Every finding on record at Buffalo Lake Health Care Center

Based on observation and interview, the facility failed to ensure appropriate infection control technique was maintained during 1 of 1 meal service. This had the potential to affect all 42 residents. Findings include: Observation on 1/5/26 at 12:25 p.m., in dining room during noon meal service identified dietary aid (DA)-A serving food from the hot holding steam table in the dining room. After dishing up the food and passing it to the resident, she placed the plate in front of the resident while resting her hand on the back of the resident's wheelchair. DA-A reached for a multi-use menu sitting in the center of the table, handed it to another resident and asked her what her food choices were. She returned to the steam table, picked up a plate, and used the serving utensils to dish up the food. DA-A was not observed to wash her hands, use hand sanitizer, or wear gloves. While DA-A was standing at the steam table dishing food, another aide, DA-B approached and picked up a plate. DA-B reached over DA-A and started dishing up another resident's food. He picked up a plate touching the surface, reached over DA-A to grab the serving scoops and dished the food onto the plate. DA-B then went to the table, served the plate to the resident, then picked up the multi-use menu from the table, and handed it to another resident. DA-B then took that resident's order and returned to the steam table and dished another plate. DA-B was not observed to wash or sanitize hands between tasks during the observation. Cook-B was observed picking up the multi-use menu, handing it to the resident, taking her order, then returning to the steam table to dish up another plate. DA-A was then observed to approach the steam table and pick up a stack of condiment cups and stuck her thumb inside the cup to pull one apart from the stack. She filled the cup with coleslaw and served it to a resident. None of the staff washed or sanitized their hands between tasks or wore gloves. Interview on 1/5/26 at 1:17 p.m., with DA-A, DA-B, and Cook-B identified this was how we have always done meal service and reported they do not wash hands between tasks or wear gloves unless they are touching food directly. Observation on 1/6/26 at 12:16 p.m., identified Cook-C was serving food from the steam table in the hallway between two dining areas. The lids were removed from the containers of food. Cook-C would dish the food, then walk away from the steam table to give it to the residents. The steam table also had a tray of pastries on the bottom shelf about 5 above the floor without a cover. All the food on the steam table and the pastries on the bottom shelf remained uncovered for the entire food service. Interview on 1/6/26 at 10:00 a.m., with the registered dietician identified she has never observed or audited food service at the facility and only does audits upon request of the facility per her contract. She would expect the DM to complete audits to ensure staff were following good infection prevention practices. Interview on 1/8/26 at 4:02 p.m., with the administrator in training identified it was her expectation staff would practice infection prevention while serving meals. They should always wash their hands after touching unclean surfaces and prior to dishing up food. All food on the steam table should be covered prior to stepping away from the steam table. She would expect the DM to audit and provide training to staff as needed. A policy regarding infection prevention in the dining room was requested but nothing was provided before the end of the survey period.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 1 of 3 sampled staff (dietary aide) (DA)-A. This had the potential to affect all 41 residents in the facility. In addition, the facility failed to ensure a comprehensive ongoing infection control surveillance log to adequately track all staff illnesses and failed to update their infection control policies, annually. Findings include: Review of Dietary Absence Report log from May 2025 to November 2025 identified employee name, department and illnesses reported. However, the facility did not accurately complete the logs to ensure all necessary information was monitored. December 2025 employee illness log identified; DA-A was noted to have left early from work with symptoms of vomiting on 12/11/25. Review of DA-A timesheet identified that DA-A had worked on 12/11/25 from 7:10 a.m. to 09:30 a.m., for a total of 2.33 hours. DA-A returned to work on 12/13/25 and worked 11:05 a.m. to 300 p.m. and 3:38 p.m., to 7:37 p.m., for a total of 7.90 hours. Overall, there was no mention when or if DA-A symptoms resolved prior to returning to work. Interview on 1/06/2026 at 10:32 a.m., with dietary manager (DM) identified the process for her employees was to call her about their reported illness and was to remain at home until their symptoms improved. However, she had no process in place to ensure employees were to be symptom-free, unless the employee had informed her the employee was symptom free or had received treatment outside of work. She updated her staff illness logs, as needed, however, she did not communicate to the infection preventionist (IP) of her employee's symptoms. She identified the department had no formal communication process to ensure that the IP was aware of when staff were sick and when they were able to appropriately return to work. Interview on 1/08/26 at 9:57 a.m., with interim administrator (former director of nursing (DON), who is the infection preventionist (IP), identified the facility had no formal process in place to ensure all staff illnesses were recorded on an ongoing basis. Department heads did not communicate with the IP on a consistent basis of staff illnesses and identified there was a lack of monitoring of those employees with illnesses to determine, when an employee was appropriate to return to work, prior to returning. Further interview on 1/08/2026 at 9:57 a.m., with interim administrator identified the infection control program was discussed at QAPI meetings with the committee. However, there was no discussion about identifying improvement of tracking staff illnesses and the expectation of when those employees was to return back to work with the governing body. Review of current, undated BLHCC Scheduling Process sheet identified facility staff was to notify the charge nurse when ill and to report symptoms of their infection. Facility staff were expected not to return to work unless the employee was symptoms free or had no signs of infection within 24 hours. Review of October 2023 Infection Prevention & Control Policy and Procedure identified the facility was to follow national standards and guidelines to prevent, recognize and control onset and spread of infection and communicable diseases, whenever possible. The infection prevention and control program was to include a system for preventing, identifying, reporting, investigating, and control infections and communicable diseases for all residents, staff, volunteers, visitors and students from affiliated academic institutions or individuals providing services under a contractual arrangement according to regulatory standards. In addition, circumstances in which the facility was to prohibit employees with a communicable disease or infection, or skin lesions from direct contact with residents or their food if direct contact transmits the disease. Written health policies were to address reporting of staff illnesses, following work restrictions, prohibiting contact with residents or their food, and monitoring and evaluating patterns or outbreaks of illnesses among staff. IP was to identify necessary interventions, document infections, signs, and symptoms and was to keep an update map of infection to identify trends or clusters for action. Lastly, surveillance reports were to be shared with medical director, staff and practitioners to help identify impact of their care on infection rates and outcomes. Infection data and analysis was to be reported to the quality assurance (QA) committee at minimum on a quarterly basis and was to be communicated to the appropriate departments, including sharing active implementation and reporting on quality assurance and performance improvement (QAPI) projects.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate oversight of the infection control (IC) program to ensure thorough infection control and antibiotic stewardship program. This had the potential to affect all 42 residents in the facility.Findings include: Review of Monthly Infection Summary reports from May 2025 to November 2025 identified the columns for resident's name, infection date, body system affected, date symptoms resolved, infection, medication, source of the infection and if the criteria was met. However, the log lacked evidence that the antibiotic met criteria for continuation of use. R19Review of October 2025 infection log identified that R19 was to take cefuroxime (antibiotic) 250 milligrams (mg) by mouth twice a day for 5 days related to urinary tract infection (UTI) with a start date of 10/17/25 and was to end on 10/22/25. The organism was listed as Escherichia coli (E. coli) (a type of bacteria found in the intestines of humans and animals leading to diarrhea, vomiting, and fever) had met criteria for infection. On 10/24/25, R19 was to take cephalosporin (antibiotic) 500 mg by mouth twice a day for 7 days for symptoms of UTI and was to end 10/31/25. The organism was listed as Escherichia coli and was noted to have met criteria for infection. Review of R19's progress notes identified on:1) 10/15/25 at 11:30 a.m., identified family members of R19, identified on a previous occurrence that R19 that was experiencing symptoms of dizziness, fatigue, lightheadedness, and low blood pressure was linked to R19 having signs of a UTI. The facility faxed an order to R19's primary physician for a urinalysis order and to check for dehydration. 2)10/15/25 at 2:32 p.m., the facility received a fax from R19's primary physician for urinalysis to be completed.3) 10/17/25/25 at 7:17 a.m., R19 experienced the need to void, however could not produce urine. On 2 attempts, nursing staff was unsuccessful in collected urine from R19 through straight catheterization (procedure used to temporarily drain urine from the bladder, often performed by individuals who have difficulty emptying their bladder naturally) and by voiding into a cup.4) 10/17/25 at 4:00 p.m., facility staff were unsuccessful obtaining urine collection from R19. R19 had voice that she did not feel well, had chest pain with dizziness, and edema of the bilateral lower legs. R19's family was to take her to the emergency room for an evaluation. 5) 10/17/25 at 6:47 p.m., R19 returned to the nursing home from the local hospital with a diagnosis of UTI. R19's order was to started cefuroxime 250mg twice a day for 5 days. Overall, from 10/18/25 to 10/21/25 lacked an indication of an assessment to determine if the antibiotic was effective.6) 10/23/25 at 11:11 a.m., R19 complained of chest fullness and dizziness. R19 was unable to urinate and had not improved with the antibiotic she was administered. A family member was concerned that R19 was not recovering well from her urinary tract infection. The facility staff faxed R19's primary physician of R19 and family concerns, including R19's antibiotic and its susceptibilities (sensitivity of bacteria specific antibiotics determined through testing methods that was to guide effective treatment options). 7) 10/24/25 at 8:56 a.m., nursing staff left voicemail was sent to R19's primary physician to review fax that was sent the day prior. 8) 10/24/25 at 6:17 p.m., R19 returned from appointment along with family member with new order to start cephalexin 500 mg twice a day for 7 days. R19 was to take one dose on Friday evening with food and encourage water intake. From 10/25/25 to 10/28/25 lacked an indication of an assessment to determine if the antibiotic was effective. Review of 10/28/25 Hospital & Clinic emergency room note identified that R19 was treated with cephalexin antibiotic medication related to UTI. R19's urine culture on 10/24/25 showed less than 10,000 colony-forming units (CFM) per milliliter (ml) of mixed bacteria growth and identified a true bladder infection was unlikely. R31Review of August 2025 infection log identified that R35 was to take cephalexin (antibiotic) 500 mg three times a day for urinary tract infection with a start date of 8/31/25 for a total of 15 administrations of the antibiotic. The log lacked indication of an end date of the antibiotic and f a urine culture was obtained. The log identified that R35 met criteria to be treated with the antibiotic. On 9/01/25, R31 was to take cefdinir (antibiotic) 300 mg twice a day for 5 days with a start date of 9/05/25 and an end date of 9/10/25. The log identified R19's urine culture was noted to be negative and met criteria to be treated with the antibiotic. Review of R31 progress notes identified on:1) 8/31/25 at 6:23 p.m., R31 had increased difficulty in standing from a fall and was sent to the local hospital for an evaluation.2) 8/31/25 at 11:59 p.m., local hospital informed nursing staff was to send R31 back to the facility tonight and had evidence of a UTI and was to start of cephalexin. A urine culture was ordered and R31's white blood cell count (WBC) was 15 (normal range of WBC was 4,500- 11,000). R31's imaging results came back negative with no acute findings.3) 9/01/25 at 2:21 a.m., identified R31 arrived back to the facility at 12:30 a.m., with orders for cephalexin 500mg three times a day for acute cystitis (infection of the bladder caused by E. coli) with hematuria (presence of blood in the urine).4) 9/01/25 at 6:52 a.m., R31 had received 1st dose of cephalexin 500mg that was pulled from the emergency kit (Ekit).4) 9/04/25 at 11:14 a.m., identified R31 was readmitted to the local hospital and returned to the facility with diagnosis of a fracture and new orders to start cefdinir 300mg twice a day for 5 days for UTI.5) 9/06/25 at 11:35 p.m., 9/07/25 at 3:32 p.m., and 9/08/25 at 2:48 p.m., identified R31 had a UTI and was currently on antibiotics. However, the progress notes lacked an indication of an assessment to determine if the antibiotic was effective. Employee SurveillanceReview of Dietary Absence Report log from May 2025 to November 2025 identified employee name, department and illnesses reported. However, the facility did not accurately complete the logs to ensure all necessary information was monitored. December 2025 employee illness log identified; DA-A was noted to have left early from work with symptoms of vomiting on 12/11/25. Review of DA-A timesheet identified that DA-A had worked on 12/11/25 from 7:10 a.m. to 09:30 a.m., for a total of 2.33 hours. DA-A returned to work on 12/13/25 and worked 11:05 a.m. to 300 p.m. and 3:38 p.m., to 7:37 p.m., for a total of 7.90 hours. Overall, there was no mention when or if DA-A symptoms resolved prior to returning to work. Interview on 1/08/2026 at 9:57 a.m., with interim administrator (former director of nursing (DON), who was the infection preventionist (IP) identified facility nursing staff who worked on the evenings, who had not obtained IP training or certification, was assigned to update and maintain resident surveillance infection logs monthly. The process was for nursing staff to identify resident symptoms to rule out potential illness. If an illness was to occur, nursing staff was to use the McGeer criteria (a template used to identify infections) that was accessible to nursing staff on the units. A call was to be placed to the resident's primary provider to obtain a specimen. The specimen was collected and sent for testing and antibiotics were ordered for the resident, depending on their symptoms. Medication administration was given, and an antibiotic timeout or assessment was to be completed by the nursing staff within the 48-to-72-hour timeframe. The local pharmacy was to send reminders to the facility of a pending antibiotic assessment; however, it was not done consistently. IP acknowledged the surveillance logs were not monitored on a consistent basis and found the logs had discrepancies to identify indication of antibiotic use. She acknowledged her oversight as the IP was not up to her standards and would implement a process to ensure compliance of the infection control program. Further interview on 1/08/2026 at 9:57 a.m., with interim administrator identified the infection control program was discussed at QAPI meetings with the committee. However, there was no discussion to identify improvement of tracking staff illnesses and the expectation of when those employees were to able to appropriately return back to work with the governing body. Review of October 2023 Infection Prevention & Control Policy and Procedure identified the facility was to follow national standards and guidelines to prevent, recognize and control onset and spread of infection and communicable diseases, whenever possible. The infection prevention and control program was to include a system for preventing, identifying, reporting, investigating, and control infections and communicable diseases for all residents, staff, volunteers, visitors and students from affiliated academic institutions or individuals providing services under a contractual arrangement according to regulatory standards. In addition, circumstances in which the facility was to prohibit employees with a communicable disease or infection, and skin lesions from direct contact with resident or their food if direct contact transmits the disease. Written health policies were to address, reporting of staff illnesses, following work restrictions, prohibiting contact with residents or their food, and monitoring and evaluating patterns or outbreaks of illnesses among staff. IP was to identify necessary interventions, document infections, signs, and symptoms and was to keep an update map of infection to identify trends or clusters for action. Lastly, surveillance reports were to be shared with medical director, staff and practitioners to help identify impact of their care on infection rates and outcomes. Infection data and analysis was to be reported to the quality assurance (QA) committee at minimum on a quarterly basis and was to be communicated to the appropriate departments, including sharing active implementation and reporting on quality assurance and performance improvement (QAPI) projects.

