Every finding on record at Gil-Mor Manor

Based on observation, interview and document review the facility failed to ensure test strips used to test chemical concentration in a low temperature dishwasher were not outdated, and the tests were performed according to the manufacture's guidelines. This had the potential to affect all 33 residents who received meals at the facility.Findings include: Observation and interview on 9/8/26 at 12:59 p.m., of the facility kitchen, with the certified dietary manager, (CDM) identified the facility utilized a low temperature, chemical dishwasher. The CDM reported the representative came monthly and as needed to check the chemical concentration. She provided a plastic container of Hydrion Chlorine test strips that were to be utilized to measure the Chlorine chemical concentration of the washer solution. She reported she had not been performing a routine check using the chemical test strips, and was not aware she needed to do so. Observation of the container of test strip paper identified it had an expiration date of May 1, 2021. The CDM confirmed she was not aware of the outdate, and confirmed if they had tested the dishwasher solution, this was the container of strips that would have been utilized. Review of the Micro Essential Lab manufacture's guidelines identified: Hydrion Chlorine Test Paper provides a simple, reliable, and economical means to measure the concentration of free available chlorine in sanitizing solutions. With color matches at 10-25-50-100-200ppm, the test paper measures concentrations between 10-200ppm. Federal, State and Local health regulations require users of chlorine-based sanitizer solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer. Storage and Preparation: Store Hydrion pH paper at room temperature, away from heat, light and chemical fumes. Do not use after the expiration date. When opening a new roll, affix a Date Opened label and record the lot number and expiration date on a log sheet. Interview on 9/10/26 at 1:30 p.m., with the CDM identified she had contacted her chemical provider who confirmed kitchen staff should be testing and documenting chemical concentrations daily. The CDM reported she had obtained new test strips and would implement daily testing and documentation of the parts per million concentrations of the dishwasher sanitation. Review of the April 2023, Cleaning Dishes/Dish Machine policy identified all flatware, dishes and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy failed to include the process for testing chemical concentrations, or the inclusion of a log to document results of the testing.

Based on interview and document review, the facility failed to develop a comprehensive care plan that included bleeding precautions and/or use of diuretics for 4 of 5 sampled residents (R1, R2, R3, and R4). Based on interview and document review, the facility failed to develop a comprehensive care plan that included bleeding precautions and/or use of diuretics for 4 of 5 sampled residents (R1, R2, R3, and R4). Findings include: Review of the 6/6/23, Rx List article, Coumadin (aka Warfarin), located at https://my.clevelandclinic.org/health/treatments/22288-anticoagulants, identified (warfarin) is a blood anticoagulant that inhibits the function of vitamin K dependent coagulation used to inhibit the coagulation (clotting) of blood to reduce or prevent the chance of developing heart attacks, strokes, and other blood clots located elsewhere in the body, produced with atrial fibrillation. Common side effects of Coumadin include easy bruising and bleeding, nausea, vomiting, stomach pain, bloating, gas, or altered sense of taste. People should seek medical care or call 911 at once if they have the following serious side effects: Serious eye symptoms such as sudden vision loss, blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights; Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out; Severe headache, confusion, slurred speech, arm or leg weakness, trouble walking, loss of coordination, feeling unsteady, very stiff muscles, high fever, profuse sweating, or tremors. Serious adverse effects include hemorrhage (bleeding). Warfarin can cause major or fatal bleeding. Risk factors for bleeding include high intensity of anticoagulation, age greater than or equal to 65, history of highly variable INRs (lab used to measure effectiveness of therapy), history of gastrointestinal bleeding, high blood pressure, cerebrovascular disease (reduced blood brain flow), anemia (low iron), cancer, trauma, renal (kidney) impairment, and long duration of warfarin therapy. Drug and dietary changes can affect the levels of the medication. Patients were cautioned to avoid any activity or sport that may result in traumatic injury and obtain regularly scheduled laboratory tests and make regular visits to their physician or clinic to monitor therapy. Review of the 6/6/23, Rx List article, Lasix (aka furosemide), located at https://www.rxlist.com/lasix-drug.html, identified Lasix was used to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, or renal failure, or high blood pressure. Lasix may cause serious side effects including: lightheadedness, ringing in your ears, hearing loss, muscle spasms or contractions, pale skin, easy bruising, unusual bleeding, increased thirst, increased urination, dry mouth, fruity breath odor, little or no urination, swelling in your feet or ankles, feeling tired, short of breath, loss of appetite, upper stomach pain, nausea, vomiting, dark urine, yellowing of the skin or eyes (jaundice) drowsiness, feeling jittery, feeling unsteady, irregular heartbeats, fluttering in your chest, numbness or tingling, muscle cramps, and muscle weakness or limp feeling. Patients were directed to get medical help right away, if you have any of the symptoms listed above. R2's comprehensive, Minimum Data Set (MDS) assessment, accepted on 8/26/26 identified R2 had intact cognition and diagnoses of Parkinson's disease, type 2 diabetes mellitus, high blood pressure, chronic atrial fibrillation (heart rhythm irregularity that can cause blood clots), gastro-esophageal reflux disease (GERD), high cholesterol, history of fractures in spine, chronic kidney disease Stage 3, osteoporosis (degenerative bone disease), history of urinary tract infections, unspecified osteoarthritis (degenerative joint disease), and urinary incontinence. R2 had no impairment to either side of her body, was independent with walking and wheeling herself short distances, but otherwise utilized a wheelchair with partial to moderate assistance by staff. R2 also required partial to moderate assistance with toileting and dressing and transfers and was dependent upon staff for putting on her footwear. R2 was administered anticoagulant (thins the blood) and diuretic (helps flush extra fluid from body) medications. R2's current, undated Order Summary report identified she was to be given: Lasix (diuretic) 20 milligrams (mg) by mouth twice daily for high blood pressure. Warfarin (anticoagulant) 4 mg by mouth each evening related to her atrial fibrillation. R2's current, undated care plan identified R2 was at risk for falls related to her limited mobility, catheter tubing, potential medication side effects, Parkinson's disease, diabetes, high blood pressure, atrial fibrillation, history of fractures, and her osteoarthritis and osteoporosis. R2 was to remain free from falls. There was no indication R2's care plan was appropriately developed to indicate to staff of the serious concerns and/or side effects of her medication, such as increased bleeding, the necessity to get a medical examination if she were to fall related to her increased risk of bleeding, or that the diuretic therapy would impact staffs needs to anticipate her increased level of need to toilet and how often R2 would need laboratory tests for the use of her medications. Interview and care plan review on 9/10/26 at 1:45 p.m., with the administrator and the regional consultant (RNC)-A regarding the above-mentioned concerns for care planning identified they agreed residents on blood thinners and diuretics should have had their care plans developed to ensure risks were identified and monitoring noted. They agreed for example, a fall with head injury for a resident on Coumadin would put them at high risk for a brain bleed and because of R2's dependence upon staff for toileting, staff may need to anticipate her needs of more frequent urination. R1's accepted 7/23/26 at 2:14 p.m., comprehensive Minimum Data Set (MDS) identified R1 was admitted [DATE] with a diagnosis of atrial fibrillation, heart failure, and high blood pressure. R1 was moderately cognitively impaired and required partial/moderate assistance with Activities of Daily Living (ADL's) and transfers. R1 had taken anticoagulants (blood thinners) on a daily basis. R1's September 2026, Order Summary Report identified apixaban (blood thinner) 5 milligrams (mg), was to be given twice a day for atrial fibrillation (irregular heart rhythm that causes heart palpitations, shortness of breath, and fatigue) on 6/25/26. R1's current, undated care plan lacked evidence of anticoagulant monitoring, interventions, and safety precautions. R3's accepted 5/28/26 at 10:17 p.m., quarterly Minimum Data Set (MDS) identified R3 was admitted [DATE] with a diagnosis of anemia and hypertension (HTN). R3 was cognitively intact and required substantial/maximal assistance with toileting and sit to lying transfers. She had taken anticoagulants on a routine basis. R3's September 2026, Order Summary sheet identified Eliquis 5 mg was to be given twice a day for atrial fibrillation on 11/19/25. R3's current, undated care plan lacked evidence of anticoagulant monitoring, interventions, and safety precautions. R4's 7/6/26, accepted quarterly, Minimum Data Set (MDS) assessment identified her cognition was intact. She ambulated in room and hall using a walker with staff in attendance. R4 had been identified as a fall risk related to limited mobility, pain, incontinence, potential side effects of medications, and visual impairment. She had a diagnosis of bilateral lower extremity edema related to hypotensive chronic kidney disease. R4's current medication orders included Lasix 20 milligrams (mg) by mouth (PO) daily (QD) for bilateral lower extremity edema with a start date of 7/9/25. R4's current 6/26/26 revised, care plan identified R4 had episodes of incontinence due to diuretic use, but failed to include monitoring of electrolytes, and the potential for dehydration due to fluid loss. Review of the 2001 Care Plans-Comprehensive policy identified care plans were to be based on a thorough assessment and have incorporated risk factors associated with identified problems.

Based on interview and document review the facility failed to act promptly and provide resolution for resident concerns brought forth at resident council meetings by 5 of 6 residents (R1, R9, R10, R13 and R14). Findings include: Review of the July 2026 Resident Council Meeting minutes identified Facility Announcements and Department Updates nursing: Residents in attendance voiced concern that staff failed to consistently announce themselves prior to entering a resident room. Review of the August 2026 Resident Council Meeting minutes identified:The following questions: Do staff knock on your door before entering?Are your call lights being answered in a timely manner?Are staff treating you with respect and dignity:Are staff handling you gently when doing cares?Residents' response indicated they answered yes to all the questions. There was no mention or discussion of a resolution being provided to residents regarding the continued issue of staff failing to announce themselves prior to entering a resident's room. Interview on 9/9/26 at 1:36 p.m., with the resident council members in attendance (R1, R9, R10, R13 and R14) identified when the resident council voiced concerns or grievances, the facility had not made any changes or reported back to the resident council what resolutions to concerns were being implemented or revised. Concerns voiced at the meeting by residents included: Staff responded to a call light and turned off the call light without responding to the resident request. Staff enter rooms without knocking or announcing themselves repeatedly.Staff fail to respect resident privacy. Interview on 9/9/26 at 2:07 p.m. with the social services designee (SSD) identified she managed the grievance process for the facility. The process was for a grievance form to be completed either by staff for a resident or by the resident and forwarded to her. She would then forward the grievance to the appropriate department head for follow-up and resolution. The SSD reported she was not aware of any current concerns regarding staff failure to respect resident privacy, knock before entering a resident room, and/or responding to resident needs. Review of July 13, 2026, Resident Council Meeting Minutes identified: Staff failed to consistently announce themselves prior to entering a resident room. The minutes included an intervention that staff would be educated. No documentation or audits were provided to indicate education had taken place. Review of August 17, 2026, Resident Council Meeting Minutes identified: Continuing concerns of staff not announcing themselves prior to entering a resident room. There was no documentation of any follow up from the same concern voiced at the July meeting. Interview on 9/9/26 at 2:12 p.m. with the assistant director of nursing (ADON) identified she was aware of the above, resident council minutes, and concerns staff failed to provide personnel care to a resident. She reported the issue had been addressed with the individual staff member. She identified she was not aware if the reported concern had been documented, a response provided to the residents, or education provided to other staff members. Interview on 9/9/26 at 2:18 p.m. with the regional nursing consultant (RNC)-A identified was aware of the concerns included in the July, August and September Resident Council Minutes. She reported she thought some of the residents' concerns had been when the former DON was at the facility and since there had been a change in the DON the situation was improving. The RNC-A identified she was not aware of resident notification, education, or audits completed. Interview on 9/10/26 at 2:11 p.m. with the activity director identified she arranged the resident council meetings and took minutes. When there was a concern expressed at the meeting the process was to document the concern on a grievance form, The form was copied and provided to the department head responsible for the area of concern. A response was expected by the next resident council meeting, but she stated it was usually within a week. Following receipt of the completed form, she presented the resolution at the next meeting under Old Business. She confirmed the August and September minutes failed to contain any follow-up to the identified concerns. Interview on 9/10/26 at 3:36 p.m. with the administrator identified the identified concerns had been taken to the previous DON, but there was no documentation identifying a resolution or update had been provided to the resident council. She voiced her expectation for grievance to be filed, investigated, and staff to have developed a plan to resolve the issue. She reported her expectation for a response to be provided to the residents within 5 days. Review of November 2025, Resident Grievance/Concern Policy and Procedure listed the purpose of prompt resolution of all grievances, concerns, and suggestions. The Procedure identified: The concern/grievance was to be discussed with the persons involved and documented or verbalized using the Grievance/Concern form and provided to the Grievance person responsible.The Grievance person was expected to respond both verbally and in writing within five working days of receiving the concern.If the issue was not resolved the involved party was to take their concern to the DON or administrator.If the issue was not resolved to their satisfaction, a written grievance could be filed with the administrator.Unresolved areas of concern could also be forwarded to the S. A. or Ombudsman's office. The grievance official was responsibilities included:Oversight of the grievance process.Lead investigations.Maintain confidentiality.Communicate decisions with residents and any involved agencies.Ensure action implemented to prevent further violations of resident rights.Report appropriately violations of abuse, neglect, or misappropriation to the appropriate entities.Ensure all grievance decisions include the date received, summary of the grievance, investigation, findings, any actions taken regarding the grievance, and the date a written decision was issued.A log of grievances with all components included was to be maintained for a period of three years.

