Every finding on record at Edgebrook Care Center

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 3) 2025, (April 1 - June 30) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified excessively low weekend staffing had triggered. Review of the nursing schedule from April 1st through June 30th of 2025, identified most weekends had scheduled 7 nursing assistance (NA) and 1 licensed nurse for both the morning shift and the afternoon shift. There were 6 weekends identified that fell below the 7 NA's however, there was an additional licensed nurse scheduled. Interview on 11/18/25 at 2:00 p.m., with the administrator identified on the weekends that had lower nursing assistance scheduled due to call ins or no available staff, the facility had scheduled a licensed practical nurse (LPN) to work the floor as a NA. She confirmed she had coded the LPN's time in PBJ as a licensed nurse verses a NA as the PBJ guidance identified to do when there was a change in LPN's normal role. This was likely what triggered the low weekend staffing. A policy on coding the PBJ report was requested but not provided by end of survey.

Based on interview and document review, the facility failed to implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. The facility failed to include in their surveillance viral-like illnesses not treated with an antibiotic for staff or residents. In addition the facility failed to ensure staff utilized Personal Protective Equipment (PPE), during 1 of 3 (R37) insulin administration observations. Findings include: Review of the monthly infection surveillance and staff call-in logs from August through October 2025 identified in: 1.August 2025, the surveillance identified 6 UTI's, 2 skin infections, and 1 fungal infection. The log did not identify medications prescribed or that an antibiotic time out had been completed. No residents on enhanced barrier precautions were included in the surveillance. The staff illness log identified 5 staff had called in with nausea and vomiting. 1 staff with diarrhea and fever, and 2 staff with upper respiratory symptoms and fever. The log did not indicate when the symptoms had resolved, the last day the staff worked, or when staff returned to work. 2.September 2025, the resident surveillance identified 3 UTI's, 3 skin infections, and 3 respiratory infections. The log did not identify residents on enhanced barrier precautions, and the log did not give a complete and accurate description of medications prescribed that included dose, frequency, or duration. The resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff illness log identified 5 staff had called off with GI symptoms. 5 staff with respiratory symptoms, and 3 staff with other. The log did not identify when the symptoms resolved, the last day worked, or when the staff had returned to work. 3.October 2025, the resident surveillance log identified 6 residents with urinary infection symptoms, 3 with respiratory symptoms, 1 with GI symptoms, and 4 with skin. The log did not identify medications prescribed or that an antibiotic time out had been completed. No resident on enhanced barrier precautions were included in the surveillance and the resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff call in log identified 7 staff had called in with nausea and vomiting and 3 staff with respiratory symptoms. The staff log did not identify when the symptoms had resolved, the last day worked, or the date they returned. Interview on 11/17/25 at 3:00 p.m., with the infection preventionist agreed with the above findings, she identified there was missing information on both the resident infection log and the staff illness log. She reported several staff that were out with nausea and vomiting and respiratory symptoms returned to work the next day, and at least one staff did not stay out for any time. She said that when staff call off, they must take a covid test and if it is negative they are allowed to return to work. She did not follow up with any of the staff that had called in ill with GI symptoms to see if their symptoms had resolved prior to them returning to work. She revealed that she does not get the staff illness information until the end of each pay period, and that caused difficulty with tracking staff illness. Interview on 11/18/25 at 8:14 a.m., with licensed practical nurse (LPN)-C identified when a resident has symptoms of a respiratory infection, they complete a covid test. If the test was negative and they do not have a fever they do not place them on precautions. They just notify the primary doctor to see if they want to do any additional testing or medications. The facility Surveillance policy dated 11/10/25, lacked any indication of what should be included in the infection surveillance log, when a resident should be placed on precautions, or what type of precaution should be implemented. In addition, the policy does not give any guidance on staff illness surveillance. Observation on 11/18/25 at 11:32 a.m., with licensed practical nurse (LPN)-C as she prepared to administer R37's Lispro insulin identified R37 had physician orders for Lispro insulin 5 units, subcutaneous (SQ) before meals (AC) if his blood glucose (BG) was greater than 200. LPN-C used hand sanitizer, retrieved the Insulin Lispro Injection pen from the drawer of the medication cart, cleansed the end of the pen with an alcohol pad, applied the disposable needle, primed the pen by wasting 2 units, then dialed the dose to 5 units and presented the pen to be viewed. At 11:35 a.m. LPN-C proceeded to R37's room. She confirmed his BG on his Dexacom meter, explained she needed to administer his insulin, raised his shirt, wiped his skin with an alcohol pad and administered the insulin dose. She then wiped the area with the alcohol, pad, disposed of the used pad in the trash, returned to the medication cart where she removed the used needle and disposed in the sharp's container, and returned the pen to the top drawer of the cart. Throughout the process of administering and disposing of the used sharps, LPN-C failed to apply gloves. Interview on 11/18/25 at 11:40 a.m. with LPN-C confirmed she had forgotten to apply gloves and she stated she should have done so. She usually wore gloves when preparing and administering insulin, but she had not done so this time. Interview on 11/19/25 at 8:15 a.m. with the director of nursing (DON) identified her expectation for staff to follow infection control (IC) practices of wearing gloves when administering insulin and/or doing any practice that had the potential for exposure to blood or body fluids. A policy for the use of PPE was requested but not received by the end of the survey period.

Based on interview and document review, the facility failed to ensure appropriate oversight by the infection preventionist (IP) to ensure thorough implementation of the infection control program. Findings include: Review of the monthly infection surveillance and staff call-in logs from August through October 2025 identified in: 1.August 2025, the surveillance included no map that identified location of the infections. The log identified 6 UTI's, 2 skin infections, and 1 fungal infection. The log did not identify medications prescribed or that an antibiotic time out had been completed. No residents on enhanced barrier precautions were included in the surveillance. Resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff illness log identified 5 staff had called in with nausea and vomiting, 1 with diarrhea and fever, and 2 with upper respiratory symptoms and fever. The log did not indicate when the symptoms had resolved, the last day the staff worked, or when they returned to work.2.September 2025, the resident surveillance included no map that identified the location of the infections. The log identified 3 UTI's, 3 skin infections, and 3 respiratory infections. The log did not identify residents on enhanced barrier precautions, and the log did not give a complete and accurate description of medications prescribed that included dose, frequency, or duration. Resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff illness log identified 5 staff had called off with GI symptoms, 5 with respiratory symptoms, and 3 with other. The log did not identify when the symptoms resolved, the last day worked, or when the staff had returned to work.3.October 2025, the resident surveillance included no map that identified the location of the infections. The log identified 6 residents with urinary infection symptoms, 3 with respiratory symptoms, 1 with GI symptoms, and 4 with skin. The log did not identify medications prescribed or that an antibiotic time out had been completed. No resident on enhanced barrier precautions were included in the surveillance and the resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff call in log identified 7 staff had called in with nausea and vomiting and 3 staff with respiratory symptoms. The staff log did not identify when the symptoms had resolved, the last day worked, or the date they returned. Interview on 11/17/25 at 3:00 p.m., with the infection preventionist agreed with the above findings, she identified there is missing information on both the resident infection log and the staff illness log. She reports that several staff that were out with nausea and vomiting and respiratory symptoms returned to work the next day and at least one staff did not stay out for any time. She said that when staff call off they have to take a covid test and if it is negative they are allowed to return to work. She did not follow up with any of the staff that had called in ill with GI symptoms to see if their symptoms had resolved prior to them returning to work. She revealed that she does not get the staff illness information until the end of each pay period, and this has caused difficulty with tracking staff illness. She revealed she was aware of the concerns with tracking and trending but had not implemented any changes to ensure the surveillance was thoroughly documented. She further agreed she had not provided oversite as the infection preventionist of the infection control program. The Infection Prevention and Control Program-All Service Lines policy identified an infection prevention and control program is a set of evidence-based policies, procedures, and practices implemented in healthcare settings to prevent and minimize the spread of infections among residents/patients/clients, employees, and visitors. An Infection Preventionist, or healthcare setting-specific equivalent, must bedesignated with responsibility for oversight of the infection prevention and control program. The Infection Preventionist, or appointed designee, will oversee the infection prevention and control program, in collaboration with the Safety Committee and Quality Assurance and Process Improvement Committee. The Rehab/Skilled and LTC Infection Preventionist must:1. Have primary professional training in nursing, medical technology,microbiology, epidemiology, or other related field; and2. Be qualified by education, training, experience, or certification; and3. Work at least part-time onsite at the facility; and4. Have completed specialized training in infection prevention and control(i.e., CDC Nursing Home Infection Preventionist Training Course).There was no mention how the facility was to ensure appropriate oversight occurred.