Based on interview and document review the facility failed to provide timely notification to the designated family member of a change in condition for 1 of 1 resident (R47) with a change of condition requiring hospitalization, failed to update the physician of additional signs and symptoms of physical decline for 1 of 1 resident R45, who had continued high blood sugar levels and bloody stools, and timely notify the physician to a previous choking episode for 1 of 1 resident R7. Refer also to F684 and F808.Findings include: R47's 12/23/25-Significant Change Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment and required moderate assistance with activities of daily living (ADLs). She was transferred via ceiling sling lift and utilized a wheelchair for mobility. R47 had diagnosis including a kidney infection, bone infection of her left foot, heart failure, diabetes, high blood pressure, Methicillin-resistant Staphylococcus Aureus (MRSA) (bacterial infection resistant to several common antibiotics), cognitive impairment, hydronephrosis (swelling of one or both kidneys due to a backup of urine), diabetic ulcer of her right foot, and chronic obstructive pulmonary disease (COPD). Interview on 1/7/26 at 2:40 p.m., with family member (FM)-A identified R47 had been hospitalized multiple times over the past year with multiple concerns including wound infections, and UTIs. FM-A reported the most recent hospitalization was from 12/23/25 until 1/2/26, with a diagnosis of a kidney infection. It was reported R47 had been experiencing blood in her urine for 2 days before being sent to the clinic for evaluation and as a result, was hospitalized . FM-A reported concerns of not being timely notified of R47's change in condition as she felt it could have been prevented with earlier notification and intervention. R47's progress notes identified:12/21/25 at 7:57 p.m. staff reported R47's urine was a little pinkish in color. She failed to voice any urinary complaints and reported ongoing pain in her lower back.12/22/25 at 7:00 a.m. had a large dark colored, foul-smelling stool and reported nausea, but did not vomit, BP 118/62.12/22/25 at 10:15 a.m. staff reported two black stools that smelled like old blood. R47 was receiving iron supplement, but the old blood smell was new. MD updated via fax.12/22/25 at 10:34 p.m. R47 continued to be quiet and sleepy this shift. R47 went to an appointment with FM-B during the afternoon and complained of a stomachache. R47's color was noted to be paler than normal and had decreased appetite. Staff noted no stools were reported during the afternoon and R47 went to bed early. The MD was updated via fax of changes, but no emergent needs were identified. R47 declined going to the emergency room (ER) for evaluation of their condition when offered. 12/23/25 at 8:18 a.m., staff documented they called to update the MD and reported symptoms to the care team who directed R47 be brought to clinic for further evaluation. R47 did not respond when updated about going to clinic for evaluation. 12/23/25 at 10:19 a.m. FM-B was contacted for transfer of R47 for further evaluation and was referred to contact FM-C for transport in facility van. 12/23/25 at 3:44 p.m. MD responded to the previously sent fax on 12/22/25, with order for lab tests, and suggested R47 be sent to urgent care or the ER for further evaluation and was updated R47 had been sent to the ER by 12:00 p.m. 12/23/25 at 4:35 p.m., the facility was updated R47 had been admitted to the hospital. Interview on 1/8/26 at 3:21 p.m., with licensed practical nurse (LPN)-A identified R47's doctor (MD) was faxed with updates on 12/22/25 and 12/23/25, but the family was not contacted until 12/23/25, when they were contacted to arrange for transportation to urgent care for further evaluation. There were no indication family members were notified that R47 was experiencing bloody urine prior to her being sent for further evaluation. She agreed family should have also been updated following updates sent to the MD. Interview with on 1/8/26 at 3:30 p.m. with registered nurse (RN)- B and LPN-B identified they confirmed R47's family was not updated when she began experiencing bloody urine, and they should have been notified following notification of the provider of a change in condition. Interview on 1/8/26 at 3:52 p.m. with the assistant director of nursing (ADON) and administrator in training reported their expectation was for families to be notified of changes in condition in a timely manner. The agreed R47's family should have been updated when R47 began experiencing hematuria and possible blood in her stools. Review of the 10/20/25, Change of Condition-Notification policy identified the facility was to notify the physician, family, and/or responsible person when a resident experienced a change in their condition. Notifications with time and date were to be documented in the medical record.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA) when 1 of 12 (R17) sampled residents had new on-set of mental illness since admission.Findings include: R17's, March 2023 Preadmission Screening Results (PASAR) had a diagnosis of Parkinson's disease and did not have a current diagnosis of a mental illness. R17's, undated, current medical dx sheet, identified R17 had a diagnosis of Parkinson with dyskinesia with fluctuations 4/16/24 and depressive episodes on 3/23/25. R17 received a new diagnosis of generalized anxiety disorder on 3/25/25, dementia with anxiety on 9/16/25, and major depressive disorders with severe psychotic symptoms on 9/24/25. R17s medical record lacked any indication that the county SMHA had been notified since the new onset of R1's mental illnesses. R17's, accepted 11/04/25 at 3:05 a.m., quarterly Minimum Data Set (MDS) identified R17 was cognitively alert and had no behaviors. R17 had little interest or pleasure in doing things, felt down, depressed or hopeless never to 1 day, and had sometimes experience social isolation. R17 taken antipsychotics, antianxiety and antidepressant medications. Review of undated, current care plan identified that R17 had potential for drug related complications associated with use of Seroquel (antipsychotic) that was ordered September 2025. Interventions was to administer medication, monitor/document for side effects and effectiveness, monitor/record/report to MD as needed (PRN) and adverse reactions of psychoactive medications, such as unsteady gait, refusal to eat, difficulty swallowing, dry mouth, diarrhea, insomnia, weight loss, vomiting, behavior symptoms, pharmacy review of medications, alert MD of pharmacist recommendations for gradual dose recommendations or changes and follow MD orders, educate resident, family, caregivers about risks, benefits, and side effects of toxic symptoms of Seroquel, monitor/report to MD an behavior feelings, signs and symptoms of anxiety, feeling nervous, restless or tense, having sense of impending danger, panic or doom, increased heart rate, and trouble concentrating or thinking about anything other than the present worry. R17's progress notes identified on: 1) 9/10/25 at 10:22 a.m., R17 experienced difficulty managing her distress and was not a candidate for hospice services. R17 called her primary provider requesting an increase in her Xanax (antianxiety medication), valium (used to treat anxiety, muscle spasms and alcohol withdrawal, and baclofen (treats spasms and muscle pain in people with spin cord conditions) to assist with muscle contraction and relaxation.2) 9/16/25 at 7:59 p.m., R17 was visited by her primary provider along with R17's family member in attendance by phone. Staff were to administer Seroquel 25 milligrams (mg) by mouth every night.3) 10/21/25 at 8:04 p.m., R17 was seen during physician rounds through web access with orders to increase Seroquel to twice a day. Nursing staff were to check orthostatic (lying, sitting, and standing) blood pressures twice weekly for 2 weeks and send the results to R17's primary physician in 2 weeks. Review of 12/17/25, rural psychiatry provider initial assessment identified R17 was referred for psychiatric evaluation. R17 reported progressive weakness and tremors throughout the day, medication-related nausea, severe early morning pain in extremities, and obsessive behaviors regarding medication timing. She expressed sadness of missing family activities, visitations with her family, and was frequently calling her primary provider for medication changes. Review of 12/30/25, rural psychiatry follow up provider note identified R17 had experience mood fluctuations with periods of feeling like she was not going to make it or was dying. R17's anxiety worsened around noon, and she had social isolation due to worrying about Parkinson's movement symptoms. R17 anxiety significantly impacted her daily functioning, as she rarely came out of her room, and worried about not fitting in. R17's Seroquel was increased in October 2025 but had no significant improvement in her condition since that time. Interview on 01/07/2026 3:15 PM with licensed social worker stated a level II PASARR was not completed and would implement a process to review and address changes of residents diagnoses to determine if a Level II was needed to ensure compliance. Review of September 2025 Pre-admission Screening and Resident Review (PASARR) policy identified the facility was to identify indicators was present for a referral for Level II evaluation. A resident who experiences a significant change in condition, a new diagnosis of mental illness was identified and determined, a Level II was to be completed. In addition, the facility was to monitor PASARR compliance through routine audits to ensure compliance.