Based on interview and document review the facility failed to report an allegation of suspected abuse to the State Agency immediately (with in 2 hours) for 1 of 1 resident (R84) who reported rough handling by 1 of 1 staff (nursing assistant (NA)-A) during the provision of personal cares. Findings include: Review of the 1/22/26 at 4:23 p.m., report to the State Agency (SA) identified facility staff became aware of an incident of potential physical abuse on 1/21/26 during the provision of toileting after the supper meal. The incident was reported by R48 to an unidentified staff member following the incident on 1/21/26. The director of nursing (DON) became aware of the incident on 1/22/26 at 12:30 p.m. and updated the administrator of the reported incident. Review of the facility investigation report identified NA-A was suspended on 1/22/26, following notification of the reported incident. Interviews of staff and residents were conducted by the DON and assistant DON (ADON) on 1/22/26. R48 identified she was afraid of NA-A and did not want her to provide cares for her, but she felt safe with other staff members. She reported NA-A was assisting her to the toilet and was very rough pulling down her pants. She reported it was painful and she had almost fallen over. Following sitting on the toilet NA-A had waited a very long time before she had returned to assist her off the toilet. Two additional unidentified residents reported the provision of rough cares from staff but declined to identify the staff members. R48's 7/6/26, accepted quarterly, Minimum Data Set (MDS) assessment identified her cognition was intact. She required assistance with Activities of Daily Living (ADLs) due to impairment of her upper extremities and one side of her lower extremities. She required substantial to maximal assistance with toileting hygiene. R48 had diagnosis of anxiety and pain related to a previous surgical procedure on her lower leg for removal of a lesion on her lower leg. Interview on 9/9/26 at 2:00 p.m. with R48 identified she had experienced rough handling during cares provided by NA-A previously but had not reported it. She identified she was afraid of NA-A and did not want her to provide care for her but denied being afraid of any other staff members. R48 reported NA-A did not like her, and made comments of not answering her call light and waiting until someone else responded. When NA-A assisted her to the toilet, she did not return, for a long time and when she did finally returned, she made her uncomfortable by making comments, and being rough when she assisted her. R48 reported she was fearful of NA-A hurting her because she was rough, would not listen and did not take time to be careful when helping her. She also reported that following the incident the DON had visited with her and NA-A was no longer at the facility. Interview with the administrator on 9/9/26 at 4:14 p.m. identified she was aware of the 2-hour reporting period for reporting alleged abuse. She identified she had not followed the facility policy for submission of a report to the SA within 2 hours of being informed. She could not recall the time she received notification of the incident but stated it was the morning of 1/22/26. Review of the 6/3/26 Vulnerable Adult Policy identified allegations or incidents of suspected abuse, exploitation, neglect, mistreatment, or misappropriation of property was to be immediately reported to the charge nurse. She was to immediately notify the administrator and DON following notification of the reported incident. In the case of abuse, neglect, mistreatment or misappropriation of property, the administrator, DON, or social services designee was to report the initial incident to the Minnesota Department of Health (MDH). upon discovery of the incident.

Based on interview and document review, the facility failed to ensure 1 of 2 residents (R39) was given the risk to benefit of leaving Against Medical Advice (AMA) and document that discussion to ensure R39 and/or their representative were aware of leaving AMA. In addition, the facility failed to ensure 1 of 5 sampled residents (R16) and/or their personal representative was informed in advance, of the risk to benefit of increasing the dosage on their psychoactive medication. Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. R39's undated diagnoses sheet identified diagnoses of major depressive disorder, recurrent and severe with psychotic symptoms, generalized anxiety disorder, catatonic disorder due to known physiological condition, schizoaffective disorder, unspecified, neuroleptic induced parkinsonism, bipolar disorder, unspecified, suicidal ideations, age-related cataract, high blood pressure, constipation, moderate protein-calorie malnutrition, fibromyalgia, repeated falls, high cholesterol, osteoarthritis (degenerative joint disease) of knee, difficulty swallowing, age-related osteoporosis, carpal tunnel syndrome, radiculopathy (pain radiating to other parts of body) cervical region, and Alzheimer's disease. R39's progress notes identified on: 4/17/26 at 2:45 p.m., R39's family member (FM)-A was planning on taking R39 home tonight with orders to discharge (DC) home on current medications and care plan. Staff noted FM-A had public health contacts he was working with. 4/17/26 at 3:00 p.m., FM-A had changed his plans. He was to take R39 home on a leave of absence through Monday 4/20/26. A bed hold was signed and staff noted they would need a physician's order to DC to home (on leave) with meds and a plan of care, and home care services and/or social services. 4/17/26 at 3:23 p.m., staff noted FM-A was taking R39 home for a 3 day stay with a bed hold in place. Medications were currently being prepared for her home stay. FM-A reported he planned to DC R39 completely from the facility on Monday 4/20/26. FM-A reported he contacted the local home health services as well as another service (Aging Pathways). There was no indication staff verified these services were in place prior to DC on a leave of absence (LOA). 4/18/26 at 12:12 p.m., staff documented FM-A had advised them he contacted Lutheran Social Services for added assistance and not Aging Pathways he originally advised staff about. There was no documentation to support staff verified these services were in place, or that they had offered to set up these services knowing R39 would likely be permanently DC'd. Staff noted they would ask FM-A Monday if he wanted a referral. 4/19/26, R39 and 4 family members arrived at the facility to clean out R39's room for a permanent DC. FM-A advised nursing staff well thank you guys for everything. Everything is out of her room except a few tape blotches on the walls. When asked if staff would see them tomorrow FM-A reported, No I don't think so unless I have to come in and see them up there. and pointed up toward the front of the building at the office area. Well good-bye everyone. A call was placed to the administrator and a message was sent to the director of nursing (DON). There was no documentation to show staff had stopped R39 or FM-A for a discussion on risks to benefits of leaving the facility AMA or ensured they had attempted to ensure R39's safety by verifying appropriate home care was provided. 4/20/26 at 11:25 a.m., the social worker 9SW) noted a follow-up call was placed to FM-A to assess how things were going. FM-A reported things were going well. FM-A advised the SW he had come up the day prior and removed all R39's belongings from her room. and he reported he would formally like to DC R39 from the facility. There was no mention the SW had been aware on 4/18/26 when staff were made aware of R39's DC at that time. The SW further documented a referral was submitted at that time for Aging Pathways to arrange a potential home visit to provide additional resources and support to ensure a successful transition for R39 to her home. There was no indication staff had done this previously when FM-A had made his intentions known of his likely plans on 4/17/26 or had advised R39 and FM-A of the risk to benefit of leaving AMA. Review of the physician notifications faxes identified on: 4/17/26 at 2:45 p.m., a fax was placed to a partner (MD-B) of R39's physician (MD-A) explaining R39 was planning to DC and asking for medications to be sent along with a plan of care. A fax was sent back that same day at 3:40 p.m. with the physician noting AS above .ok. No other comments were made by MD-B. 4/17/26 at 3:00 p.m., another fax was sent noting there was a change of plan, R39 would be leaving on an LOA and it was asked to send medications home with the resident through Monday with a bed hold. Staff requested an order for home care services and a home care social worker referral. A fax was sent back to the facility that same day at 3:54 p.m., from MD-B, replying ok with above. Interview on 9/9/26 at 1:46 p.m., with FM-A identified he advised the facility on 4/17/26 he was taking R39 home. He was not given risks to benefits of doing so. He stated he had to sign a bed hold in order to get medications to make it through the weekend. He was not sure why he had to do that as staff knew he was not bringing R39 back, but he needed her medication. He reported staff spoke about what an AMA was but that was it. FM-A and R39 ran out of money and could not receive Medicaid assistance. He owed the facility approximately 22 thousand dollars and could not afford more. R39 was ok for about a week, when he had to call the ambulance to take her to a regional hospital. R39 stayed at the hospital for almost 1 month. FM-A reported the facility made no attempt to get him services outside of the facility, he had to arrange that on his own. R39 being at home was too much for him originally, but now R39 was on hospice care, and received services at home in that manner. R39 has a long history of mental illness and has been in treatment for years. She weighed about 98 pounds currently and had weighed 200 lbs. prior to her decline (unknown timeframe) with her mental health. FM-A reported he really liked the facility . he just could not afford it anymore. Interview on 9/9/26 at 2:16 p.m., with the administrator identified she was aware of the financial concerns from R39 and FM-A. The facility recommended FM-A take R39 home on a trial basis through the weekend. That is why a bed hold was placed. She agreed R39 and/or her family had not signed an AMA form, nor was there documentation to support risks to benefits were given to them in order to make an informed decision. The previous interim DON has since left the facility and she was unsure if she ever reviewed R39's discharge to see if it had been appropriate. She agreed a risk-to-benefit needed to be given and appropriate services set up. She would try to find out more information. She also was unaware of what a recapitulation of stay was, or a discharge summary. She noted that was likely not in the chart as she was unaware it was a note that documented what R39's care was like in the facility and was required. Staff can call an on-call physician for urgent matters like an AMA versus fax as there is no guarantee when a provider may see the fax. Interview on 9/9/26 at 2:38 p.m. with registered nurse (RN)-A identified she was aware of the AMA with R39 and had documented some of the progress notes. She could not recall what, if any, direction was given for AMA. The SW handled all referrals for services needed at home. Interview on 9/9/26 at 2:56 p.m., with the SW identified she recalled FM-A was taking R39 home on a trial after staff had spoken to him about it. That is when FM-A signed a bed hold. She reported FM-A had some things lined up for home health, but staff had not initially ensured that had occurred when FM-A first identified he was taking R39 home. The SW was aware the facility was required to do a recapitulation of R39's stay and a DC summary, however, they had not been doing so. Review of the 2012, Discharging a Resident without a Physician's Approval policy identified should a resident or representative request an immediate DC, the resident's attending physician was to be promptly notified. If a resident and/or their representative insisted upon being DC without a physician's order, they must sign a release of responsibility form. Should party refuse to sign, it must be documented in the medical record. The DON or charge nurse was to inform the resident and/or their representative about the potential hazards involved in an early discharge. There was no mention on how staff were to identify specific risks or hazards a resident may have if they left AMA. R16's undated, current face sheet identified he had a diagnoses of dementia with agitation, age related cognitive decline, and disorder of the brain. Review of the physician notifications faxes identified on: 6/10/26 at 7:50 a.m., a fax was placed to unknown primary provider explaining that R16 was exit seeking over the past few weeks with increased behaviors. Nursing staff had difficulty redirecting R16 and found that R16 had cut of his wander guard on two occasions. Staff asked if an increase of R16's Seroquel (antipsychotic medication) would help. R16 was ordered to take 12.5 milligrams (mg) at night. 6/10/26 at 4:36 p.m., a fax was sent back from unknown primary provider to check for other signs of infection and to consider a urinalysis (diagnostic test that examines urinary tract infections and kidney disease). If there were no signs or symptoms of infection, staff was to increase R16's Seroquel up to 25 mg by mouth at night. R16's progress notes identified on: 6/10/26 at 7:06 a.m., he attempted to leave the building by placing his walker by the television in the dining room and walked out of the front door. Staff caught him and redirected him back into the building. Staff nurse asked R16 if he had his wander guard on. R16 pointed to his walker and was found attached to his walker. R16 was asked if he was hungry, he replied no. Nursing staff were to keep an eye on R16 and report to the nurse if he attempted to elope again. R16'S family were notified of the incident. There was no mention on the medical record that staff had a discussion on the risk to benefits for increase of the Seroquel. 6/18/26 at 9:48 a.m., the pharmacy review identified the pharmacist made no new recommendations, even though R16'S Seroquel had been recently increased on 6/10/26. 7/02/26 at 2:22 p.m., a care conference was held without R16 in attendance. R16's face sheet was reviewed, and the power or attorney (POA) paperwork was discussed. The note lacked evidence that a risk to benefits was provided for his psychoactive medication. 7/17/26 at 4:30 p.m., The pharmacy review identified no concerns or recommendations at this time and had not still addressed the 6/10/26 increase. 8/11/26 at 3:13 p.m., R16 was seen by his primary provider for exam and medication updates. There was no change to medications or their plan of care. Again, there was no mention on the medical record that staff or primary provider had reviewed the risk to benefits for increase of the Seroquel. R16's June through September 2026, Medication Administration Record (MAR) identified R16 was taking 12.5 milligrams (mg) at night for dementia with agitation. The medication started on 2/5/26 and ended 6/10/26. R16 was to take 25 mg of Seroquel at night with a starting on 6/10/26. July, August, and September identified R16 had received 25 mg of Seroquel nightly. Interview on 9/10/26 at 9:08 a.m., with licensed pharmacist identified consent forms for psychoactive medication changes were to be completed within 30 days after the start of the medication change. She expected the nursing staff to reach out to R16 and his family to ensure education for the Seroquel change had been communicated appropriately. If the consent had not been obtained within the timeframe, in her professional judgment, the Seroquel dosage was to be resumed back to original order. Interview on 9/10/26 at 11:07 a.m., with regional nurse consultant (RNC)-A identified during care conferences psychoactive medications and consents were discussed and reviewed with residents and families. She acknowledged R16's Seroquel consent was not done, prior to his medication order change. Review of 2023, Psychotherapeutic Medications-Use of policy identified psychotherapeutic medications that were ordered required a consent from the resident or resident representative before initiation of the medication. Information regarding effects and side effects were to be provided to the residents and family. The resident and/or resident representative were to be notified regarding medication dosage changes and documented in the resident medical record.

