Every finding on record at Good Samaritan Society - Mountain Lake

Based on observation, interview, and document review, the facility failed to reconcile liquid controlled narcotic medications in 1 of 2 medication cart to prevent potential diversion for 5 sampled residents (R7, R8, R26, R36, and R53).Findings include: Observation and interview on 8/11/26 at 2:13 p.m., with registered nurse (RN)-B and licensed practical nurse (LPN)-A as they completed the change of shift narcotic count. RN-B counted the narcotic pills located in the medication cart locked box while LPN-A confirmed the count. RN-B finished with the narcotic pills and proceeded to shut and lock the lock box located in the medication cart and then lock the medication cart. RN-B did not pick up or confirm the amount of 7 bottles of liquid narcotic medications also located in the locked box. RN-B stated, we don't count morphine as it is hard to tell as a liquid, RN-B did confirm the facility documented in the narcotic book when they administered the liquid narcotic medications. Located in the locked box within the medication cart that was not reconciled was:R7's Morphine liquid 20 milligram (mg)/per milliliter (ml), 21.5 mlR8's Morphine liquid unknown strength, 24 mlR23's Morphine liquid 20 mg/ml, 28.25 mlR26's Codeine liquid solution, 68 mlR36's Morphine liquid 100mg/5ml, 23.5 mlR36's Morphine liquid100mg/5ml (2nd bottle), 25.75 mlR53's Lorazepam liquid solution, 30 mlLPN-A confirmed that the facility had not been verifying the liquid narcotic medication. Interview on 8/11/26 at 2:20 p.m., with RN-C reported all the narcotics should be reconciled including the liquid narcotics. Everything that was in that locked box should be counted to confirm the correct amount remained. Interview on 8/11/26 at 2:22 p.m., with RN-A confirmed all narcotics should be counted shift to shift to verify the amount. She would expect that each nurse completed narcotic counting would be checking all controlled medications. Interview on 8/11/26 at 2:57 p.m., with director of nursing (DON) identified nurses should be counting all narcotics shift to shift between 2 staff. Liquid narcotics should be counted even though they can be hard to count. She was not aware that the nurses were not counting the liquid narcotics and stated, I wonder how long they have not been doing that. She confirmed that staff are to count each narcotic medication liquid or pill to confirm amount. Interview on 8/12/26 at 11:21 a.m., with regional clinical service director identified she would expect that the facility was reconciling all controlled medications shift to shift to monitor for diversion. Staff should be taking each medication out of the locked box and verifying the count including the liquid medication. Interview on 8/12/26 at 1:48 p.m., with consulting pharmacist identified she would have expected that the facility staff would be reconciling all controlled medication. She revealed she did quarterly medication pass audits; however, was not usually there at time of narcotic count between shifts but when she was there, she would review the narcotic book. She would expect a system to be in place to count and monitor all controlled medications for potential diversion. Review of the 6/30/26, Medications: Controlled policy identified reconciliation was a system to monitor controlled medication. All controlled medication would be verified when delivered and documented in the bound narcotic record book. Each time the keys that secured the controlled medication locked box the oncoming and off-going nurse/medication aide would reconcile all the controlled medications to ensure the count matched the remaining amount listed.

Based on interview and document review the facility failed to notify the ombudsman of 1 of 2 (R49) sampled resident discharges. Findings include: R49's 6/17/26, accepted discharge Minimum Data Set (MDS) assessment identified R49 was discharged to his home/community with return not anticipated. R49's 6/25/26, discharge summary identified he was independent with activities of daily living (ADLS) following completion of skilled physical and occupational therapies. His cognition was intact, and the decision was made to transfer to Assisted Living following discharge. Interview on 8/11/26 at 10:29 a, m. with registered nurse (RN)-D reported R49 had originally transferred from the [NAME] facility where he was originally admitted following hospitalization. He was admitted for skilled therapies, and following completion he and his family made the decision to discharge to the local Assisted Living facility. Interview on 8/12/26 at 8:09 a.m. with the director of nursing (DON) and licensed social worker (LSW) identified they were not aware the ombudsman was supposed to be informed when residents voluntarily discharged to the community, and as a result had not done so. Email response on 8/12/26 at 10:36 a.m. from the Ombudsman reported she had reviewed documentation she had received from the facility, and she was only being informed of residents that went to the hospital. She identified she should have been notified of all resident discharges and transfers regardless of the destination. Interview on 8/12/26 at 1:02 p.m. with the administrator reported she was not aware appropriate notifications of transfers or discharges were not being provided to the Ombudsman. She identified her expectations for the notification requirements to be followed. Review of January 15, 2026, Discharge and Transfer policy identified when a resident was transferred or discharged , the location must send a notification to the Office ofthe State Long-Term Care Ombudsman.