been. On 4/20/17, at 3:35 p.m. the administrator indicated the usual facility protocol for resident incidents was, staff notified the DON, administrator or social services designee. The DON and/or administrator then reviewed the incidents and made the determination of whether or not to report it to the state agency. The administrator indicated the procedure to identify a reportable incident was determined by using a decision tree form from their provider organization revised 11/16. The administrator indicated the decision tree directed the incident was not reportable if the injury could be explained by the resident. The administrator stated, they could tell me if there was abuse or not. Although R50 was identified to be cognitively impaired and unable to explain the injury, the administrator would not agree the bruising could not be explained. On 4/21/17, at 10:00 a.m. licensed practical nurse (LPN)-A verified the incident report was accurate. R50 had a bruise which extended across the abdomen from one side to another and down into the groin. LPN-A indicated R50 was unable to remember or explain how the injury occurred. LPN-A identified the usual procedure for this and all injuries was to write an incident report, notify the doctor, family, and administrator. The administrator then decided what was to be reported and made the report if needed.

Based on observation, interview and document review, the facility failed to prepare food in a safe manner related to the use of unpasteurized eggs in the dietary department. This deficient practice resulted in an immediate jeopardy for 12 of 36 residents, including two residents (R26, R31) for whom undercooked unpasteurized eggs were observed to have been prepared; and 10 residents (R4, R6, R13, R14, R15, R33, R35, R39, R46, R50) who were identified by the facility to have received soft cooked, unpasteurized eggs. The preparation of these undercooked eggs placed all 12 residents at risk for the development of the food borne illness, Salmonella Enteritis. This practice had the potential to affect 36 out of 43 residents in the facility. The immediate jeopardy (IJ) began on 8/5/15, due to the systemic failure of the facility to appropriately prepare unpasteurized eggs during observation of the breakfast meal, when yellow, runny egg residue was observed to be smeared over the diameter of R26 and R31's breakfast plates. The practice of serving the undercooked eggs had the potential to cause Salmonella Enteritis. The administrator and the director of nursing (DON) were notified of the IJ on 8/5/15, at 2:20 p.m. The IJ was removed on 8/6/15, at 12:21 p.m. however, noncompliance remained at the lower scope and severity level of E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During the initial kitchen tour on 8/3/15, at 12:15 p.m. a large brown box was observed on the bottom left side of the refrigerator which contained unpasteurized shell eggs. The dietary manager (DM) stated all eggs currently used in the facility were unpasteurized, except the liquid eggs which were pasteurized. The DM reported the facility was having a difficult time obtaining shelled, pasteurized eggs, but stated the facility was just not preparing any soft cooked eggs during this time. On 8/5/15, at 8:48 a.m. during the breakfast meal, R31 was seated at a table in the facility's dining room. R31's breakfast plate was observed with yellow runny egg yolk residue and small white particles of egg on the plate. R31 confirmed he had eaten his breakfast. On 8/5/15, at 9:05 a.m. R26 was observed leaving a table in the facility dining room. R26's breakfast plate remained on the table, and was observed to be covered with yellow, thin, runny egg residue smeared across the entire plate. On 8/5/15, at 9:06 a.m. dietary aide (DA)-A was present in the dining room and confirmed the yellow, thin and runny residue on R26 and R31's breakfast plates was from over easy eggs the residents had been served and eaten for breakfast. DA-A stated the facility normally had pasteurized eggs, but did not currently have any pasteurized eggs. On 8/5/15, at 9:07 a.m. cook (C)-A reported she had prepared the over easy eggs for breakfast for the facility's sunny day cafe event which was held every Wednesday. C-A explained that during the sunny day cafe eggs were made to order for any residents who requested them. C-A was able to verify 20 eggs were cooked over easy that morning, stating some residents had been served 2 eggs. C-A confirmed the eggs she had used that morning for the over easy eggs were unpasteurized. C-A stated the facility had been having a very hard time getting pasteurized eggs and stated she was aware they were supposed to only use pasteurized eggs when preparing the over easy eggs. C-A stated she had questioned the DM about whether the staff should continue to use the unpasteurized eggs when making over easy eggs, and stated the DM had told her to continue to use the unpasteurized eggs for preparing the over easy eggs. C-A stated the facility