Based on interview and document review, the facility failed to ensure timely notification and documentation was obtained from medical providers and subsequent notification and documentation was given to 2 of 2 residents and/or their perspective admitting facilities upon discharge for 2 of 3 sampled residents (R39 and R40) reviewed for leaving Against Medical Advice (AMA). Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. R39's undated diagnoses sheet identified diagnoses of major depressive disorder, recurrent and severe with psychotic symptoms, generalized anxiety disorder, catatonic disorder due to known physiological condition, schizoaffective disorder, unspecified, neuroleptic induced parkinsonism, bipolar disorder, unspecified, suicidal ideations, age-related cataract, high blood pressure, constipation, moderate protein-calorie malnutrition, fibromyalgia, repeated falls, high cholesterol, osteoarthritis (degenerative joint disease) of knee, difficulty swallowing, age-related osteoporosis, carpal tunnel syndrome, radiculopathy (pain radiating to other parts of body) cervical region, and Alzheimer's disease. R39's progress notes identified on:4/17/26 at 2:45 p.m., R39's family member (FM)-A was planning on taking R39 home tonight with orders to discharge (DC) home on current medications and care plan. Staff noted FM-A had public health contacts he was working with. 4/17/26 at 3:00 p.m., FM-A had changed his plans. He was to take R39 home on a leave of absence through Monday 4/20/26. A bed hold was signed and staff noted they would need a physician's order to DC to home (on leave) with meds and a plan of care, and also home care services and/or social services. 4/17/26 at 3:23 p.m., staff noted FM-A was taking R39 home for a 3 day stay with a bed hold in place. Medications were currently being prepared for her home stay. FM-A reported he planned to DC R39 completely from the facility on Monday 4/20/26. FM-A reported he contacted the local home health services as well as another service (Aging Pathways). There was no indication staff verified these services were in place prior to DC on a leave of absence (LOA). 4/18/26 at 12:12 p.m., staff documented FM-A had advised them he contacted Lutheran Social Services for added assistance and not Aging Pathways he originally advised staff about. There was no documentation to support staff verified these services were in place, or that they had offered to set up these services knowing R39 would likely be permanently DC'd. Staff noted they would ask FM-A Monday if he wanted a referral. 4/19/26, R39 and 4 family members arrived at the facility to clean out R39's room for a permanent DC. FM-A advised nursing staff well thank you guys for everything. Everything is out of her room except a few tape blotches on the walls. When asked if staff would see them tomorrow FM-A reported, No I don't think so unless I have to come in and see them up there. and pointed up toward the front of the building at the office area. Well good-bye everyone. A call was placed to the administrator, and a message was sent to the director of nursing (DON). There was no documentation to show staff had stopped R39 or FM-A for a discussion on risks to benefits of leaving the facility AMA or ensured they had attempted to ensure R39's safety by verifying appropriate home care was provided. 4/20/26 at 11:25 a.m., the social worker SW) noted a follow-up call was placed to FM-A to assess how things were going. FM-A reported things were going well. FM-A advised the SW he had come up the day prior and removed all R39's belongings from her room. and he reported he would formally like to DC R39 from the facility. There was no mention the SW had been made aware on 4/18/26 when staff were made aware of R39's DC at that time. The SW further documented a referral was submitted at that time for Aging Pathways to arrange a potential home visit to provide additional resources and support to ensure a successful transition for R39 to her home. There was no indication staff had done this previously when FM-A had made his intentions known of his likely plans on 4/17/26 or had advised R39 and FM-A of the risk to benefit of leaving AMA. Review of the physician notifications faxes identified on:4/17/26 at 2:45 p.m., a fax was placed to a partner (MD-B) of R39's physician (MD-A) explaining R39 was planning to DC and asking for medications to be sent along with a plan of care. A fax was sent back that same day at 3:40 p.m. with the physician noting AS above .ok. No other comments were made by MD-B.4/17/26 at 3:00 p.m., another fax was sent noting there was a change of plan, R39 would be leaving on an LOA and it was asked to send medications home with the resident through Monday with a bed hold. Staff requested an order for home care services and a home care social worker referral. A fax was sent back to the facility that same day at 3:54 p.m., from MD-B, replying ok with above. Interview on 9/9/26 at 1:46 p.m., with FM-A identified he advised the facility on 4/17/26 he was taking R39 home. He was not given risks to benefits of doing so. He stated he had to sign a bed hold in order to get medications to make it through the weekend. He was not sure why he had to do that as staff knew he was not bringing R39 back, but he needed her medication. He reported staff spoke about what an AMA was but that was it. FM-A and R39 ran out of money and could not receive Medicaid assistance. He owed the facility approximately 22 thousand dollars and could not afford more. R39 was ok for about a week, when he had to call the ambulance to take her to a regional hospital. R39 stayed at the hospital for almost 1 month. FM-A reported the facility made no attempt to get him services outside of the facility, he had to arrange that on his own. R39 being at home was too much for him originally, but now R39 was on hospice care, and received services at home in that manner. R39 has a long history of mental illness and has been in treatment for years. She weighed about 98 pounds currently and had weighed 200 lbs. prior to her decline (unknown timeframe) with her mental health. FM-A reported he really liked the facility . he just could not afford it anymore. Interview on 9/9/26 at 2:16 p.m., with the administrator identified she was aware of the financial concerns from R39 and FM-A. The facility recommended FM-A take R39 home on a trial basis through the weekend. That is why a bed hold was placed. She agreed R39 and/or her family had not signed an AMA form, nor was there documentation to support risks to benefits were given to them in order to make an informed decision. The previous interim DON has since lef the facility and she was unsure if she ever reviewed R39's discharge to see if it had been appropriate. She agreed a risk to benefit needed to be given and appropriate services set up. She would try to find out more information. She also was unaware of what a recapitulation of stay was, or a discharge summary. She noted that was likely not in the chart as she was unaware it was a note that documented what R39's care was like in the facility and was required. Staff can call an on-call physician for urgent matters like an AMA versus fax as there is no guarantee when a provider may see the fax. Interview on 9/9/26 at 2:38 p.m. with registered nurse (RN)-A identified she was aware of the AMA with R39 and had documented some of the progress notes. She could not recall what, if any, direction was given for AMA. The SW handled all referrals for services needed at home. Interview on 9/9/26 at 2:56 p.m., with the SW identified she recalled FM-A was taking R39 home on a trial after staff had spoken to him about it. That is when FM-A signed a bed hold. She reported FM-A had some things lined up for home health, but staff had not initially ensured that had occurred when FM-A first identified he was taking R39 home. The SW was aware the facility was required to do a recapitulation of R39's stay and a DC summary, however, they had not been doing so. R40's undated face sheet identified he was admitted to the facility in September 2023 and discharged [DATE]. R40 had diagnoses of congestive heart failure, iron deficiency anemia (low iron in blood), gastro-esophageal reflux disease (GERD) without esophagitis, pain in the left knee, weakness, high blood pressure, type 2 diabetes, osteoarthritis, abnormal heart rhythms such as sick sinus syndrome, atrial fibrillation, history of a pacemaker for his heart, history of kidney cancer, sick sinus syndrome, chronic atrial fibrillation, lung cancer, enlarged prostate, and chronic kidney disease Stage 4 (severe). R40's progress notes identified on:3/6/26 at 2:49 p.m., staff documented they were notified by R40 and his family member (FM-B), that R40 was moving to an assisted living facility (ALF) in another town. Previously, the original plan was discussed to have R40 and FM-B tour the facility and be assessed for admittance. A DC order was sent to MD-C for his signature. Staff noted they had coordinated care with the ALF, and it was confirmed (unknown how) they were able to accept R40 on 3/7/26 if he chose to proceed. FM-B was noted to have reported the move with the ALF as well. 3/6/26 at 4:37 p.m., staff documented a return fax was received from MD-C regarding a wheelchair order. MD ok with WC order.3/7/26 at 1:34 p.m., R40's family was at the facility and packed up his belongings. FM-B signed an AMA for R40's DC form. The ALF was noted to have called the facility and ask if the facility had received any DC orders. Staff reported they had not and the ALF also reported they had not received any either. R40 ate some lunch and left the facility without any medications at noon. There was no indication what risks R40 had related to his DC, if risks were discussed, or if he was simply given a release of liability AMA form. There was no indication the receiving facility had been given a plan of care to know how to care for R40, if the facility had called the MD and arranged for medication prescriptions, DC orders etc. Review of the 3/6/26 at 2:15 p.m. fax to MD-C identified R40 was DC to the ALF. Staff requested to have a DC order on current medication and plan of care. A return fax was recieved on 3/26/26 at 4:42 p.m., (twenty days later). with remarks Ok from the physician. Review of R40's 3/7/26 AMA form identified it was a blanket AMA form noting the resident had been made aware of the risks and consequences of leaving the facility and the benefits of staying. There was no indication what specific risks R40 had leaving the facility. There was no information on what services R40 required if any, etc. The form was signed by RN-A and FM-B at 11:15 a.m A call was placed to FM-B on 9/9/26 but not returned. Interview on 9/9/26 at 12:12 p.m., with the director of nursing (DON) of the ALF identified the ALF had no idea R40 was moving in. He and his family just showed up at their facility. No papers on how to care for R40, what medications he was on etc. was sent with R40 by the facility staff. Interview on 9/9/26 at 12:31 p.m., with RN-B identified she was aware of the AMA by RN-A. No DC papers were sent with R40 or to the ALF. RN-A was advised to call MD-C however, she was unsure if that occurred. A few days after DC, staff called the ALF. Since the ALF did not ask for anything, facility staff didn't send anything. Interview on 9/9/26 at 12:40 p.m., with the administrator identified there was no recapitulation of stay completed or a DC summary. She was unsure what DC documents were sent to the ALF. She was aware staff faxed notification to the MD but was unsure when the MD had received it. Her DON was out ill and she would have to ask other staff if they knew any more information. Further interview on 9/10/26 with the administrator and regional nurse consultant (RNC)-A identified they agreed with concerns over appropriate notification being sent to physicians for AMA residents. They also agreed R40's ALF should have been sent information on how to care for R40, once it was made known that was where R40 was going. They were not sure on any specific risk to benefits for each resident, as the AMA for is a legal liability release. They thought nursing staff would discuss any risks identified with residents at the time of their signing the AMA. Both agreed the facility needed to do a recapitulation of stay and DC summary for transfers or discharged from the facility, and that had not been done. Review of the 2012, Discharging a Resident without a Physician's Approval policy identified should a resident or representative request an immediate DC, the resident's attending physician was to be promptly notified. If a resident and/or their representative insisted upon being DC without a physician's order, they must sign a release of responsibility form. Should party refuse to sign, it must be documented in the medical record. The DON or charge nurse was to inform the resident and/or their representative about the potential hazards involved in an early discharge. There was no mention on how staff were to identify specific risks or hazards a resident may have if they left AMA. Review of the undated Change of Condition or Status policy received on 9/12/26 identified the charge nurse or supervisor was to notify the physician or on-call physician when a discharge was occurring without proper medical authority. The policy directed staff if it was not an emergency, notifications were to be made within 24 hours of the change. There was no mention an AMA would potentially put residents at immediate risk and/or harm and that notifications should be made immediately via phone.