Based on interview and document review, the facility failed to appropriately assess, monitor, update the physician of additional signs and symptoms of physical decline, and intervene for 1 of 1 sampled resident (R45) who had continued high blood sugar levels and bloody stools, and intervene when immediate medical evaluation warranted a face-to-face by a physician. Findings include: R45's [DATE], hospital discharge summary identified R45 had been sent to the emergency room (ER) for concerns of high blood sugar. At the ER, R45's family reported R45 had been passing dark/bloody stools since yesterday as well. An occult stool test was administered and was positive for blood. Upon arrival and during treatment, R45 presented to the ER as pale in color, with high blood sugars and very low blood pressure. ER evaluation by the medical doctor revealed evidence of hemorrhagic shock (life-threatening condition caused by significant blood loss, leading to inadequate blood flow and oxygen delivery to vital organs), GI (internal abdominal) bleeding, low oxygen, and associated heart attack. R45 was placed on comfort cares after conferring with family and was returned to the facility. R45's primary physician was updated. R45's [DATE], accepted comprehensive Minimum Data Set (MDS) identified R45 had moderately impaired cognition, and required substantial to total assistance with cares. R45 received scheduled pain medication, insulin, antidepressant, and antipsychotic medication. R45's [DATE], accepted MDS identified she had died in facility on [DATE]. R45's [DATE], Medical Diagnosis list identified R45 had diagnoses of diabetes, psychotic disorder with hallucinations, major depression, high blood pressure, peripheral vascular disease (decreased blood flow to extremities), Alzheimer's disease, insomnia, long term use of aspirin, low magnesium, low iron, and a history of stroke. R45's undated, care plan identified R45 was on a diabetic diet. R45 had diabetes with potential for complications. Staff were to administer medication and monitor for side effects, monitor weight and report significant changes to R45's physician, obtain ordered labs, monitor blood sugars, and monitor for hypo or hyper-glycemia. Review of R45's physician orders identified on [DATE], R45 was to be administered 24 units once daily of Lantus (long-acting insulin) subcutaneously (injected into fat layer under skin). Staff were to cut her dose in half if she had not eaten and call the physician if her BS (blood sugars) were lower than 60 deciliter/millimeters of mercury (dL/mmhg) or greater than 400 dL/mmhg. Review of R45's documented blood sugars (in dL/mmhg), and corresponding progress notes identified:On [DATE] at 5:41 p.m., R45's BS was 514. The physician (MD)-E was notified via fax that R45's BS had risen, however, MD-E had not replied back via fax until [DATE]. From [DATE] through [DATE], R45's BS ranged from 171 to 378.On [DATE] at 9:01 a.m., R45's BS rose again to 418 and MD-E was notified. Staff documented R45 had complained of feeling dizzy while standing. It is unclear if staff reported those finding to MD-E as well.On [DATE] at 11:48 a.m., R45's BS rose to 587 and MD-E was again notified. MD-E gave a verbal order to give R45 10 units of fast acting insulin and recheck her BS in one hour and call back with the results.On [DATE] at 12:44 p.m., BS was 581. MD-E was notified of the result and ordered staff to administer 20 more units of fast acting insulin and to recheck R45's BS. If the BS was over 300, staff were to call back for more orders. Staff rechecked R45's BS and it had lowered to 412. MD-E then ordered another 10 units of fast acting insulin and instructed staff to watch R45 closely throughout the evening and overnight and report back if R45's BS stayed higher or dropped too low.On [DATE] at 4:52 p.m., R45's BS was 144.On [DATE] 9:28 p.m. R45's BS was 391. Staff notified MD-E who gave another order for staff to administer 10 units of fast acting insulin (Humalog) and to increase her Lantus (long-acting insulin) to 34 units beginning [DATE]. From [DATE] after 9:28 p.m., until [DATE] at 6:52 a.m. there was no indication staff had followed MD-E's orders and monitored R45's BS throughout the night or had taken other vitals to identify a change of condition that warranted a face-to-face evaluation by a physician. Review of [DATE], facility 24-hour report identified documentation next to R45's name that R45 had large loose dark stools 3 or 4 times yesterday with no emesis. Further review of R45's documented BS and corresponding progress notes identified:On [DATE] at 6:54 a.m., staff noted R45 slept well overnight and did not have any loose stools or vomiting. She continued to be very thirsty and out on her call light for water. R45 refused to get up to use the bathroom overnight. On [DATE] at 5:00 a.m Staff noted they took R45's BS and it was high again at 508. Her blood pressures were low at 91/44 millimeters of mercury (mm/hg) (normal 120's/80's), pulse was 70, respirations at 19 and her temperature was 97.4 degrees Fahrenheit (F). Staff noted she was asleep in her recliner. There is no indication staff had identified the consistent high blood sugars combined now with her low blood pressure indicated the necessity to be seen by a physician for a face-to-face medical exam.On [DATE] at 11:51 a.m, staff left a message for MD-E asking for orders to check a urine sample to rule out a bladder infection. There was no indication staff had also notified MD-E of any current BS levels.On [DATE] at 12:08 p.m., staff noted R45's BS was 493. On [DATE] at 4:09 p.m., staff noted R45 performed upper body exercises and noted she was not feeling well.On [DATE] at 6:18 p.m., a medication administration progress note identified staff attempted to take R45's BS, however they were unable to get a reading. At 6:20 p.m., staff finally sent R45 to the ER for medical examination after they noted she was declining. Color waxy and pale.On [DATE] at 11:59 p.m., staff documented they assisted R45 up for supper and to the table. They noted they were unable to get a BS reading after taking it twice and it just said it was high with no associated number. R45 was noted to be pale and waxy looking and had confusion. Staff called R45's family and requested permission to send R45 to the ER and a 911 call was placed at that time. Staff then called the ER and was told R45 was not doing well and family decided to implement comfort cares. R45 was noted to be returning that evening. Staff also noted R45's hemoglobin (a protein in blood. Low levels can be caused by conditions such as blood loss) was low.There was no documentation in R45's progress notes identifying all staff were aware of R45's bloody stools, or any indication that had been reported to MD-E, nor evidence staff had identified a change of condition timely and delayed R45 in sending her to the ER for medical evaluation. Interview on [DATE] at 9:16 a.m., with registered nurse (RN)-A identified R45 really struggled with her BS but she had other medical issues going on also. Interview on [DATE] at 11:45 a.m., with RN-C identified on [DATE], after morning report and hearing that R45's BS was so high she had re-checked the BS and let the charge nurse know, who then called MD-E to update them. She reported she had a hard time telling if R45's BS was high as R45 did not act any different. R45 typically liked to sleep a little later as she stayed up at night. MD-E did order for staff to administer insulin and to check on her frequently that day. R45 came out for meals and conversed with staff on [DATE] but might have acted a little more tired that day and been flushed in the face. RN-C was unaware of any dark loose stools other than what had been reported during report that morning on [DATE]. There had been a similar situation with another resident when that resident had a BS of 500 as that resident was sent to the ER for evaluation. RN-C noted she was surprised R45 had not been sent to the ER to be evaluated by a physician. In general, for residents with BS below 90 or above 300, staff were to contact the physician. Interview on [DATE] at 12:24 p.m., with nursing assistant (NA)-B identified R45 did have dark colored stools the day before she was sent to the hospital [[DATE]]. The stools were black, almost tar looking. The charge nurse (LPN-C) was notified of the dark stools. R45 continued to have loose, dark stools that evening on [DATE]. Interview on [DATE] at 12:36 p.m., with RN-D identified any resident with extremely high or low BS would be sent to the ER for evaluation if it was out of their normal limits. Nurses were to use their critical thinking skills. There was a change in condition policy that could be referenced by staff for procedures, or the nurse could contact the physician for direction on how to proceed if unsure of what to do. Interview on [DATE] at 1:05 p.m., with licensed practical nurse (LPN)-C identified she had been the nurse on duty the night of [DATE] into [DATE]. She reported R45 had been running high BS and the provider had made some insulin changes. R45 had gained a little weight the week before [DATE]. She had noted R45 had fluid in her legs however, R45 denied that her legs hurt. She had been made aware of the dark stools and reported that R45 even had blood when staff had wiped her after toileting. She thought that another family remember had been made aware of the blood in the stool but she herself had not made MD-E aware of the bloody stools after becoming aware by the NA's. Review of R45's progress notes identified there was no mention that a family member or MD-E had been notified of R45's bloody stools. Interview on [DATE] at 2:38 p.m., with the administrator-in-training identified typically, any BS over 300 was concerning and staff should contact a provider and for BS over 500 along with any accompanying symptoms. If a resident also had symptoms, the resident should be seen by the physician for a face-to-face medical evaluation. The facility glucometer machine will register as high if a BS was over 600. She noted the nurse did send R45 to the ER when she was unable to get a reading on the glucometer. She agreed that on [DATE] when R45 developed dark bloody stools and with her continued unstable BS, the physician should have been notified. She further agreed that the medical record lacked any documentation of dark loose stools. Nursing staff were able to use the policy book from Pathways as a professional standard or they were able to search online. The nurse can also call the on-call physician for direction if there were questions. Interview on [DATE] at 10:36 a.m., with medical director identified he was unfamiliar with R45 and her baseline blood sugars. He noted some residents do good with high BS and other do not and would need to be evaluated in the ER. The symptoms of the high BS of 508 at 5:00 am on [DATE] and dark stools the day before, at a minimum, should have been conveyed to a physician. Interview on [DATE] at 11:45 a.m., with RN-D identified during her shift on [DATE], she had communicated a lot with the provider related to R45's high BS and stated she had advocated for R45 asking MD-E if she needed to be seen, however there was no documentation to support RN-D had made those recommendations for a face-to face evaluation. MD-E had ordered additional insulin and a urine culture. On [DATE], she kept a close eye on R45 and sat with her during meals. She was unaware of any dark loose stools, and none had been reported to her while she was working as the charge nurse on [DATE]. R45's blood sugars were much higher than normal for her on [DATE]. Interview on [DATE] at 2:20 p.m., with MD-E identified R45 was a [AGE] year-old who was diabetic and wanted to stay on insulin. Staff had notified her of R45's high blood sugars and she had provided orders for additional insulin to be given to control the high BS, which was appropriate treatment. The family did not want aggressive treatment and it was reported R45 seemed to be acting herself during these times of high BS until she was sent into the ER. MD-E was not aware of the large dark stools until she had been updated by the ER provider. MD-E felt there was no correlation with the bloody stools with her high BS. She would have expected to be notified of high BS and if R45 had started to have dark loose stools. The outcome would not have changed considering her age and declining health, along with her multiple comorbidities. She had no indication previously of a GI bleed concern until the ER provider updated her. Review of Assure Glucometer manufactures book identified BS levels more that 600 would read as HI on the glucometer and BS levels less than 20 would read as LO on the glucometer. Review of [DATE], Proper Glucose Management policy identified blood glucose levels would be monitored, documented, and addressed. Hyperglycemia was defined as BS levels above specified by the physician orders. Residents were to have ongoing reassessment as clinically indicated. BS's would be monitored per the physician orders and reported to the physician if outside ordered parameters. The facility would monitor for signs and symptoms of hyperglycemia, including increased thirst, frequent urination, fatigue, and blurred vision. Persistent or significantly elevated BS would be reported promptly to the provider. Abnormal readings and provider notification were to be clearly documented in the resident's record. Review of undated, Hyperglycemia policy provided identified BS checks would be done for signs or symptoms of hyperglycemia. BS over 300 would be reported to the provider immediately or if the resident was displaying severe signs of hyperglycemia staff were to call 911. Review of the revised [DATE], Change of Condition policy identified a resident's condition was to be assessed and reported to the MD immediately if a resident experienced vital signs that varied significantly from the residents normal limits, or have been monitored for 24 hours and have not improved with basic nursing interventions, any dramatic fluctuations in diabetic status such as BS levels, and levels of consciousness changes, and any other significant change of condition as determined by the licensed nurse. Residents' condition was to be assessed and reported in a timely manner either verbally or in writing. There was no mention in the policy of what change of condition warranted immediate face-to-face medical evaluation by a physician, or when staff should send the resident to the ER.