Based on observation, interview, and document review, the facility failed to accurately assess 1 of 1 resident (R6) for a wrist brace/splint present upon admission. Findings include: R6's 10/28/25 5-day admission Minimum Data Set (MDS) assessment identified her cognition was intact, she required the assistance of 1 staff for activities of daily living, (ADLS) and transfers, and had an indwelling Foley catheter in place. She had diagnosis of diabetes type II, high blood pressure, cellulitis, (a bacterial infection of the skin's deeper layers, causing symptoms like redness, swelling, pain and warmth) of her left lower leg, lymphedema (swelling in limbs caused by malfunctioning of lymphatic system), morbid obesity, weakness, urinary retention, disorders of bone density, and heart failure. The MDS failed to include the use of a glove and wrist splint worn daily on her right wrist since admission. Observation of R6 during the period of 10/27/25 through 10/29/25, noted she wore a protective glove under a wrist splint on her right wrist. Interview on 10/27/25 at 2:00 p.m. with R6 reported she had a bone infection of her right wrist and wore the glove and splint because of that. She denied any pain or discomfort in her wrist, but reported she had worn the splint for a long time. She was not able to recall when she had the infection, or any treatment other than the use of the splint but identified she had been wearing the splint when she was admitted to the facility and every day since then. No staff had ever asked her about the use of the brace. R6's current undated care plan, physician orders, Medication administration record (MAR), and treatment record (TAR) identified no mention of R6's use of the protective glove and right wrist splint. R6's 10/22/25, Nursing Admit Re-Admit Data Collection form, completed by licensed practical nurse (LPN)-C, failed to include any restriction of mobility of her right hand and wrist or identify the use of a protective glove and splint. Interview on 11/19/25 at 7:30 a.m., with registered nurse (RN)-B reported she was not aware R6 was admitted with or currently was using a right wrist splint. RN-B noted it should have been assessed at the time of admission and included on the MDS assessment, the care plan, and on the TAR to monitor for any skin issues. Interview on 11/19/25 at 9:30 a.m., with RN-A (co-director of nursing) identified her expectation for a resident admitted with a splint or other device should be assessed, an order obtained and documentation placed in the care plan. She identified this was not present on R6's medical record and had not been assessed at the time of admission. Review of the 12/2/24, [NAME] Policy care Plan-R/S, LTC, Therapy & Rehab identified development of a comprehensive care plan to meet the individual needs of the resident. Identified needs, problems were to include measurable goals with time frames for achievement of both medical, functional, and physical plans for reaching identified goals. A policy for use of splints, or therapeutic devices was requested but not provided by the end of the survey period.

Based on observation, interview, and document review, the facility failed ensure staff clarified a treatment order and accurately documented the administration of an order for 1 of 1 resident (R3) with physician orders for the application of lymphatic boots (devices using air compression to move lymph fluid out of the affected limbs and back into the circulatory system). Findings include: R3's accepted Minimum Data Set (MDS) assessment on 11/11/25, identified R3's cognition was moderately impaired. R3 required substantial assistance with cares and total assistance with toileting. R3 was noted during assessment period to have physical behaviors towards others 1-3-days, verbal behaviors towards others 1-3 days, and other behaviors (not directed at others) for 1-3 days. R3 was noted to wander within the facility 1-3 days and had a wander guard placed. R3 hallucinated and had delusions. R3 had diagnoses of Alzheimer's disease and depression. R3 took an antianxiety, antidepressant, and scheduled pain medication. R3's 9/15/25, provider dictated note identified R3 had been seen by another provider on 8/27/25 related to chronic venous disease left lower extremity status post left great saphenous vein ablation (procedure for vein destruction used to redirect blood flow). The plan was to have R3 continue wearing compression socks and start using her lymphedema pumps. R3's 9/15/25, Clinic Referral form, used for communication with physicians during appointments, identified handwritten orders on the form to please place patient in recliner after lunch with legs elevated to help with edema for 15-20 minutes at least. Ensure patient is using lymphedema pumps. R3's November 2025, Treatment Administration Record (TAR) identified the following orders:After noon dinner, offer to place R3 in recliner to elevate her legs and put on her lymphedema pumps.Use lymphedema pumps for 1 hour daily at HS (hour of sleep) and as needed. The administration record had a check mark as completed in each day through 11/18/25, except for 11/5/25. R3's 10/30/25, Clinical Referral form for visits to the doctor identified handwritten orders on the form to continue with lymphedema pumps nightly, compression hose on in morning and off at night, and to elevate legs in evening. Observation on 11/17/25 at 2:55 p.m., of R3 in her room identified R3 was seated in her recliner with her legs elevated and covered with a blanket. No lymphedema boots were noted to be on. At 6:28 p.m., R3 was again noted to be in her room, seated in her wheelchair, with no lymphedema boots were observed being on. R3's TAR identified on 11/17/25, at 12:30 p.m., staff marked her lymphedema compression boot order as administered. On 11/18/25 at 12:30 p.m., staff also marked the boots were applied and the treatment administered. Further review of R3's TAR for the month of November 2025 identified a check mark was completed each day as administered, except for 11/11/25 and 11/12/25, which had been noted by staff as refused. Further observations at various times from 11/18/25 through 11/19/25, of R3 in her room after meals and HS identified no lymphedema boots had been applied as indicated on the TAR. Interview on 11/18/25 at 2:09 p.m., with nursing assistant (NA)-A identified sometimes R3 would sit in her recliner after lunch but today she had refused. Staff would offer her to assist in helping her sit in the recliner each day after lunch. R3 did not wear her boots during the day. The nurse was to put them on her in the evening. Interview on 11/18/25 at 4:22 p.m., with licensed practical nurse (LPN)-C identified R3 had not allowed the lymphedema pumps to be put on after lunch for a long time now. When staff attempted to apply the boots, R3 would often become combative. Interview on 11/18/25 at 4:40 p.m., with the interim director of nursing (IDON) identified that the order to offer R3 to sit in recliner after lunch and put the lymphedema boots on had been charted daily for the month of November except for the 11th, and 12th which had been documented as refused by R3. She confirmed the order to apply the lymphedema boots on at HS for 1 hour had been charted as done each day except one day where there was no charting. The IDON noted R3 did refuse to wear the lymphedema boots frequently and on the TAR, two days had been charted as refused, but the other days the IDON revealed it looked like the treatment was administered. The IDON was made aware R3 had refused to sit in her recliner after lunch on 11/18/25, but it had still been charted as administered, she agreed the documentation could be interpreted two ways, as either completed as pumps were applied, or staff had just offered to apply them. To her it looked like R3 had been placed in the recliner and had lymphedema boots applied on 11/18/25, as it was not charted as refused like 2 of the other days had been. The IDON placed a call to an evening nurse (LPN-B) to verify if the lymphedema boots had been applied and were being worn. LPN-B revealed R3 most often refused to wear the lymphedema boots. LPN-B stated she would mark the order as administered prior to applying the lymphedema boots. When she would attempt to put the boots on R3, and R3 refused, she would forget to go back and mark the order as refused vs. administered. LPN-B acknowledged she should not be documenting a treatment order as administered prior to the administration taking place, in case R3 would refuse. LPN-B noted documenting the administration of an order prior to executing an order was incorrect and could lead to incorrect or misleading documentation. Further interview on 11/19/25 at 11:29 a.m., with LPN-B identified R3 did not wear her lymphedema boots on any of the 5 days (11/6/25, 11/8/25, 11/9/25, 11/13/25, and 11/14/25) she had worked. LPN-B revealed she was not to be charting prior to completing a task. Interview on 11/19/25 at 12:31 p.m., with LPN-A identified she had charted on 11/18/25, for the portion of the treatment order to offer the recliner after dinner and put lymphedema boots on. R3 had refused to get into the recliner, but she had charted yes because she had been offered, and not because it had been administered. She revealed maybe that order should have been clarified and needed to be re-worded to identify if it was to be offered marked as administered. Interview on 11/19/25 at 1:20 p.m., with the IDON identified it was her expectation staff were accurately documenting in the residents' medical records and not charting prior to completing a task. The 2/10/25, Legal Documentation Standards policy identified individuals documenting in the medical record would be trained and competent in fundamental documentation practices and legal standards. Documentation in the medical record will be done following the occurrence and never in advance. The 4/6/25, Physician/Practitioner Orders policy identified clarification of orders were needed when reviewing any type of order that was incomplete or raised questions. Staff were to never attempt to guess or determine what the order might say.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 2 of 3 resident (R35 and R42) who had an order for an antibiotic with no indication that an antibiotic time out had been completed.Findings include: R35's 8/31/25 quarterly Minimum Data Set (MDS) assessment, identified his cognition was moderately impaired, he had diagnosis of heart failure, diabetes mellitus, and dementia. R35 was independent with activities of daily living (ADL)'s. R35's August 2025, medication administration record (MAR) identified he was administered cephalexin 500 milligrams three times a day from 8/11/25 to 8/19/25. Review of the facilities monthly infection log identified R35 had been prescribed an antibiotic for a urinary tract infection (UTI) on 8/11/25. The log lacked any indication that an antibiotic time out had been completed. R42's 10/8/25 quarterly Minimum Data Set (MDS) assessment identified his cognition was severely impaired, he had diagnosis of dementia and Parkinson's disease and was dependent on staff to complete ADL's. R42's November 2025, MAR identified he was administered cefdinir oral capsule 300 mg by mouth twice a day from 9/24/25 to 9/30/25. Review of the facilities monthly infection log identified R42 had an upper respiratory infection (URI) with an onset date of 9/21/25. He was prescribed an antibiotic. The infection was resolved on 10/31/25. The infection log had no indication that a antibiotic time out had been completed. Interview on 11/17/25 at 3:00 p.m., with the infection preventionist identified no antibiotic time out was sent to the physician for R35 or R42. Staff should be adding a nursing order on the treatment administration record (TAR) to complete a time out 48 hours after the resident starts the new antibiotic. They have a template for the nurse to complete with the assessment information and that was to be sent to the physician for review. She believed nursing was forgetting to get the order added to the treatment administration record (TAR) and that is why it was being missed. Review of the facilities Antibiotic Stewardship Plan dated 7/8/25, identified staff were to complete an assessment 48-72 hours after a resident starts an antibiotic. The assessment was to include the infection type, the current antibiotic name, dose, route, frequency and start date. The culture results including source/date, identification, and sensitivity. The response to the ordered antibiotic, and the name of the physician who would review the assessment.