Based on interview and document review the facility failed to ensure Notice of Medicare Non- Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) was given to 1 of 3 (R27) sampled residents.Findings include:R27's accepted 7/31/26 at 9:35 p.m., Tracking (entry/death record) Minimum Data Set (MDS) identified R27 was a [AGE] year-old male admitted from an acute hospital.R27's, Notice of Medicare Non-Coverage identified services will end on 8/28/26. R27 signed on the form on 8/27/26. Interview on 09/10/2026 at 4:23 p.m., with administrator identified that the clinical consultant was responsible for issuing a Notice of Medicare Non-Coverage (NOMNC) and Skilled nursing Facility Advanced Beneficiary Notice) SNFAB to residents. Her expectation was that the notices would be provided 48 hours prior to last covered day. Review of December 2019, Medical and Nursing Policies and Procedures identified that the NOMNC and SNFABN were to be serviced to the beneficiary or person acting on the beneficiary's behalf no less than 48 hours in advance. A progress note was to be recorded in the medical record once the notices had been served.

Based on interview and document review, the facility failed to ensure 2 of 3 sampled residents (R39 and R40) had a recapitulation of stay describing the resident's course of treatment while residing in the facility and included, but not limited to, their diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results. Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. R39's undated diagnoses sheet identified diagnoses of major depressive disorder, recurrent and severe with psychotic symptoms, generalized anxiety disorder, catatonic disorder due to known physiological condition, schizoaffective disorder, unspecified, neuroleptic induced parkinsonism, bipolar disorder, unspecified, suicidal ideations, age-related cataract, high blood pressure, constipation, moderate protein-calorie malnutrition, fibromyalgia, repeated falls, high cholesterol, osteoarthritis (degenerative joint disease) of knee, difficulty swallowing, age-related osteoporosis, carpal tunnel syndrome, radiculopathy (pain radiating to other parts of body) cervical region, and Alzheimer's disease. R39's 3/30/26, last quarterly, Minimum Data Set (MDS) assessment conducted while R39 was still living at the facility identified R39 had moderate cognitive impairment. R39 had no behaviors, had no impairments to her extremities, but required a use of a walker for ambulation. R39 was independent with eating, required set-up for oral hygiene, was independent with toileting, and required only supervision with bathing and was occasionally incontinent of urine. R39 had a fall without injury since her admission and had had frequent pain for which she received medication. R39 received an antipsychotic, antianxiety, antidepressant medication. R39 had no active discharge planning completed at that time. R39's electronic medical record (EMR) identified there was no documentation to support a recapitulation of stay or had been completed. R40's undated face sheet identified he was admitted to the facility in September 2023 and discharged [DATE]. R40 had diagnoses of congestive heart failure, iron deficiency anemia (low iron in blood), gastro-esophageal reflux disease (GERD) without esophagitis, pain in the left knee, weakness, high blood pressure, type 2 diabetes, osteoarthritis, abnormal heart rhythms such as sick sinus syndrome, atrial fibrillation, history of a pacemaker for his heart, history of kidney cancer, sick sinus syndrome, chronic atrial fibrillation, lung cancer, enlarged prostate, and chronic kidney disease Stage 4 (severe). R40's 2/18/26, last comprehensive, MDS assessment conducted while R40 was still living at the facility identified R40 had no cognitive impairment and had minimal depression with no behaviors noted. R40 had no impairments to his extremities but required a walker or wheelchair for ambulation. R40 was independent with eating, required set-up with oral hygiene, and substantial to maximum assistant by staff for toileting, bathing, dressing, personal hygiene, mobility, and transfers. R40 was frequently incontinent of urine, and occasionally incontinent of bowel. R40 was at risk of developing pressure ulcers and had 1 unhealed pressure ulcer at that time. R40 received blood thinning and diuretic medication. R40's electronic medical record (EMR) identified there was no documentation to support a recapitulation of stay had been completed. Interview on 9/9/26 at 2:16 p.m., with the administrator identified she was unaware of what a recapitulation of stay was. She noted that was likely not in the EMR as she was unaware it was a note that documented what R39's care was like in the facility and was required. Interview on 9/9/26 at 2:56 p.m., with the SW identified the SW was aware the facility was required to do a recapitulation of R39's stay and a DC summary, however, they had not been doing so. Review of the 2016, Transfer or Discharge, Preparing a Resident For policy identified a post DC plan was to be developed for each resident. Nurses were responsible for preparing a DC summary.

Based on interview and document review, the facility failed to send appropriate discharge information for 2 of 3 sampled residents (R39 and R40) including advanced directives, instructions for ongoing care, care plans and goals, or other information to ensure safe and effective transition of care.Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. R39's undated diagnoses sheet identified diagnoses of major depressive disorder, recurrent and severe with psychotic symptoms, generalized anxiety disorder, catatonic disorder due to known physiological condition, schizoaffective disorder, unspecified, neuroleptic induced parkinsonism, bipolar disorder, unspecified, suicidal ideations, age-related cataract, high blood pressure, constipation, moderate protein-calorie malnutrition, fibromyalgia, repeated falls, high cholesterol, osteoarthritis (degenerative joint disease) of knee, difficulty swallowing, age-related osteoporosis, carpal tunnel syndrome, radiculopathy (pain radiating to other parts of body) cervical region, and Alzheimer's disease. R39's 3/30/26, last quarterly, Minimum Data Set (MDS) assessment conducted while R39 was still living at the facility identified R39 had moderate cognitive impairment. R39 had no behaviors, had no impairments to her extremities, but required a use of a walker for ambulation. R39 was independent with eating, required set-up for oral hygiene, was independent with toileting, and required only supervision with bathing and was occasionally incontinent of urine. R39 had a fall without injury since her admission and had had frequent pain for which she received medication. R39 received an antipsychotic, antianxiety, and antidepressant medication. R39 had no active discharge planning completed at that time. R39's electronic medical record (EMR) identified there was no documentation to support a discharge summary had been completed or that information had been sent with R39 and/or their representative. R40's undated face sheet identified he was admitted to the facility in September 2023 and discharged [DATE]. R40 had diagnoses of congestive heart failure, iron deficiency anemia (low iron in blood), gastro-esophageal reflux disease (GERD) without esophagitis, pain in the left knee, weakness, high blood pressure, type 2 diabetes, osteoarthritis, abnormal heart rhythms such as sick sinus syndrome, atrial fibrillation, history of a pacemaker for his heart, history of kidney cancer, sick sinus syndrome, chronic atrial fibrillation, lung cancer, enlarged prostate, and chronic kidney disease Stage 4 (severe). R40's 2/18/26, last comprehensive, MDS assessment conducted while R40 was still living at the facility identified R40 had no cognitive impairment and had minimal depression with no behaviors noted. R40 had no impairments to his extremities but required a walker or wheelchair for ambulation. R40 was independent with eating, required set-up with oral hygiene, and substantial to maximum assistant by staff for toileting, bathing, dressing, personal hygiene, mobility, and transfers. R40 was frequently incontinent of urine, and occasionally incontinent of bowel. R40 was at risk of developing pressure ulcers and had 1 unhealed pressure ulcer at that time. R40 received blood thinning and diuretic medication. R40's electronic medical record (EMR) identified there was no documentation to support a discharge summary was completed or that necessary documentation had been sent via with the resident or via fax to the receiving provider. Interview on 9/9/26 at 2:16 p.m., with the administrator identified she was unaware of what a discharge summary was. She noted that was likely not in the EMR as she was unaware it was a note that documented what, if any, information was sent with R39 and/or family. Interview on 9/9/26 at 2:56 p.m., with the SW identified the SW was aware the facility was required to do a DC summary; however, they had not been doing so. Review of the 2016, Transfer or Discharge, Preparing a Resident For policy identified a post DC plan was to be developed for each resident. Nurses were responsible for obtaining orders, preparing a DC summary, and providing the resident or representative with required documents such as a DC summary and plan, and completing a discharge note in the medical record. There was no mention of sending a receiving facility information.

Based on interview and document review, the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data, submitted to the QAPI committee to ensure Performance Improvement Projects (PIPS) areas identified had oversight and a documented action plan. This had the potential to affect all 38 residents living in the facility. Findings include: Review of QAPI meeting minutes provided from October 2025 through July 2026, identified department heads were bringing data forth to QAPI on various topics such as; infection control with an upward trend of skin infections, data analysis of employee illnesses, resident booster vaccinations, identified requirement of consents needed for psychotropic medication use, prevalence of pressure sore in high-risk residents and worsening or serious resident behavior problems identified. There was no identified PIP project selected in QAPI. Interview on 9/10/26 at 2:23 p.m., with the administrator identified they acknowledged the facility failed to develop and implement a PIP. No policy related to QAPI was provided by the end of survey.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R1 and R8) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC).Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC), Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. R1's accepted 8/26/26 at 11:57 p.m., comprehensive Minimum Data Set (MDS) identified R1 was [AGE] years old with a diagnosis of pneumonia. R1 received PCV-13 on 9/30/15 and PPSV-23 on 1/2/19. Section O-Special Treatments and Programs identified R1's vaccines were up to date. The medical record lacked evidence that R1 was offered or had signed a declination for the vaccine. R8's accepted 7/6/26 at 7:52 a.m., comprehensive MDS identified that R8 was [AGE] years old with a diagnoses of diabetes type 2 and hypertension (HTN). R8 received PPSV-23 on 9/22/08 and PCV-13 on 7/2/16. Section O-Special Treatments and Programs identified R8's vaccines were not up to date. Pneumococcal vaccine was not offered. The medical record lacked evidence that R8 was offered or had signed a declination for the vaccine. Interview on 9/10/26 at 5:01 p.m., with the regional nurse consultant (RNC)-A identified that resident immunizations were to be reviewed annually and as needed to ensure vaccinations were up to date. Review of 2020, Infection Prevention and Control Manual, Pneumococcal Vaccine Program policy identified newly admitted residents were to be screened by licensed nursing staff. If the resident was eligible, education was to be provided, including orders to administer the vaccine. Residents or resident representatives were provided an opportunity to refuse the vaccine and that information was to be placed in their medical record.