Based on observations, interview, and document review, the facility failed to ensure 1 of 1 resident (R7) had received the appropriate therapeutic diet as ordered by the physician, timely notify the physician of a previous choking episode, and follow policy and procedure by having only cooks dish up food from the serving line to serve to residents in order to ensure diets were accurately given as ordered to each resident. Findings include: Review of the 12/25/25, facility reported incident to the State Agency identified R7 had been seated at a table in the dining room. Nursing assistant (NA)-A observed R7 coughing and turning red. NA-A approached R7 and patted him on the back and directed him to spit the food out of his mouth. R7 was able to cough up the food, and he spit a piece of hamburger out and told staff he was okay. NA-A reported R7 had spit out chunks of hamburger. Medication Aid (TMA)-A summons the charge nurse licensed practical nurse (LPN)-B to the dining room. LPN-B arrived in the dining room and noted R7's face to be purple/maroon in color and was coughing. His oxygen was on top of his nose as he was spitting. LPN-B applied his oxygen and removed resident from the dining area and took him to his room. R7 maintained an open airway and his color quickly returned to normal. R7 was alert and talking. LPN-B assessed temperature, lung sounds, and oxygen saturations. LPN-B reported R7 did not receive the appropriate texture diet of puree meat per his care plan. R7's accepted 10/29/25 quarterly Minimum Data Set (MDS) assessment identified his cognition was severely impaired, he had diagnosis of dysphasia (difficulty swallowing) and dementia. R7's Section K: Swallowing and Nutritional Status identified he had no coughing or choking during meals during the 7-day lookback period. R7'S 2/9/25, progress note identified R7 had a choking spell while eating the ground turkey, which did have gravy on it. The nurse aide (NA) had called nursing to dining area. Staff observed R7's face was a deep red color. He was coughing and taking a breath at that time. The NA reported she felt he did lose his airway. Staff assisted him back to his room and noted they felt like everything [food] was cleared [from his airway} at that time. His color was back to normal, and he was talking to staff. Staff were to check R7's temperature and O2 [oxygen] saturation levels, along with assessing his lung sounds every shift x 3 days for assessment of aspiration. Staff noted they were questioning if R7 shouldn't be on pureed meat for safety and passed that information along in the nursing report. There was no indication in the note that R7's physician had been notified at the time of the incident to determine if R7 needed immediate medical evaluation. R7's 2/10/25, facility communication with the physician note identified staff documented May we please have ST (Speech Therapy) orders to evaluate and treat due to a choking episode on 2/9/25. The physician responded with new orders to proceed with ST for evaluation due to diagnosis of dysphagia. R7's 2/19/25 ST summary identified a 7-day trial of puree meats with moisture was completed from 2/11/25 through 2/18/25. ST recommendation for pureed meats with moisture, cut food into bite size, supervision at meals, upright for oral intake, thin liquids within functional limits (WFL) chewing of puree and no refusal of meals. R7 demonstrated no choking and coughing event with the current trial diet. R7 agreed at that time to continue with the above diet. If R7 requested an upgrade of his food, a risks verses benefit was to be completed. ST provided patient and caregiver training in safe swallowing strategies, specifically R7's current dietary modification. Supervision by staff was required when eating. Staff were to ensure R7 was given an NDD3 diet consisting of pureed meats with moisture and thin liquids. Staff were to cut other food into bite size pieces. R7 was to be upright for intake and use safe swallowing strategies, such as eating at a slow pace, chewing all food well, taking small sips of fluids, and alternate liquids and solids in order to preserve R7's current level of function with 100% carryover demonstrated during the session. Observation on 1/5/26 at 12:25 p.m., identified multiple staff dishing food for residents in the dining room. DA-B observed standing at the steam table, while she was dishing a plate of food DA-A approached the steam table and reached over DA-B and dished up another resident's food. [NAME] B was also observed dishing food from the steam table. Interview on 1/5/26 at 7:07 p.m., with dietary aid (DA)-A identified he had dished up R7's meal on 12/25/25, from the food off the steam table. The food was already prepared. He said the containers are not normally marked to their contents, but the meat looked pureed from the top. DA-A stated, I wasn't really paying super close attention. I was going too fast, and I put it on the plate and served it. R7's 8/19/25 physician telephone order identified the facility was to change his diet order to NDD3, pureed meat regular texture and fluid. R7 may have potato chips. R7's current, undated care plan identified he was to maintain a healthy nutritional status during his stay at the facility. R7 was to use adaptive devices to stay as independent as possible. He was to have a National Dysphasia Diet level 3 (NDD3) thin liquid diet with pureed meats. The care plan noted he had No difficulty chewing. R7 was to have covered cups to prevent spillage, and potato chips were approved by ST when on the menu. There was no revision of the care plan to include ST's instructions for staff noting staff were to cut food into bite size pieces. R7 was to be upright for intake and use safe swallowing strategies, such as eating at a slow pace, chewing all food well, taking small sips of fluids, and alternate liquids and solids. Interview on 1/6/26 at 11:11 a.m., with NA-A identified on 12/25/25, staff were bringing residents into the dining room. She was waiting for a dietary staff to bring food in. R7 was seated across from her and eating his food. R7 started coughing. When she looked at him, his face was turning red, and he was hunched over. She got up and started patting him on the back [since he was coughing and not obstructed] and told him to keep coughing and spit out what was in his mouth. He spit food out onto his shirt, and it was chunks of ground beef, a little bigger than a pea but not as big as a bean. By that time trained medication aide (TMA)-A came in and said if he is coughing do not intervene. R7 managed to get the food out and clear his own throat. TMA-A alerted licensed practical nurse (LPN)-B. LPN-B came to the dining room and assessed R7. NA-A and LPN-B took R7 back to his room to clean him up and change his clothes. NA-A reported to LPN-B what happened, and LPN-B said R7 was supposed to have pureed meat. NA-A was a contracted staff and was not aware R7 was on a mechanically altered diet. She did not receive any training from the facility that was specific to each resident, when her employment began at the facility, but had been instructed to read and review each resident's care plan and stated she had not done that. Interview on 1/6/26 at 12:09 p.m., with cook-A, identified she was not in the dining area on 12/25/25, and did not dish up the food that R7 received. The DA told her what happened later, and she thought the meat placed into the serving station steam table had been appropriately pureed. After food is prepared, it is placed in containers on the steam table. The containers are not marked to what consistency or food was held within the container. The DA's dish up and serve the food. The kitchen does not use diet cards in the dining room to ensure residents receive the correct diet at time of placing their plate at the table, but noted there is a list of residents with diet cards in a drawer on the steam table. She received training when she started on how to puree food. She was told to add liquid with the food to a blender and blend until no chunks were visible. Interview on 1/7/26 at 10:00 a.m., with the registered dietician (RD) identified she was not aware of the incident on 12/25/25. She would expect the facility to have one person dishing from the steam table. Typically, it should be the cook who prepared the food since they are the most aware of the different diets. The DA's and other support staff would assist in passing the trays. She has never observed or audited food service at the facility and only does audits upon request of the facility per her contract. She would expect the dietary manager (DM) to complete competencies with kitchen staff that are responsible for preparing or serving therapeutic diets and all kitchen staff should receive training on therapeutic diets upon hire. Interview on 1/6/26 at 9:30 a.m., with the DM identified she had completed competencies prior to the incident but had not completed any updated competencies or audits following the training that occurred after the incident at the time of this interview. The facility provided documentation of International Dysphasia Diet Standardization Initiative (IDDSI) training provided to the dietary staff on 12/26/25, along with a sign-off sheet identifying all kitchen staff had attended. Review of the facility provided undated Dining Service Policy identified the facility would serve food at the proper temperature and texture as ordered by the physician using the mobile steamtables to deliver the food to all parts of the facility. The cook was to prepare the food in the kitchen area following the texture requirements needed for each meal and place the food into the steamtable. The cook was to serve the food to the residents following their tray cards [diet cards]. The assistants (DA) would then be able to serve fluids, any yogurts, fruit cups, etc. to the residents while following their diet orders. When the assistant was done serving from the juice cart, they were to assist the cook with serving meals to any residents that do not have their food yet, following diet try cards. Review of the [NAME] checklist identified at meal service; the cook was to serve the meal for the small dining room and then continue to the main dining room.

Based on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 sampled residents (R19 and R31) reviewed for antibiotic stewardship.Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the residents' current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out [ATO]. Review of Monthly Infection Summary reports from May 2025 to November 2025 identified the columns for resident's name, infection date, body system affected, date symptoms resolved, infection, medication, source of the infection and if the criteria were met. However, the log lacked evidence that the antibiotic met criteria for continuation of use. R19Review of October 2025 infection log identified that R19 was to take cefuroxime (antibiotic) 250 milligrams (mg) by mouth twice a day for 5 days related to urinary tract infection (UTI) with a start date of 10/17/25 and was to end on 10/22/25. The organism was listed as Escherichia coli (E. coli) (a type of bacteria found in the intestines of humans and animals leading to diarrhea, vomiting, and fever) had met criteria for infection. On 10/24/25, R19 was to take cephalosporin (antibiotic) 500 mg by mouth twice a day for 7 days for symptoms of UTI and was to end 10/31/25. The organism was listed as Escherichia coli and was noted to had met criteria for infection. Review of R19's progress notes identified on:1) 10/15/25 at 11:30 a.m., identified family members of R19, identified on a previous occurrence that R19 that was experiencing symptoms of dizziness, fatigue, lightheadedness, and low blood pressure was linked to R19 having signs of a UTI. The facility faxed an order to R19's primary physician for a urinalysis order and to check for dehydration. 2)10/15/25 at 2:32 p.m., the facility received a fax from R19's primary physician for urinalysis to be completed.3) 10/17/25/25 at 7:17 a.m., R19 experienced the need to void, however could not produce urine. On 2 attempts, nursing staff was unsuccessful in collected urine from R19 through straight catheterization (procedure used to temporarily drain urine from the bladder, often performed by individuals who have difficulty emptying their bladder naturally) and by voiding into a cup.4) 10/17/25 at 4:00 p.m., facility staff were unsuccessful obtaining urine collection from R19. R19 had voice that she did not feel well, had chest pain with dizziness, and edema of the bilateral lower legs. R19's family was to take her to the emergency room for an evaluation. 5) 10/17/25 at 6:47 p.m., R19 returned to the nursing home from the local hospital with a diagnosis of UTI. R19's order was to started cefuroxime 250mg twice a day for 5 days. Overall, from 10/18/25 to 10/21/25 lacked an indication of an assessment to determine if the antibiotic was effective.6) 10/23/25 at 11:11 a.m., R19 complained of chest fullness and dizziness. R19 was unable to urinate, and symptoms had not improved with the antibiotic she was administered. A family member was concerned that R19 was not recovering well from her urinary tract infection. The facility staff faxed R19's primary physician of R19 and R19's family concerns, including R19's antibiotic and its susceptibilities (sensitivity of bacteria specific antibiotics determined through testing methods that was to guide effective treatment options). 7) 10/24/25 at 8:56 a.m., nursing staff left voicemail was sent to R19's primary physician to review fax that was sent the day prior. 