Based on interview and document review, the facility failed to follow physician orders to provide R1 with a minced and moist diet. This resulted in an immediate jeopardy (IJ) for R1 when she was given her dinner which was not minced and moist. As a result, R1 choked and required the Heimlich maneuver and oxygen.The IJ began on 8/15/25 at 5:50 p.m., when R1 was given cheese cubes. The administrator and director of nursing (DON) were informed of the IJ on 8/22/25 at 10:07 a.m. The facility had implemented corrective action on 8/19/25, prior to the start of the survey, and was therefore past noncompliance.Findings include: R1's Face Sheet undated, identified R1 had active diagnoses including dysphagia (difficulty swallowing) and Parkinson's disease with dyskinesia (abnormal body movements). R1's care plan revised 7/17/25, identified R1 had a minced and moist texture diet with moderate (honey) consistency fluids. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, had loss of liquid/ solids from mouth when eating or drinking, would holding food in mouth/cheeks or had residual food in mouth after meals, had coughing or choking during meals or when swallowing, had mechanically altered diet, and needed extensive assistance with eating. R1's physician orders dated 8/13/25, identified R1 had a regular diet with minced and moist texture. R1's progress note (PN) dated 8/15/25 at 7:21 p.m., identified R1 had a choking episode at supper. Back thrusts and Heimlich maneuver were preformed, oxygen was placed on resident, and per hospice request morphine was administered to try and see if the medication would relax R1 so the food would pass through her throat. R1's meal card for 8/15/25, identified R1 was to receive a regular diet with minced and moist texture. Menu identified grilled cheese sandwich, tomato soup, crackers, cantaloupe, and cheese cubes. A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on 8/19/25 at 3:25 p.m. The report identified, on 8/15/25 at 5:50 p.m., R1 experienced a choking incident requiring the Heimlich Maneuver and oxygen. During an interview on 8/21/25 at 10:43 a.m., R1 stated she choked on her food on 8/15/25, during dinner time. She received chunks of cheese on her plate, she put the cheese in her soup and choked on the cheese once she started eating her soup. Staff wrapped their arms around her and lifted her up to try and get the food out. No food ever came out but staff doing the Heimlich Maneuver helped R1 breathe better. During an interview on 8/21/25 at 10:58 a.m., dietary assistant (DA)-A stated on 8/15/25, during dinner he plated R1's food. DA-A stated he forgot to review R1's meal card and mistakenly placed cheese cubes on R1's plate. DA-A stated R1 was to receive a minced and moist diet and cheese cubes were not a part of R1's diet. During an interview on 8/21/25 at 11:46 a.m., DA-B stated on 8/15/25, during dinner she brought R1 her meal. DA-B did not check R1s meal card because the person plating the food was expected to do that. R1 received cheese cubes, tomato soup, and a pureed chicken sandwich on her plate. During an interview on 8/21/25 at 12:58 p.m., licensed practical nurse (LPN)-A stated on 8/15/25, at dinner, R1 was brought to the nurses station. R1 was choking and her lips were blue. LPN-A preformed the Heimlich maneuver and back thrusts and nothing came out of R1's mouth. LPN-A did a mouth sweep with her finger and there was nothing in R1's mouth. Trained Medication assistant (TMA)-A and the activity director (AD)- A started taking turns doing the Heimlich maneuver on R1 until she was breathing better. R1's oxygen saturation was in the 70s, (normal mid to upper 90's) LPN-A placed oxygen on R1 and her oxygen saturation when up to the 90s and R1's lips were no longer blue. LPN-A called hospice and R1's family. During an interview on 8/21/25 at 1:10 p.m., speech therapist (ST)-A stated the last time he worked with R1 was 5/27/25, at that time ST-A recommended a minced and moist diet and moderate to extremely thick fluids. Cheese cubes were not a safe food for R1 to have due to it not being minced and moist. During an interview on 8/21/25 at 1:15 p.m., activity director (AD)-A stated on 8/15/25, during dinner, AD-A heard R1 gasping and called out that R1 was choking. R1 was brought the nurses station and LPN-A started the Heimlich maneuver on R1. R1s lips were blue but once oxygen was placed on R1, she started breathing better and her lips returned to a normal color. AD-A looked at R1's tray and saw cheese cubes, regular crackers, soup, and a pureed sandwich on her plate. AD-A stated R1 should not have had crackers or cheese cubes due to her diet. During an interview on 8/21/25 at 1:58 p.m., hospice registered nurse (HRN)-A stated on 8/15/25 at 5:30 p.m., the facility called and stated R1 was choking. HRN-A told LPN-A to give R1 morphine and oxygen and HRN-A was on her way. HRN-A arrived at 5:45 p.m., R1 was coughing and gasping however, R1 was not blue. HRN-A preformed the Heimlich maneuver on R1 but nothing came out. At 6:15 p.m. R1 was able to talk with HRN-A and was breathing normally again. During an interview on 8/21/25 at 2:21 p.m., dietary manager (DM)-A stated staff who plated and passed residents food were expected to look at the name and diet on each meal card to ensure the meal was correct and given to the right resident. DM-A stated the incident on 8/15/25, with R1 occurred due to human error and staff not paying attention. During an interview on 8/22/24 at 8:46 a.m., R1's medical doctor (MD)-A stated cheese cubes were not safe for R1 to eat because they were too big and not soft enough. MD-A stated she expected staff to assist R1 with meals and follow R1's diet. MD-A stated R1 receiving cheese cubes caused harm to R1 and could have caused her death. During an interview on 8/22/25 at 9:57 a.m., the director of nursing (DON) stated it was expected that staff read the meal card for each resident to ensure the resident received the right diet and textured meal. During an interview on 8/22/25 at 10:00 a.m., the administrator stated the staff were expected to ensure each resident received the right diets when preparing and passing meals. The facility policy Proper Reading of Diet Cards and Meal Delivery undated, indicated staff would accurately read diet cards, verifying patient identification, and ensuring the correct dietary items were provided to each patient. The past noncompliance immediate jeopardy began on 8/15/25. The immediate jeopardy was removed, and the deficient practice was corrected by 8/19/25, after the facility implemented a systemic plan that included the following actions: The facility re-educated all staff who prepare and pass meals on the policy and procedure of meal service. The facility completed audits twice a week by observing staff preparing and passing meals to the correct residents with the right diet and the results were to then be brought to QAPI committee. Verification of corrective action was confirmed by observation, interview, and document review on 8/21/25 and 8/22/25.