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, depending upon their symptoms for 2 of 3 sampled staff (nursing assistant (NA)-B with gastrointestinal illness.Findings include: Review of the 2024-2025 Norovirus Information for Long-term Care Facilities, located at, https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf, identified Norovirus is transmitted through a fecal (stool)-oral route with symptoms of diarrhea, vomiting, nausea, abdominal pain, low grade fever, headache, and or body aches. Individuals generally become ill 12-48 hours after exposure (swallowing Norovirus). Infected individuals shed the virus in their stool and contaminate food, surfaces, and objects and can be shed in the stool for several weeks after recovery. Products used to clean Norovirus must say they are effective against Norovirus. Hand sanitizer does not work to kill the virus. Individuals should wash their hands for 20 seconds with soap and water. Individual cases of Norovirus are not reportable to the State, however, possible outbreaks or multiple cases with Norovirus-like symptoms must be reported. Documentation of possible outbreaks was to include: Use the RESIDENT ILLNESS LOG and STAFF ILLNESS LOG to document illnesses among staff and residents/patients:Contact managers of each unit, etc. as necessary to gather illness information. Send both ILLNESS LOGS back to MDH within 2 business days of reporting the suspected outbreak. Epidemiology staff will use this to assess A) which pathogen is causing the outbreak, B) the likely route of transmission, and C) whether additional prevention measures are needed.Gather additional informationList activities, events, etc., held during the week prior to the first illness (especially if food was served).Determine when and where there were any vomiting incidents or diarrheal accidents in the facility.If requested by MDH, provide a dietary menu (breakfast, lunch, and dinner).If requested by MDH, provide names and phone numbers for staff and/or residents (in rare cases, MDH may want to conduct interviews).Collect a stool sample from three (3) residents and/or staff and send to MDH Laboratory for analysis (MDH will provide specimen collection kits; the testing is free of charge). If stools from residents or staff were sent to a clinical laboratory, notify MDH of any results.Send both completed ILLNESS LOGS back to MDH between 1 and 2 weeks after the last illness.IMPLEMENT OUTBREAK CONTROL MEASURES:Monitor for resident illness (record on RESIDENT ILLNESS LOG) and when possible, isolate residents while they are ill and for 72 hours after symptoms have stopped. Consider halting new admissions until the outbreak has ended. Exclude actively ill residents from games/activities where touching common items occurs (e.g., checkers, cards).Monitor for staff illness (record on STAFF ILLNESS LOG) and restrict ill staff/volunteers from patient care and food handling duties until 72 hours after their vomiting/diarrhea has ended. Review of the current, undated Centers for Disease Control (CDC) Norovirus guidelines, located at https://www.cdc.gov/norovirus/index.html, identified Norovirus is a very contagious virus that causes vomiting and diarrhea. It is sometimes called the stomach flu or the stomach bug. However, norovirus illness is not related to the flu. The flu is caused by the influenza virus. Norovirus causes acute gastroenteritis, an inflammation of the stomach or intestines. Most people with norovirus illness get better within 1 to 3 days; but they can still spread the virus for a few days after. Most common symptoms: Diarrhea, vomiting, nausea, stomach pain. Other symptoms: Fever, headache, and body aches. Food workers should stay home when sick and for at least 48 hours after symptoms stop. This also applies to sick workers in schools, daycares, healthcare facilities, and other places where they may expose people to norovirus. Review of the March 2026 through June 2026, Employee Absence [NAME] Report, Employee Call out logs, and comparative timesheets identified:LPN-A was noted to have called in to work with symptoms of diarrhea (loose watery stool) on 3/21/26. LPN-A reported to be absence/[NAME] on 3/22/26. Employee timesheets identified LPN-A returned to work on 3/24/26. There was no indication LPN-A had been screened prior to coming back to work to ensure they had been removed from patient contact for 48-72 hours after symptoms resolved. NA-B was noted to have called in to work with symptoms of nausea, vomiting and diarrhea on 6/20/26. NA-B was reported to be absence/[NAME] on 6/20/26 with symptoms of a sore throat, nausea, vomiting, and diarrhea. Employee timesheets identified NA-B returned to work on 6/21/26. There was no indication NA-B had also been screened prior to coming back to work to ensure they had been removed from patient contact for 48-72 hours after symptoms resolved. Overall, there was no mention on the Absence/[NAME] Reports when or if LPN-A or NA-A's symptoms resolved prior to returning to work. The section at the bottom of the report sheet to identify if an employee was clear to work was left blank. Interview on 8/12/2026 at 11:52 a.m., with registered nurse (RN)-C, who is the Infection Preventionist (IP) revealed both director of nursing (DON) and IP tracked employee call outs and illnesses electronically. She acknowledged she provided oversight and did not implement appropriate monitoring of employee illnesses when they occur. Interview on 8/12/2026 at 12:50 p.m., with DON stated the employee Absence/[NAME] Report sheet was used to track employee illnesses at the facility. She acknowledged the sheet should have been filled out appropriately to determine whether an employee illness was resolved and/or if it was clear for the staff to return to work. Review of 9/23/25 Employee Health Conditions Reporting and Managing, Infection Control-Rehab/Skilled, Senior Living policy identified the administrator, or designee was responsible to ensure supervisors and staff were trained and understand the importance of reporting and managing employee illness and symptoms. Employees were to consult their supervisor to evaluate the condition and consult the IP, if available. Employees returning after an illness were to consult their supervisor and the supervisor may involve clinical members, such as the IP, DON, or a licensed nurse. Review of 3/25/26 Identification/Surveillance, Management, and Reporting of Suspected/Confirmed Infections, AL, R/S, LTC, Home Health, Hospice policy identified the IP or appointed designee, was to review additional information to identify indicators of infection, collect data to confirm/suspected infections, such as employee illness records to determine disease and/or outbreak reporting requirements.