8) 10/24/25 at 6:17 p.m., R19 returned from appointment along with family member with new order to start cephalexin 500 mg twice a day for 7 days. R19 was to take one dose on Friday evening with food and encourage water intake. From 10/25/25 to 10/28/25 lacked an indication of an assessment to determine if the antibiotic was effective.Review of 10/28/25 Hospital & Clinic emergency room note identified that R19 was treated with cephalexin antibiotic medication related to UTI. R19's urine culture on 10/24/25 showed less than 10,000 colony-forming units (CFM) per milliliter (ml) of mixed bacteria growth and identified a true bladder infection was unlikely. R31Review of August 2025 infection log identified that R35 was to take cephalexin (antibiotic) 500 mg three times a day for urinary tract infection with a start date of 8/31/25 for a total of 15 administrations of the antibiotic. The log lacked indication of an end date of the antibiotic and f a urine culture was obtained. The log identified that R35 met criteria to be treated with the antibiotic. On 9/01/25, R31 was to take cefdinir (antibiotic) 300 mg twice a day for 5 days with a start date of 9/05/25 and an end date of 9/10/25. The log identified R19's urine culture was noted to be negative and met criteria to be treated with the antibiotic. Review of R31 progress notes identified on:1) 8/31/25 at 6:23 p.m., R31 had increased difficulty in standing from a fall and was sent to the local hospital for an evaluation.2) 8/31/25 at 11:59 p.m., local hospital informed nursing staff was to send R31 back to the facility tonight and had evidence of a UTI and was to start of cephalexin. A urine culture was ordered and R31's white blood cell count (WBC) was 15 (normal range of WBC was 4,500- 11,000). R31's imaging results came back negative with no acute findings.3) 9/01/25 at 2:21 a.m., identified R31 arrived back to the facility at 12:30 a.m., with orders for cephalexin 500mg three times a day for acute cystitis (infection of the bladder caused by E. coli) with hematuria (presence of blood in the urine).4) 9/01/25 at 6:52 a.m., R31 had received 1st dose of cephalexin 500mg that was pulled from the emergency kit (Ekit).4) 9/04/25 at 11:14 a.m., identified R31 was readmitted to the local hospital and returned to the facility with diagnosis of a fracture and new orders to start cefdinir 300mg twice a day for 5 days for UTI.5) 9/06/25 at 11:35 p.m., 9/07/25 at 3:32 p.m., and 9/08/25 at 2:48 p.m., identified R31 had a UTI and was currently on antibiotics. However, the progress notes lacked an indication of an assessment to determine if the antibiotic was effective.Interview on 1/08/2026 at 9:57 a.m., with interim administrator (former director of nursing (DON), who was the infection preventionist (IP) identified facility nursing staff who worked on the evenings, who had not obtained IP training or certification, was assigned to update and maintain resident surveillance logs monthly. The process was for nursing staff to identify resident symptoms to rule out potential illness. If an illness was to occur, nursing staff was to use the McGeer criteria (a template used to identify infections) that was accessible to nursing staff on the units. A call was to be placed to the resident's primary provider to obtain a specimen. The specimen was collected and sent for testing and antibiotics were ordered for the resident, depending on their symptoms. Medication administration was given, and an antibiotic timeout or assessment was to be completed by the nursing staff within the 48-to-72-hour timeframe. The local pharmacy was to send reminders to the facility of a pending antibiotic assessment; however, it was not done consistently. IP acknowledged the surveillance logs were not monitored on a consistent basis and found the logs had discrepancies to identify indication of antibiotic use. She acknowledged her oversight as the IP was not up to her standards and to was implement a process to ensure compliance with the infection control program. Review of Alixa RX Antibiotic Stewardship Program Addendum to Clinical Pharmacist Service Agreement identified the company was to render a clinical pharmacist to perform a review of antibiotics issued on site, review supporting lab work, to serve on an infection control committee on a quarterly basis, provide and conduct, when request by the facility annual education in-service sessions, appropriate educational material related to antibiotic stewardship, including annual updates to policies/procedures with supporting documentation, regular evaluation of facility antibiotic utilization of trends and missed opportunities to facility leadership. In addition, reports were to be sent in writing, may be sent electronically for any irregularities when appropriate. Review of July 2025 Antibiotic Stewardship Policy identified the facility was to promote appropriate use of antibiotics to treat infections and reduce advents events associated with antibiotic use. The facility administration was to identify a lead to be responsible for the program oversight. Leadership was to communicate annually with nursing staff and clinicians to antibiotic stewardship and expectations of the nursing home enforcement of antibiotic stewardship policies. At minimum the medical director, director of nursing and infection preventionist ensure antibiotics were prescribed when appropriate. Antibiotic stewardship actions were to include knowledge of a potential infection, clinical and historical information gathered for the provider, submission of diagnostic specimens, assess appropriateness of antibiotics prescribed and how to identify adverse outcomes associated with antibiotics. McGeer's criteria was to be used to determine if criteria was met to obtain microbiologic test, such as urine, stool, wound, respiratory and blood cultures. In addition, the facility was to ensure that staff, providers, residents and families received education upon hire on Educare (online education module) and annually through in-services. Requested copies of R31's documents. However, none was received during survey window.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had impaired cognition, and exhibited physical and verbal behaviors directed towards others daily that significantly interfered with R1's care. On 12/20/23 at 2:00 p.m. a Facility Reported Incident (FRI) submitted to the SA indicated nursing assistant (NA)-A had threatened to hit R1. On 12/28/23 at 12:10 p.m., registered nurse (RN)-A stated she was the charge nurse on 12/19/23. At approximately 10:30 p.m. on 12/19/23, NA-B told RN-A she had observed NA-A place her hands on R1 shoulders while speaking harshly to R1. RN-A could not remember what the exact words were reported to her. RN-A reported the incident to the director of nursing (DON) via text at approximately 10:45 p.m. on 12/19/23. On 12/28/23 at 1:03 p.m., the DON stated she received a text from RN-A the night of 12/19/23 indicating a staff member wanted to meet with her the next day. The DON she was not aware of the reason why. The DON stated this incident should have been reported to her right away after it occurred. The DON stated NA-A continued working with residents the evening of 12/19/23. On 12/28/23 at 1:27 p.m., the social worker (SW)-A stated she interviewed NA-B at 10:30 a.m. on 12/20/23. SW-A stated NA-B told her during cares on 12/19/23 at 4:15 p.m. she observed NA-A grab R1's shoulders and shout at R1. SW-A stated she was told NA-A said to R1, If you keep hitting me, I'm going to hit you back. The facility's Vulnerable Adult Policy dated 1/26/22 directed the facility will ensure all alleged violations including abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute reasonable suspicion of a crime are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.

Based on interview and document review, the facility failed to notify a provider of a drop in blood pressure for 1 of 1 residents (R4) reviewed for orthostatic blood pressure (a measure of blood pressure before and after a change in position). Findings include: R4's face sheet printed 12/20/23, noted diagnoses included hypertension and type 2 diabetes mellitus. R4's signed physician's orders dated 12/6/23, included an order to check orthostatic blood pressure (blood pressure checked first when lying, then sitting, then standing) every four weeks. The order failed to provide instructions for updating the physician. Review of R4's orthostatic blood pressure results 10/2023-12/2023 were as follows: - 10/8/23 lying 154/89, sitting 147/54 - 11/5/23 sitting 167/74, standing 94/48 - 12/3/23 lying 138/65, sitting 151/112 R4's nurse notes for 10/2023 thru 12/20/23 failed to note changes in R4's orthostatic blood pressures or action taken as a result. On 12/20/23 at 9:23 a.m., R4's primary provider stated she did not recall being notified of the change in R4's blood pressure on 11/5/23, if she had, she would have made changes to R4's medications. She expected to be notified with any change in condition, including orthostatic blood pressures with a 20 point or greater drop in the systolic blood pressure (top number- measurement taken when the pressure on the walls of the artery is at the highest). On 12/20/23 at 11:13 a.m., registered nurse (RN)-A explained the process to check orthostatic blood pressure included initially checking the blood pressure while the resident is lying, then have the resident sit up for at least one minute before checking the blood pressure again, finally have the resident stand for at least one minute before checking the blood pressure for a third time. If the resident is unable to remain in either the sitting or standing position it is acceptable to check the blood pressure after only one change in position. The purpose of the orthostatic blood pressure was to monitor for a drop in the systolic. RN-A considered a big drop to be 10-15 points. If a big drop occurred, RN-A would update the charge nurse and document in the residents record if there were signs of dizziness, feeling faint or unsteady and what the actions were taken. When asked to review R4's orthostatic blood pressures from 11/5/23, RN-A stated R4's provider should have been notified of this drop as it was a big drop and was concerning. RN-A noted there was no documentation is R4's nurse notes regarding the change in blood pressure or actions. On 12/20/23 at 11:29 a.m., director of nurse (DON) stated a change of 20 points or great in the systolic blood pressure, the provider should have been updated. DON left it up to the nurse completing the orthostatic blood pressure to decide if they blood pressure should be rechecked later. DON expected the results and actions taken following the results were documented in the nurses' notes. DON confirmed there were not nurse notes in R4's record regarding the orthostatic blood pressures taken on 11/5/23. The facility did not have a policy that provided direction for rechecking orthostatic blood pressure. With R4's history of falls, the different from sitting to standing was concerning as it could increase R4's risk for falling. Facility policy titled Change of Condition- Physician, Resident, Family/Responsible Party Notification with a review date 10/2023, instructed to notify the physician any time there is a change in condition.

Based on observation, interview and document review, the facility failed to ensure confidentiality of health conditions for 1of 1 residents (R42) who was reviewed for right to privacy. Findings include: R42's admission MinimumData Set (MDS) dated [DATE], identified resident as having intact cognition and frequent incontinence of bowel and bladder. R42's order summary report dated 12/20/23, indicated resident was taking Vancomycin (an antibiotic medication) for enterocolitis (inflammation of the inner lining of the small intestine and colon) due to clostridium Difficile (C. diff- an infection in the colon). R42's care plan dated 12/18/23 indicated the potential for complications r/t (C.diff) and instructed staff contact precautions were in place due to C. diff infection. During observations 12/18/23 at 2:33 p.m., 12/19/23 at 9:24 a.m., and 12/20/23 at 8:56 a.m., a cart with personal protective (PPE) supplies was present in the hall outside R42's room door and signage was hung on the outside of R42's door. The hung signage included the type of isolation precautions staff should use when entering the resident room for cares, how to don and doff PPE, and to stop and check with the nurse before entering. One posted sign on the door was titled Contact Precautions with instructions to remove the sign after the room was cleaned and listed Common conditions and If patient has diarrhea (C. difficile) use contact enteric precautions highlighted in yellow. Posted on the wall in the hall next to R42's door was a typed paper sign titled Reminders for C. Diff Precautions and included bullet points regarding where residents should shower and use the bathroom. When interviewed on 12/20/23 at 8:11 AM, trained medication aide (TMA)-A stated when a resident need to be on isolation protocol is to place a cart with PPE outside the room and to put signage on the door directing staff which type of precautions to use during cares depending on which infection the resident had. The signage should include the type of precautions necessary to assist with resident cares. When interviewed on 12/20/23 at 9:07 a.m., the director of nursing (DON) stated when isolation precautions are implemented for a resident with an active infection the charge nurse placed the carts and signage. The signage should instruct staff to the type of precautions to use, the PPE necessary for cares and should not indicate the specific infection the resident has. The DON reviewed the signage on R42's door and confirmed the two signs specifying C. diff were visible to other residents and visitors to the facility and did not need to be there. The DON stated there was a verbal and written shift report system where staff were notified of the type of infection a resident had and their personal information should be protected from those who did not need to know. The facility policy Transmission Based Precautions Policy and Procedure Buffalo Lake Healthcare Center dated October 2023, identified Signage can either indicate the CDC category of Transmission-based Precautions and must comply with resident's rights to confidentiality and privacy.

Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold policy at the time of hospital transfer for 2 of 2 residents (R24 and R40) who was reviewed for hospitalization . Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], indicated R24 had moderately impaired cognition. R24's progress notes indicated R24 was hospitalized on [DATE] and returned to the facility on [DATE]. R24 was re-hospitalized on [DATE] and returned to the facility on [DATE]. R24's medical record lacked evidence a bed hold was provided at the time of transfer for either hospitalization . R40's MDS dated [DATE], indicated R40 had moderately impaired cognition. R40's progress notes indicated R40 was hospitalized on [DATE] and returned to the facility on [DATE]. R40's medical record lacked evidence a bed hold was provided at the time of transfer for hospitalization . During an interview on 12/20/23 at 9:40 a.m., the director of nursing (DON) expected when a resident was transferred out of the facility a bed hold was initiated by the charge nurse and was sent with to the hospital. DON stated she expected the social worker to follow up to determine if the resident wanted to continue holding the bed. If staff had asked the resident and or family it would be documented in the progress notes. DON confirmed that she could not find communication with the resident and or family in regard to a bed hold for R24 or R40's hospitalization s. During interview on 12/20/23 at 9:45 a.m. DON stated she followed up with her social worker to see what exactly the process was with the social worker stating when a bed hold was sent with the resident, SW assumed that the resident wanted their bed held and did not follow up the following day to discuss. DON stated it is important for the resident and/or family to be aware and have a written notice of a bed hold so they are aware of what they may have to pay for and that they have a spot to come back to. A facility policy titled Bed Hold and Return to Facility with a date of 3/2017, identified the resident or their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain in contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate. Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leave the facility. The facility will provide the resident or resident representative a written notice which specifies the duration of the bed-hold policy at the time of transfer for hospitalization or therapeutic leave. In cases or emergency transfer, notice at the time of transfer means that the facility will send the notice along with the necessary paperwork to the receiving setting and the resident representative will be notified the next business day. The social worker will contact the resident or the representative on the next business day to ensure that they understand the bed hold and return to facility information. Documentation of bed hold notice will be filed in the individual medical record.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R26, R31 and R40) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R26's face sheet, dated 12/20/23, indicated he was [AGE] years old. The immunization record, dated 12/20/23, indicated he received a PPSV23 on 6/22/2012 followed by the PCV13 on 10/17/2014. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R26 was offered or received PCV20. R31's face sheet, dated 12/20/23, indicated she was [AGE] years old. The immunization record, dated 12/20/23, indicated she received a PCV13 on 10/14/2007 followed by a PCV13 on 9/25/2013 and a PCV13 on 10/30/2015. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R31 was offered or received PCV20. R40's face sheet, dated 12/20/23, indicated he was [AGE] years old. The immunization record, dated 12/20/23, indicated he received a PCV13 on 10/31/2006 followed by a PCV13 on 11/22/2011 and a PCV13 on 8/22/2017. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R40 was offered or received PCV20. During record review, the Vaccine Consent Form offered residents the following vaccinations: PCV13, PPSV23, Influenza and COVID-19. PCV20 is not mentioned on this form for residents to receive. During an interview with infection preventionist (IP) on 12/20/2023 at 9:55 a.m., the IP indicated immunizations were verified upon admission through MIIC (Minnesota Immunization Information Connection). IP stated residents and/or their families were asked and consents are obtained if immunizations are needed. IP stated IP is using the immunization hand dial for pneumococcal immunizations. IP verified R26, R31, and R40's pneumococcal immunizations as listed above. IP stated that IP was just recently made aware of the PCV20 and stated that it has not been implemented or offered by the facility. IP verified they had not been offered or provided education on PCV20. IP verified there had been no shared clinical decision making with the provider regarding pneumococcal immunizations for R26, R31 and R40. A facility policy titled Pneumococcal, Influenza, COVID Vaccines with a review date of 10/23 was provided. Policy indicated: Resident/legal representative will receive and sign or provide a verbal consent for vaccines for influenza, pneumococcal and COVID vaccination on/or during the admission process or during the flu season. They will also receive a copy of the current vaccine information statement (VIS) related to the risks and benefits of receiving the immunization at the time of the immunization. Each resident wishing to receive the immunization will receive it as soon as possible.

Based on interview and document review, the facility failed to ensure allegations of potential physical abuse were thoroughly investigated to ensure resident protection by immediately removing the alleged perpetrator (AP) following an abuse allegation and resident interviews were conducted for 1 of 1 allegation of abuse This had the potential to affect all nine residents who were currently residing on the North wing under the AP's care. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R1 exhibited physical and verbal behaviors. Review of facility report number 6 made to the State Agency (SA) on 1/6/22, alleged R1 was combative and attempting to bite trained medication aide (TMA)-A and nursing assistant (NA)-A while the staff were assisting R1 with evening cares. NA-A took resident's [R1] own hand and put it in resident's mouth and commented 'how does that taste [R1]?' Review of the five-day investigation submitted to the SA dated 1/11/22, indicated NA-A denied allegation. Further review of investigation indicated the director of nursing (DON) interviewed other staff following the allegation and there were no concerns reported regarding NA-A, however investigation lacked evidence other residents under the care of NA-A were interviewed to determine if there were additional concerns for abuse or care. In addition, NA-A was put on a suspension during the internal investigation, but investigation lacked evidence that NA-A was immediately removed from the care of residents after the physical abuse allegation was made on 1/6/22. Review of facility's schedule for the nursing department dated 1/6/22, indicated NA-A was scheduled to work from 2:00 p.m. until 9:30 p.m. On 1/12/22, at 3:09 p.m. licensed practical nurse (LPN)-A indicated she was the floor nurse on 1/6/22, the evening the allegation was made. LPN-A indicated TMA-A reported NA-A had taken R1's hand and put it in R1's mouth when R1 was attempting to bite NA-A and said something about how does that taste which occurred around 8:00 p.m. LPN-A indicated she immediately called the DON following the allegation, and the DON directed LPN-A to file a report to the SA. Further, when asked how R1 and other residents under the care of NA-A were protected after the allegation was made, LPN-A stated I didn't do anything with [NA-A]. I knew it was the end of the day and I think she had a bath yet to do. She finished her shift. I was not given direction on needing to do anything with [NA-A] and I usually don't have anything to do with that. I take the direction of the DON and LPN-A confirmed the DON did not give direction on removing NA-A from the facility. In addition, LPN-A indicated she assessed R1's skin following the allegation and she did have a couple of bruises on her right hand. I did ask [TMA-A] about it and we couldn't verify if they [bruising] were there prior or occurred with the incident. On 1/12/22, at 3:36 p.m. TMA-A indicated he was assisting R1 in the bathroom with her evening cares when NA-A entered the room. TMA-A told NA-A he would finish assisting R1 with her evening cares and NA-A could assist other residents. NA-A refused to leave and R1 became upset and started hitting, kicking, and biting [NA-A]. [NA-A] was kind of shouting at her [R1] to stop and other random things. [NA-A] was grabbing [R1]'s hands and took her hands and stuck it in her mouth and said 'how does that taste [R1]?' I told NA-A she needs to leave. Further, TMA-A indicated R1's eyes seemed glossed, confused and seemed like there was pain following the incident. In addition, TMA-A indicated he reported the incident to LPN-A and I was freaking out because I was scared. It was an incident that shouldn't have happened. TMA-A indicated after the allegation was reported, [NA-A] still worked with other residents as her shift was not finished until 9:30 p.m. On 1/13/22, at 9:03 a.m. DON indicated R1 exhibited kicking, hitting, and biting behaviors that often occurred all of a sudden. Further, DON indicated she was notified of the abuse allegation on 1/6/22, at 8:04 p.m. when LPN-A called her. DON indicated it was reported to her that TMA-A was upset. He had been providing care for [R1] and [NA-A] came in and [R1] became agitated and trying to bite them and [NA-A] brought [R1]'s hand to her mouth and commented 'how does that taste [R1]?' When asked what the staff did to protect the residents following the allegation, DON indicated NA-A was removed from the situation, she was still in the building, it was around 8:00 p.m. and she was due to leave by 9:30 p.m. When asked what the facility's process was for removing an employee following an allegation, DON indicated the alleged perpetrator was to be removed as soon as possible, and LPN-A had asked the DON on the phone that evening if she needed to remove NA-A and DON stated LPN-A hadn't checked for bruising yes she was trying to determine if she needed to remove her or not. I checked the schedule, and she was not scheduled to work over the weekend. We determined a 3-day suspension and based on [NA-A]'s overall work performance she hasn't ever been a person in an abuse situation, but we didn't know that at the time, so we did not immediately remove her from the building I was more worried about trying to make sure we got the report filed and begin the investigation. Further, while referencing the facility's abuse policy, DON stated, according to the policy they contact administration for help or guidance if it's a situation they feel they need to remove them they can remove them immediately. I feel like it was a he said she said situation. She said she didn't bring it to her mouth. I don't know if [LPN-A] talked to [NA-A] that night. In addition, when asked the importance of removing the AP from the building following an abuse allegation, DON stated, I don't think it would have protected others in this situation. I really think you are putting others at risk being there is no one to care for them if I removed her and no there is no one to put others to bed. [TMA-A] has a rapport with [R1] that is beyond anyone and [NA-A] was not taking care of anyone on the wing with those behaviors so removing her from [R1] was our main priority. DON indicated during the investigation following the allegation she interviewed other staff members which showed no concerns regarding NA-A, however DON stated, I did not interview other residents at all because of the timing of the whole incident. I was three hours up north, [Administrator] was gone, [Social Worker] was gone. Typically, me and the [Social Worker] do all interviews together depending on the situation we interview residents. In addition, DON indicated interviewing residents during the investigation would be important to make sure there is nothing going on behind closed doors that you don't know about. On 1/13/22, at 11:34 a.m. when asked what the facility's policy is for removing an AP once an allegation was made, administrator stated, it would depend on the situation that occurred. We are removing them from the situation that occurred, the alleged situation. It depends its not a hard and fast rule there is a charge nurse in the building, and they have judgment if they need to leave the building right away. Further, administrator indicated it was important to remove the AP until we can determine what actually happened. When asked how the staff protect other residents following an allegation of a staff member, administrator stated the charge nurse is expected to keep the other residents out of danger. In addition, administrator indicated interviewing other residents following an abuse allegation can be part of the process, but it's not a requirement. When asked why it would be important to interview other residents, administrator was unable to give answer but stated, it would be important and depends on the situation. Review of facility policy titled Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 6/14/21, indicated it is the policy of this facility that the resident (s) will be protected from the alleged offender(s), physical and psychosocial harm during and after the investigation. Further, safety, security, and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: the alleged perpetrator will immediately be removed, and resident protected. Employee's accused of alleged abuse will be immediately removed from the resident's area and will remain removed pending the results of a thorough investigation. In addition, policy lacked procedure of interviewing other residents following an abuse allegation as part of a thorough investigation.