Based on interview and document review, the facility failed to ensure the required amount of staff determined by their resident census and care levels, resident assessments and individual plans of care, and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 4/1/24 through 6/30, 24 days Triggered = Submitted Weekend Staffing Data Excessively Low. Review of the facility's staffing requirements for weekends during the identified PBJ period of 4/1/24 through 6/30/24 identified staffing numbers required were: Days: 1 nurse: 6:30 a.m. -7:00 p.m. 1 nurse: 6:30 a.m. -3:00 p.m. 1 trained medication aide (TMA)/or Restorative aide (RA) 6:30 a.m. - 2:30 p.m. 1 RA: 6:00 a.m. - 2:30 p.m. 4 nursing assistants (NA): 6:30 a.m. - 2:30 p.m. and 1 NA/bath aide. 6:30 a.m. - 1:00 p.m. Evenings: 2 NAs: 2:30 p.m. - 11:00 p.m. 2 NA's: 2:30 p.m. -9:30 p.m. 1 NA: 5:00 p.m. - 8:00 p.m. 2 TMA's: 4:30 p.m. - 8:30 p.m. 1 nurse: 7:00 p.m. - 7:00 a.m. Nights: 1 overnight nurse: 7:00 p.m. - 7:00 a.m. 2 NA's: 10:45 p.m. - 6:15 a.m. Review of working schedules and time cards for Fiscal year Quarter 3, 2024 (April 1 through June 30, 2024) identified less than the amount of identified staff worked for 4 of 8 weekend evening shifts with the above identified number of needed staff on duty to provide care and services to the residents. On: 1) 4/7/24 (Sunday), review of time cards identified 2 of the scheduled 4 NAs and 1 of 2 scheduled TMA's worked on the evening shift. 2) 4/14/24 (Sunday), review of time cards identified 3 of 4 scheduled NAs and one of 2 scheduled TMA's were on duty for the evening shift. 3) 4/20/24 (Saturday), review of time cards identified 3 of 4 scheduled NAs and 1 of 2 TMA's were working during the evening shift. 4) 4/27/24 (Saturday), review of time cards identified 3 of 4 scheduled NAs and 1 of 2 scheduled TMA's worked on the evening shift. Interview on 10/15/24 at 5:07 p.m. with the administrator and director of nursing (DON) reported she included contract staff in the PBJ report, and was not certain why it had triggered. The administrator reported she reviewed and approved the time punches but the national campus did the actual submission of the PBJ report. They reported when a staff person called in the process was to call unscheduled staff by using the On Shift (a computerized program utilized to notify staff of an open shift). If that process was not effective in finding a replacement, the next step was to contact the nurse on call and either they or the DON covered the shift. The administrator and DON identified they attempted to fill an open shift if there was a call in on all shifts. They reported other options to fill shifts included use of contract staff, or to mandate staff to work extended hours. Review of the 7/2/24, Facility Assessment identified the facility was to assess daily needs and utilize a program called On Shift to send messages to staff when needed to fill shifts. The facility noted the utilized contracted staff to cover open shifts and were to mandate staff stay to ensure safe staffing levels. They measured and monitored staffing needs for their resident population to ensure shifts were filled. There was no indication in the above documents the facility utilized approaches to fill the shifts when their numbers could not be attained.

Based on observation, interview, and document review, the facility failed to ensure a system for periodic reconciliation of controlled substances for the emergency kit stored in a refrigerator. Findings include: On interview and observation 10/13/24 at 3:27 p.m., a tour of the medication room with registered nurse (RN)-A included an unlocked refrigerator with a plastic container that had a breakaway tag on with number 6229540. Inside of the plastic kit was 1 vial of morphine liquid 100 mg/5 ml, Tramadol 50 mg tablets, and 2 vials of lorazepam 2 mg/ml. RN-A indicated they switched pharmacies a few months ago and she stated they have not been counting the narcotics, nor verifying the security of the lock, for medications kept in the refrigerator but probably should be. On interview 10/13/24 at 7:00 p.m., trained medication aide (TMA)-A indicated she does participate in narcotics counts at the end of the shift, but has never counted the narcotics in the medication room refrigerator, or verified the lock was intact. There was no mention of doing either in the medication reconciliation book. On interview 10/13/24 at 7:01 p.m., licensed practical nurse (LPN)-A stated they have not been reconciling or verifying the lock remained intact for narcotic medications in the refrigerator and was unsure if they were reconciling them prior to the pharmacy change. On interview 10/13/24 at 7:02 p.m., the director of nursing confirmed the narcotics in the refrigerator in the medication room are not being reconciled or locks verified to remain intact, and haven't been since the new pharmacy took over in September 2024. The Medications: Acquisition, Receiving, Dispensing and Storage policy, dated 3/29/24, included, controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments, except when a single unit package drug distribution is used. If the medication requires a refrigerator, these need to be locked in a separate container. These drugs will be reconciled at least daily through an appropriate system of records of receipt and disposition established by the licensed pharmacist.

Based on interview and document review, the facility failed to notify the resident and/or their representative, in writing, of the care facility's bed hold policy, including any potential costs included with the bed hold, at the time of transfer to the hospital for 1 of 5 residents (R10) reviewed for hospitalization s. Findings include: R10's 9/17/24, quarterly Minimum Data Set (MDS) identified R10 had unclear speech, was usually understood, had severe cognitive impairment, displayed continuous disorganized thinking, altered level of consciousness, and had verbal behaviors daily. R10 used a wheelchair for mobility and required total assistance with cares. R10 was identified to have Alzheimer's disease. She had no indications of pain; she had no falls and did not take any psychoactive medication. R10's 6/28/24, progress note identified R10 was positive for COVID-19 and was on droplet precautions. On 6/29/24, at around 7:00 p.m., R10 was assessed and found to have unstable vital signs with shortness of breath and was transported to the emergency room for evaluation. The family was notified of the transfer to the hospital. On 7/2/24, R10 returned to the facility with diagnosis of pneumonia and COVID. R10 had received 3 days of IV antibiotics while at hospital and was to start oral antibiotics twice a day for next 7 days. The progress notes indicated the family had been notified of the hospital transfer however, there was no indication that the nurse had discussed the bed hold policy or that the family had been provided the bed hold policy, including potential cost included with the bed hold. Interview on 10/14/24 at 2:12 p.m., with registered nurse (RN)-A identified typically when a resident was sent to the hospital the charge nurse would ask the family if they would like a bed hold. If the family wanted a bed hold the nurse would document a verbal confirmation on the bed hold form and the family will come in and sign the bed hold at their convenience. Interview on 1014/24 at 3:45 p.m., with director of nursing identified facility staff had not discussed or provided the bed hold notice to the family of R10 when she discharged to the hospital on 6/29/24. Review of the 12/7/23, Bed-Hold-Rehab/Skilled policy identified in emergency transfer the notice of bed hold policy would be sent with the resident to the hospital. The family would be provided the bed hold policy within 24 hours of the transfer. This was to ensure the resident or family was made aware of the bed hold policy including potential cost prior to or upon transfer to the hospital in order to determine if a bed hold was wanted.

Based on observation, interview and document review the facility failed to ensure the infection control program used enhanced barrier precautions (EBP) per Centers for Disease Control (CDC) recommendations for 2 of 2 residents (R47 and R19) who had indwelling device present or multi-drug-resistant organism (MDRO). Findings include: R46's diagnosis list printed 10/14/24 included gastrostomy (a feeding tube inserted into the stomach through the abdomen) status. R46's plan of care, dated 9/13/24, included the resident requires tube feeding related to dysphagia (difficulty swallowing). Interventions included no water pitcher at bedside due to nothing per mouth status and elevate head of bed 30-45 degrees during and 30 minutes after the tube feeding is stopped. R46's plan of care did not include EBP precautions. On observation and interview on 10/13/24 at 5:03 p.m., registered nurse (RN)-A gathered supplies for tube feeding, put on a gown she brought with her to R46's room. RN-A stated that when providing cares such as tube feedings or medication administration with the gastrostomy tube (GT) they need to wear a gown and gloves. RN-A entered R46's room and R46 stated he needed to go the bathroom before his tube feeding. RN-A called for assistance stating she didn't want to contaminate her gown since she was going to give the tube feeding. On the back of the entry door was a sign that stated Enhanced Barrier Precautions which included gowns and gloves were required for all high contact resident care activities that included changing briefs, assisting with toileting. A yellow bag with gowns present in the pockets was hanging on R46's bathroom door. At 5:03 p.m., nursing assistant (NA)-A entered room and without gowning or gloving assisted R46 to the bathroom. NA-A put on gloves and assisted R46 with wiping and perineal care, then removed gloves, washed hands and assisted R46 to his bed. NA-A stated they do not need to gown when providing direct patient care. RN-A stated gowns are not required for direct patient care unless related to the GT. On observation and interview on 10/14/24 at 12:14 p.m., R46 was in his bathroom brushing his teeth. Licensed practical nurse (LPN)-B was present and assisted R46 out of bathroom to his wheelchair when R46 stated he just wet himself. LPN-B assisted R46 to the toilet, put on gloves and changed soiled pad and using disposable wipes provided perineal care. LPN-B assisted R46 to pull his pants up then assisted R46 to his wheelchair. LPN-A did wear gloves with direct care but did not wear a gown. LPN-B indicated staff only have to gown when doing tube feedings and his medications which are also through the GT, otherwise for general care, gowns are not needed. R19's care plan included the resident requires EBP related to MDRO colonization (CRE - Carbapenem resistant enterobacerales). Interventions included wear gown and gloves when performing high contact care activities including dressing, bathing, providing hygiene such as changing incontinence product, checking and changing and assisting with toileting task. On observation and interview 10/14/24 at 8:25 a.m., R19 returned to her room from breakfast. On the back of room door was a yellow bag with EBP sign present. On the bathroom door, a sign indicated Contact Precautions. R19 stated she gets herself to the bathroom. R19 indicated staff only wear a gown when she goes to the bathroom due to her MDRO being in her urine. Otherwise when assisting her with personal cares, they don't wear a gown. On observation and interview 10/14/24 at 12:38 p.m., LPN-B stated staff only have to wear gown and gloves when toileting R19 but not for personal cares. When questioned about the contact precautions sign on the bathroom door, LPN-B stated she wasn't sure why that was there. During interview on 10/14/24 at 2:32 p.m., the director of nursing (DON) also identified as infection preventionist, indicated staff only need to gown for R46 if using the GT because that is why he is on EBP. The DON indicated for R19, staff only need to gown and glove if possible contact with urine because R19's MDRO is in her urine. The DON stated I don't know why we would gown and glove for anything else. The DON stated she was not aware of R19 being on contact precautions or why that sign is in her room and will have it removed. After the DON reviewed the facility policy, the DON stated for EBP, staff should be wearing gowns and gloves for all high contact resident care activities and not just with cares related to the reason for being on EBP. A Standard and Transmission-Based Precautions Policy and procedure dated 4/2/24 included: Enhanced Barrier Precautions: - Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. - EBP are needed for residents with chronic wounds, and residents with indwelling medical devices. - EBP are also needed for residents with CDC-targeted epidemiology important MDRO infection and colonization when contact precautions do not apply. - High contact resident care activities include: Transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with the resident in the therapy gym, changing linens, device care or use and wound care. - Post clear signage indicating the type of precautions and required PPE: gown and gloves for EBP. - Signage should also clearing indicate the high-contact resident care activities that require the use of gown and gloves. - Gowns and gloves should be readily available immediately outside of the resident room unless contraindicated for a resident-specific need.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly or more often, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 7/16/23, 7/23/23, 7/29/23, 7/30/23, 8/13/23, 8/26/23, 8/27/23, 9/09/23, 9/10/23, 9/16/23, 9/17/23, and 9/30/23 for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules identified the facility had 7 staff identified to have worked, registered nurses (RN)-D, RN-E, RN-F, RN-G, RN-H, RN-I and licensed practical nurse (LPN)-A. Review of staff's time cards on the above-mentioned dates identified licensed nursing staff had worked and the data submitted in the PBJ to CMS was inaccurate. Interview on 1/24/24 at 1:01 p.m., with the administrator (ADM) acknowledge the data submitted for the PBJ report for the infraction dates had been inaccurate due to excluding contracted agency nurse hours. She revealed her corporate office completed the PBJ submission from the data she took from the employee time punches, but received no documentation to support data had been submitted accurately, as it was triggered on the [NAME] 1705D report for Quarter 4, FY 2023.Furthermore, there was no indication a [NAME] report 1702D or 1703D had been run by the facility, per CMS instructions to compare data submitted matched employee hours submitted. There was no policy related to PBJ entries provided by the end of the survey.