had been preparing the over easy eggs using unpasteurized eggs for approximately the past 3 weeks. On 8/5/15, at 10:17 a.m. C-A stated when she cooks the over easy eggs using the unpasteurized eggs she does not check the temperature of the eggs before serving, and does not cook the eggs for any specific time. C-A stated she flipped the eggs over once on the griddle and goes by the look to determine when the eggs are done. On 8/5/15, at 10:45 a.m. the administrator stated she had contacted the food supplier utilized by the facility and had been told the supplier did have pasteurized eggs available for purchase. The administrator stated she was aware the DM and C-A had verified the eggs prepared for residents during the breakfast meal were not pasteurized and indicated she doubted the accuracy of the information. The administrator requested the surveyors look into the cooler in the kitchen to see if the eggs were pasteurized. The administrator did not enter the kitchen with the surveyor to visualize the eggs. DA-B and the surveyor visually verified the eggs in the facility refrigerator were not pasteurized. The administrator stated she would obtain a list of residents who consumed the eggs at the breakfast meal. On 8/5/15, at 11:05 a.m. DM stated C-A made a lot of soft cooked eggs today, and confirmed all the eggs prepared were unpasteurized. The DM stated during the initial tour conducted in the facility, she had forgotten about the sunny day cafe and had inaccurately reported the facility did not prepare soft cooked eggs for the residents with unpasteurized eggs. The DM confirmed that every Wednesday the facility designated the breakfast meal as sunny day cafe, and verified the residents could order eggs any way they wanted them. The DM reiterated the facility had been having a difficult time getting pasteurized eggs since the bird flu began. She stated she had stressed to the cooks that when a resident chose to have an over easy egg, the whites had to be set, and the yolk had to be cooked to 140 degrees. The DM stated the facility did not check the temperature of each individual egg served, and stated each individual egg was not checked because there would have a mess on the plate, because the yolk would run all over the plate. The DM said the cook would check one sample egg for temperature, document the temperature on a log, then discard the temperature sampled egg. The DM indicated she had informed the kitchen staff the facility was having a difficult time acquiring pasteurized eggs, and told them it would not be their standard practice to cook over easy eggs with unpasteurized eggs, but at the current time they had to use the unpasterized eggs anyway because that is the way the residents want their eggs prepared. During this interview with the DM, when she was asked if any of the cooks had questioned whether they should continue using the unpasteurized eggs for the over easy style eggs, the DM replied, I am going to plead the fifth. The DM stated she had told the cooks that if the whites of the eggs were set, the egg would be adequate to serve to the residents. The DM also stated she had difficulty ordering pasteurized shell eggs from the food vendor in the past. The DM stated she utilized a computer order system for food orders and when entering the facility order, the vendor software program would automatically default the order to a substitution category of unpasteurized eggs. The DM stated she had tried to order a different brand of egg to see if the pasteurized eggs would be available, but since the facility did not regularly purchase that brand, the food vendor software had indicated they were not authorized to buy those products. The DM did not provide any information regarding attempting to contact the food vendor directly by telephone. On 8/5/15, at 11:15 a.m. the facility provided a list of residents who consumed the unpasteurized eggs. The list identified R4, R6, R13, R14, R15, R33, R35, R39, R46, R50 had consumed the unpasteurized eggs at the breakfast meal on 8/5/15. Review of the facility Food Temperature Record forms provided by the facility, from 5/4/15 to 6/28/15, 7/6/15 to 7/25/15 and 8/2 to 8/5/15, revealed the following documentation for the breakfast meal: -5/4/15 to 5/10/15: on 5/6/15 sunny day cafe, no food items were listed and no temperatures were recorded. -5/11/15 to 5/17/15: on 5/13/15 sunny day cafe, no food items were listed and no temperatures were recorded. -5/18/15 to 5/24/15: on 5/20/15 sunny day cafe, no food items were listed and no temperatures were recorded. -5/25/15 to 5/31/15: on 5/27/15, sunny day cafe, identified test 144, however, did not identify what food item had been tested and had not include any further testing for eggs. -6/1/15 to 6/7/15: on 6/3/15, sunny day cafe, identified test egg 150, however, did not identify what type of egg had been tested and did not identify whether any further eggs had been tested . -6/8/15 to 6/14/15: on 6/10/15, sunny day cafe, however, did not identify what