Based on observation, interview and document review, the facility failed to comprehensively assess after falls, place care planned interventions based upon an assessment and follow care planned interventions to prevent falls for 1 of 3 residents (R9) reviewed for falls. Findings Include: R9's annual Minimum Data Set (MDS) dated [DATE], included, moderate cognitive impairment with diagnoses including Alzheimer's disease, anxiety and [CONDITION(S)]. R9 required extensive assistance with most activities of daily living (ADL's) and was unsteady without human assistance. R9's care plan dated 6/3/21, included risk for falling and directed staff to use antirollback device on wheel chair and grip tape on the floor. R9's Kardex Report (nurse aide worksheet) also instructed staff to use a bed alarm, chair alarm, a low bed, keep nightstand and other furniture away from bed to prevent injury, grippy socks and if in bed, to keep wheelchair within reach in case she attempted to self transfer. R9's Fall Summary dated 7/7/21, included, Found resident sitting on the floor next to her bed holding turn handle with both hands and had her head wedged between the turn handle and the bed mattress. R9's Fall Risk assessment dated [DATE], identified she was at high risk for falls, and to continue the interventions as care planned. No comprehensive assessment of this fall was documented, nor were new interventions were placed. R9's Fall summary dated 7/22/21, indicated resident found laying on the floor in [a different resident's room] by the bed. Her shoes were off and her glasses were on the nightstand so it appeared that she was attempting to lay down in that bed. Found with head towards the foot of the bed on her right side. Resident unable to give description. R9's Fall Risk assessment dated [DATE], identified she was at high risk for falls. Resident was attempting to lay down on a bed as she had her shoes and glasses off. Alarm was going off but staff could not find her at first as she was in another resident's room. Under, Interventions put in place, was, has alarms. No comprehensive assessment of this fall was documented, nor were other interventions placed following this fall to prevent it from happening again. During interview on 8/9/21, at 2:16 p.m. R9 confirmed falling but denied getting her head stuck between the assist rail (turn handle) and mattress. During interview on 8/10/21, at 2:00 p.m. the director of nursing (DON) stated that with the fall on 7/7/21, R9's head was not wedged and stated that was miscommunication as her head was never stuck. DON stated it was a, bad choice of words. During observation on 8/10/21, at 4:51 p.m. R9 was sitting in her recliner, her wheel chair was 4 feet away from her. It had not been placed within R9's reach. During observation on 8/11/21, at 7:10 a.m. R9 was laying in bed, her wheelchair was 4-5 feet away from her bed. During observation on 8/11/21, at 7:24 a.m. R9 was laying in bed, her wheel chair was 4-5 feet away from her. When interviewed on 8/11/21, at 8:00 a.m. nursing assistant (NA)-A stated R9 was at risk for falls and the wheelchair was to be placed away from resident. NA-A consulted the Kardex and then stated, Oh, that is right, we switched it back and her wheelchair is to be close to her to prevent her from falling when she self-transfers. NA-A confirmed R9's wheelchair was not next to her, but across the room. When interviewed on 8/11/21, at 8:09 a.m. licensed practical nurse (LPN)-B stated, R9's wheelchair should be next to her bed as she self transfers and is at risk for falls. LPN-B confirmed that wheelchair was not next to resident and stated, I would think its not where is should be and that it was important to be next to the bed to prevent her from falling. LPN-B moved wheelchair next to residents bed. LPN-B stated that with each fall they should be assessing the resident and figuring out why they fell or how they fell and then discuss ways to prevent further falls. When interviewed on 8/11/21, at 8:43 a.m. NA-B stated R9 was, antsy, and at risk for falls, so her wheelchair should be next to her. NA's use the Kardex to know how to care for residents. When interviewed on 8/11/21, at 9:56 a.m. registered nurse (RN)-A stated, it was important to follow the care planned interventions for R9 to help prevent her from falling. If a resident falls, the nurse checks for injury and starts the fall report, and should add interventions based upon an analysis of the fall. RN-A was unable to find an analysis of the falls which R9 had on 7/7/21 or 7/22/21, and no new interventions had been placed. When interviewed on 8/11/21, at 10:50 a.m. the DON stated when residents fall, the nurse should assess the resident, and update the care plan if needed. Staff discuss falls on a weekly basis. The DON confirmed no comprehensive assessment of R9's falls on 7/7/21 and 7/22/21, were completed and no new interventions had been placed to assist in preventing falls for R9. The DON stated R9's care plan should have been followed and staff should have placed R9's wheel chair close to her at all times. Resident incident/accident assessment and documentation related to falls policy reviewed 2/20, included, The intent of this policy is to establish guidelines and procedures that adequately identify, assess, treat, and prevent incidents and accidents that put the resident at risk for injury. All incidents will be evaluated and assessed immediately to ensure that immediate treatment and intervention(s) are initial elements of the accident/incident process. After the initial steps of assessment and treatment have been completed, the ID team shall attempt to determine the root cause(s) of the incident and the best approach(s) to prevent reoccurrence for the resident. Trends an patterns will also be identified as part of the total quality improvement process for the accident/incident policy and procedure. Effectiveness and Efficacy of both current and preventative measures shall be a component of the quality improvement system. Resident care planning procedure policy reviewed 3/21, indicated each resident has resident care plan that is current, individualized and consistent with the medical regimen. Each discipline is responsible for following the established format for care planning of the LTC (long term care) facility.

Based on observation, interview, and document review, the facility failed to ensure identified dental concerns were addressed and referred to an appropriate service for care and treatment for 1 of 1 residents (R35) reviewed for dental care. Findings include: R35's quarterly Minimum Data Set (MDS), dated [DATE], identified R35 had moderate cognitive impairment and required extensive assistance to complete her personal hygiene. In addition, R35's Census Profile, printed 8/11/21, identified R35's payer source as Medicaid with an effective date of 1/20/21. R35's admission Oral-Dental Assessment/Bathing Preference assessment, dated 1/22/20, identified R35 had broken or loose natural teeth along with . obvious or likely cavity/cavities. R35 did not wear any dentures, and the assessment outlined R35 denied oral pain or difficulty chewing at the time. However, a subsequent section labeled, Dentist, outlined R35 wished to see a dentist along with a radio-button style question which read, Does resident need a dental referral per nursing assessment? This was answered, Yes. R35's care plan, dated 7/13/21, identified R35 had potential for dental-related complications and had her own teeth with . many missing, and others in the lower front which are worn down and in bad condition. A goal was listed on the care plan which read, [R35] will be/remain free of infection, pain or bleeding in the oral cavity through [review date], along with several interventions to help R35 meet this goal. These interventions included providing assistance with oral cares and helping to coordinate appointments or transportation for dental care as needed. On 8/9/21, at 10:18 a.m. R35 was interviewed and explained she had some teeth which were broken or missing. R35 showed the surveyor her teeth which affirmed her statement along with identified visible food particles and a light white-colored substance along the gum line of several of her lower teeth. R35 voiced she was unsure when she had last seen the dentist for her teeth; however, she added it was not recently. R35 expressed her family member, (FM)-A, had been helping to set-up her financial assistance and she desired the see the dentist for her teeth as they sometimes caused her pain when eating. R35's subsequent progress notes, dated 10/26/20 to 8/5/21, identified the following recorded entries: On 10/26/20, an MDS note was entered which outlined, Resident has her own natural teeth, which are in poor condition . did agree to seeing a dentist. Writer informed medical records. Resident's [FM-A] isin [sic] the process of signing resident on with MA [Medicaid]. Medical records going to check on progress and determine payer source and where to schedule resident an appointment. On 12/28/20, an MDS note was entered which outlined, [R35] does have her own teeth, and states she has been having difficulty with chewing. Would not give details regarding this. Medical records is aware of need for dental [appointment] as able to schedule per family. On 1/12/21, an MDS note was entered which outlined, Resident has natural teeth in poor condition. Likely cavities. Resident denied any mouth/facial pain or difficulty with chewing. However, R35's medical record was reviewed and lacked evidence R35 had been referred to a dentist for her dental concerns despite being identified upon her admission assessment (dated 1/2020) as desiring and needing a dental referral for her teeth, and several subsequently recorded progress notes outlining her teeth as being in poor condition and, at times, expressing difficulty with chewing. When interviewed on 8/11/21, at 8:11 a.m. trained medication aide (TMA)-A explained R35 needed total assist for cares including oral hygiene. TMA-A stated she was aware R35's teeth aren't in the greatest condition as she had noticed they're not white anymore and sometimes they have stuff in them and build up present. TMA-A stated she was unable to recall last when, or if, R35 had seen a dentist since she admitted to the nursing home. On 8/11/21, at 9:13 a.m. a telephone call was placed to FM-A. FM-A stated they were unable to speak about R35's care right then and they would call back later in the day. A return call was not received during the recertification survey. On 8/11/21, at 9:20 a.m. registered nurse (RN)-A was interviewed. RN-A reviewed R35's medical record and verified her admission oral assessment outlined R35 had requested to see a dentist, and the nurse who completed the assessment identified R35 warranted referral to a dental provider for her teeth. RN-A voiced she was unaware what action, if any, had been taken to help coordinate a dental examination for R35 since she admitted to the nursing home. RN-A then contacted the medical records personnel and verified R35 was on Medicaid; however, the personnel were unable to recall if they ever attempted to coordinate or obtain a dental appointment for R35. RN-A stated she suspected R35's dental appointment and need to be seen had likely got lost in the shuffle with the pandemic; however, RN-A acknowledged the nursing home had resumed normal dental-related appointments several months ago. RN-A stated R35's dental appointment and needs should have been addressed sooner to help reduce the risk of tooth pain and because if someone has dental-related issues they need to be taken care of. On 8/11/21, at 1:43 p.m. the director of nursing (DON) and licensed social worker (LSW)-A were interviewed. They had reviewed R35's medical record and explained R35's dental-related notes and documentation started when the nursing home was hot and heavy in the pandemic; however, they acknowledged more normal dental care appointments had resumed several months prior. They explained there had been some issues in the past with coordinating care and appointments with FM-A; however, they voiced the facility had never contacted him, to their knowledge, about arranging to coordinating a dental examination for R35. The DON stated coordinating dental appointments for person(s) on Medicaid could be difficult, at times, with a lack of providers willing to accept these patients; however, she acknowledged the coordination process and appointment could have been started sooner to ensure R35's dental issues and needs were addressed. A facility policy on dental care visits was requested; however, was not received.