Based on observation, interview, and document review the facility failed to revise the care plan with fall interventions following falls for 1 of 3 residents (R3) reviewed for falls. Findings include R3's face sheet dated 10/1/25, identified diagnoses of Alzheimer's Disease (a progressive brain leading to memory loss), diabetes mellitus (a condition where the body does not produce enough insulin), and Parkinson's disease (a progressive neurological disorder leading to movement issues).R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 needed moderate assistance for transfers, had two or more falls since admission, and had severe cognitive impairment.R3's fall risk focus care plan dated 4/30/25, identified R3 was high risk for falls related to history of fall and psychoactive drug use. Goal to not sustain serious injury. Interventions were as followed:-call light within reach and encourage to use if for assistance.-ensure wearing appropriate footwear with non-skid soles and gripper socks on at night.-anticipate and meet my needs.-urinal to be kept at bedside during the night.-dycem (anti-slip mat) applied to wheelchair and recliner to help prevent slipping out of my chair. -chair/bed/recliner electronic alarm. Ensure device is in place as needed.-anti-roll backs on wheelchair.-physical therapy to evaluate and treat as needed. -review information on past falls and attempt to determine cause of falls. Record root causes and alter/remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary team (IDT) as to causes. R3's fall incident report dated 9/3/25 at 1:15 a.m., identified R3 was found lying on the floor in the dining room where he was sitting in his wheelchair with alarm was attached, however, the alarm did not go off as the string was too long. Immediate action taken was R3 to be placed by the nursing station for monitoring. IDT review done on 9/4/25 identified R3 was impulsive and had confusion, does not make needs known and attempts to self-transfer frequently and if R3 was willing to sit by the nursing station with a tray table for his late-night snack and tab alarms shortened. R3's care plan did not identify an intervention that R3 can sit at nurse's station for a snack utilizing a tray table to staff can keep a closer eye on him until 9/30/25.R3's fall incident report dated 9/6/25 at 4:00 a.m., identified R3's was found on his knees next to his bed on the fall mat and had sustained an abrasion to his right knee. IDT review done on 9/8/25, identified that R3 was compulsive and does not utilize the call light and does not state his needs. 1:1 would be ideal, but not feasible in this setting. Family willing to come and sit with resident when restless and irritable. Continue to toilet and reposition every 2 hours. R3's fall incident report dated 9/6/25 at 4:00 p.m., identified R3's alarm sounded, and he was found on his knees in front of his recliner after his tab alarm sounded. R3 stated he was attempting to get out of his chair and without this thing going off and now you caught me. R3 was taken to the day room and had a good rest of the night. IDT review done on 9/8/25 identified R3 was impulsive and does not utilize the call light and does not make needs known and family to sit with him when restless and agitated. R3 had a medication review done on 9/9/25 and no concerns noted. R3's care plan intervention of family to provide 1:1 when available or needed and to continue to be toileted every 2 hours not revised until 9/29/25 .R3's fall incident report dated 9/7/25 at 7:10 a.m., identified R3's was found on knees in front of his bed. R3 was incontinent at the time for the fall. Other information that R3 attempts to get up unassisted and that the bed alarm was sounding. IDT review done on 9/8/25, identified R3 continues to be impulsive and not utilize the call light to ask for assistance and he strives to be independent when R3 needs assistance. Staff will anticipate R3's needs, offer toileting and repositioning and walks to keep comfortable and reduce the amount of self-transfer attempts. R3's care plan intervention of staff to continue to anticipate needs by offering toileting and repositioning every 2 hours and walks to help mitigate irritability and self-transfers not added until 9/30/25. During an interview on 10/1/25 at 11:29 a.m., licensed practical nurse (LPN)-B stated R3 had an alarm on his wheelchair and his bed to alert staff when he attempts to self-transfer, however, R3 still is found on the floor. LPN-B was unable to articulate any further fall prevention interventions being done for R3.During an interview on 10/1/25 at 11:44 a.m., LPN- A stated because R3 falls often, staff keep a close eye on him, however, was unable to articulate how often R3 was checked on. LPN-A stated R3 had an alarm on his wheelchair and bed and was unable to articulate any further fall prevention interventions in place for R3. During an interview on 10/1/25 at 11:50 a.m., director of nursing (DON) stated R3's care plan had not been revised timely to reflect interventions that were discussed at IDT meetings following the falls on 9/3/25. 9/6/25, and 9/7/25 and the care plan should have been revised as soon a discussed, so staff are aware of the needed interventions. Review of the facility's Care Plan's Comprehensive Policy undated, identified an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Implementation as followed:-The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly.

Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and implement/revise the care plan to prevent and/or reduce the risk of falls for 1 of 3 residents (R3) reviewed for falls. Findings include:R3's face sheet dated 10/1/25, identified diagnoses of Alzheimer's Disease (a progressive brain leading to memory loss), diabetes mellitus (a condition where the body does not produce enough insulin), and Parkinson's disease (a progressive neurological disorder leading to movement issues).R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 needed moderate assistance for transfers, had two or more falls since admission, and had severe cognitive impairment.R3's fall risk focus care plan dated 4/30/25, identified R3 was high risk for falls related to history of fall and psychoactive drug use. Goal to not sustain serious injury. Interventions were as followed:-call light within reach and encourage to use if for assistance.-ensure wearing appropriate footwear with non-skid soles and gripper socks on at night.-anticipate and meet my needs.-urinal to be kept at bedside during the night.-dycem (anti-slip mat) applied to wheelchair and recliner to help prevent slipping out of my chair. -chair/bed/recliner electronic alarm. Ensure device is in place as needed.-anti-roll backs on wheelchair.-physical therapy to evaluate and treat as needed. -review information on past falls and attempt to determine cause of falls. Record root causes and alter/remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary team (IDT) as to causes. R3's bowel incontinence focus care plan dated 4/30/25, identified R3 had bowel incontinence related to Alzheimer's disease. Intervention to check resident every 2 hours and assist with toileting as needed.R3's falls risk dated 9/7/25, identified R3 was high- risk for falls due to multiple falls within the last six months; frequently incontinent of bladder; loss of balance with standing; requires hands on assistance to move from place to place.R3's fall incident report dated 9/3/25 at 1:15 a.m., identified R3 was found on the floor in the dining room where he had been sitting in his wheelchair. R3's tab alarm was attached, however, did not go off due to the string was too long. Immediate intervention was R3 placed by the nursing station for monitoring (There was no indication the care plan was revised to include an ongoing intervention to mitigate the risk of falls.) The IDT review done on 9/4/25 identified R3 was impulsive and had confusion, does not make needs known and attempts to self-transfer frequently. Intervention that if R3 would be willing to sit at the nursing station with a tray table for his late-night snack and tab alarms shortened. There was no indication of a comprehensive investigation and analysis to identify causal factors that related to impulsivity and self-transfers was completed and no indication R2's care plan was revised until 9/30/25 with the intervention of the tray table, late night snack, and tab alarms. R3's fall incident report dated 9/6/25 at 4:00 a.m., identified R3 was found on the fall mat in his room. The incident report identified he the causal factors ambulating without assistance but did not include an immediate intervention developed and implemented to mitigate the risk of falls. IDT review was not completed until 9/8/25, which identified that R3 was compulsive and does not utilize the call light and does not state his needs. 1:1 would be ideal, but not feasible in this setting. Family willing to come and sit with resident when restless and irritable. Continue to toilet and reposition every 2 hours. There was no indication of a comprehensive investigation/analysis that addressed mood/behaviors and impulsivity, and the care plan was not revised with interventions that addressed the documented causes of compulsiveness and not using the call light. In addition, even though the report identified 1:1 would be ideal there was no alternatives identified other than the family would assist with supervision, but dates/times were not identified, and the care plan was not revised with the family assistance intervention until 9/29/25. R3's record identified a second fall had occurred on 9/6/25 at 4:00 p.m., This report identified R3's was found on his knees in front of recliner, after tab alarm sounded. Immediate intervention of R3 taken to the day room and had a good rest of the night. R3 record did not include an immediate ongoing intervention developed and implemented to mitigate the risk of falls. IDT review was not completed until 9/8/25 identified R3 was impulsive and does not utilize the call light and does not make needs known and family to sit with him when restless and agitated. R3 had a medication review done on 9/9/25 and no concerns noted. There was no indication of a comprehensive analysis to identify causal factors of the impulsivity was completed and no indication R2's care plan was revised until 9/29/25 with the intervention of family to assist with supervision.R3's fall incident report dated 9/7/25 at 7:10 a.m., identified R3's was found on knees in front of his bed. R3 was incontinent at the time for the fall. Other information added that R3 attempts to get up unassisted and that the bed alarm had been sounding. IDT review done on 9/8/25, identified R3 continues to be impulsive and not utilize the call light to ask for assistance and he strives to be independent when R3 needs assistance. Staff will anticipate R3's needs, offer toileting and repositioning and walks to keep comfortable and reduce the amount of self-transfer attempts. R3's care plan intervention of staff to continue to anticipate needs by offering toileting and repositioning every 2 hours and walks to help mitigate irritability and self-transfers not added until 9/30/25. Additionally although the incident report identified R3 was incontinent at the time of the fall there was no indication R3's toileting program was assessed for appropriateness or fall interventions were effective. R3 's fall incident report dated 9/8/25 at 8:20 p.m., identified R3 was found sitting on the floor in front of his recliner and was incontinent of bowel. R3 self-transferred. IDT review done on 9/8/25, identified R3 continued to have lower extremity edema that required his legs to be elevated. R3 is restless in bed and recliner. 1:1 would be beneficial or sitting in the recliner at the nursing station if he R3 is willing. R3 is impulsive and does not make needs known and staff to continue to anticipate his needs and provide toileting and repositioning assistance. Alarms in place to alert staff that resident is attempting to start a self-transfer. Although potential causal factors of impulsivity and incontinence were identified there was no indication of further assessment of the effectiveness of the fall interventions nor evident new interventions were implemented and developed that addressed the causal factors identified. R3's fall incident report dated 9/30/25 at 7:35 p.m., identified R3 was found on the floor in the dining room. R3 had removed his tab alarm from his jacket. IDT review done on 10/1/25 that IDT reviewed, and root cause identified as resident suffers from confusion and impulsivity and removed his tab alarm and intervention to change the placement to the bottom of his shirt when he is in his wheelchair. During an interview on 10/1/25 at 11:44 a.m., LPN-A stated R3 had an alarm on his wheelchair and his bed, however, R3 continues to have repeat falls. LPN-A stated staff try to keep a close eye on R3 when he is up in his wheelchair, but he is so fast and still falls. LPN-A was unable to articulate any further of R3's fall prevention interventions.During an interview on 10/1/25 at 10:25 a.m., director of nursing (DON) stated R3's falls had not had a comprehensive analysis, causal analysis or root cause determined for each fall and she was not aware that this needed to be done. DON stated IDT does meet to discuss each fall, however, the IDT only reviews the data for each fall and does perform a comprehensive analysis of the falls to determine the root cause of the fall nor create appropriate interventions to mitigate the risk of future falls. DON further stated R3 needed to be 1:1 at times, however, the facility is unable to provide that service, but had not create interventions for R3 to increase supervision. Review of the facility's Falls-Clinical Protocol dated 2/18/24, identified the following:Cause Identification:-For an individual that has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.-If the cause of the falls in unclear, or if a fall may have a significant medical cause, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors.-the staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.Monitoring and Follow-Up: -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling.-If the interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed.-If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions.