type of eggs were utilized (pasteurized or not) and did not list any further eggs had been tested . -6/15/15 to 6/21/15: on 6/17/15, sunny day cafe, test 150, however, did not identify what type of egg had been tested and did not list any further eggs had been tested . -6/22/15 to 6/28/15: on 6/24/15, sunny day cafe, test 152, however, did not identify what type of egg had ben tested and did not list any further eggs had been tested . -7/6/15 to 7/12/15: on 7/8/15, sunny day cafe, eggs 143, however, did not identify what type of egg had been tested and did not list any further eggs had been tested . -7/13/15 to 7/19/15: on 7/15/25, sunny day cafe, eggs 146, however, did not identify what type of egg had been tested and did not list any further eggs had been tested . -7/20/15 to 7/24/15: on 7/22/15, sunny day cafe, fried egg 149, however, did not identify what type of fried egg had been tested and did not list any further eggs had been tested . -8/3/15 to 8/5/15: on 8/5/15 at 9:15 a.m., the record was reviewed with C-A. The Food Temperature Record on 8/5/15, listed the scrambled eggs temperature had reached 170 degree,s however, lacked documentation of any sample egg test temperatures for the over easy cooked eggs. C-A confirmed she had served many over easy eggs and had not checked the temperature of any of the eggs. C-A indicated she determined by looks as to whether the unpasteurized eggs were cooked and ready to be served. A copy of the Food Temperature Record for the week of 8/5/15 was provided on 8/6/15, with an added notation for 8/5/15 which noted OE (over easy) 145. On 8/5/2015, at 1:19 p.m. the DM confirmed the food temperature records and the current facility policy. The DM confirmed on 7/8/15, a sample OE egg temperature had been tested to reach 143 degrees. The DM verified the food temperature record did not indicate whether unpasteurized eggs had been used on 7/8/15, or not and stated she had understood the unpasteurized eggs only needed to be cooked to 140 degrees, and not until the yolk was firm. The DM reiterated she had understood the yolk only needed to reach 140 degrees just like any other hazardous foods. During a telephone interview on 8/6/15, at 5:44 p.m. the facility's registered dietician (RD) consultant stated she comes to the facility monthly and was not aware the facility utilized any unpasteurized eggs for made to order eggs for residents. The RD indicated she was aware the facility had been having a difficult time getting the pasteurized eggs through their usual food vendor. In addition, the RD stated the DM had not discussed with her preparation education, or regulatory guidance, regarding cooking made to order unpasteurized eggs for the facility's residents. The RD stated use of unpasteurized eggs for making made to order eggs was an unacceptable practice. Review of the facility's policy Monitoring Egg Preparation for Sunny Day Cafe, dated 5/5/15, indicated staff had been directed to check random temperatures of eggs ordered by residents for over-easy or over-medium eggs. The policy identified the temperature checks would be in place during times when pasteurized eggs were unavailable to ensure the egg temperature was at or above 140 degrees internally. The policy lacked direction to cook an unpasteurized egg until both the yolk and white were firm. Review of the facility's US Food invoices dated 6/14, 6/21, 6/24, 7/1, 7/5, 7/8 and 7/26/15, all indicated each shipment had been received for 15 dozen shelled unpasteurized eggs. The invoices did not include any orders for shelled, pasteurized eggs. Review of the facility's policy Preventing Food Borne Illness-Food Handling dated 3/2010, indicated food would be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The policy identified critical factors implicated in food borne illness to include: poor personal hygiene of food service employees, inadequate temperatures, contaminated equipment and unsafe food sources. Further, the policy identified critical factors as the primary focus of preventative measures to minimize the risk of foodborne illness for the residents. The immediate jeopardy that began on 8/5/15, was removed on 8/6/15, when it was determined the facility had provided education to all of the dietary staff regarding use of unpasteurized eggs, had revised facility policies regarding the use of unpasteurized eggs, and had a plan in place for auditing eggs served made to order with the results reported to the quality assurance committee. Interview with staff verified all dietary staff had been re-educated to the use of unpasteurized eggs. In addition, on 8/6/15 an observation of the facility's food storage revealed 15 dozen pasteurized eggs and a carton of liquid pasteurized eggs. An observation of a meal revealed no made to order eggs were served and a dietary aid verified only scrambled eggs had been served. However, non-compliance remains at the lower scope and severity of E, a pattern with no actual harm, but potential for more than minimal harm.

