Every finding on record at Folkestone

Based on observation, interview, and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 3 of 3 residents (R3, R16, and R21) who's confidential information was observed to be visible on the open computer screen in the hallway.Findings include:During a medication pass observation on 11/17/25 at 6:33 p.m., trained medical assistant (TMA)-A prepared R16's prescribed medication for administration. TMA-A locked the Salon medication cart, went to R16's room, closed the door, and gave R16 the prescribed medication. The computer screen on the Salon medication cart was left open to R16's confidential information. TMA-A went back to the Salon medication cart and charted the medication was given.During a medication pass observation on 11/17/25 at 6:38 p.m., TMA-A prepared R3's prescribed medication for administration. TMA-A locked the Salon medication cart, went to R3's room, closed the door, and gave R3 the prescribed medications. The computer screen on the Salon medication cart was left open to R3's confidential information. TMA-A went back to the Salon medication cart and charted the medication was given.During a medication pass observation on 11/17/25 at 6:45 p.m., TMA-A prepared R21's prescribed medication for administration. TMA-A locked the Salon medication cart, went to R21's room, closed the door, and gave R21 the prescribed medications. The computer screen on the Salon medication cart was left open to R21's confidential information. TMA-A went back to the Salon medication cart and charted the medication was given.During an interview on 11/17/25 at 6:53 p.m., TMA-A stated the computer screen was left open with the resident's confidential information on it. TMA-A stated the computer screen was not locked for the three residents. TMA-A stated the computer screen should have been locked so others could not read about the residents. During an interview on 11/20/25 at 2:50 p.m., clinical administrator (CA) there was a process for locking the computer screen so others could not view a resident's confidential information. CA stated the computer screen should have been locked when staff were not observing the computer screen. The facility policy Notice of Privacy Practices dated 7/21/21, indicated they were required by law to maintain the privacy of your health information.

Based on observation, interview, and document review the facility failed to ensure a medication was secured in a resident accessible areas. This had the potential to affect all residents who received medications from the Salon medication cart.Findings include:During an observation on 11/17/25 at 6:33 p.m., trained medical assistant (TMA)-A prepared medication for administration to R16. TMA-A locked the Salon medication cart and left a bottle of acetaminophen 500 milligram (mg) tablets about half full sitting on top of the Salon medication cart in the hallway. TMA-A went into R16's room, closed the door, and gave R16 the prescribed medication.During an observation on 11/17/25 at 6:38 p.m., TMA-A prepared medication for administration to R3. TMA-A locked the Salon medication cart and left a bottle of acetaminophen 500 mg tablets about half full sitting on top of the Salon medication cart in the hallway. TMA-A went into R3's room, closed the door, and gave R3 the prescribed medication.During an interview on 11/17/25 at 6:43 p.m., TMA-A indicated she had left the bottle of acetaminophen 500 mg tablets half full sitting on top of the Salon medication cart while she had gone into resident's rooms and closed the doors to administer prescribed medications. TMA-A stated the bottle of acetaminophen 500 mg was not locked up in the Salon medication cart as it should have been. During an interview on 11/20/25 at 12:04 p.m., clinical administrator (CA) indicated we have a process for medication storage and the medication should be stored in the locked medication cart.The facility policy Medication Ordering and Receiving from Pharmacy undated, indicated except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area.

Based on observation, interview, and document review, the facility failed to ensure food items were properly stored, labeled, and dated, and kitchen fans were kept in clean condition. Also, the facility failed to ensure that staff with facial hair wore beard nets while in the kitchen and plating food. This had the potential to affect all 29 residents , staff, and visitors who consumed food from the main and/or fourth floor kitchen. Findings include: During the initial kitchen tour with executive chef (EC) on 10/14/24 at 12:53 p.m., the walk-in refrigerator on the main kitchen was reviewed. EC stated an unopened cooked corned beef package came from the freezer Friday and was for sandwiches and added date to the package. Unopened packaged ground beef was in a cardboard box with the date 9/30/24 typed on its packaging and/or delivery sticker, and EC marked the box for next use. Other unopened packages of ground beef were thawing next to the box and not in drip-proof container. EC stated the packages of ground beef next to the box were taken from the freezer this day. EC stated they received an order today and was in the process of moving food around. The walk-in freezer of the main kitchen had uncovered pastries on a cart for breakfast. A plastic bag had breaded fish without a label and date. EC removed and asked staff to label and date the fish. The fourth floor serving kitchen area for the nursing home had a stove which was used to make items such as scrambled eggs. Above the stove was an exhaust fan which had gray, fuzzy particles on the lower boarder. EC wiped finger on area of exhaust fan and had grayish colored, fuzzy particle which came off area onto finger. Pans were placed upside down and one pan was right side up on a flat surface above the stove and below the exhaust fan. The flat surface with the pans had small particles which were removed when fingers wiped across. EC stated the fan would be cleaned, and they cleaned the fans in the main kitchen weekly. The small dish washing room connected to the kitchen area but separated by a door had a fan with scattered grayish, fuzzy particles. On 10/14/24 at 5:04 p.m., meal service on the fourth floor was observed. Dietary aide (DA)-A plated multiple plates with pulled pork sandwiches, beans, fruit, and other food items. DA-A had facial hair which covered face from side burn of face by ears to chin and upper lip and was approximately a quarter-inch thick. On 10/14/24 at 5:20 p.m., DA-A stated they wore hair nets for food service and in the kitchen. DA-A verified they did not have their beard covered and stated they do not do anything different around beards but then stated they had beard bags. On 10/15/24 at 11:06 a.m., cook (C)-A verified pastries and cinnamon rolls were uncovered on sheet slid into a cart in the freezer of the main kitchen and stated they were for the next day. On 10/15/24 at 11:07 a.m., the cardboard boxes of ground beef and unopened ground beef packages next to the box remained on the bottom shelf on the refrigerator and not contained. On 10/15/24 at 11:14 a.m., DA-A had no beard cover and temped the cold food over ice and hot food on the steam table on the fourth-floor nursing home area. On 10/15/24 at 11:38 a.m., DA-A dished up multiple plates from the steam table, which staff brought to residents, and did not have a beard cover. On 10/16/24 at 8:48 a.m., the packages of ground beef remained on the bottom shelf and not in a container. On 10/16/24 at 9:10 a.m., C-A browned ground beef. C-A stated they were not aware of a protocol for kitchen staff with facial hair and would either follow the three-day rule for use of opened items in the refrigerator or consult with EC. C-A stated food in the refrigerator and freezer should be covered and dated. C-A stated they placed food into refrigerator from freezer a day or two before it was needed, so it would be thawed out by the time of use. If unopened items were not dated, they used the first in line. C-A stated they had a certain container for thawing chicken in the fridge and raw meat was placed on the bottom shelf to thaw. C-A continued to brown ground beef, and C-B checked on muffins in the oven and took out and placed on table. A fan was on and blew into the kitchen area where the muffins and ground beef were, and the fan had speckles of grayish colored particles and hair-like substance which blew approximately two to three inches away from where it was connected to the fan. C-B stated they all cleaned the fans, and there was not a schedule for the fans, but they cleaned in their down time when they saw the need. C-B stated they saw dust on the fan and would clean. C-A stated they usually tried to clean the fan once a week and did not document and confirmed the fan needed to be cleaned. On 10/16/24 at 9:44 a.m., the fan previously noted in the dish washing room of the fourth nursing home area with scattered grayish particles was on. DA-B stated they left dishes in the rack they were washed in and placed the rack on top of the dish machine to dry. On 10/16/24 at 12:54 a.m., DA-B confirmed the fan was on and needed to be cleaned. DA-B stated they cleaned what they were able to on the outside but did not have the parts fully clean the fan. DA-B stated they had verbally told a maintenance worker the fan needed to be cleaned about a couple weeks previously. On 10/16/24 at 1:26 p.m., the culinary director (CD) stated the pastries in the freezer were prepped for next days use, and C-B stated they had not covered the cart with the pastries in the freezer in the past. CD stated uncovered food was at risk for cross contamination. CD stated they rotated food in the refrigerator to know what to use first based on their five-week menu. CD stated food had dates when delivered and expected food to have dates when out of packages delivered in. In the walk-in refrigerator, CD wrote a date on unopened, cooked chicken label. The ground beef was now in a pan with a date, and CD stated the ground beef should be in pan and dated like it was now. CD stated they had a daily and quarterly cleaning list they used, and culinary cleaned the fans when dirty. The exhaust fan was cleaned by an outside company. Fans were important to clean to serve safe food. On 10/16/24 at 3:54 p.m., regional engineering manager stated there was an inspection sticker which showed the hood fan above the oven was cleaned twice a year by an outside company, and culinary cleaned in between. A facility maintenance technician (MT)-A stated staff notified them on concerns through TELS (web-based platform which helps with building operations communication), calling, using radio, or calling the receptionist who then communicated to the maintenance department. [NAME] Weekly Sanitation Checklist undated, directed cooks to take down hood vents and send through the dish washer and replace when clean. The facility did not provide checklist documentation of completed hood vent cleaning but provided documentation to show Brothers Industrial Cleaning cleaned the kitchen exhaust system 7/16/24. Cleaning checklists did not include fans. Facility policy Labeling and Dating Ready to eat and/or Potentially Hazardous Food Items dated 1/28/14, indicated ready to eat and potentially hazardous food items were to have labels to specify date prepared, date frozen, and date thawed of any refrigerated, ready-to-eat, potentially hazardous foods. Facility policy Food Receiving and Storage dated 5/14/17, directed staff to cover, label, and date all foods stored in the refrigerator or freezer, and uncooked and raw animal products and fish were stored in drip-proof containers. Nutrition and Culinary Uniform Policy dated 9/2024, directed staff to wear hair coverings while preparing food in prep areas, such as kitchenettes where staff served food, and beard nets for beard hair half an inch or longer.

Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 9 residents (R4, R17, and R15) observed to receive medication. A total of four (4) errors out of 29 opportunities were identified which resulted in a medication error rate of 13.79%. Findings include: R4: R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact and had diagnoses of atrial fibrillation (a heart condition which causes an irregular, often rapid, heartbeat), heart failure (heart muscle does not pump blood as well as it should), and hypertension (high blood pressure), kidney failure (loss of kidney function which normally removes waste and excess fluid from blood), and diabetes mellitus [condition which affects how the body uses blood sugar (glucose)]. R4's Order Review Report signed 9/26/24, identified R4 required polyethylene glycol 3350 oral packet 8.6 gram by mouth in the morning for constipation with order date of 5/9/24. On 10/15/24 at 8:30 a.m., trained medication assistant (TMA)-A stated they prepared medication while reviewing the medication rights and checks. R4's polyethylene glycol 3350 oral container had a sticker which directed there was a change in the medication's directions. R4's electronic medication administration record (MAR) directed staff to give 8.6 gram (gm) by mouth in the morning. TMA-A took the cap off the polyethylene glycol container, poured the powder into the cap until the line which read 17 gm, and poured the powder into a plastic beverage cup. TMA-A prepared R4's other medications, locked the MAR screen and medication cart, and walked towards R4's room with medication and polyethylene glycol in hand. TMA-A was stopped and asked to verify the polyethylene glycol. TMA-A returned to the medication cart and confirmed the powder was poured to the 17 gm line and the order was for 8.6 gm. TMA-A dumped out the polyethylene glycol, filled the cap half-full of powder, and poured the powder into a plastic beverage cup. On 10/15/24 at 2:12 p.m., registered nurse (RN)-A stated they would check residents for signs and/or symptoms of side effects and update the provider and family member or other representative if medication given incorrectly. RN-A stated R4 had a history of intestinal obstruction, and R4 was at risk for excessive bowel movements and dehydration if given more polyethylene glycol than ordered. R17: R17's significant change MDS dated [DATE], identified R17 had moderate cognitive impairment and diagnoses of dementia, hypertension, coronary artery disease (also called atherosclerotic heart disease; a condition of narrowing or blockage of coronary arteries which supply blood and oxygen to the heart), and kidney failure. R17's Order Review Report signed 9/26/24, identified R17 required brimonidine tartrate ophthalmic solution 0.2% one drop in left eye two times a day for ocular hypertension (condition where the pressure inside the eye is higher than normal) with an order date of 11/22/23. On 10/15/24 at 8:54 a.m., TMA-A prepared an eye drop for R17. R17's brimonidine 0.2% eye drop label instructed to give one drop into left eye two times daily. TMA-A entered R17's room, performed hand hygiene, and donned gloves. R17 was laying in bed and TMA-A administered one drop to R17's left eye and one to R17's right eye. TMA-A confirmed one drop to both eyes were given and verified the MAR and label directed to give one drop to left eye. TMA-A stated R17 had other eye drops which instructed to give to both eyes. On 10/15/24 at 2:12 p.m., registered nurse (RN)-A stated staff followed orders for how many eye drops to give and which eye to give the drops in. RN-A stated follow-up for giving eye drops differently than ordered depended on which kind of eye drop was given, such as an eye drop for an eye condition like glaucoma. R15: R15's quarterly MDS dated [DATE], indicated R15 had moderate cognitive impairment and diagnoses of hypertension, kidney failure, and diabetes mellitus. The MDS indicated R15 had orders for insulin and received insulin injections seven days out of the last seven days of the MDS look back period. R15's Treatment Administration Record (TAR) for October 2024, indicated R15 required 8 units subcutaneously of insulin lispro injection solution 100 unit/mL (milliliter) three times a day for diabetes mellitus type two before each meal and hold if blood glucose less than 150 with start date of 9/17/24. R15 required 20 units subcutaneously of insulin glargine subcutaneous solution 100 unit/mL in the morning for diabetes mellitus type two with start date of 10/2/24. On 10/16/24 at 7:53 a.m., RN-A checked R15's blood glucose level, and the result was 186. RN-A removed gloves, completed hand hygiene, placed on new gloves, and stated R15 received eight units of insulin lispro before each meal and was held if blood glucose was less than 150, and 20 units of insulin glargine in the morning. RN-A placed needle on Humalog KwikPen (insulin lispro) 100 units/mL without wiping tip of pen with an alcohol swab and dialed pen to two and set aside. RN-A placed needle on Lantus Solostar (insulin glargine) without wiping tip of pen with an alcohol swab and dialed pen to two and set aside. RN-A wiped R15's abdomen with alcohol wipe, dialed Humalog KwikPen to eight units, and administered to R15's abdomen. RN-A wiped the other side of R15's abdomen with alcohol wipe, dialed Lantus Solostar from two units to 20 units, and was questioned about priming technique. RN-A stated the needle was primed when the pens were dialed to two units, verified they did not press the pen plunger before dialing from two to required units, and then administered to R15's abdomen. RN-A returned supplies to the cupboard in R15's room, removed gloves, performed hand hygiene, and exited R15's room. RN-A verified they did not wipe the tip of the insulin pens prior to attaching the needle, since they took the pen cap off and inserted needles without touching the tip of the pens. RN-A stated they wiped the top of insulin vials before withdrawing medication with needle, because the chances of touching the top of the vial was high. RN-A stated ensuring the pen tip was clean before needle attachment was important for infection purposes, and insulin pens were primed as part of instructions to administer the correct dosage. On 10/16/24 at 10:19 a.m., the clinical administrator (director of nursing; DON) stated they completed a medication variance report for the eye drops which were given in both eyes rather than the left eye. On 10/16/24 at 1:04 p.m., the DON stated R4 was focused on their bowels, and correct administration of bowel medications helped maintain R4's baseline and avoided loose stools or constipation. DON stated R17's brimonidine eye drop was intended for R17's left eye and not both eyes, and staff completed follow-up observations on R17. The DON referred to manufacturer instructions and facility competencies related to the need to wipe insulin pen tips or not prior to needle insertion and how to prime needles and insulin pens. The DON stated priming removed air from needles, and infection control was important for set-up of insulin administration. The DON expected staff to follow medication protocols and review the electronic MAR and medication packaging and follow provider orders. On 10/16/24 at 2:22 p.m., the DON confirmed priming occurred when insulin pens were dialed to two and plunger pressed to zero, and then the pens were redialed to administered amount. The DON also verified staff were to wipe the tip of insulin pens prior to attaching needle. Lantus Prescribing Information which contained Instructions for Use dated 12/2020, instructed to wipe the rubber seal with alcohol prior to attaching new needle and to perform a safety test before each injection to ensure an accurate dose by ensuring the pen and needle work properly and removing air bubbles. The directions to perform a safety test included turning the dosage selector to two units, holding the pen with needle pointing upwards and tapping insulin reservoir so air bubbles rise up towards the needle, pressing the injection button all the way in and checking if insulin comes out the needle tip. The dose window should show 0 (zero) following the safety test before selecting the dose. The Medication Administration Policy dated 5/2021, directed staff to follow the 8 rights of drug administration which included right drug, dose, and route. The Medication Administration Procedures dated 1/27/19, directed staff to remove the cap from the insulin pen and wipe the rubber stopper with an alcohol wipe and then attach a new needle to the insulin pen following manufacturer's guidelines. Further, the procedure directed staff to turn dose selector to two units, hold pen with the needle pointing up and tap the cartridge to move collected air to the top of the cartridge, press the injection button all the way in until the dose selector is back to zero, observe for a stream or drop of insulin at the tip of the needle or follow specific pen guidelines for additional testing if no drop appears, and select dose by turning the dose selector to the number of units to be administered.