Based on interview and document review the facility failed to ensure timely submission of a Death in facility Minimum Data Set (MDS) for 1 of 1 resident (R9) who was reviewed for an MDS record over 120 days old. Findings include: R9's medical record identified last scheduled Minimum Data Set (MDS) assessment that had been completed and submitted was on 9/17/23. R9's death in facility MDS was signed by the responsible party on 10/2/23, and locked on 10/11/23. The death in facility MDS had not been successfully submitted and/or transmitted; as R9's electronic health record identified it had been completed rather than accepted under the status section, indicating it had not been submitted. Observation and Interview on 1/23/24 at 9:02 a.m., with registered nurse (RN)-A who revealed she was responsible for R9's MDS completion and submission. Her process was to submit completed MDS's each week. The electronic medical record program, Point Click Care (PCC) would create a batch of MDS's that were eligible for submission. Following submission of a batch of MDS's there would be a validation report for review that would confirm the submission date of each resident's MDS that had been submitted. After review of the validation reports with RN-A for batches that were submitted it was identified that the death in facility MDS had not generated in any of the MDS batches to be submitted. RN-A was unsure why R9's death in facility MDS did not generate as eligible for submission. Interview on 1/23/23 at 9:29 a.m., with regional consultant (RC) for the facility's MDS completion and submission process. She logged in remotely and confirmed that R9's death in facility MDS had not been submitted. The MDS had been locked during the final steps in PCC after completion. The system asked yes or no prompting staff if they wanted to submit. It must have been accidentally check as no causing the MDS to be locked verses eligible for submission. Interview on 1/23/24 at 10:24 a.m., with administrator who identified her expectation was that all MDS assessments would be completed and submitted timely. A facility policy was requested but not provided.

Based on interview and document review, the facility failed to notify the designated State Mental Health Authority (SMHA) when 1 of 2 residents (R14) had changes in mental health and/or had new-onset mental illness diagnoses. Findings include: R14's 1/23/24, face sheet identified she was admitted to the facility in June of 2022, with diagnosis of depression. R14's diagnosis list identified that upon admission, she had no diagnosis of mental illness or related condition. On 1/23/23, R14 had a new diagnosis added of psychotic disorder with delusions due to known physiological condition, and new onset anxiety disorder due to a known physiological condition. R14's medical record lacked any indication that the SMHA had been notified of the new diagnoses. R14's 5/16/23, annual Minimum Data Set (MDS) assessment identified R14 experienced delusions and verbal behaviors directed towards others and herself that put R14 at significant risk for injury. R14's 6/27/22, pre-admission screening (PAS) results identified she was being admitted with a primary diagnosis of cognitive impairment with no serious mental illness and no hallucinations or delusions within the past 6 months. R14's PAS identified she did not meet the criteria for mental illness at that time and did not require a level II (PASRR) Preadmission Screening and Resident Review to be completed. R14's 1/24/24, current medication administration record identified she was being administered quetiapine (antipsychotic) 75 mg, 2 x daily for delusions. Interview on 1/23/23 at 2:33 p.m., with the social service designee identified she thought that if a resident had a primary diagnosis of dementia, she did not have to notify the SMHA of a new onset mental illness. Interview on 1/24/23 at 1:30 p.m., administrator identified she had recently received training on PASRR and would have expected her social service designee to notify the SMHA of a new diagnosis of mental illness in this instance. A policy was requested, nothing was provided by end of the survey.

Based on observation and interview the facility failed to follow their policy and ensure discontinued medications were immediately removed from 1 of 1 resident's (R8) medication and not co-mingled with thier current medication supply located in the [NAME] medication cart, and secure them in a locked compartment in the medication room for final destruction. Findings include: R8's 11/29/23, Significant Minimum Data Set (MDS) assessment identified R8's cognition was intact, she required maximal assistance with daily cares, was identified as having pain and took pain medication. She had frequent pain that was severe and took an anti-anxiety, anti-depression, and opioid (narcotic used for pain) medication. R8 had identified diagnosis of anxiety and depression. Observation and interview on 1/24/24 at 10:37 a.m., with registered nurse (RN)-B of the [NAME] medication cart. The locked narcotic box located within the west medication cart contained 2 punch cards for R8 that had a yellow sticker on the punch card that identified it had been discontinued. The first punch card label identified lorazepam 0.5 milligrams (mg) take 1 tablet by mouth twice a day, with 14 doses remaining. The narcotic count book had d/c (discontinued) written on the page with no date. The second punch card label identified lorazepam 0.5 mg take 1 tablet at bedtime and 1 tablet 6 hours after scheduled dose as needed for anxiety, with 30 doses remaining. The narcotic count book had d/c written on the page with no date. RN-B was not certain when either order had been discontinued. The locked narcotic box also contained a punch card for R8 with a label that identified lorazepam 0.25 mg give 1/2 tablet at bedtime, with 23 doses. The narcotic count book identified on 1/17/24, the facility had received the lorazepam 0.25 mg doses. RN-B indicated that the facility used 2 licensed nurses to destroy controlled medications however, sometimes there were not 2 facility licensed nurses on duty, and they preferred to use the facility nurses' verses contracted nurses to destroy controlled medications. RN-B reported the process to destroy controlled medication would be to scan the bar code linked to the Omnicare system electronically. She acknowledged the lorazepam should have been destroyed by 2 licensed nurses after receiving the physician order to discontinue the medication. R8's physician orders identified an order was placed on: 1) 11/15/23, for lorazepam 0.5 mg by mouth twice a day for anxiety. 2) 11/29/23, to discontinue lorazepam 0.5 mg by mouth twice a day for anxiety. 3) 11/29/23, for 0.5 mg 1 tablet of lorazepam to be administered as needed twice a day for anxiety. 4) 12/20/23, to discontinue the Lorazepam 0.5 mg twice a day as needed for anxiety. 5) 12/20/23, for lorazepam 0.5 mg to be administered at bedtime for anxiety. 6) 1/3/24, to discontinue lorazepam 0.5 mg at bedtime for anxiety. 7) 1/3/24, for lorazepam 0.5 mg 1 tablet to be administered at bedtime and 1 tablet 6 hours after scheduled dose, as needed for anxiety. 8) 1/17/24, to discontinue the lorazepam 0.5 mg 1 tablet at bedtime and 1 tablet 6 hours after scheduled dose as needed for anxiety. 9) 1/17/24, for lorazepam 0.25 mg to be administered at bedtime for anxiety. Interview on 1/24/24 at 11:09 a.m., with RN-A identified controlled medication required 2 licensed nurses to destroy when medications are discontinued or when a resident discharges. Interview on 1/24/24 at 11:27 a.m., with RN-C identified controlled medications required 2 licensed nurses to destroy and that destruction should occur as soon as possible. Review of the 6/13/23 Medications: Controlled-R/S LTC policy identified controlled medications that were discontinued should be placed in a lock box in the medication room as soon as they are discontinued and continued to be counted by 2 nurses until disposal was completed. There was no indication staff had followed the policy in the above observations and interviews and removed the medication from the medication cart as not to be co-mingled with in-use medication.