Based on observation, interview and document review the facility failed to ensure Enhanced Barrier Precautions (EBP)- (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities), were implemented or followed during a transfer to reduce the risk of infection to others for 1 of 1 resident (R3).Findings include:R3's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses of Alzheimer's disease and diabetes.R3's order summary dated 8/30/25, identified an order to clean wound on top of left foot, apply clean Mepilex (absorbent foam dressing) due to drainage and extremity weeping in the AM and check and make sure the dressing is dry and intact due to weeping and drainage in the PM. R3's care plan was reviewed and did not identify the need for EBP with high-risk cares due to a weeping wound on top of his left foot.R3's Treatment Administration Record (TAR) dated November 2025 identified R3's left foot wound to clean wound and apply clean Mepilex due to drainage and extremity weeping in the AM and check and make sure the dressing is dry and intact due to weeping and drainage in the PM. During an observation and interview on 10/1/25 at 9:09 a.m., upon entrance to the left of R3's door was a paper sign taped to the wall. There were two STOP signs noted. Signage read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following activities. Dressing, Bathing/Showering, Transferring, changing linens, Providing Hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheotomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The sign also had pictures of hand cleanser, gloves, and gown. There was a personal protective equipment (PPE) cart across the hallway observed. Nursing assistant (NA)-B and director of nursing DON walked in R1's room without applying PPE and DON proceeded to apply a gait belt around R3 while her body was touching R3's body. NA-B applied gloves and had R3 stand up, NA-B pulled R3's pants down and put a new brief on R3 and proceeded to change R3's pants as they were wet. NA-B stated she did not use EBP because she thought you only needed to use EBP for emptying a catheter or doing wound change. NA-B further stated R3 was not on EBP because he did not have a PPE cart outside his room but did verify the EBP sign was outside his door.During an interview on 10/1/25 at 9:23 a.m., licensed practical nurse (LPN)-A stated staff should be using EBP with transfers and toileting due to the wound on R3's left foot.During an interview on 10/1/25 at 9:24 a.m., infection preventionist Registered nurse (IP/RN) stated R3 has a wound on his left foot and staff should be using EBP to include gown and gloves with high contact cares like toileting and transfers. IP/RN stated gowns and gloves she be worn by all staff when an EBP sign was on a resident's door. During an interview on 10/1/25 at 10:17 a.m., DON stated she was under the assumption that EBP only needed to be used with wound or catheter cares not with transfers and toileting. Facility policy, Enhanced Barrier Precautions, effective 11/4/24, identified a purpose: This policy aims to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDROs) within [NAME]-[NAME] Manor by implementing Enhanced Barrier Precautions (EBP). This policy seeks to prevent the spread of MDROs among residents and staff members by expanding the use of personal protective equipment (PPE) during high-contact care activities for certain residents. Policy Statement: To implement Enhanced Barrier Precautions to reduce the transmission of multidrug-resistant organisms in [NAME]-[NAME] Manor. EBP- are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Residents on EBP are not restricted to their rooms and are not restricted from participating in group activities or therapy outside of their room. High-contact resident care activities- are activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Examples of high-contact resident care activities requiring gown and glove use for residents on EBP include, but are not limited to: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting (including ostomy care), indwelling medical device care and wound care: chronic wounds. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility.

Based on observation, interview, and document review the facility failed to ensure emergency medications stored in 1 of 1 medication storage room were not expired.Findings include: Observation and interview on 7/23/25 at 12:33 p.m., with licensed practical nurse (LPN)-A of the medication room identified the emergency medication kit (E-kit) was observed sitting on the counter. On the top of the E-kit a sticker was observed that said exp (expiration) 6/27. LPN-A was not certain if that meant the medications in the E-kit expired on 6/27/25 or June of 2027. Observation of the medications inside the E-kit identified 2 Morphine filled syringes 4 milligrams/milliliter (mg/mL). The manufacturers expiration date printed on the syringe was June of 2025. In addition, there were several other medications that had printed medication expiration dates that were listed as expired and handwritten expiration dates that were listed as not expired. LPN-A agreed the medications listed were expired. She was not certain which date they were to use to determine if the medication was expired. Interview on 7/23/25 at 3:31 p.m., with the pharmacy contact person agreed the 2 morphine pre-filled syringes were expired. She identified the printed expiration dates on the other medications were for the prescription and the handwritten expiration dates were for the medications. She agreed it was unclear on the label but stated the staff are aware. Interview on 7/23/25 at 5:15 p.m., with the director of nursing and administrator identified they agreed with the above findings. They would have expected the pharmacy to remove the expired medications from the E-kit to avoid the potential administration of the outdated medications. In addition, they agreed that the expiration dates noted on the other medications in the Ekit were not clearly identified. A policy was requested but nothing was provided by the end of the survey period.

Based on interview and document review, the facility failed to have a thorough, ongoing infection control surveillance program that included resolution of symptoms and/or if any transmission-based precautions (TBP) had been implemented during 3 of 3 months reviewed (April, May, and June of 2025). The facility also failed to identify when employees would be able to return to work after having signs and symptoms of potential Norovirus for 8 of 8 staff (Cook-A, nursing aide (NA)-A, Cook-B, dietary (aide)-A, trained medication aide (TMA)-A, the infection preventionist (IP), NA-B, and TMA-B) reviewed for January of 2025.Findings include: Resident SurveillanceReview of resident surveillance for April, May, and June of 2025, identified a form included the wing of the facility, resident name, and the onset date. The form also listed resident diagnoses of urinary tract infection, lower respiratory infection, upper respiratory infection, skin, blood, gastrointestinal infection, Foley catheter, Other, and fever. There was a place to document signs and symptoms, mental status change, identified organism, X-ray, treatment and dates, and the resolved date. The form had no place to document if any TBP had been implemented or removed or what the resolution date was or if there had been a need to alter treatment. Review of undated, Infection Surveillance policy identified prevention started with routine and ongoing surveillance to identify possible outbreaks and infections before they can spread to others. The facility would establish a system for collecting, analyzing and interpretation of the data to identify infections, risks and outbreaks. Interview on 7/22/25 at 2:20 p.m. with the IP identified she confirmed she had not been documenting a resolution date or had been identifying if a resident was placed on precaution or not on her surveillance.Staff surveillanceReview of staff call in log for January, February, and March of 2025, identified a form the facility was using included an area to document, the report date, employee, vomiting, fever, diarrhea, jaundice, cough/sore throat/runny nose, infected skin lesions, fatigue/body aches, Comments or Other symptoms, date returned to work, and if they had notified the Minnesota Department of Health (MDH). Review of the month of January 2025, identified 8 staff with potential signs and symptoms of Norovirus: Dietary (cook)-A called in on 1/3/25, with vomiting and diarrhea and returned to work on 1/5/25, 2 days later.Nursing assistant (NA)-A called in on 1/7/25 with vomiting and returned to work on 1/8/25, 1 day later.Cook-B called in on 1/8/25 with vomiting and returned to work on 1/9/25, 1 day later.Dietary (aide)-A called in on 1/9/25 with vomiting and returned to work on 1/11/25, 2 days later.Trained medication aide (TMA)-A called in on 1/12/25 with vomiting and returned to work on 1/13/25, 1 day later.Infection preventionist called in on 1/16/25 with vomiting and diarrhea and returned to work on 1/17/25, 1 day later.NA-B called in on 1/22/25 with diarrhea and returned to work on 1/23/25, 1 day later.TMA-B called in on 1/24/25 with diarrhea and returned to work on 1/26/25, 2 days later. Interview on 7/22/25 at 2:20 p.m. with the IP identified staff had Norovirus back in January 2025, but no residents got sick. She agreed staff with signs and symptoms of Norovirus should have been out for a minimum of 48 hours after symptoms resolved according to the facility policy and the Norovirus reported to the MDH. When asked why she returned to work, she reported she did not think she had norovirus but that had not been confirmed by a physician. Continued interview on 7/23/25 at 10:30 a.m., with the IP identified no staff had confirmed norovirus, but she suspected it related to the signs and symptoms staff were calling in for. Staff were not allowed to return to work unless they had been symptom free for 24 hours without medication use. The IP was unaware the MDH required all staff with direct patient care duties, and duties for preparing and serving food were to be kept off work until 72 hours after all symptom resolution. Interview on 7/23/25 at 5:15 p.m., with the director of nursing identified her expectation was that staff followed the facilities policies and procedures for infection control surveillance and for staff illness and return to work. Review of the undated, Employee Illness policy identified examples of possible work restrictions for health care workers, that instructed the facility to contact their state department of health for clarification on work restriction. The policy identified employees with symptoms consistent with Norovirus infection, stay home for a minimum of 48 hours after symptom resolution. There was no indication the policy was reviewed for accuracy. Review of the 2024-2025, Minnesota Department of Health Norovirus information for Long-term care facilities, located at: https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf identified, common symptoms of Norovirus were diarrhea, vomiting, nausea, abdominal pain, low-grade fever, headache, and body aches. By Minnesota state law ([NAME]. Rules part 4605.7050), any pattern of cases, suspected cases, or increased incidence of any illness beyond the expected number of cases in a given period shall be reported immediately to MDH. This includes suspected outbreaks, increases in GI illnesses, or unusual disease activity at your facility. Facilities were to restrict healthcare workers from patient care and food handling duties until 72 hours after their vomiting/diarrhea has ended.

Based on interview and document review, the facility failed to ensure 1 of 1 infection control preventionist (IP) had provided oversight of the infection control program and the antibiotic stewardship program.Findings include: Review of monthly resident surveillance for April 2025 through June 2025, identified columns to document location within the facility, resident name, onset date, type of illness, signs and symptoms, mental status changes, organism, treatment and dates, resolution, and comments. The form lacked a column for antibiotic time-out and/or if precautions were implemented. The form was not completed in full as the resolved date had not been identified and documented. Review of monthly staff surveillance for January 2025 through March 2025 identified columns to document call in date, employee, vomiting, fever, diarrhea, jaundice, cough/sore throat/runny nose, infected skin lesions/ fatigue/body aches, comments or other symptoms, date returned to work, notified health department. The surveillance identified 8 staff that returned to work prior to the recommended work restrictions for potential symptoms of norovirus. Interview on 7/23/25 at 10:30 a.m., with infection preventionist (IP) identified she was unsure how she provided oversight. She documented staff call-ins and symptoms that the staff reported to her. However, the charge nurse was supposed to be completing a call-in form but that had not been getting completed like it was supposed to. For resident surveillance, she reported she reviewed the 24-hour report upon arrival and if a resident had been started on an antibiotic she would go to the chart and review the documentation. For residents who were ill but not on an antibiotic, that information would be documented in the resident progress notes. She only documented residents on antibiotics on the monthly resident surveillance form. She revealed she had no documentation of any follow up for protocols not being followed. There was not an effective process in place to for providing oversight of the programs. Interview on 7/23/25 at 5:15 p.m., with the director of nursing (DON) identified her expectation was that the IP would be providing oversight of both the infection control program and the antibiotic stewardship program. The IP should be monitoring and ensuring the policies and protocols are being followed and if not, educate and implement a plan to correct why not being followed. The DON was unaware the IP was not performing her duties as required. Review of the 2020, Infection Prevention and Control Manual-Infection Surveillance Overview policy identified the intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, Surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention.1.The Infection Preventionist (IP) was to collect and review data on an ongoing basis including:elevations in temperatures/presence of fever,purulent drainage,culture results or other diagnostic test results consistent with potential infections,change in X-ray results consistent with possible infection,increased falls,changes in mental status,changes in vital signs,signs and symptoms of infection based upon nationally accepted surveillance definitions (i.e. CDC/[NAME] Position Statement: Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria or NHSN).2. The Infection Preventionist will ensure data collection to complete a comprehensive Monthly Infection Control Log for surveillance activities on:The infection sitePathogen (if known)Signs and SymptomsResident LocationSummary and Analysis of number of residents and/or staff with infectionsObservations of staff adherence to policies and proceduresIdentification of outcomes that are unusual or unexpected that could potentially lead to patterns, trends or outbreaks 3. The Infection Preventionist and the Infection Prevention and Control Committee were to utilize the information collected from both Process and Outcome Surveillance activities in order to calculate rates and analyze the data to identify opportunities for improved care and process and identify an action plan for follow up and corrective action and reporting.Findings are summarized and reported to the Infection Control (IC) oversight committee and departments that were observed. If indicated, a Performance Improvement Project will be identified and included as part of the QAPI process. A summary of results will be identified to the Quarterly OAA Committee. There was no indication the IP was being overseen by an IC committee.