Based on interview, observation, and document review, the facility failed to accurately transcribe a medication order, and failed to check the medication administration record (MAR) against the medication label and clarify administration instructions prior to giving medication for 1 of 1 resident (R4) who received an anticoagulant (also known as blood thinners; medication used to prevent or reduce blood clots) during medication administration observation. Findings include: R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact and had diagnoses of atrial fibrillation (a heart condition which causes an irregular, often rapid, heartbeat), heart failure (heart muscle does not pump blood as well as it should), hypertension (high blood pressure), kidney failure (loss of kidney function which normally removes waste and excess fluid from blood), and diabetes mellitus [condition which affects how the body uses blood sugar (glucose)]. R4's undated care plan, identified R4 was at risk for side effects of anticoagulants due to anticoagulant use and directed staff to complete labs per provider orders and monitor for side effects, which included bruising, bleeding, CVA (cerebrovascular accident, also known as stroke; blood supply to part of the brain is blocked or reduced), heart attack (flow of blood to heart is severely reduced or blocked), and blood clots (clumps of blood which change from a liquid to a gel and controls bleeding). On 10/15/24 at 8:30 a.m., trained medication assistant (TMA)-A stated they prepared medication while reviewing the medication rights and checks. R4's apixaban (an anticoagulant) 2.5 mg (milligram) medication pack was observed, and the label instructed to give one tablet orally two times daily. TMA-A placed one 2.5 mg tablet of apixaban in R4's medication cup, prepared R4's other medications, and administered medication to R4. During subsequent document review, R4's Order Review Report signed by provider on 9/26/24 and MAR, directed staff to give 2.5 tablet of apixaban 2.5 mg orally two times a day with order start date of 3/20/24. During interview on 10/15/24 at 1:51 p.m., TMA-A confirmed R4's apixaban label directed to give one tablet of 2.5 mg apixaban and the MAR directed to give 2.5 tablet. TMA-A stated someone typed the order wrong and would let the nurse know. During interview on 10/15/24 at 2:12 p.m., registered nurse (RN)-A stated providers filled out order forms and the first nurse would enter the order and a second nurse completed a second check. Providers also gave orders through the telephone and nurses would write the order and have providers sign the orderp; or providers would fax the orders. Once orders were processed, they were placed in the resident binder. RN-A stated they would check residents for signs and/or symptoms of side effects and update the provider and family member or other representative if medication given incorrectly. RN-A verified R4's apixaban order, which reflected on MAR, directed to give 2.5 tablets of apixaban 2.5 mg instead of 1 tablet of apixaban 2.5 mg. RN-A stated orders entered incorrectly could lead to medication errors and was the reason nursing completed a second check after an order was entered. On 10/16/24 at 8:10 a.m., the clinical administrator (director of nursing; DON) stated a medication variance report was completed for the apixaban, the pharmacy had sent apixaban 2.5 mg tablets and no others for R4. The order was reviewed with the provider and changed to reflect 2.5 mg instead of 2.5 tablets of apixaban 2.5 mg. The DON provided R4's orders from M Health Fairview Southdale electronically signed 7/1/24, and the orders directed to give apixaban 2.5 mg, 1 tablet by mouth two times daily and had two initials written by the order. During interview on 10/16/24 at 12:44 p.m., TMA-A stated the pharmacy label on medication and MAR were supposed to match, and they followed the pharmacy label or called the DON when directions did not match. During interview on 10/16/24 at 1:02 p.m., RN-A stated they followed the rights of medication administration and reviewed provider orders in the resident binder when there was a discrepancy between medication labels and the MAR. During interview on 10/16/24 at 1:04 p.m., the DON stated they clarified the transcription of R4's apixaban order and believed R4 received the right medication and right dose. The DON expected staff to follow medication protocols and review the electronic MAR and medication packaging and follow provider orders. The Medication Administration Procedures dated 1/27/19, directed staff to verify the medication label matched the MAR with the right resident, medication, dose, time, route, reason, form of drug, and documentation. The Medication Administration Error Policy dated 5/2021, indicated a medication error occurred when there was failure to compare doctors' orders with pharmacy labels and medication administration record. The Order Processing Policy dated 5/2024, indicated staff obtained telephone, verbal, or written orders from providers and orders included the name, strength, dosage, time and frequency of medication, diagnosis for medication, and route of administration. Each order was noted and processed and received a second check by a qualified staff. The Medication Administration Policy dated 5/2021, indicated accurate transcription of medication orders was the responsibility of licensed nursing staff, and medications were transcribed from the physician order sheet to the MAR in the electronic MAR.

Based on observation, interview, and document review, the facility failed to ensure required nurse staff data was posted daily before each shift, including over the weekend, and the accuracy of the posted nurse staffing information. This had potential to affect all 29 residents residing in the facility and/or visitors who may wish to view the information. Findings include: On 10/14/24 at 2:23 p.m., the PHS-Daily Hours Posted was in a holder on the wall near the nursing station and administrators' office. The posting was dated 10/11/24. The clinical administrator (director of nursing; DON) confirmed the posting was for 10/11/24 and stated they sometimes pulled the weekend information and reviewed before placing the posting back in holder. The facility staff posting dated 9/16/24, indicated the evening shift had no licensed staff and four non licensed staff. The daily roster dated 9/16/24, indicated the evening shift had one licensed practical nurse (LPN) from C.S. (central staffing) and five non licensed staff. The facility staff posting dated 9/24/24, indicated the evening shift had one licensed registered nurse (RN) and four non licensed staff. The daily roster dated 9/24/24, indicated the evening shift had one licensed RN and six non licensed staff. The facility staff posting dated 9/25/24, indicated the day shift had two RNs with one RN who worked 8:30 a.m. to 9:30 a.m The daily roster dated 9/25/24, indicated the day shift had one RN. The facility staff posting dated 9/16/24, 9/19/24, 9/24/24, 9/25/24, 10/1/24, 10/3/24 and 10/8/24, indicated the night shift had two registered nurses (RNs). The daily roster dated 9/16/24, 9/19/24, 9/24/24, 9/25/24, 10/1/24, 10/3/24 and 10/8/24, indicated the night shift had one RN. On 10/16/24 at 4:44 p.m., the care center administrator (administrator) stated they gave nursing copies of the facility staff posting for them to post over the weekend. The administrator stated they placed the facility staff posting in the wall holder each morning when they were here and did not switch posting on 10/14/24. There was a white board nursing updated in real time and visible for residents and family members but did not list specific hours. The administrator reviewed staffing information for 9/16/24 and confirmed there were six staff present, including one LPN, and the posting coded four staff. The administrator reviewed staffing information for 9/24/24 and stated the posting had not included the staffing coordinator (SC) who worked on the floor or the staff who was completing TMA or RN training. Staff postings were to include staff in training on the floor. The administrator reviewed staffing information for 9/25/24 and stated one RN should not be included in the posting since they were completing nondirect hours at an in-service. The administrator reviewed the night shifts which were coded as two RNs on the facility staff postings and daily rosters which indicated one RN. The administrator confirmed there was one RN who worked the night shifts on those days, and the other RN was on a leave and their shift showed up on the Dayforce (platform which helps manage payroll and workforce management) schedule. The administrator stated the human resources team who coded the RN in the system fixed the RN's status to reflect accurately. On 10/17/24 at 10:50 a.m., the SC stated they printed the daily schedule and changed the schedule to reflect call-ins or staff who switched shifts, and the nurses put the schedule on the board. The SC stated the weekend schedules were printed up until Monday morning, and the nurses made them aware of any staff changes and were responsible for updating the paper schedule on the weekends. The Nurse Hours Posting Policy dated 10/2022, indicated nursing staff data was posted on a daily basis at the beginning of each shift, reflected the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and was updated by the staffing personnel to include the actual hours worked by direct nursing staff.