Based on observation, interview, and document review the facility failed complete a comprehensive assessment and develop and individualized toileting program to maintain or improve bowel/bladder continence for 1 of 1 resident (R2) reviewed for incontinence. Finding include: R2's significant change Material Data Set MDS dated [DATE], indicated R2 had severe cognitive impairment. R2's diagnoses included cerebral vascular accident (CVA or stroke), anxiety disorder, and overactive bladder (OAB). R2 required extensive assistance of one staff person with toileting, personal hygiene, and ambulation. MDS further indicated that R2 did have a toileting program and was occassionally incontinent of bladder and always continent of bowel. R2's activities of daily living (ADL) care plan indicated the following interventions:. -toilet use limited assist of one staff to use toilet (dated 3/29/23). -staff to monitor for signs and symptoms of complications urgency, incontinence and signs and symptoms of urinary tract infection (UTI) (dated 3/20/23), -review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs, receives Botox injections to bladder, (dated 5/4/23), R2's record did not include a comprehensive bowel and bladder assessment that identified history of incontinence, type of incontinence, voiding/bowel patterns, and modifiable risk factors in order to establish and individualized toileting schedule or program that prevents or reduces the risk of worsening incontinence and infections. R2's record identified R2 had fallen six times between 5/13/23 and 7/11/23, attempting to self-transfer to the bathroom. -5/13/23 at 1:20 p.m., R2 wheeled self into the bathroom, stood up to wash her hands and fell , no injury. Last toileted at 11:50 a.m. -5/25/23 at 7:45 a.m., R2 went to her room after breakfast, tried to take self to the bathroom, no injury. Last toileted at 6:00 a.m. New intervention was updated toileting schedule to include to offer toileting after meals as well. R2's care plan that was intiated on 3/29/23 that directed staff to toilet R2 at 6:00 a.m., 9:00 a.m., 11:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., 10:00 p.m., and as needed and after meals was discontinued on 5/31/23; the record did not include an evaluation for effectiveness. On 5/31/23 the care plan was revised to encourage R2 to rest in bed or recliner after meals, offer toileting after meals prior to laying down. -6/2/23 at 7:45 p.m., R2 found on floor, attempting to self-transfer. Last toileted at 5:00 p.m. -6/10/23 at 5:20 a.m., R2 attempted to self-transfer and fell , no injuries. Last toileted at 4:00 a.m. New intervention was to start a 72-hour bowel and bladder assessment. In review of R2's record it was not evident a 72-hour bowel and bladder assessment was completed. -7/1/23 at 3:40 a.m., R2 attempted to self-ambulate to the bathroom, no injuries, Last checked on at 3:00 a.m. -7/02/23 at 7:20 a.m., self-transferred to toilet, no injuries. Last toileted at 6:11 a.m. During an observation on 7/11/23 at 3:30 p.m., nursing assistant (NA)-C assisted R2 to use the toilet. NA-C assisted R2 to standup using a gait belt and removed R2's wet incontinent brief. At 3:44 p.m. R2 turned on her bathroom call light, NA-C assisted R2 with personal cares and placed a new brief on R2. During an interview on 7/11/23 at 2:48 p.m., NA-A indicated that R2 was anxious and impatient person. R2 was able to use call light and make needs known. NA-A explained staff took R2 to the bathroom as she requested, but R2 would not void everytime they took her. During an interview 7/12/23 at 10:55 a.m., NA-N indicated R2 was not a toileting schedule. R2 used the call light to alert staff for when she needed to use the bathroom. During an interview on 7/12/23 at 3:55 p.m. director of nursing (DON) reviewed R2's record, and reported she was not able to find a comprehensive bowel and bladder assessment. DON stated she was able to see a 72-hour bowel and bladder monitoring was to be initiated on 6/14/23, but not able to find results or the evaluation of the information. DON stated that bowel and bladder assessments are completed at admission, new onset of incontinence or with a change in condition. Review of Facility policy titled, Bowel and Bladder: Evaluation Assessment, toileting Programs, dated 4/26/23, indicated that the program was based on the resident's comprehensive assessment. These assessments were to be completed on admission, documented on weekly and once a successful toileting program has been established, documentation is required to be done at least quarterly.

Based on observation and interview, the facility failed to maintain 1 or 1 ice machine to prevent potential contamination and to ensure food and drinks were served in a safe and sanitary manner during meal service in the dining room. This had the potential to effect 45 of 48 residents who ate breakfast in the dining room. ICE MACHINE During initial tour of the kitchen and interview on 10/17/22, at 12:55 p.m., an ice machine located in the kitchen storage room had white, lumpy deposits present along the lid of the ice container and along the right side of the machine. A yellow light was lite on the top of the machine. The dietary manager (DM) indicated it is lime scale build up and is aware the machine needs to be cleaned routinely. DM indicated maintenance has been notified of it needing to be cleaned. Requested maintenance documents on the ice machine and DM indicated there will not be any as they have experienced turn over in the maintenance department and it hasn't been cleaned in over a year. During interview on 10/19/22, at 12:58 p.m., service department of ice machine manufacturer (Scotsman) was contacted and spoke with SD-A who indicated maintenance is required at a minimum every 6 months but stated it also depends on water quality. If facility has hard water the machine should be cleaned every 3-4 months. SD-A indicated a yellow indicator light will turn on when cleaning is required. SD-A indicated if white scaling substance is on the outside of the machine, it is also on the inside of machine which can contaminate the ice being made. Review of manufacture's recommendations dated January 2015, included: All models have an indicator light that switches on to inform the user that the cleaning interval has been reached. It does not stop the machine from making ice. The clean button drains the reservoir and refills it. The cleaning process is designed to use straight nickel safe ice machine scale remover, added between draining and refilling. The cleaning time is designated by person running the clean cycle and is dependent on cleaning need. A second push of the clean button starts the flush out process. This process should last at least 20 minutes to fully flush out the scale remover and loose scale. After the scale remover has been drained out, the water distributor must be inspected for loose scale and cleaned if any. Removal of the sump cover, pump bracket and curtain is next to be sure those parts have been cleaned. Cycle power to the controller as a final step before restarting ice making. During observation and interview 10/20/22, at 9:48 a.m., the administrator and maintenance (M)-A observed the ice machine. The yellow light remained on the machine and this was confirmed by the administrator. M-A confirmed there was a white, lumpy deposit present on the ice machine and indicated he wasn't aware routine maintenance needed to be completed on this machine. M-A indicated he is unaware of the last maintenance completed on the ice machine. DRINKS R39's admission Minimum Data Set (MDS) dated [DATE], indicated R39 had mild cognitive deficits and required extensive assistance of one staff with all activities of daily living (ADLs) and supervision of one staff for eating. During an observation and interview on 10/19/22, at 7:29 a.m. The cook (CK) was observed placing uncovered juice, coffee, water and tea orders and bananas with the ends cut off, on all the tables in the dining room. Of the 45 residents who ate breakfast in the dining room, only three residents were seated at tables. The CK stated the drinks and bananas were always placed on the tables early and although they were not covered, there was no concern for contamination from other residents, staff or visitors walking by. The CK further stated there was no policy requiring the drinks to be covered during dining service. During an observation on 10/19/22, at 7:33 a.m. R39 was observed self-propelling her wheelchair around her assigned table, picking up another banana on the table and comparing the cut end to her banana. R39 decided she preferred her banana and left the second banana at the preset place for another resident who had not arrived yet for breakfast. No staff were present during the incident. During an interview on 10/20/22, at 10:46 a.m. registered nurse (RN)-C stated she had previously seen residents pick up uncovered, cut bananas on the dining tables to compare their ripeness and staff would gladly switch out the bananas if they were asked to. Although there was concern for contamination, RN-C also stated she had not discussed changing the process with anyone because the kitchen was in charge of meal service and delivery. During an interview on 10/19/22, at 11:05 a.m. the dietary director (DD) stated although drinks were served prior to residents entering the dining room, they were only required to be covered during room tray delivery. The DD further stated there was no concern for contamination of the drinks from other residents or staff walking by or reaching over the drinks. The DD stated, however; a resident picking up uncovered, cut bananas that were intended for other residents would be a concern for contamination and the cut end of the bananas should have been covered. The facility policy on food service was requested but not received.