Based on documentation review and interview, the facility failed to ensure residents were free from physical abuse for 1 of 1 (R1) residents in the sample who was physically abused by a staff person who was assisting the resident with the evening meal. Findings include: R1's record was reviewed. R1's care plan with a goal date of 9/12/12, revealed the resident usually needed staff assistance to eat and to anticipate the resident's needs. The care plan directed staff to offer R1 encouragement at all meals. The care plan indicated R1 had short and long term memory impairments and staff were to offer the resident simple choices and supervise decision making. Review of the facility's incident report form dated 6/18/2012, revealed on 6/17/12, during the evening meal in the dining room nursing assistant (NA) (A) was assisting R1 to eat. The report stated NA (A) was feeding large portions of food at one time to R1 and was yelling at the resident for playing with her food. According to the report, R1 attempted to hit NA (A) and NA (A) responded by slapping R1's hand. Interview with NA (B) at 5:57 p.m. on 6/28/12, revealed on 6/17/12, during the evening meal NA (B) witnessed NA (A) assisting R1 to eat putting a large amount of food on each spoonful. NA (B) said some of the food was coming out of R1's mouth and the resident was wiping the food with her hand. NA (B) said at that time, NA (A) in response to R1 wiping the food from her face, told R1 that if she was going to play with her food, she was finished eating and wiped the resident's mouth of food. NA (A) turned her back to R1 and the resident lightly tapped NA (A) on the backside. NA (A) turned around and quickly slapped R1's hand. According to NA (B), R1 did not respond verbally or physically to the slap however, NA (B) said she immediately intervened and told NA (A) to leave. NA (B) said she was standing approximately twenty feet away from the incident and could hear the slap. NA (B) said she did not observe any redness on R1's hand from the slap. NA (B) immediately reported the incident to registered nurse (RN) (D). Interview with NA (C) at 2:28 p.m. on 6/28/12, revealed on 6/17/12, during the evening meal, she was sitting approximately four to five feet away from R1 assisting another resident to eat, with her back to the resident and NA (A) . According to NA (C) she heard a slap and NA (B) say to NA (A) that staff can not hit residents. NA (C) said she reported the incident immediately to RN (D). Interview with RN (D) at 3:17 p.m. on 6/28/12, confirmed on 6/17/12, after the evening meal (unknown time) NA (B) and NA (C) reported to her that NA (A) had slapped R1 on the hand. RN (D) said she spoke to NA (A) who denied slapping R1. Interview with the Social Service Designee (SSD) (E) at 12:30 p.m. on 6/28/12, revealed NA (A) resigned her position at the facility on 6/18/2012, the day following the incident with R1. Review of the facility's policy and procedure titled Abuse Prevention Plan updated 2/6/12, stated physical abuse included slapping a resident.