Based in interview and document review, the facility failed to ensure a care conference was conducted and residents and their representatives were involved in the revision of the plan of care for 1 of 1 residents (R4) reviewed for participation in care. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired, and required extensive assistance of one staff for bed mobility, transfers, and toilet use. R4's care plan was last reviewed on 10/3/23. R4's Profile printed 12/5/23, identified R4's daughter as responsible party. R4's Medical Diagnosis list dated 12/5/23, included dementia and anxiety. R4's Care Conference Summary dated 7/7/23, identified R4, R4's spouse, and R4's daughter as attendees. R4's progress note dated 10/2/23, indicated RSD (resident services director) called to schedule care conference multiple times and daughter has no returned call. Will continue to try. R4's medical record lacked evidence of a quarterly care conference after 7/7/23. During interview on 12/4/23 at 7:22 p.m., R4 stated they did not think they had any care conferences, and R4's spouse thought their daughter arranged them. During interview on 12/7/23 at 9:36 p.m., director of nursing stated the RSD was shared with another facility, and either the RSD or administrator scheduled care conferences, and the clinical coordinator (CC) attended them. During interview on 12/7/23 at 9:38 a.m., CC stated care conferences were usually scheduled along with the MDS assessment period, depending on family availability. The meeting was documented in the electronic medical record and included the names of all who were invited as well as those who were in attendance. She stated sometimes residents or family did not want one, however the interdisciplinary team would still meet to discuss resident care and complete the documentation. During interview on 12/7/23 at 9:42 a.m., licensed practical nurse (LPN)-A stated she was unsure when R4's care conference was due. LPN-A reviewed R4's record and confirmed there was no documentation of a care conference since 7/2023, and whether the resident and/or family had attended or not, there should have been documentation. During interview on 12/7/23 at 10:11 a.m., administrator stated they knew when care conferences were due by viewing the MDS log. They stated RSD usually scheduled them and administrator usually attended them. Those invited included the resident, family, clinical coordinator, administrator, and others as needed, and attendees were documented in the care conference form in the computer. They confirmed the facility would still have the care conference, even if the resident and/or family did not wish to attend. They reviewed R4's records and verified R4 had not had the care conference due in 10/2023, and identified there was room for improvement in the process as they noted a few times recently where care conferences had not been done. Administrator confirmed they were unable to reach R4's family and schedule a meeting after multiple attempts, however the facility should have followed up and met as a team to discuss R4's care. The Care Plan Policy and Procedure dated 11/2022, indicated the care plan will be reviewed at least quarterly during MDS assessment period and with any significant change, and the care plan is not complete until the care conference has been held and reviewed with the resident and/or resident representative.

Based on interview, observation, and document review, the facility failed to accurately transcribe a medication order, and failed to check the medication administration record (MAR) against the medication label prior to giving medication to ensure staff dispensed the correct medication for 1 of 4 residents (R1) observed during medication administration. Findings include: R1's quarterly Minimum Data Set, dated dated dated [DATE], included R1 was severely cognitively impaired, and had diagnoses of high blood pressure, kidney failure, and lung disease. R1's care plan dated 9/13/23, included R1 had an alteration in cardiovascular status related to high blood pressure and heart conditions and instructed staff to give medications as ordered. R1's order report dated 12/6/23, included: -Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour, 25 milligrams (mg), give 1.5 tablets (37.5 mg) in the morning for high blood pressure starting 3/4/23 and discontinued 10/10/23. (An extended-release tablet which can be taken once per day.) -Metoprolol Tartrate Oral Tablet 25 mg, give 1.5 tablets by mouth one time a day for high blood pressure starting 10/11/23. (An immediate release tablet needing to be taken several times per day. There are differences in the dosages and indications for both metoprolol tartrate and metoprolol succinate and they are not considered interchangeable. Metoprolol Succinate vs Tartrate - What's the difference between them? (drugs.com)). A progress note dated 10/10/23, at 6:58 a.m. indicated R1 had shortness of breath and low blood oxygenation levels despite being on oxygen. The nurse practitioner (NP) was updated and prescribed one dose of 'metoprolol' which was given by the nurse. A provider note dated 10/10/23, indicated the on-call provider was notified early in the morning because R1 had complaints of shortness of breath and chest pain, even on 6 liters of oxygen. Staff were instructed to give R1 their morning dose of metoprolol earlier than normal. During observation of medication administration on 12/6/23 at 7:55 a.m., trained medication aide (TMA)-A prepared R1's morning medications. TMA-A looked at the electronic MAR which read metoprolol tartrate 25 mg and removed R1's blister pack of metoprolol succinate 25 mg from the medication cart. There were 6 doses left of the 31 supplied. They popped one dose into the container of previously prepared medications, locked and left the medication cart, and walked down the hallway to administer them to R1. TMA-A was stopped prior to reaching R1. TMA-A stated the nurses entered the orders into the computer system and TMA-A normally looked at the label to compare it to the MAR. They identified they needed to confirm the five rights before administration of any medication (right drug, right dose, right patient, right route, right time), and they did not notice the discrepancy between the MAR and the package. During interview on 12/6/23 at 11:15 a.m. licensed practical nurse (LPN)-B stated when she took a telephone or verbal order, she wrote it down on scratch paper, entered it into the computer, printed the order, faxed it to pharmacy, and placed it in a box for the next shift to review and double check before it was placed in another box for the provider to sign. During interview on 12/6/23 at 11:31 a.m. registered nurse (RN)-A stated if they received a verbal or telephone order they repeated it back to the provider, entered it into the computer, documented the method by which it was received (verbal, telephone, written), and if it was a verbal or telephone order the system prompted the staff to print a form, fax it to pharmacy, and place it in a bin for the next nurse who double checked it and placed it in another bin for the provider to sign. After the provider signed it, they uploaded it into the computer system. RN-A confirmed R1 originally had an order for metoprolol succinate, and when R1 had an episode of elevated blood pressure the overnight nurse called the provider and got a one-time order to give R1's morning dose of metoprolol succinate early that day. They identified the nurse discontinued the original order, selected the wrong medication for the one-time dose, and then re-ordered the wrong medication to begin again the next day. They identified since the order was entered as a written order instead of telephone or verbal, the system did not require a printout, fax to pharmacy, or provider signature, so the pharmacy continued to send the correct medication. They stated if staff were comparing the order to the package during medication administration, they should have caught it much earlier, as it had been incorrect for nearly two months. During interview on 12/7/23 at 9:00 a.m., director of nursing (DON) stated an on-call nurse who did not often work at the facility was working on 10/10/23. They contacted the provider when R1 had cardiac symptoms, who ordered the nurse to give the morning dose of metoprolol succinate earlier than scheduled. They stated instead of giving it early, they discontinued the old order, re-ordered it to be given at the new time for that day, and then added another order to start the following day to get back on schedule. However, instead of selecting the metoprolol succinate, they errantly selected the metoprolol tartrate from the list in the computer for both the one-time and the new order to begin the following day. Further, they entered it as a written order, which did not require a printing of a form, fax to pharmacy, or second check by another nurse. They stated they relied on the nurses to transcribe orders properly and follow the five rights of administration, and it should have been caught earlier to ensure the resident received the correct medication to lead to a positive outcome. During interview on 12/7/23 at 9:51 a.m., pharmacist stated when medications were sent from the pharmacy to the facility, staff checked the labels against the MAR to make sure they were the same. During interview on 12/6/23 at 2:47 p.m. nurse practitioner (NP)-A stated her expectation was for staff to enter the order correctly in the computer. They stated they should have added the one-time dose and left the original order which would have avoided the issue, and the error should have been caught sooner. During interview on 12/7/23 at 3:00 p.m. medical director stated in this situation there was little chance of an outcome, however if it had been a different medication, it could have been a bigger concern. They identified there could be improvements made in the medical record to prevent this issue, and the nurses needed to make sure they were looking at the full names of the medications when transcribing, entering, and administering them to avoid errors. The Medication Administration Policy dated 5/2021, indicated accurate transcription of medication orders is the responsibility of the licensed nursing staff, and the 8 rights of drug administration will be followed when administering all medication, including the right drug. The Order Processing Policy dated 7/2021, included staff were to obtain telephone, verbal, or written order from prescriber using the Provider Order Form and the order should include the name of the medication and the order it was received. Each order should be noted by the nurse to include the date and time the order was proceed, and a second review of all orders is required. If limited staffing on a shift, a process is to be implemented to ensure the orders are second checked by a qualified staff in the next shift.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R11, R77, R19) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], indicated R11 had severe cognitive impairments and diagnoses of femur fracture and Alzheimer's disease. Furthermore, R11's MDS indicated R11 was not up to date on the pneumococcal immunization. R11's Minnesota Immunization Information Connect (MIIC) dated 6/21/23, indicated R11 had not received any pneumococcal vaccine. R11's pneumococcal vaccination consent form dated 6/22/23, indicated R11's family consented for R11 to receive a pneumococcal vaccination. Review of the current CDC recommendations 03/15/23, revealed the CDC identified individuals who have not previously received a pneumococcal conjugate vaccine (PVC) should receive the receive the PVC 15 or PVC 20. R11's electronic medical record lacked evidence R11 had received the CDC recommended pneumococcal vaccine or indication why it should not be given. R77's entry MDS dated [DATE], indicated R77 was recently admitted to the facility and had a diagnosis of Alzheimer's disease. R77's medical record lacked indication R77's pneumococcal vaccine status was known. R77's pneumococcal vaccination consent form dated 11/23/23, indicated R77's family had signed the form, however the form did not indicate consent to receive or declination of the pneumococcal immunization. R19's quarterly MDS dated [DATE], indicated R19 had severe cognitive impairment and diagnoses of heart failure. R19's MDS further indicated R19 was up to date for pneumococcal immunization. R19's MIIC report dated 4/23/23, indicated R19 had completed the PPSV23 and PCV13 pneumococcal vaccine. R19's pneumococcal vaccination consent form dated 4/24/23, indicated R19's family consented for R19 to receive the pneumococcal vaccines recommended by the CDC. A CDC Pneumococcal Vaccine Timing dated 3/2023, identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13) then the resident and provider may choose to administer PCV20 who had received PCV13 at any age and PPSV23 at or after [AGE] years old. R19's medical record lacked evidence the provider, R19, and facility had determined if R19 offered the PCV20 vaccine. When interviewed on 12/7/23 at 8:42 a.m., the infection preventionist (IP) stated upon admission resident's immunization status was determined by the MICC or resident report. Residents or their representative also signed consents for all vaccinations at that time. IP stated focus was placed on offering long term residents the pneumococcal vaccination rather than the short-term rehabilitation residents. The IP further stated short term residents were educated on their options but were referred to their primary clinic. IP reviewed R11 and was not sure why the PVC20 had not been given. IP verified R77 was a short-term rehabilitation resident and not a resident the facility would normally administer a pneumococcal vaccination to unless the provider wanted it. IP verified R19 admitted just before the facility's immunization policy changes. IP stated the facility had not reviewed residents who were already in the facility for recommendations or determination of if the provider had talked to R19 or no and was not able to find anything in the medical record to determine what the change was. When interviewed on 12/7/23 at 12:33 p.m., the Director of Nursing (DON) stated resident vaccinations were offered upon admission. The admission nurses will obtain a consent or declination and educate the resident or family at that time. Furthermore, the DON stated since the new policy was implemented pneumococcal vaccinations did not have to be offered to short-stay residents. DON expected staff to ensure consents were filled out and expected follow up on R77's consent. DON was not sure how the resident and provider determined if the PCV20 would be given and wasn't aware of any conversation or decision for R19. R11's family had wanted to delay the pneumococcal vaccination while working with therapy and there had been several conversations, but acknowledged follow up was needed. DON stated understanding the vaccination status and ensuring residents are offered and given if consented was an important preventative health measure for residents who reside in the facility. A facility policy titled Pneumococcal Vaccination Policy revised 7/2023, directed staff to ensure each resident was offered the pneumococcal immunization unless the immunizations are medically contraindicated, the resident declines, or the resident was already immunized.