Based on observation, interview and record review the facility failed to ensure safe, and appropriate water temperatures were maintained below 120 degrees Fahrenheit to prevent potential [CONDITION(S)] to residents residing in 15 of 36 rooms observed in the facility. Findings include: During a tour of the facility on 10/17/2,2 at 7:10 p.m., the water temperatures were obtained in degree of Fahrenheit (F). The following rooms were as follows: (1) R24's room water temperature was 124.0 F (2) R8 and R35's room water temperature was 123.8 F (3) R20 and R36's room water temperature was 124.2 F During tour of the facility on 10/18/22, at 2:00 p.m., the water temperatures were obtained in degree of Fahrenheit (F) in the following rooms: (1) R13's room water temperature was 129.2 F (2) R45's room water temperature was 127.9 F (3) R48's room water temperature was 130.6 F (4) R42's room water temperature was 125.0 F (5) R14's room water temperature was 127.5 F (6) R41's room water temperature was 123.6 F Review of the 3/20/12, Consumer Product Safety Commission at https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf identified water temperatures should be maintained at less than 120 degrees to prevent [CONDITION(S)]. During interview and observation on 10/19/22, at 10:05 a.m. with administrator and maintenance (M)-A and M-B, rooms belonging to R24, R8 and R35, R2, R20 and R7 identified water temperatures at that time ranged from 98 to 104 degrees F. The administrator indicated the facility recently purchased a new water heater and was currently having difficulty maintaining safe and/or comfortable parameters of temperature. The administrator indicated maintenance had been monitoring temperatures and working with the company to resolve the issue. M-A indicated he had turned down the water heater on 10/18/22 due to temperatures being too high. There was no indication the administrator had a plan in place or had educated staff on what to do when water reached high temperatures 120 degrees or higher to prevent potential [CONDITION(S)] for all 48 residents. During observation and recheck of water temperatures on 10/20/22, at 8:20 a.m. the following room water temperatures were as follows: (1) R48's room water temperature was 132.0 F (2) R28's room water temperature was 130.0 F (4) R41's room water temperature was 127.2 F (5) R1's room water temperature was 130.0 F (6) R8 and R35's room water temperature was 132.2 F (7) R2's room water temperature was 128.0 F During record review on 10/20/22, at 8:42 a.m., a copy of the facility monitoring included on: 1) 9/21/22 at 10:00 a.m., rooms belonging to R6 and R16, and R45 had water temperature to be 120 F. 2) 10/5/22 at 11:00 p.m. rooms belonging to R28 and R14 had water temperatures noted to be 120 F. 3) 10/12/22 at 2:00 p.m. rooms belonging to R27 and R22, and R43 had water temperatures note to be 120 F. Each time staff noted the high temperature and adjusted the water heater. There was no indication nursing staff were alerted to the potential for increased risk of resident [CONDITION(S)]. During interview on 10/20/22, at 8:32 a.m., nursing assistant (NA)-A indicated water was either too hot or too coldover the past few weeks. NA-A indicated to her knowledge there have been no injuries related to the water temperatures and was not educated on what to do if water temperatures were too high and had the potential to burn residents. During interview on 10/20/22, at 8:34 a.m., NA-B indicated the water temperatures have fluctuated over the past month being either too hot or too cold. To her knowledge, no resident had injuries related to hot water temperatures. Staff just know to check it before residents would potentially wash their hands or before putting residents into the bathtub. During interview and document review on 10/20/22, at 9:51 a.m., administrator and M-A indicated they were performing routine monitoring of temperatures daily, but it is on a separate sheet than the normal weekly monitoring. M-A indicated he did check the water temperature at 7:00 a.m. that morning which was too high, so the water heater was turned down. M-A indicated he did not notify nursing staff of the hot water issue. The administrator had an invoice dated 9/1/22 for the new water heater, but the administrator stated it was not installed until after that date and was unaware when it was reportedly to have been installed. Review of water temperature monitoring provided by maintenance included dates 9/1/22 through 10/19/22 completed daily with water temperatures ranging from 110 to 115 degrees F. Three temperatures on 9/21/22, 10/5/22 and 10/12/22 were noted to be at 120 degrees F. On 9/21/22 and 10/5/22, the water temperatures was note to be adjusted. The temperature monitoring sheet did not include time or location the water temperature was checked. During subsequent interview on 10/20/22, at 11:30 a.m., the administrator confirmed more frequent water temperature monitoring and also communication with staff was imperative to ensure the safety of all residents. A policy and procedure titled Water Temperatures dated 2/2/2022 identified residents typically had thinner skin so the risk of [CONDITION(S)] even with brief exposure to unsafe high water temperatures was substantial. Additionally residents may have medical conditions that limited their ability to communicate or even recognize that the water they are exposed to had the potential to burn them. The exposure time required to produce a third degree burn was 120 degrees F for five minutes. At 127 degrees, it took 1 minute to cause [CONDITION(S)]. Monitoring water temperaures was to be done on a weekly basis or more frequently if conditions were identified to ensure a comfortable and safe environment for residents. Monitoring was to include rooms closest to and furthest away from the water source at least weekly per wing or water loop. The recommended temperature range for hot water at the point of use, was between 100 and 115 degrees F. Documenting water temperatures should include the following information: - Name or initials of the person taking the temperature - Specific location of the monitoring (for example: room number) - Date and time of the monitoring - Temperature of the water.

Based on interview, observation and document review, the facility failed to monitor 1 of 1 resident (R38) for potential complications post-[CONDITION(S)] and have a method of communication with the [CONDITION(S)] facility to ensure consistent continuity of care. Finding include: R38's face sheet 10/29/22, included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's quarterly Minimum Data Set (MDS) dated [DATE], included R38 was cognitively intact, independent with activities of daily living and on [CONDITION(S)]. R38's plan of care dated 5/2/22, included R38 needed hemodialysis related to end stage kidney disease with a goal to have no signs and symptoms of complications related to [CONDITION(S)]. Staff were to monitor and document for peripheral [CONDITION(S)], hypovolemia (increased pulse, increased respirations, decreased systolic blood pressure, sweating, and anxiousness) or hypervolemia (increased blood pressure, lung crackles, headache, and/or shortness of breath). R38 attended [CONDITION(S)] Mondays, Wednesday and Fridays with Thursdays at the [CONDITION(S)] health care provider discretion. If bleeding was noted to R38's fistula site, staff were to apply immediate pressure and call for nurse. During observation and interview on 10/17/22, at 5:32 p.m., R38 returned to the facility from [CONDITION(S)] and wheeled himself straight to the dining room. An unidentified staff brought him his medications in a cup. No vital signs were completed and the fistula was not visualized or assessed after returning from [CONDITION(S)] During observation and interview on 10/17/22, at 6:18 p.m., R38 indicated he has been receiving [CONDITION(S)] for 3 years ever since he moved into this facility. R38 showed his port, which was located in the left upper arm and had two 2x2' gauze pads held on by tape on his fistula which were dry and intact. R38 indicated the staff do not monitor or assess the [CONDITION(S)] site. He usually just removes the dressing himself. R38 indicated he generally takes it off the following day or [CONDITION(S)] staff will take it off other following day when he goes for his next treatment. During an observation and interview 10/18/22, at 3:25 p.m., R38 indicated he removed his bandage this morning around 7:00 a.m., when the nursing assistant (NA) took him to get his bath. R38 indicated nursing staff do not look at his [CONDITION(S)] port or complete any assessment when he returns. During interview on 10/19/22, 7:20 a.m., registered nurse (RN)-A indicated they fax 2 forms which includes a pre-[CONDITION(S)] assessment to the [CONDITION(S)] unit on the morning R38 goes for his [CONDITION(S)] treatment. RN-A indicated when R38 returns he will check in with the nursing staff. RN-A indicated R38 was to notify staff if he is having any bleeding at the site or if there was any trouble after [CONDITION(S)]. RN-A added R38 likes to manage the fistula site himself. There was no indication the facility had a process to ensure an assessment was performed, or communication was maintained between facility staff and [CONDITION(S)] staff vs. rely on R38 to assess himself. During interview on 10/19/22, at 9:14 a.m., RN-A indicated they receive post-[CONDITION(S)] reports via fax from the [CONDITION(S)] center but was unsure when they actually arrived or were noted. RN-A added if there are any new orders, she felt they would come from R38's medical doctor and not the [CONDITION(S)] facility. During interview on 10/19/22, at 10:13 a.m., dietary personnel (DP)-A indicated [CONDITION(S)] used to send a renal report card for R38 that included most recent lab work, weights before and after [CONDITION(S)] and if they ran extra fluid offload. DP-A reported the registered dietician (RD) had contacted the [CONDITION(S)] facility requesting information but had not received a return call, after multiple attempts. DP-A indicated there was not adequate communication being received from the [CONDITION(S)] company. During interview 10/19/22, at 12:33 p.m., patient care technician (PCT)-A from [CONDITION(S)] company indicated she worked with R38 frequently when he received [CONDITION(S)]. R38 frequently arrives with extra fluid onboard and they will do an extra run for [CONDITION(S)] to just pull extra fluid off after his 4 hour [CONDITION(S)] run. PCT-A indicated they used to send his post-[CONDITION(S)] sheet with R38 to give to the facility, but they frequently found it remained in his bag when he returned for his next [CONDITION(S)] visit. PCT-A indicated they now fax the information to the facility since they weren't removing it from his bag. The post-[CONDITION(S)] report included pertinent lab information, pre and post weights, vitals signs and if an extra run was completed due to excess fluid. PCT-A indicated R38 does come periodically with the previous dressing still on his fistula site. [CONDITION(S)] nursing expected it be removed the evening post-[CONDITION(S)] by the facility after assessing and monitoring his site until it can safely be removed. [CONDITION(S)] patient's with venous catheters had different expectations. During interview on 10/19/22, at 9:56 a.m., health information management (HIM)-A indicated the last time they received the post-[CONDITION(S)] report from facility staff was on 8/31/22. They scan any information sent to them into the resident's electronic medical record. During interview on 10/19/22, at at 10:41 a.m., the director of nursing (DON) was unsure if staff received a post -[CONDITION(S)] report and was unsure if an assessment was completed by the nursing staff when R38 would return from [CONDITION(S)] treatment. The DON indicated she will check further into this. Further interview on 10/19/22, at 12:15 p.m., with the DON indicated the [CONDITION(S)] company has not been sharing information post-[CONDITION(S)]. The DON confirmed they have no way to know how R38 did through his [CONDITION(S)] treatment or post-treatment and do not know how much fluid was removed or what his current medical information was. The DON indicated staff are completing a pre-[CONDITION(S)] assessment but confirmed the nursing was not completing a post-[CONDITION(S)] assessment or monitoring upon return from [CONDITION(S)]. She further clarified there wasn't a good method of communication between the facility and [CONDITION(S)]. A policy and procedure dated 9/17/21 titled [CONDITION(S)] Services included: -Locations caring for residents receiving [CONDITION(S)] services must have an agreement in place with the provider of the service. -The clinical monitoring titled [CONDITION(S)] UDA is available in electronic medical record for use in monitoring the resident receiving [CONDITION(S)]. Review of the self renewing [CONDITION(S)] contract dated 1/21/10 between the facility and Total Renal Care/Pipestone [CONDITION(S)] included: -Each party agreed to timely furnish the other party, in writing, any and all [CONDITION(S)]-related information pertinent to a resident's skilled nursing facility plan of care, including but not limited to, the areas listed below. Each party also agrees to make itself reasonably available to the other party's staff who may have questions regarding the care of resident's receiving [CONDITION(S)] treatment: -In addition to developing its own plan of care with respect to each resident/client receiving [CONDITION(S)] treatment, provider agrees to cooperate with LTC staff in modifying and maintaining as current, each such resident's skilled nursing facility plan of care. Those areas the LTC plan of care in which Provider shall furnish direction to LTC facility shall include but is not limited to: Procedures for handing medical and non-medical emergencies, including complications, equipment failure and a provider contact in case of emergencies; follow-up care, observation and monitoring; medications; nutritional needs and fluid restrictions and resident education.