Based on interview and document review the facility failed to ensure 1 of 5 residents (R1) had a Consent for Psychotropic Medication Use identifying the risks, benefits, and alternative treatments available. Findings include: R1's 5/30/25, quarterly Minimum Data Set (MDS) assessment identified her cognition was intact, she had no signs of significant depression and displayed no behaviors. R1 had diagnosis of dementia and depression, she was administered an antidepressant on a routine basis and required assistance with activities of daily living (ADL)'s. R1's July 2025, Medication Administration Record identified she was administered citalopram 30 milligrams (MG) by mouth daily for major depressive disorder. Interview on 7/22/25 at 3:12 p.m., with registered nurse (RN)-A identified that the facility was to have the resident or resident representative sign a consent for psychotropic medication use when starting a medication. When an order was obtained for a psychotropic medication, the nurse should be reviewing the consent with the resident and/or representative of the risks and benefits and have the consent signed. She confirmed that R1's consent for use of a psychotropic medication for citalopram (an antidepressant), for the diagnosis of major depressive disorder had not been completed. Interview on 7/23/25 at 5:15 p.m., with the director of nursing and administrator identified they agreed with the above findings and would expect staff to ensure residents' who start a new psychotropic medication would be provided the risks, benefits, and alternative treatments available in writing. Review of the undated, Psychotropic Drug Policy and Procedure identified staff would provide the resident/resident representative with the indication, dose, side effects, adverse consequences and goal of treatment. They would obtain the informed consent, and it would be added to the resident's medical record. The consents would be reviewed quarterly at the resident's care conference.

Based on interview and document review the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS-10055 for 1 of 3 residents (R6) reviewed.Findings include: Review of R6's medical record identified she had received skilled Medicare covered services from 11/3/25 through 2/7/25. Review of R6's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) identified services had been discontinued by the facility prior to benefit days being exhausted. R6 had been notified on 2/6/25 that her coverage would end on 2/7/25. Interview on 7/22/25 at 2:13 p.m., with registered nurse (RN)-A identified she was responsible for providing the non-coverage notices to residents and had missed the deadline for providing the notice. Interview on 7/23/25 at 5:15 p.m., with the director of nursing and administrator agreed with the above findings and identified it was their expectation that staff would ensure the SNFABN notices would be provided no later than 2 days prior to the last covered day. Review of the 12/18/19 Issuing the NOMNC and SNFABN policy identified the SNFABN must be served to the beneficiary or person acting on the beneficiary's behalf no less than 48 hours (2 days) in advance. A progress note was to be recorded in the medical record when serving these notices.

Based on interview and document review the facility failed to have 2 of 6 residents (R4, R11) assessed by a physician for need to continue taking an as needed antianxiety medication. Findings include: R4R4's 7/22/25, quarterly Minimum Data Set (MDS) assessment identified R4's cognition was intact and required minimal assistance with cares. R4 took an antianxiety and antidepressant medication. R4's 7/23/25, Medical Diagnosis list identified anxiety disorder, chronic obstructive pulmonary disease with exacerbations, pulmonary emphysema, major depressive disorder, alcohol dependence with alcohol induced anxiety disorder, and chest pain. R4's 7/23/25, Order Summary Report identified an order for Ativan 0.25 milligrams (MG) every 24 hours as needed (PRN) for anxiety started on 4/4/25. R4's 7/1/25, physician visit notes made no mention of a rationale for continued use of her Ativan PRN medication, or review of how often she was needing the medication and if it was effective and there was no documentation to support the physician had reviewed or renewed the Ativan PRN order since 4/4/25. R4's pharmacy reviews from April 29th, 2025, through July of 2025 all identified that a chart review had been completed with no concerns or recommendations. There was no indication that the pharmacist identified there was no end date or review date identified for the Ativan PRN order that had been initiated on 4/4/25. R11R11's 6/20/25, quarterly MDS assessment identified R11's cognition was moderately impaired, and she required extensive assistance with cares. R11 took an antianxiety medication. R11's 7/23/25, Medical Diagnosis list identified a diagnosis of anxiety disorder. R11's 7/23/25, Order Summary Report identified an order for clonazepam (Klonopin) 0.25 mg every 12 hours PRN started on 11/7/24. R11's 5/20/25, physician visit notes made no mentioned of a rationale for continued use of her Klonopin PRN medication or review of how often she was needing the medication and if it was effective and there was no documentation to support the physician had reviewed or renewed the Klonopin PRN order from 11/7/24 to present. R11's pharmacy reviews from November 2024 through July of 2025 all identified that a chart review had been completed with no concerns or recommendations. There was no indication that the pharmacist identified there was no end date or review date identified for the Klonopin PRN order from 11/7/24 Interview on 7/22/25 at 3:12 p.m., with registered nurse (RN)-A identified R4 and R11's psychotropic PRN medications should have been re-assessed every 14 days unless the provider otherwise documented a rationale for use and an extended re-assessment time frame. RN-A felt the charge nurses knew psychotropic PRN medications need to be assessed every 14 days and was unsure why that had not occurred. She would be working on a new system to ensure that was occurring. Interview on 7/23/25 at 12:02 p.m., with consulting pharmacist (RPh) identified she reviewed as-needed medication while completing her monthly review. The RPh confirmed R4 had an order for Ativan PRN. R11 had started Klonopin PRN medication in November 2024. She typically checked psychotropic medications every 6 months and then yearly to see if there needed to be a dose change. The RPh confirmed neither R4 or R11 had a review that she could find since starting the psychotropic PRN medication. When a resident was on a psychotropic PRN medication, she would notify the facility a 14-day assessment needed to be completed. The RPH did not notify the provider of the need, but she did notify the facility, and they were expected to make sure it had been completed. Interview on 7/23/25 at 5:15 p.m., with director of nursing (DON) and administrator identified their expectation was all psychotropic PRN medications would be re-assessed by a physician every 14 days or have a documented rationale for continued use if an extended re-assessment timeframe was to occur. A policy on psychotropic as needed medications was requested but not provided by end of survey.

Based on observation, interview, and document review, the facility failed to develop and implement COVID vaccination policies and procedures to ensure appropriate staff COVID-19 vaccination or exemptions for 3 of 72 staff who were not vaccinated nor had they any approved religious or medical exemption. The facility also failed to develop and implement policy and procedures for mitigating potential transmission of COVID for 15 of 72 staff with approved religious exemptions. The facilities failures resulted in 7 of 27 of residents (R2, R3, R4, R5, R9, R21, and R25) contracting COVID-19. The IJ began on 5/7/22 when 1 of 7 residents (R2) became positive for COVID-19 after repeated staff COVID-19 outbreak infections since December 2021. The facility administrator and director of nursing (DON) were notified of the IJ on 5/26/22 at 3:58 p.m., which was identified as a L-WIDESPREAD. The IJ was removed on 5/27/22 at 2:45 p.m., but non-compliance remained at the lower scope and severity of F-WIDESPREAD, no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: Review of the facility list of residents with COVID-19 infections identified there was 7 residents with COVID 19 from 5/7/22 to 5/10/22. Review of the staff vaccination data identified the facility had a 90% vaccination rate. There were 72 employee's total. Of those 72, 54 were fully vaccinated, but 3 staff had no vaccine or exemption and were providing direct care to residents, and 15 staff were given religious exemptions. Review of the facility COVID-19 positive staff and residents' lists identified on: 1) 12/1/21, 12/15/21, and 12/28/21, there was 1 staff who had tested positive on each day (trained medication aide (TMA)-A, former employee (FE)-A, and business office manager (BOM)-A) 2) 12/29/21, dietary aide (DA)-C tested positive. 3) 12/30/21, laundry aides (LA)-A and LA-B tested positive. 4) 1/6/22, DA-D and TMA-B tested positive. 5) 1/13/22, NA-F and DA-E tested positive. 6) 1/14/22, FE-B tested positive. 7) 1/20/22, NA-G, H-A, NA-H tested positive. 8) 1/21/22, NA-I tested positive. 9) 1/27/22, cook (C)-A, H-B, and TMA-C tested positive. 10) 2/10/22, LA-C tested positive. 11) 2/14/22 and 2/17/22, Minimum Data Set (MDS) nurse (MDS-A) and registered nurse (RN)-B tested positive. 12) 5/7/22, R2 tested positive. 13) 5/8/22, R4, R5, R9 and R25 had tested positive. 14) 5/10/22, R3 and R21 tested positive. 15) 5/12/22, 5/19/22, and 5/23/22, BOM-B, licensed practical nurse (LPN)-B, and activity aide (AA)-A tested positive. Observation and interview on 5/24/22 at 11:35 a.m., with NA-D identified she was unvaccinated and had no exemption. NA-D stated she was required to do 1 PCR and 2 rapid tests per week. She was not told she needed to do any enhanced mitigating factors since she was not vaccinated. NA-D was observed only wearing a routine surgical mask. Interview on 5/24/22 at 12:27 p.m., with MDS-A identified during an IDT meeting approximately 1 year ago, the vaccination policy was created. The administrator was responsible to monitor who was vaccinated, any staff with exemptions. She believed the governing body board members were in charge of granting or declining exemptions. Staff not vaccinated or have exemption had no additional measure to mitigate risk to the residents at the facility. Interview and staff vaccination documentation review on 5/24/22 at 1:54 p.m., with the director of nursing (DON) identified the administrator oversaw staff vaccinations. She was unaware of a process to request an exemption or how staff were to request that. She thought the governing body board reviewed requests once a month for staff that requested an exemption. Unvaccinated staff were not required to use any additional measures of mitigating transmission of potential COVID. She had no vaccination information on contracted physicians. The DON confirmed 3 staff were unvaccinated and had no exemptions. Interview on 5/25/22 at 10:20 a.m., with the medical director (MD) identified he had not been aware of or been asked to discuss any policies on COVID since his last review 2 years ago at the very beginning of the COVID pandemic. Appropriate policies and procedures were not routinely discussed in Quality Assurance Performance Improvement. The MD was aware the facility had a recent resident outbreak, but was unaware of how many residents had been infected. He was also unaware the facility had had staff outbreak since December 2021. He was unaware the facility had no policy and procedures to ensure staff had appropriate vaccinations, exemptions, or mitigating factors to decrease the potential to spread infection of COVID-19. He was also unaware 3 staff had not been vaccinated or had requested and been granted any type of exemption. Interview on 5/25/22 at 3:51 p.m., with RN-B who was the infection preventionist identified all unvaccinated staff were to be tested with 2 COVID antigen tests and 1 PCR test each week. RN-B was unaware of Centers for Medicare and Medicaid QSO memos and unsure of current CDC guidance related to staff vaccination. She agreed the current policy identified offering vaccination and unvaccinated staff were not required to do not do anything extra other than the testing to mitigate transmission of COVID. She was unaware the facility needed to have measures in place for mitigation strategies and a plan to get staff up-to-date on vaccinations. RN-B stated she was new in her role, had received about a week of training . related to infection control (19 hours). The ICP identified most all of the facility COVID policies had not been reviewed since 2020. The current vaccination policy was created in January 2021 related to offering vaccines only. RN-B agreed without mitigating factors to prevent transmission, it could be possible staff had infected residents with COVID in May after having weekly staff COVID outbreaks since December 2021. Interview and COVID vaccination policy review on 5/25/22 at 5:14 p.m., with director of nursing (DON) confirmed the facility's current policy and procedure related to COVID vaccinations only noted the facility would offer vaccinations. It had not been updated to include who would need to be vaccinated, how staff would request and exemption, or how exemptions would be approved, nor did it identify mitigating factors for staff who were not vaccinated to prevent the spread of COVID-19. Review of the 1/27/21, COVID Vaccination Policy identified the facility was to offer COVID vaccines to all residents and staff and document any declination. There was no mention of how the facility would assure they met 100% compliance with staff vaccination or exemption, as recommended by the Centers for Disease Control (CDC). The facility policy did not include a process for implementation of additional precautions to mitigate transmission and spread for those staff unvaccinated, and a method to ensure the facility maintained documentation of who was vaccinated or had received approval for exemption. There was also no process for a contigency plan for those staff who were not fully vaccinated, or how staff would received boosters as recommended by CDC to ensure staff were up-to-date. Further, the policy did not address how the facility was to identify approval or denial of exemptions for staff not wanting vaccination. The IJ was removed on 5/27/22 at 2:45 p.m., when it could be verified by observations, interviews, and document review, the facility had updated existing policies to ensure staff vaccination or exemption were corrected, additional measures were implemented and observed having been put into place to ensure staff who were not vaccinated were using processes to mitigate transmission.