Based on interview and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency (SA) immediately (within two hours) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive impairment and dementia. R1's care plan dated 1/19/22, indicated R1 was at risk for abuse and/or neglect due to physical weakness and cognitive skills. Interventions directed staff to always keep R1 safe and follow the facility's vulnerable adult policy. The facility's Nursing Home Incident Tracker (NHIR) dated 7/21/22, indicated the date and time of R1's allegation was 7/21/22, at 11:30 a.m. The report further indicated R1's allegation was reported to the SA on 7/21/22, at 6:12 p.m. which was over 6 hours after R1's allegation was made. During an interview on 7/28/22, at 10:40 a.m. social services (SS)-A stated during a psychosocial assessment on 7/21/22, , R1 stated she needed protection and was not safe. R1 then reported a female staff had thrown R1 down to the ground. R1 further had described the staff as being a slender, tall female. SS-A stated R1 was upset at the time and was unable to identify who the staff member was or when the allegation occurred. SS-A stated the allegation sounded like abuse needed to be reported right away. SS-A further stated R1's allegation was reported to the DON around 11:30 before the daily interdisciplinary team (IDT) meeting. During an interview on 7/28/22, at 12:12 p.m. DON verified SS-A reported R1's allegation on 7/21/22, at approximately 11:30 a.m. before the daily IDT meeting. DON verified R1 alleged a staff member had thrown her to the floor and had not felt safe. DON verified R1's allegation was considered an allegation of abuse and was reported to the SA the evening of 7/21/22 after discussion with corporate team. DON further stated their understanding was the facility was not required to report within 2 hours since R1 had no serious bodily injury. DON stated reporting allegations of abuse was important to ensure resident safety and follow Centers for Medicaid and Medicare Services (CMS) regulations. During an interview on 7/28/22, at 12:38 p.m. the Administrator verified SS-A had reported R1's allegation of staff throwing her on the floor and the resident did not feel safe between 11:00 a.m. and 12:00 p.m. on 7/21/22. The Administrator stated she expected staff to report any allegations right away. Administrator considered R1's allegation an allegation of abuse. The Administrator stated if R1 had severe bodily injury the report had to be completed within 2 hours, otherwise the facility had 24 hours to report. The Administrator further stated reporting allegations of abuse was important to ensure they are investigated, and residents are safe. A facility policy titled Vulnerable Adult Abuse Prevention Plan, revised 9/2020, directed staff to report allegations of abuse or incidents resulting in serious bodily injury to the SA no later than two hours after the allegation was made.

Based on observation, interview, and document review, the facility failed to ensure prescribed controlled substance medication reconciliation was completed to allow for rapid detection of potential diversion for 2 of 2 medication carts and 1 of 1 medication room reviewed for medication storage. This had the potential to affect all residents who received controlled substance medications at the facility. Findings include: R23's Admission Record dated 9/9/21, indicated R23's diagnoses included [CONDITION(S)]. During an observation on 9/8/21, at 2:07 p.m. a medication cart handoff was observed between registered nurse (RN)-C and trained medication assistant (TMA)-A. RN-C counted the controlled substance medications while TMA-A reviewed the narcotic log. The Salon unit medication cart was counted first, followed by the Fish unit medication cart. Upon completion of counting each medication cart, TMA-A and RN-C signed the narcotic log. The Salon unit medication cart and Fish unit medication cart narcotic logs were noted to have signature pages with multiple blank spaces. RN-C verified each signature line needed to be filled in and controlled medications needed to be counted at each shift handoff. Review of the record book for Salon unit medication cart revealed: -For June 2021, there were 90 opportunities to reconcile medications, however, only 61 opportunities were logged. -For July 2021, there were 93 opportunities to reconcile medications, however, only 62 opportunities were logged. -For August 2021, there were 93 opportunities to reconcile medications, however, only 63 opportunities were logged. -For September 2021, there were 18 opportunities to reconcile medications, however only 15 opportunities were logged. From April 2021 through 9/8/21, controlled medications were reconciled 72% for the Salon unit medication cart. Review of the record book for Fish unit medication cart revealed the following: -For June 2021, there were 90 opportunities to reconcile medications, however, only 64 opportunities were logged. -For July 2021, there were 93 opportunities to reconcile medications, however, only 82 opportunities were logged. -For August 2021, there were 93 opportunities to reconcile medications, however, only 66 opportunities were logged. -For September 2021, there were 18 opportunities to reconcile medications, however only 10 opportunities were logged. From April 2021 through 9/8/21, controlled medications were reconciled 72% for the Fish unit medication cart. During observation of the fourth-floor medication room on 9/8/21, at 2:22 p.m. RN-C opened a locked medication fridge and a locked emergency kit which contained a multi-dose vial of lorazepam (controlled medication used for anxiety) was noted. Additional individually dosed oral syringes labeled as lorazepam were noted for R23. R23's lorazepam and the emergency kit medication were not observed to be reconciled during the medication cart sign off between TMA-A and RN-C. During an interview on 9/8/21, at 1:54 p.m. TMA-A stated the medication cart keys were kept by the TMA and nurse who were working. TMA-A stated counts for controlled substances was reviewed during shift handoffs. During an interview on 9/8/21, at 2:22 p.m. RN-C stated there was no daily check for the emergency kit unless the kit was opened, but it was important to make sure the kit was not opened. RN-C stated R23's lorazepam was included in the Salon unit medication cart narcotic log, but was not normally checked with TMAs' when doing shift counts. During an interview on 9/8/21, at 2:56 p.m. RN-B stated controlled substance counts were completed three times a day and can be completed by nurses or TMA's. RN-B stated facility policy was to check daily, however, best practice was to complete counts shift-to-shift. RN-B verified controlled medication counts included any controlled medication including those in the fridge. RN-B also stated staff needed to ensure the emergency kit was locked. During an interview on 9/8/21, at 3:55 p.m. the director of nursing (DON) stated each medication cart had a sign out sheet to complete during handoff. The DON stated the sheets were collected at the end of each month. The DON stated all controlled substances at the facility needed to be counted. During an interview on 9/9/21, at 9:53 a.m. the pharmacy consultant stated controlled medications and log was spot checked when onsite. The pharmacy consultant stated, Best practice for medication reconciliation was once a day, but more often was good. When checking medication counts, all controlled substances were to be reconciled including a check to ensure locks were intact on emergency kits. During a follow-up interview on 9/9/21, at 10:05 a.m. the DON reviewed medication narcotic signature logs and stated there should be signatures on every in and every out, but facility policy indicated medication verification needed to be completed at least daily. The DON stated signature sheets provided four opportunities for staff to complete medication counts each day. The DON stated if controlled substance counts were off, and investigation would start immediately. The DON stated the identification of possible diversion may be delayed but would still be found. A facility policy titled Narcotic and Controlled Substance Count Policy modified August 2016, directed narcotics and controlled substance supplies need to be checked at least daily and when counting, the staff going off duty gives the narcotic keys to the oncoming staff after the count has been reconciled.