Based on observation, interview, and document review, the facility failed to ensure 2 of 2 residents (R32 and R39) observed to have medications left at their dining tables were assessed and approved to be able to safely self-administer medications. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had mild cognitive deficits and required extensive assistance of one staff for dressing, personal hygiene, and toileting and was independent for eating. R32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's care plan dated 6/23/22, indicated R32 had impaired cognitive function related to short term memory loss. Interventions included monitoring and documenting any changes in cognition, decision making ability, memory, recall and general awareness. R32 also had altered cardiovascular status and high blood pressure. R32 also had an activities of daily living (ADL) deficit related to dementia and episodes of confusion. R32's care plan lacked indication R32 had been assessed and approved to self-administer medications. R32's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 milligrams (mg) for high blood pressure -Tylenol extra strength 1000 mg for pain -[MEDICATION(S)] 20 mg for GERD -[MEDICATION(S)] 20 mg for high blood pressure -[MEDICATION(S)] 2.5 mg for bladder [CONDITION(S)] -[MEDICATION(S)] 50 micrograms (mcg) for [CONDITION(S)] -[MEDICATION(S)] 20 mg (a diuretic for water retention) R32's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R32's medical record lacked a Self-Administration of Medication assessment. During an observation on 10/18/22, at 8:52 a.m. a medication cup with multiple medications was observed on the dining table in front of R32. It was not known how long the medications had been there and no nursing staff was in the dining room. After an unidentified tablemate got a cup of water from the dining kitchenette for R32, R32 began taking her medications with no nursing staff present in the dining room to ensure they were taken safely and completely. During an interview on 10/19/22, at 8:01 a.m. R32 stated the nurse would always leave her morning medications at her table for R32 to take when she wanted. During an interview on 10/20/22, at 3:05 p.m. registered nurse (RN)-B stated some residents liked to take their medications themselves and the staff would walk around and make sure they were taking them. RN-B stated the residents should probably have a self-administration of medication form filled out if she was going to leave the medications on the resident's table to take later and verified R32 did not have one completed. RN-B stated they have had residents pocket their medications in the past. RN-B further stated she liked to watch the residents take their medications but some just take a while. During an interview on 10/20/22, at 2:17 p.m. the director of nursing (DON) stated unless a resident had an evaluation and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Medication: Administration Including Scheduling and Medication Aides policy dated 8/24/22, indicated a resident had the right to self-administer medication if the interdisciplinary team (IDT) determined it was safe for the resident and it was documented in the resident's care plan, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident had not been evaluated for safe self-administration of medication and there was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Resident Self-Administration of Medication policy dated 10/15/21, indicated staff must complete a Self-Administration of Medications UDA to determine if the resident could safely administer medications. The IDT would determine if the resident required education or accommodation in-order to self-administer medications, where the medication would be stored, where the medication would be administered, and who would document the administration. The IDT would document their determination of self-administration on the UDA and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and document review, the facility failed to provide adequate supervision for 1 of 1 resident (R5), who was left unsupervised and fell after attempting to stand, resulting in actual harm to R5 when R5 suffered a neck fracture as a result of the fall. Findings include: Review of the 8/24/21 at 9:28 p.m., report to the State Agency (SA) identified R5 was left in the dining room unattended following the supper meal on 8/24/21 at 6:44 p.m. and experienced a fall. A large hematoma was noted on the right side of R5's forehead on assessment. R5 was sent to the local emergency room where it was discovered she had a neck fracture. R5's recent significant change Minimum Data Set (MDS), dated [DATE], identified R5 had severe cognitive impairment, verbal and physical behaviors directed toward others, and rejection of care with diagnoses of [CONDITION(S)], generalized weakness, anxiety disorder, and difficulty walking. R5 required extensive assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toileting and personal hygiene. The Care Area Assessment (CAA) identified R5 had falls secondary to impaired gait and mobility and the level of assistance required with transfers. R5 had a history of falls, weakness and physical performance limitations affecting balance, gait, strength and muscle endurance. R5's current, undated care plan identified she was at risk for falls. R5 was known to bend forward to pick up items from the floor and needed to be reminded to use a grabber device. R5 had a terminal diagnosis of Alzheimer's disease with decline in Activities of Daily Living (ADLs), and increased irritability and combativeness. The care plan failed to identify the need for increased supervision due to unsteadiness and risk for falls. R5's 8/24/21 at 9:04 p.m., progress note identified R5 was found on the floor in the dining room at 6:44 p.m. with a 5 centimeter (CM) bruise located on the right side of her forehead. R5 was upset and yelling but due to extent of dementia, staff were not able to get accurate information. R5 did report her neck and head hurt. Staff noted R5 had poor-safety awareness and often would get up on her own and had poor balance. Interview and video footage review of the incident on 8/24/21, at 6:44 p.m. was conducted on 11/10/21 at 1:53 p.m., with the administrator present. R5 was observed in her wheelchair as she moved herself around tables in the dining room. No staff were observed in the dining room during this time and all tables had been cleared. R5 bent forward at the waist and raised the left foot pedal while holding onto the arm of her chair, sat back upright and then bent forward and rocked back and forth and slowly stood up. R5 took a couple of steps forward, turned to the right and fell face forward onto the floor beside the table. The table blocked view of how R5 landed or if she struck any objects as she fell . The administrator stated staff noted R5 had refused to leave the dining room following the supper meal. Staff left R5 unattended in the dining room to assist other residents. At the time of the fall, R5 did not have a pressure alarm on her wheelchair (w/c) which would have alerted staff of an attempt to self transfer. The administrator was not certain how long it was before staff responded, as staff reported they heard R5 yelling for help to get up. The administrator confirmed R5 should have been supervised for safety and placed in an area where staff would have been able to monitor her activities. Review of the 6/24/20, Fall Prevention and Management policy identified after a fall, a root cause analysis was to be performed to identify solutions to be put into place. Staff were to communicate a fall had occurred during stand-up and shift change, report to the SA, and monitor for effectiveness of interventions. There was no mention of a review to ensure appropriate supervision was in place or education to staff was to occur when it was discovered staff failed to appropriately supervise a resident. R5's physician wasn't available for interview at the time of the survey.