Based on observation, interview and document review, the facility failed to prepare food in a safe manner related to the use of non-pasteurized eggs in the dietary department. This deficient practice resulted in an immediate jeopardy for 2 of 34 residents (R9, R21) for whom undercooked unpasteurized eggs were observed to have been prepared. The preparation of these undercooked eggs placed 2 residents (R9, R21) at risk for the development of the food borne illness, Salmonella Enteritis. This practice had the potential to affect all 34 residents in the facility. The immediate jeopardy (IJ) began on 11/19/15, due to the systemic failure of the facility to appropriately prepare unpasteurized eggs during observation of the breakfast meal, when yellow, runny egg yolks were served to R9 and R21. The practice of serving the undercooked eggs had the potential to cause Salmonella Enteritis. The administrator was notified of the IJ on 11/19/15, at 10:26 a.m. The IJ was removed on 11/19/15, at 1:28 p.m., however, noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During the initial kitchen tour on 11/17/15, at 10:55 a.m. a large box was observed located on the bottom left side of the refrigerator which contained unpasteurized shell eggs. The dietary manager (DM) stated all shell eggs utilized by the facility were unpasteurized due to the egg shortage and difficulty obtaining pasteurized eggs. The DM stated that prior to the egg shortage, only pasteurized eggs had been used for resident consumption. When the facility weekly menus dated August 2015 thru November 2015 were reviewed, it was noted that eggs of choice was listed as an option for breakfast. Review of the facility's Ala Cart Dining menu included, Eggs made to order including Fried, Scrambled, Poached, and Hard Boiled. When interviewed on 11/18/15, at approximately 5:05 p.m. dietary aide (DA)-A confirmed residents could order eggs to their specifications, including fried eggs with a soft yolk and poached eggs. During observation of the breakfast meal on 11/19/15, at approximately 7:15 a.m. R21 was observed to order a fried egg. At 7:25 a.m. dietary staff delivered 1 fried egg to the table where R21 was seated. It was observed when R21 cut into the fried egg, the egg yolk appeared yellow/runny and the yolk spilled out onto the plate. R21 was interviewed at that time and confirmed he preferred his eggs cooked as served (soft yolk). When interviewed on 11/19/15, at 7:28 a.m. the dietary manager (DM) confirmed unpasteurized shell eggs were utilized in the dietary department as well as pasteurized liquid eggs. The DM confirmed R21 preferred his eggs cooked with a soft yolk and therefore staff honored this choice. After the surveyor prompted, the DM requested dietary staff to retrieve the runny egg served R21. DM confirmed she was aware that unpasteurized eggs should be properly cooked but stated there were two residents (R21, R5) who were adamant about wanting their eggs cooked soft/runny. The DM also acknowledged that unpasteurized eggs not cooked properly have a potential for food borne illness. However, DM further indicated she wanted to honor resident choice; and then added when it comes to choice vs. safety - safety should come first. At approximately 7:33 a.m., dietary staff returned after approaching R21 about the undercooked egg and stated R21 wouldn't agree to replace the soft, fried egg with another properly cooked egg. During further observation in the main dining room on 11/19/15, at approximately 7:45 a.m. R9 was observed seated at a table with a plate containing 2 poached eggs. It was observed that as R9 cut into one of the eggs, the yolk spilled out onto the plate with a watery type consistency. On 11/19/15, at 8:00 a.m. DM confirmed she had served R9 two (2) poached eggs per resident request after the surveyor had previously interviewed the DM related to (r/t) unpasteurized egg preparation and the potential for food borne illness. DM indicated she did not want to upset R9 if her request was denied; confirming that R9 always ordered soft poached eggs. DM confirmed she does not routinely check the temperature of eggs unless they are scrambled and further clarified it was not as much of an issue as pasteurized liquid egg products were utilized for scrambled eggs. When questioned further, the DM stated she was unsure of the date the facility stopped ordering/receiving pasteurized eggs; indicating it was possibly this past spring (2015). She stated that at times the facility still received pasteurized eggs from their food source, US Foods, but when pasteurized eggs weren't available, unpasteurized eggs were ordered from the other supplier. The DM also confirmed she had received the memo dated 5/20/14, from CMS related to unpasteurized eggs and the potential for food borne illness. DM stated she had talked to a small group of residents, including R9 and R21 individually, about the potential risks of food borne illness when consuming soft cooked unpasteurized eggs. However, the DM confirmed such education had not been documented in the resident's records nor in staff meeting minutes. When interviewed on 11/19/15, at 8:14 a.m. R9 was asked whether staff had spoken with her related to the potential risk for food borne illness when ordering soft cooked eggs. R9 responded it didn't matter as the eggs used by dietary were pasteurized. When R9 was informed the eggs served were unpasteurized, R9 stated she was unaware of this and then responded it didn't matter because she was going to die of something and wanted her eggs cooked according to her choice. When interviewed on 11/19/15, at 8:15 a.m. R21 confirmed he always orders his eggs with a soft yolk and if unable to have them cooked per his preference, he probably wouldn't eat them. R21 stated staff may have discussed unpasteurized egg use but he still preferred them cooked to his specifications anyway. Review of the facility's food vendor invoices dated 10/15/15, 10/22/15, 10/29/15 and 11/5/15, indicated each shipment included 15 dozen shelled unpasteurized eggs. The invoices did not include any orders for shelled, pasteurized eggs. Review of previous food vendor invoices dated 9/24/15, 10/1/15, 10/8/15, also did not include shelled, pasteurized eggs but only unpasteurized eggs. Review of the food vendor invoice from the facility's other supplier, dated 9/30/15, 10/21/15, 11/4/15 and 11/11/15, also did not include any orders for shelled, pasteurized eggs. A facility undated Food Preparation policy included: 3. Egg, Cheese, Dairy Cookery a. Eggs 1) Use low to moderate heat. 2) Cook eggs until white and yolk are firm, not runny. 3) Recommend purchasing pasteurized or vendor guaranteed salmonella free eggs. 4) It is strongly recommended that soft cooked and poached eggs should not be offered to clients who may be susceptible to infections. 7) Poached (not recommended because of risk of salmonella infection) ·Water should be simmering, not boiling. ·Simmer 5 minutes to reach internal temperature of 145° F for 15 seconds. Cook until yolk and white are no longer liquid. · Inform and document, re., the risk of salmonella infection with clients who request poached eggs. The immediate jeopardy that began on 11/19/15, was removed on 11/19/15, when it was determined the administrator had provided education to the dietary manager regarding the use of unpasteurized eggs; had revised facility policies to reflect the facility will purchase and use only pasteurized eggs in all food preparation; had purchased pasteurized eggs for immediate use; had a plan in place for auditing food orders weekly to ensure the facility is only purchasing pasteurized eggs for food preparation; and had established monthly auditing by the registered dietician to ensure the facility is only using pasteurized eggs for facility's food preparation.

Based on interview and document review the facility failed to ensure residents received scheduled insulin and sliding scale insulin as ordered by the physician for 1 of 3 residents (R1) reviewed for insulin administration. R1 was hospitilized for mild diabetic ketoacidosis an uncontrolled diabetes mellitus. Findings include: R1's medical record was reviewed and revealed that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The insulin orders included [MEDICATION NAME] 80 units to be administered in the morning and [MEDICATION NAME] 40 units to be administered at night. The admission orders [REDACTED] For a BS of 80 = hold insulin and recheck in 10 minutes For a BS of 81-100 = administer 2 units of Humilin R insulin For a BS of 101-150 =administer 4 units of Humilin R insulin For a BS of 151-200 = administer 6 units of Humilin R insulin For a BS of 201-250 = administer 8 units of Humilin R insulin For a BS of 251-300 = administer 10 units of Humilin R insulin For a BS of 301-350 = administer 12 units of Humilin R insulin For a BS of 351-400 = administer 14 units of Humilin R insulin For a BS of 401-450 = administer 16 units of Humilin R insulin "45 call MD give 16 units" Review of R1's September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s sliding scale insulin was not transcribed from the admission orders [REDACTED]. R1's blood sugar readings were recorded on the September 2013 medication administration sheet and R1 missed the following 7 of 7 doses of sliding scale insulin between 9/24/2013 and 9/26/2013: 9/24/2013 at 5:00 p.m. - BS 200 - no sliding scale insulin was administered 9/24/2013 at bedtime (H.S.) - BS 275 - no sliding scale insulin was administered 9/25/2013 at 8:00 a.m. -BS 235 - no sliding scale insulin was administered 9/25/2013 at 12:00 p.m. - BS 399 - no sliding scale insulin was administered 9/25/2013 at 5:00 p.m. - BS 325 - no sliding scale insulin was administered 9/25/2013 at H.S. - BS 507 - no sliding scale insulin was administered Review of R1's September 2013 blood sugar readings reveal that R1's blood sugar was checked according to physician orders [REDACTED]. Review of the blood sugar readings from 9/24/2013-9/26/2013 reveal blood sugar readings ranging from 200-507. A progress note dated 9/26/2013 at 8:00 a.m. revealed that R1 left the facility at 7:30 a.m. for an appointment. Prior to leaving the facility for the appointment the resident did not receive his/her a.m. blood sugar check or a.m. dose of [MEDICATION NAME]. This information was given to R1's primary physician as well as the facility where R1 had the appointment. A progress note dated 9/26/2013 at 11:00 a.m. revealed that R1 had a blood sugar reading of 427 and electrolytes were "off balance". R1 was admitted to the hospital on [DATE]. Hospital documentation from 9/26/2013 reveals that the resident went to an appointment at the clinic where labs were drawn revealing a sodium level of 122 and a glucose level of 447. The resident was admitted to the hospital on [DATE] with the following Diagnosis: [REDACTED]. The resident remained hospitized overnight and returned to the facility on [DATE] with a change in insulin orders. Interview with an administrative nurse (RN-A) on 10/2/2013 at 11:56 a.m. confirmed that R1 came with an admission physician's orders [REDACTED]. RN-A also confirmed that from 9/24/2013-9/26/2013 R1 did not receive sliding scale insulin and that the morning of 9/26/2013 R1 did not recieve R1's scheduled blood sugar check or dose of AM [MEDICATION NAME] and was later hospitilized for elevated blood sugars. An undated facility policy entitled "Medication Orders" states that "the nurse receiving the medication order should question the physician whenever orders are ambigous or are uncommon".