Based on observation, interview, and document review, the facility failed to ensure a call light was accessible for 1 of 1 resident (R24) who was dependent upon staff for assistance. Findings include: R24's admission Minimum Data Set (MDS) dated [DATE], indicated R24 had intact cognition and was totally dependent upon staff for transfers. R24 was unable to ambulate and required extensive staff assistance with locomotion. R24's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R24's care plan dated 7/28/21, indicated, Place call light within reach and answer promptly. A progress note dated 8/12/21, at 9:31 p.m. indicated, Daughter requested to ensure that [call light] is within his reach at all times because he becomes anxious when he cannot reach it. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/7/21, at 1:59 p.m. R24 was in his room and seated in a Broda wheelchair. A call light was noted to be laying across R24's bed which had been stripped of sheets. The call light was not within R24's reach. R24 stated nursing assistant (NA)-A brought him back from the dining room after lunch. R24 stated when he needed assistance, he used the call light to notify staff. R24 gestured to the front of his shirt and stated, It should be clipped here. R24 glanced around his room but was unable to locate the call light. On 9/7/21, at 2:18 p.m. R24 was calling out, Help, Is anyone there, and I need help from his room. The call light remained out of R24's reach. No staff responded to R26's calling out. On 9/7/21, at 2:26 p.m. NA-A entered R24's room with clean sheets. The call light remained laying across R24's bed. In the process of putting sheets on the bed, NA-A picked up the call light and clipped it to R24's shirt. R24 stated, Its frustrating when staff move things and do not put them back where they belong. R24 stated, They should put it back where it belongs. I can't get it if its behind the wheelchair. During an interview on 9/7/21, at 2:47 p.m. NA-A stated it was important to make sure R24's call light was placed within reach and for staff to ask if he needed anything prior to leaving the room. Contrary to observation, NA-A stated the call light was left within R24's reach after he assisted him back to his room after lunch earlier during the day. NA-A confirmed the call light was on the bed, rather than clipped to R24's shirt, but was within R24's reach. During an interview on 9/8/21, at 2:43 p.m. registered nurse (RN)-B stated it was important for R24 to have his call light within reach as he gets, Very nervous without it. RN-B stated R24 recently had a care conference where specific preferences, including ensuring specific personal items were placed within his reach prior to staff leaving his room, were discussed with R24 and his family member. RN-B stated he reviewed the preferences with R24's direct care staff. RN-B stated, We know [R24] is anxious so staff is checking on call light placement before leaving his room. RN-B added, Call lights being clipped to the residents clothing or within reach is a standard of practice. During an interview on 9/8/21, at 3:09 p.m. the administrator stated she attended R24's care conference where preferences, such as ensuring a call light was within reach, was discussed. The administrator stated a list of R24's specific preferences was posted in his room per family request. RN-B educated direct care staff about the preferences, and it was expected staff accommodated R24's preferences. Facility policy titled Call Light Policy dated, 2/16, directed, Position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light when needed.

Based on observation, interview, and document review, the facility failed to determine if the practice of self-administration of medications (SAM) was safe for 3 of 3 residents (R10, R17) who were observed to have medications at bedside without an order to self-administer. Findings include: R10's [DIAGNOSES REDACTED]. In addition, R10's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R10 had intact cognition. R10's care plan dated 5/13/19, did not address R10 was supposed to self administer medications however directed staff to administer medications as ordered by the physician. On 6/30/19, at 1:03 p.m. R10 was observed to have Ocean nasal spray and Vicks vapor inhaler stick at the end table next to the chair in his room. R10's Self Administration assessment dated [DATE], indicated that R10 did not want to self-administer medications and according to the order summary report, dated 7/1/19, R10 did not have an order for [REDACTED]. R17's [DIAGNOSES REDACTED]. In addition, MDS indicated R17 had severely impaired cognition. On 6/30/19, at 2:22 p.m. R17 was observed to have a bottle [MEDICATION NAME] and a bottle of [MEDICATION NAME] powder (medication for yeast infection) were observed in the room on the counter to the right of the sink. R17's SAM assessment dated [DATE], indicated that R17 did not want to self-administer medications. On 7/1/19, at 2:11 p.m. register nurse (RN)-B indicated the medication found in R10's room was not from the facility pharmacy. RN-B also indicated R10 or family may have brought the medication to the facility and that there was no doctor orders for either medication. RN-B further indicated R10 and R17 did not have a SAM completed and that staff should remove medication from room and locked them up in the medication cart. RN-B further indicated R17 had not been using [MEDICATION NAME] powder for about a month and thought the family may have brought [MEDICATION NAME] into the facility. On 7/1/19, at 2:24 p.m. RN-A indicated if medications are in someone's room, then they should have had a SAM assessment completed, and a doctor order for the medication. RN-A also indicated if family brings in medications into the facility and there is no doctor order for the medications, then the medication should be locked in the medication cart until an order can be received from the doctor. RN-A further indicated staff should remove medications from the rooms when noticed. On 7/2/19, at 2:08 p.m. during the quality assurance plan meeting with the facility administrator and director of nursing, the director of nursing stated staff usually assessed residents on admission and if the resident had expressed the wish to SAM then update the physician would be updated, an order was obtained and it was care planned. The DON further stated the staff were supposed to let the nurse know if they saw medications in the room so the medications would be removed until it was appropriate for them to keep in room.

Based on observation, interview and document review, the facility failed to utilize the appropriate mechanical lift vest for 1 of 1 resident (R15). In addition, failed to safely transfer 1 of 1 resident (R15) reviewed for accidents with transfers. Findings include: R15's [DIAGNOSES REDACTED]. In addition, the MDS indicated R15 had severely impaired cognition and required extensive physical staff assistance of two staff with transfers and had impairment to range of motion to both lower extremities. R15's care plan dated 5/14/19, identified R15 had limited physical mobility, weakness/impaired balance/gait, [MEDICAL CONDITIONS] and Dementia. The care plan directed staff for TRANSFERS: Out of bed in the AM, assist of 2 with Golvo lift and medium sling. Other transfers during the day I require assist of two with a stand lift and medium vest. R15's Resident Transfer- V6 dated 5/24/19, indicated R15 was able to partially bear weight as resident was able to stand for 8 seconds safely while holding onto an assistive device. In addition, the assessment indicated R15's level of cooperation and comprehension was unpredictable, two staff were supposed to be present with all transfers and staff was supposed to use Medium size vest when using the Sabina II assist lift. On 7/1/19, at 9:45 a.m. nursing assistant (NA)-A was observed to wheel R15 into the room. After parking R15's wheelchair NA-A left the room and went right outside the hallway and was observed to wheel a mechanical lift (Sabina II) into R15's room and shut the door. -At 9:47 a.m. NA-A approached R15 and stated she was going to assist him to lay down as it would be more comfortable than the wheelchair. NA-A approached R15 from the front and asked R15 to lean forward and NA-A was observed to put the vest behind R15's lower back. NA-A then wheeled R15 close to bed then pulled the Sabina II lift towards R15's wheelchair and hooked the outer vest straps to the Sabina II stand lift to both side hooks and cued R15 to hold on to the bars on the sides. NA-A then cued R15 to hang on to the bars then started to lift R15 up using the remote. NA-A then identified R15's feet were not on stand platform and stopped. NA-A then bent down and was observed to stabilize R15's feet as she reached behind R15's knees and applied the leg strap then cued him to stand tall as she used the remote to bring R15 to a standing position then she pulled the mechanical lift out. NA-A then pulled the mechanical lift with R15 standing on it approximately four feet away from the bed then left R15 standing on the mechanical lift as she moved the wheelchair from underneath R15 and out of the way. During the observation, R15's knees were observed bent over and as R15 held onto the bars with his hips bent in v-shape with buttocks thrust out. R15 continued to hold onto the bars on the sides and the vest was observed riding down as R15 stood. -At 9:51 a.m. NA-A pushed the mechanical lift to R15's bed and a black cord was observed lying on the floor and NA-A then was observed attempt to maneuver the mechanical lift over the cord to get the lift under the bed. NA-A was alone doing the transfer. NA-A then lowered R15 to the bed using the remote and as she unhooked R15 from the mechanical lift she pushed the lift out of the way. At 9:52 a.m. NA-A was observed to cue R15 she was going to swing his feet to bed as she held onto his upper body. During this observation R15 was not assisting at all, his eyes were closed and was not responding or following the commands. At 9:53 a.m. after NA-A managed to get R15 to bed as she attempted to reposition R15 by herself this surveyor intervened and asked her if she needed assistance. -At 10:02 a.m. NA-A took the mechanical lift out of the room and surveyor verified with NA-A the vest that had been used on R15 was marked as Large as she wheeled the Sabina II lift out of the room to the hallway. On 7/1/19, at 10:09 a.m. registered nurse (RN)-B verified she had observed the Sabina II mechanical lift in the room when she assisted NA-A to reposition R15. -At 10:11 a.m. RN-A stated R15 was supposed to use a Golvo lift in the morning when getting out of bed and when using the toilet R15 was to use the Sabina II however two staff were supposed to be in the room during all transfers with any mechanical lift. On 7/2/19, at 10:32 a.m. the director of nursing (DON) stated staff are to follow the plan of care as we have communicated it to them. The DON also stated R15 required two staff assistance with transfers and in the morning the staff was to use a full body mechanical lift when getting R15 out of bed and for other transfers and to the toilet the staff was to use the Sabina II mechanical lift. When asked what vest size R15 was supposed to use when using the Sabina II mechanical lift, the DON stated Medium vest. The DON further stated if he was visibly sagging they are supposed to stop the transfer and call the nurse and he is a two staff assist as he did not help a lot. When we became aware we started to educate the staff on following the plan of care. On 7/2/19, at 1:42 p.m. NA-A stated she had misread the assignment sheet and thought R15 required assistance of one when using the Sabina II mechanical lift. NA-A stated she did not know R15 always required two staff assistance when using any of the mechanical lift transfer machines. NA-A further stated she was supposed to follow the plan of care and was to ensure all resident transfers were safe.