Based on observation, interview and document review, the facility failed to comprehensively assess new onset pain for 1 of 2 residents (R20) reviewed for pain management. Findings include: R20's annual Minimum Data Set, dated dated dated [DATE], indicated no cognitive impairment and required extensive assistance with bed mobility and transfers. and dressing, independent with eating, and R20 did not have pain during the assessment period. R20's facesheet printed 8/11/21, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Pain Management assessment dated [DATE], indicated, R20 denied having pain in last 5 days, and had not used any prn (as needed) medications. R20's care plan dated 6/28/21, indicated needs pain management and monitoring related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . should assess, record, and report to MD as needed for signs of distress or pain unrelieved by ordered treatment and medication. administer medications as ordered, and anticipate resident' need for pain relief and respond as soon as possible to any complaint of pain. R20's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] Aspercream lotion 10% apply to back topically every 4 hours as needed for pain. started 7/28/21. [MEDICATION(S)] (helps with nerve pain) Capsule 400 mg give 1 capsule by mouth three times a day related to type 2 diabetes mellitus with diabetic [CONDITION(S)]. started 12/28/14. [MEDICATION(S)] (pain medication) give 50 mg by mouth at bed time related to low back pain started 9/16/20. Tylenol (pain reliever) give 1000 mg by mouth three times a day for pain related to low back pain and [CONDITION(S)] and chronic pain started 12/21/18. Tylenol 325 mg given 650 mg by mouth every 4 hours as needed for pain do not exceed 4000 mg in a 24 hour period started 6/24/20. [MEDICATION(S)] gel 1% apply to left great toe topically every 4 hours as needed for pain started 7/28/21. [MEDICATION(S)] gel 1% apply to left shoulder and elbow topically every 4 hours as need for pain may use up to 4 times a day 4 grams per application started 7/28/21. R20's progress notes on 7/23/21, at 6:20 p.m. indicated R20 reported right lower abdominal pain. resident received [MEDICATION(S)] (to promote stool) on day shift and so far no results. R20 was encouraged to drink plenty of fluids. R20's progress notes on 7/24/21, at 10:00 pm indicated R20 reported right side pain worsening and during EZ stand (standing lift to transfer a resident from sit to stand or stand to sit) resident frowning and moaning. R20's progress note dated 7/25/21, at 5:59 a.m. resident was given as needed Tylenol with minimal relief due to right abdomen pain. R20's progress notes dated 7/25/21, at 6:38 a.m. resident continued to report severe pain and tenderness in the right abdomen. Resident was sent to emergency room for evaluation. R20's progress note dated 7/25/21, at 12:19 p.m. indicated R20 returned from [NAME] Health emergency room via ambulance with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No new orders were provided. R20's ER After Visit Summary and CT report dated 7/25/21, indicated visit for abdominal pain and [CONDITION(S)] was given [MEDICATION(S)] (narcotic pain reliever) at 7:33 a.m. with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's progress note dated 7/30/21, at 6:21 a.m. indicated R20 reported right abdomen pain was offered Tylenol overnight but declined. During observation on 8/10/21, at 5:34 p.m. LPN-V went into residents room to administer insulin and resident reported pain. LPN-V did not address pain and said the nurse just gave him Tylenol. There was no follow up if tylenol was effective. During interview on 8/10/21, at 5:39 p.m. R20 stated that he gets a sharp shooting pain when he goes from sitting to standing in his lower abdomen. R20 stated his pain was a 7 out of 10 in severity (moderate to severe). During interview on 8/11/21, at 7:21 a.m. R20 stated pain was good today and tolerable but does shoot up when he goes from standing to sitting or sitting to standing. R20 reported he did tell staff about the pain. During interview on 8/11/21, at 8:14 a.m. licensed practical nurse (LPN)-B stated R20 had been sent to theER on [DATE], for right side abdominal pain due to severe pain and, he, could hardly move. LPN-B stated R20 returned with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-B stated she was unsure if a pain assessment was completed but should be if new pain exist. LPN-B further stated it was important to monitor pain every shift as no one should have to be in pain. During interview on 8/11/21, at 9:56 a.m. registered nurse (RN)-A stated that R20 came back from the ER 7/25/21, due to having new onset of right abdominal pain with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated that R20's provider came in and addressed the CT but no orders pertaining to his right sided pain noted. RN-A stated R20 had reported abdomen pain last night and just started the comprehensive pain assessment now but did not start it for the right side pain back in July. RN-A confirmed that is should of been started with any new complaints of pain to monitor if improving or not. RN-A stated that if a resident reported pain it should be charted. No documented assessment of this new onset pain had been completed after he had returned from theER on [DATE]. During interview on 8/11/21, at 10:50 p.m. director of nursing (DON) stated, R20 went out to the ER in July due to new onset of right sided abdominal pain and came back with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No monitoring of this new onset pain was completed or assessments post ER visits to follow up on residents pain from visit to ER in 7/25/21. DON stated they did start the pain assessment this morning as resident reported pain again on the overnight shift. DON stated she was not aware of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, R20 should have had pain monitoring as it was a new pain for the resident. DON stated it was important to monitor and assess pain as no one should have to be in pain. Pain management policy and procedure dated 11/19, indicated It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. The facility assessment will include review of expressions of pain, which may be verbal or nonverbal and are subjective. A resident may avoid the use of the term pain. Complete a pain interview and/or implement pain monitoring with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and document review, the facility failed to immediately report, no later than two hours, to the State Agency (SA) an allegation of staff to resident abuse for 1 or 1 residents (R1) reviewed for an allegation of abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment. R1's hearing and vision were adequate, and speech was clear. R1 was able to make herself understood and was able to understand others. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS indicated extensive physical assistance from staff was required for bed mobility, transfers, dressing, toilet use and personal hygiene. A facility reported incident (FRI) submitted to the SA on 6/4/21,10:22 a.m. alleged physical abuse described as, slapping, that occurred on 6/3/21, at 12:00 p.m. According to the report, the allegation of staff to resident abuse was reported by R1 to nursing assistant (NA)-A during the night shift. On 6/9/21, at 11:48 a.m. NA-A stated she was talking with R1 on 6/4/21, at approximately 5:00 a.m. R1 reported to NA-A that another staff member slapped her on the left side of her face. NA-A stated R1 told her it happened the previous day (6/3/21). NA-A stated she reported the allegation to licensed practical nurse (LPN)-A approximately 20 minutes later. On 6/9/21, at 1:30 p.m. LPN-A stated, at approximately 5:00 a.m. on 6/4/21, NA-A reported R1 was crying and reported to NA-A that a staff member slapped her. LPN-A indicated she interviewed R1 on 6/4/21, at approximate 5:20 a.m. R1 stated she was slapped by a staff member during the morning shift on 6/3/21. LPN-A stated she did not report the allegation to the SA immediately because she was not certain of R1's mental state at the time of the report. LPN-A reported the allegation to registered nurse (RN)-A who came in for the morning shift on 6/4/21. LPN-A stated the requirement for reporting suspected abuse was within 24 hours. LPN-A indicated she was aware how to complete reports to the SA. On 6/9/21, at 2:46 p.m. Director of Nursing (DON) stated an abuse allegation should be reported to the charge nurse immediately. The charge nurse is responsible to determine if the allegation should be reported to the SA. DON stated she believed the reporting requirement depended on the seriousness of the allegation but should be reported within 24 hours. After DON reviewed the facilities abuse policy she confirmed allegations of abuse were required to be reported to the SA within two hours but continued to state, If they asked me, I would have said they have twenty-four hours. DON confirmed she would consider an allegation of slapping to be abuse and on 6/4/21, when this abuse allegation was made, LPN-A was the charge nurse. On 6/9/21, at 3:08 p.m. licensed social worker (LSW) stated she was made aware of the allegation of abuse on 6/4/21, at 9:00 a.m. LSW confirmed she interviewed R1 and attempted to interview staff prior to submitting the report to the SA on 6/4/21, at 10:22 a.m. LSW confirmed, allegations of abuse are required to be reported to the SA immediately, but not later than two hours after the allegation is made. LSW confirmed, the allegation was not reported to the SA within two hours. On 6/9/21, at 3:34 p.m. RN-A confirmed, LPN-A reported the abuse allegation to her on 6/4/21, at approximately 6:15 a.m. RN-A stated she did not report the allegation to the SA because she was not certain of R1's mental state. RN-A confirmed, R1's allegation that a staff slapped her remained consistent. RN-A stated she would call the Director of Nursing or Assistant Director of Nursing if she had questions about reporting an allegation of abuse. RN-A confirmed, she did not call to ask about this allegation, but waited for the social worker to arrive to the facility. RN-A stated allegations of abuse should be reported to the SA no later than two hours after the allegation is made. Facility document, Vulnerable Adult Policy, revision date 5/20/19, indicated the facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute reasonable suspicion of a crime are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview, and document review the facility failed to ensure staff performed hand hygiene as instructed during the noon meal service delivery for 5 of 5 residents (R1, R2, R3, R4, R5) to decrease the risk of infection transmission in the facility. This had the potential to affect all 46 resident in the facility during the focused infection control survey. Findings include: On 12/21/20, at 11:55 a.m. during continued observation dietary cook (C)-A exited R1's room and immediately entered R2's room. C-A touched R2's recliner, tray table, readjusted R2's right leg brace velcro strap, raised the tray table and brought it closer to R2, opened a pop can, and conversed with R2. At 11:58 a.m. C-A exited R2's room and obtained two beverage glasses and a set of napkin wrapped silverware from a designated container located on a cart that contained beverages and non-food lunch items. After C-A filled the two glasses with beverages, she entered R3's room and placed the glasses on R3's tray table. After exiting R3's room, C-A obtained another set of silverware, a hot beverage mug, a glass, and filled them with beverages. C-A handed the filled mug and glass to an unidentified staff member after the staff member approached and asked for beverages for an unidentified resident. After, C-A filled a replacement mug and glass and entered R4's room. C-A placed the mug and glass on R4's tray table and moved R4's kleenex box that had been located on R4's tray table to another spot on the tray table. After exiting R4's room, C-A touched the beverage cart handle, mug tray, and obtained a mug and filled it. C-A handed the filled cup to RN-A who then entered R5's room with the mug. C-A obtained a set of silverware and a glass and filled it. C-A entered R5's room, placed the items on R5's tray table, placed a plastic lid on R5's mug, and pushed it onto the mug with her palm to secure it. After exiting R5's room, C-A entered R4's room and touched the back of R4's wheelchair while she conversed with R4. At 12:02 p.m. C-A exited R4's room and obtained a plate from the metal food warming cart. C-A touched numerous food container metal lids and serving utensils while she placed food items on the plate. Further, C-A touched the dessert tray and an individual serving dessert bowl. At 12:04 p.m. C-A brought the plate and dessert bowl to R4 and unfolded R4's set of silverware. After, C-A exited R4's room she entered R2's room. C-A had her hands in her pockets as she conversed with R2 about R2's lunch preferences. C-A exited R2's room, obtained a plate off of the serving cart and touched numerous food container lids, serving spoons, drawer handles, a piece of paper in one of the drawers, a knife used to cut a potato, condiment packages, and salt and pepper shakers. After, C-A brought R2 the lunch plate, unfolded the silverware from the napkin, touched the silverware, placed the napkin on R2's chest, and opened a pop can. At 12:08 p.m. C-A exited R2's room and proceeded to push the beverage cart off of the unit. During the entire continued observation, C-A had failed to perform hand hygiene upon exiting or entering R1, R2, R3, R4, and R5's rooms. When interviewed on 12/21/20, at 12:10 p.m. C-A stated she had been trained on hand hygiene. She explained each resident room had sanitizer available for use and that she was to perform hand hygiene when entering and exiting a resident's room. C-A explained she typically does not perform hand hygiene when going into a resident room but will use the sanitizer when exiting. Further, C-A explained she had used the sanitizer in two of the resident rooms during the continued observation; however, stated she forgot on the rest of them. In addition, C-A had been unable to verbalize any potential risk to the residents due to her having failed to perform hand hygiene when she dished up resident food and interacted with each resident; instead, she stated, It has been hectic. During interview on 12/21/20, at 12:41 p.m. dietary manager (DM) stated she expected dietary staff to perform hand hygiene when entering and exiting resident rooms and when working directly with food items. DM explained the dietary staff were at increased risk for spreading COVID or whatever that person might have to other residents if facility policies and expectations were not followed during meal services. When interviewed on 12/21/20, at 1:26 p.m. the director of nursing/infection control preventionist (DON) stated she expected all staff to perform hand hygiene when entering and exiting resident rooms. The DON explained that it may be harder for hand hygiene upon entering a resident's room if a staff member were to be carrying an item, such as a meal plate; however, she stated staff should at a minimum perform hand hygiene between residents. The DON verbalized there was a potential risk of bringing [MEDICAL CONDITION] or bacteria into a resident's room which could get others sick if staff did not follow hand hygiene instructions. A facility policy for Safe Food Procedure, undated, identified food safe sanitizer was to be used after handling food items and between residents. Further, the policy directed staff to sanitize their hands prior to serving any food or fluids.

Based on interview and document review, the facility failed to ensure all staff entering the facility were being actively screened (other facility staff performing the screening process) for the prevention and potential transmission of infection, including COVID-19. This had the potential to affect all 48 residents currently residing in the facility at the time of the COVID-19 Focused survey. Findings include: On 4/24/20, at 9:50 a.m. the survey team entered the facility via the building's back entrance. A facility employee took the temperature and asked COVID-19 symptom screening questions of the survey team before allowing entrance to the facility. When interviewed on 04/24/20, at 10:00 a.m. the director of nursing (DON) stated the facility did not have any presumptive or confirmed cases of COVID-19. During interview on 4/24/20, at 10:23 a.m. registered nurse (RN)-A stated she had been self screening (taking her own temperature and answering applicable COVID-19 questions) when entering the building for the shift. RN-A was not aware if anyone reviews the screening questionnaires or temperatures. When interviewed on 4/24/20, at 10:45 a.m. RN-B stated she screened herself when coming in for the day. RN-B further stated all staff were responsible for checking their own temperatures. The screening questionaire, temperature, hand hygiene and putting a mask on was to be done before the building was entered. RN-B was not sure who reviewed the screening questionnaires or temperatures or when this was done. When interviewed on 4/24/20, at 11:41 a.m. trained medication aide (TMA)-A stated it was preferred that there was a nurse around when self-screening but staff were responsible for answering the screening questions and taking own temperature. During interview on 4/24/20, at 12:00 p.m. the director of nursing (DON) stated they were following the Centers for Medicare & Medicaid Services (CMS) guidance QSO-20-14-NH for actively screening staff at the beginning of their shift in accordance with Centers for Disease Control (CDC) guidelines for COVID-19. DON further stated they interpreted active screening as the staff could self-screen when they entered the facility. DON stated the screening questions and temperatures were reviewed but not at the time they were taken, For instance if someone comes at an off time like 4:00 a.m. the nurse may not look at it until 6:00 a.m. A provided Respiratory illness Outbreak COVID-19 Specific Policy updated 3/14/20, identified Staff would have their temperature taken upon arrival at the facility and would answer a series of screening questions. The policy did not identify whom (self or other employee) was expected to conduct the employee screening.