Based on observation, interview, and document review the facility failed to ensure the sanitation solution in cleaning buckets were at proper sanitization parts per million. This had the potential to affect all 28 residents in the facility. Findings include: The initial kitchen tour was conducted on 5/29/18, at 11:48 a.m. with the Executive Chef (EC) when two sanitation buckets were observed in use on the 4th floor kitchenette and dining area. While in the 4th floor kitchenette the EC explained the bucket with water solution sitting on the sink was utilized to sanitize the work areas and surfaces of the kitchen. EC explained there was also one in the dining area. EC stated the water in the bucket should have been tested for proper sanitation levels of Quat Sanitizer when the buckets were filled for use. EC obtained an orange quaternary test strip (expiration date (MONTH) (YEAR)) and placed it in the liquid in the bucket and held it there for 10 seconds with the strip turning yellow/brown color. EC stated the results were below the 200 parts per million measurement (PPM), and it should have been 400 PPM. On 5/29/18, at 12:00 p.m. the EC followed the same process and checked the sanitation solution for the bucket being used in the 4th floor dining room area. The results indicated the PPM was approximately 150 ( a yellow/brown color on the test strip). EC explained staff supposed to let the water run for about 30 seconds to make sure the air was out of the lines and the sanitizer solution was running prior filling the bucket. On 05/29/18, at 4:45 p.m. the EC was present on the 4th floor dining area and was requested to check the sanitation levels of the solutions in bucket being used in the dining area. EC obtained an orange quaternary test strip and placed it in the sanitizer solution portion and held it there for 10 seconds. The results indicated the PPM was approximately 150 (a yellow/brown color on the test strip). During interview on 5/29/18, at 4:45 p.m. the dietary aide (DA)-A stated that she had filled the sanitation bucket and that she did not test concentrations of the solution. DA-A explained the bucket had Quat sanitizer solution in it used to wipe dining tables and areas in the dining room. At 4:47 p.m. the cook (C)-A stated that usually the cooks or chef would check the concentration of the solution, but sometimes the servers would do that too. C-A stated he had not checked the solution on that day. On 5/30/18, at 12:01 p.m. the EC stated he had looked at the sanitation system and noted there was a hole in the solution bag in the dispenser letting air into the lines and that at least one other dispenser in the facility had a pinched tube. EC further stated he did education with the staff and called Ecolab (the vendor who supplies the sanitizer) to come and look at the Quat disinfection dispensers. During an interview on 05/31/18, at 7:33 a.m. DA-D stated the red buckets were used for sanitation solution to wipe down the surfaces of tables and other areas of food preparation. DA-A explained the solution should have been changed every three to four hours and tested for disinfection concentration when prepared. DA-D also stated the server was responsible for this, or the cooks did it when they got to the unit. DA-A explained that staff supposed to turn on the tap of the dispenser and let it run until the lines were clear of air; then when staff pushed the button, the dispenser would deliver the correct amount of solution to the water. DA-A further explained the solution was a preset amount of sanitizer to water ratio, and the results of the test strip had to be at 400 (PPM). DA-A verified they served 28 residents three meals a day. During a telephone interview on 5/31/18, at 9:55 a.m., the representative from Ecolab stated he came to the facility and checked the sanitation solution meters on 5/30/18, sometime in mid-afternoon, and found that the metering tip on the device was not functional and was changed. The Ecolab representative did not know for how long the dispenser was not functioning properly, and stated representatives usually came to the facility monthly to monitor dispensers to assure functionality. On 5/31/18, at 8:10 a.m. the administrator stated that she would expect the staff to follow the policy for testing the sanitation solution and to report any issues to the appropriate supervisor. On 05/31/18 at 8:12 a.m. the director of nursing stated all residents ate in the dining. The Oasis 146 Multi Quat Sanitize policy dated 1/28/14, indicated 5. Solution must be changed at least every 4 hrs and tested each time it is changed. The undated facility's guide for Oasis 146 Multi Quat Sanitizer instructed staff to utilize pHydrion papers QT-40 test strips and to tear off a one to two-inch strip and immerse it in solution for 10 seconds. Further, the guidelines instructed staff to compare the strip color to the chart on the package.

Based on observation, interview and document review the facility failed to provide comfortable and safe temperature levels for 1 of 2 residents (R16) who expressed concern that the room was too hot. Findings include: R16's quarterly Minimum (MDS) data set [DATE], indicated R16 had moderately impaired cognition. During interview on 5/30/18, at 2:24 p.m. family member (FM)-A stated she reported to staff that the air conditioner was not working in R16's room on 5/24/18, or since, and the air conditioner was still broken. FM-A explained R16 did not tolerate heat well and R16 had anxiety over the weekend due to her room being hot. FM-A further explained nothing was done to address the broken air conditioner or help make R16 more comfortable. FM-A stated staff did not bring a fan into R16's room until 5/28/18, when FM-A requested one. R16 stated she was hot all weekend. At this time room temperature was 77 degrees according to wall thermometer, and the air in the room felt stagnant and humid. On 5/30/18, at 3:25 p.m. the director of engineering (DE) stated the air conditioner in R16's room was currently broken, and the plan was to fix it that night. DE acknowledged R16's room currently felt warm and stated they would place a fan in the hallway this evening to try to bring some cool air from the hallway into R16's room. On 5/31/18, at 10:12 a.m. FM-A clarified that in the morning on 5/24/18, she noticed the ceiling vent in the bathroom was dripping water and thought the air conditioner was broken. FM-A stated she reported it immediately to the nurse on duty. FM-A had a personal aid checking in on R16 from 5/25/18 through 5/28/18, who reporter to her that it was over 80 degrees in R16's room and had also notified the weekend staff about the broken air conditioner. On 5/31/18, at 9:52, a.m. the registered nurse (RN)-A stated she received a call from FM-A on 5/28/18 stating the air conditioner was broken in R16's room. RN-A stated she then called the emergency maintenance number to address this issue. RN-A acknowledged she was aware the air conditioner had been broken for a few days when FM-A called and did not know why the weekend staff did not call this issue in. RN-A explained there was always an emergency maintenance number to call on weekends and holidays. RN-A further stated the emergency maintenance worker came to assess the air conditioner in R16's room on 5/28/18, but was not able to fix it that day. RN-A then brought a fan in R16's room later in the day on 5/28/18. On 5/31/18, at 11:46 a.m. DE stated he first became aware that R16's air conditioner was broken on 5/28/18, and the emergency maintenance staff came to look at it. On 5/31/18, at 11:48 a.m. the facility administrator (FA) stated she was not aware of the broken air conditioner in R16's room until 5/28/18. FA stated staff were expected to call maintenance or put in a work order right away when any maintenance issues were identified. A work order dated 5/29/18, regarding the broken air conditioner in R16's room indicated no work had yet been done on it by facility maintenance staff. Weather report for Wayzata, MN indicated the following temperatures: -5/24/18, 89 degrees -5/25/18, 88 degrees -5/26/18, 93 degrees -5/27/18, 89 degrees -5/28/28, 99 degrees -5/29/18, 94 degrees -5/30/18, 74 degrees A facility policy regarding the work order system updated 4/12/18, was provided. The policy did not indicated who's responsibility was to place work orders in the system.

Based on observation, interview and record review the facility failed to apply compression stockings per physician order [REDACTED]. Findings include: R3's admission Minimum Data Set ((MDS) dated [DATE], indicated R3 needed physical assistance of one person for putting on or taking off all items of clothing. The MDS also indicated R3 was cognitively intact. R3's had a physician order [REDACTED]. R3's most recent body audit on 5/22/18, indicated R3 had mild [MEDICAL CONDITION] in feet, ankles and calves. During interview on 5/29/18, at 3:02 p.m. R3 stated she had swelling in her legs and had compression stockings to assist with reducing the swelling. R3 further stated the compression stockings were comfortable for her to wear, and was observed wearing compression stockings at that time. On 5/30/18, at 2:20 p.m. R3 was observed again, but was not wearing compression stockings. The compression stockings were observed on the window sill in R3's room. R3 stated she needed staff's help to them on and take them off, since she was not able to put them on or take them off by herself. R3 stated her compression stockings had not been put on her that day. On 5/30/18, at 3:42 p.m. registered nurse (RN)-B confirmed that R3 was not wearing compression stockings per physician order. RN-B stated R3 was mainly independent and thought she was able to apply the compression stockings independently. RN-B applied R3's compression stockings at that time, and confirmed R3 had swelling in her legs. RN-B stated staff should be making sure R3 had the compression stockings on as ordered. A facility policy titled antiembolytic stockings, approved (MONTH) 2014, was provided for review. The policy did not indicate who's responsibility was to apply compression stockings.

Based on observation, interview and document review, the facility failed to maintain a sanitary food storage environment and failed to serve food in a sanitary manner. This had the potential to affect all 29 residents residing in the facility. Findings include: During an initial kitchen tour with the executive cook (EC) on 4/17/17, at 12:24 p.m., the following observations were made: - A scoop was noted in a bin filled with bread crumbs. The EC stated scoops should not be stored in the bin, but should be hung up. He picked the scoop out of the bin and placed it on a designated hook. A bin filled with granola had a disposable plastic cup stored in it. The EC removed the cup from the bin and threw it away. Another bin containing flour also had a scoop stored in it which the EC removed. - The freezer contained two open boxes of fish in open plastic bags. The open container was not dated. A bag of chicken fingers and a bag of hash browns were also open and undated. The EC stated the bags may have been opened recently since it was the beginning of the week, but confirmed they should be dated when opened. - The ice machine had an ice scoop laying directly on top of the machine. Two screws were sticking out of the wall on the left side of the ice machine. The EC stated the ice scoop should be hanging next to the machine, but the hanger had broken and had not yet been repaired. The EC removed the ice scoop from the top of the machine and placed it in a plastic container and set it on top of the machine. During a meal service observation on 4/17/17 at 5:14 p.m., the following was observed: Dietary aide (DA)-A was noted wearing gloves. DA-A picked up a tray and set it on a lower counter. DA-A then took out a bin of condiments and placed them on the counter, began opening and closing cabinets and placing her gloved hands on the counter tops. DA-A then peeled off the plastic from the pans on the steam table, picked up parmesan cheese with her fingers and sprinkled it on the spaghetti. DA-A picked up garlic bread, with the same gloved hands and was noted to touch the spaghetti, wearing the same pair of gloves. DA-A picked up the meal slips and moved them. She then stated, I should probably not touch the resident meal slips. DA-A instructed staff to spread the meal slips out on the counter then removed her gloves, washed her hands, and put on a new pair of gloves. On 4/19/17, at 10:45 a.m., the Culinary and Food Services Director (CFSD) stated a work order had been put in for the ice scoop rack to be repaired. The CFSD stated, whoever put the scoops and cups in the bulk bins should have placed them on the hooks as it was a sanitation issue. The CFSD stated the servers in the kitchenettes were to wear gloves when working with food and stated if there was a change in activity, staff should remove their gloves, wash their hands and then put on a clean pair of gloves. The CFSD stated it was okay to touch the front counter and the individual resident meal tickets, but stated it was not okay for the server to touch the back cupboards without washing hands and changing gloves. The CFSD stated if a server was going to touch resident food, the facility expectation was they should be using utensils. On 4/19/17, at 2:11 p.m., a facility policy regarding kitchen and food sanitation was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure infection control practices were followed by 1 of 1 resident companion (RC-A) who was observed to assist 1 resident (R3) and R3's three table mates during dining to prevent the spread of infection. Findings include: During an observation on 4/17/17, at 4:54 p.m., R3 was sitting in the dining room. She had a resident companion (RC)-A with her at the dining room table. RC-A was observed walking around the dining area. She took a clothing protector off a large pile of clothing protectors from a tray and placed it around R3's neck. RC-A with her gloved hand pulled open her shirt and sneezed down it. RC-A did not change her gloves. She was noted to have had her hands in her lap, on the table and on the arms of the chair At 5:30 p.m., RC-A scratched her head with her left hand and got up from her chair, pushing herself up by using the arm rest. As she was walking to the kitchen, she pulled up her pants, still wearing the gloves. When RC-A returned to the table, she touched back of a wheel chair and wiped her mouth with her gloved hand. She then sat down, took a utensil, and assisted R3 to eat but didn't change her gloves. At 5:38 p.m., RC- A pushed herself up using the arm rests of the chair. She walked over to the clean dishes, took a cup and two glass, and pushed the button on the ice machine and filled a glass with ice. RC-A put some ice in the coffee cup, poured some coffee in the cup; added ice to another glass and filled it with a red juice, and then filled the remaining glass with ice in it with water. RC-A brought the items back to the table where she distributed them to other residents at the table. Throughout this observation, RC-A did not remove her gloves or sanitize her hands. During an interview on 4/17/17 at 5:49 p.m., the assistant director of nursing (ADON) stated staff are expected to wash their hands prior to assisting in the dining room and if they contaminate their hands by scratching their head or wiping their mouth, they should be performing hand hygiene. The ADON also stated when a RC leaves the table and returns, they should perform hand hygiene. The ADON stated there had been no training provided by the facility for RC-A in regard to infection control. The ADON verified RC-A was not a family member, but had been hired by the family to assist R3. The ADON stated R3 was the only resident who had a RC who assisted with feeding, and acknowledged RC-A should not be providing food or liquid items to other residents. During interview on 4/17/17 at 5:59 p.m., the director of nursing (DON) stated he thought RC-A was a family member and was not aware of the issues. On 4/18/17 at 11:42 a.m., the administrator verified the facility had not provided RC-A any formal training related to infection control, gloves or washing hands. During a subsequent interview on 4/19/17 at 7:40 a.m., the administrator stated, we would hope that they (resident companions) would follow all infection control policies and procedures. We would hope they would wash their hands and keep the resident safe. The facility's policy, Feeding Residents-Family, Volunteers, and Non-Nursing Staff dated June 2000, included: Volunteers and Non-Nursing Staff: Volunteers (or any non nursing staff) who will be providing feeding assistance will complete a certified mealtime assistant training program that meets the training standards as defined in the approved state training curriculum.

Based on observation, interview and document review, the facility failed to revise the plan of care for 1 of 3 residents (R33) reviewed for activities of daily living (ADLs). Findings include: R33's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively impaired and required physical assistance with personal hygiene and bathing. R33's care plan dated April 2017, indicated a self care deficit related to dementia, limited mobility and confusion. The MDS further indicated the resident required staff assist with bathing and grooming. R33's careplan dated 3/9/17, indicated: I (R33) want to be clean and well dressed daily. R33's current care plan did not include any additional interventions to address the issue with her hair being oily. On 4/18/17, at 9:23 a.m., family member (FM)-A stated, I feel her (R33) hair could be cleaner. On 4/17/17, at 5:04 p.m., R33 sat in her wheelchair at the table in the dining room . R33's hair was slicked down and appeared oily. On 4/18/17, at 12:14 p.m., R33 was seated at the table in the dining room. Her hair was hanging straight and cut off [MEDICATION NAME] at the ends. Her hair still looked oily. On 4/18/17, at 12:27 p.m., NA-A stated R33 received one shower a week on Thursday mornings. NA-A further stated the stylist had given the NAs a particular shampoo to use on R33's hair because her hair gets extremely oily fast. NA-A stated R33's hair looked nice after the shower, but it only helped for a few days. On 4/18/17, at 1:36 p.m., the beautician stated she tried to wash R33's hair once but it did not work. She stated R33 is too stiff to wash her hair in the chair. She stated R33's hair needed to be washed in the shower and that she needed two showers a week. On 4/18/17, at 2:41 p.m., the assistant director of nursing (ADON) stated R33 had naturally greasy looking hair even after her shower. The ADON stated the facility had tried some shampoo shower caps to clean the hair, but stated the caps did not work. On 4/19/17, at 1:05 p.m., NA-C stated R33's hair was washed every Thursday morning in the shower with shampoo from the salon. NA-C stated R33 was very stiff but did not have any behaviors or anxiety in the shower. On 4/19/17, a facility policy regarding care planning was requested, but not made available.