Based on interview and document review the facility failed to follow care planned fall interventions for 1 of 3 residents (R5) reviewed for falls. This resulted in actual harm when R5 fell and required a visit to the emergency department resulting in a fractured left femur and needed surgical intervention. The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment, needed substantial to maximal assistance with toileting, and needed partial to moderate assistance with toilet transfersR5's Face Sheet dated 6/23/23, indicated R5 had dementia.R5's care plan with intervention revision dated 7/16/25, indicated R5 had an actual fall with no injury related to poor vision and unsteady gait. Intervention included: staff to toilet resident during 4:00 a.m. rounding. R5's fall tool dated 8/31/25, indicated R5 was at high risk for falls.R5's Emergency Department (ED) note dated 1/28/26, indicated R5 had a fall resulting in a closed fracture of left hip.R5's [NAME] Accountability For Excellence (SAFE) Event- Incident Report dated 1/28/26, indicated at 6:15 a.m., R5 had a fall, was sent to the ED and X-ray verified a left hip fracture.R5's progress notes dated 1/28/26:6:15 a.m., R5 was found on the floor and stated she was trying to use the bathroom.6:30 a.m., indicated R5 was complaining of left hip, knee, and leg pain.7:51 a.m. R5 was sent into the ED.9:58 a.m., facility was notified R5 had a left hip fracture. R5's Orthopedic Surgery note dated 1/29/26, indicated R5 had a closed displaced left femoral neck fracture and needed a left hip hemiarthroplasty (femoral head joint replacement).During an interview on 4/22/26 at 3:15 p.m., R5 stated she had a fall in 1/2026 but could not recall the date. R5 hurt her left leg and had to go to the hospital. Before the fall R5 was trying to get up to go to the bathroom. R5 did not think staff offered to take her to the bathroom before her fall.On 4/23/26 at 12:30 p.m., nursing assistant (NA)-A stated on 1/28/26 between 2:00 a.m. and 4:00 a.m., NA-A checked on R5 but did offer toilet assistance to R5. NA-A stated she was not aware R5 needed to be toileted during 4:00 a.m. rounds because it was not on R5's Kardex. NA-A stated she did not look at the care plan prior to her shift. NA-A stated she should have looked at R5's care plan prior to caring for R5.On 4/29/26 at 2:40 p.m., nurse practitioner (NP)-A stated the fall R5 had could have been prevented if staff would have followed the care plan and toileted R5 during 4:00 a.m. rounds.On 4/29/26 at 3:42 p.m., director of nursing (DON) stated staff are expected to follow resident care plans. DON put the intervention to toilet R5 during 4:00 a.m. rounds in R5's care plan. DON thought the intervention was on R5's Kardex but it was not. The facility now double checks the Kardex to ensure all interventions are in place.On 4/29/26 at 4:07 p.m., administrator stated staff are expected to follow the care plan. The administrator was made aware R5's toileting intervention was not on the Kardex after discussion with the DON.The facility Fall Prevention and Management policy revised 3/31/26, indicated the facility would communicate fall interventions to prevent a fall per the 24-hour report, care plan and Kardex.The facility implemented corrective action to prevent recurrence by 2/3/26 when the facility completed the following: provided education to all nursing staff on updating interventions, following care plans, and fall risks, reviewed all high fall risk residents and updated care plans, and completed high fall risk audits to ensure fall interventions were care planned and pulling to the resident Kardex. Verification of corrective action was confirmed by observation, interview, and document review on 4/22/26 and 4/29/26.

Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R3) reviewed for medication errors. This failure resulted in actual harm for R3 when she developed bradycardia (abnormally slow heart rate) which required ongoing monitoring and intravenous therapy in the emergency department (ED). The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. R3's Face Sheet dated 10/23/25, indicated R3 had dementia and Alzheimer's Disease. R3's [NAME] Accountability For Excellence (SAFE) Event Incident Report dated 3/25/26, indicated R3 was found with another resident's crushed medications in a drink. R3 became sleepy and was sent to ED. R3's Weights and Vitals Summary dated 3/25/26, indicated R3's pulse was 47 beats per minute (BPM) at 6:11 p.m. At 6:44 p.m., R1's pulse was 40 bpm. On 3/25/26 R3's progress note indicated: 5:23 p.m., R3 was sitting at the dining table across from another resident who had crushed medications in a glass of liquid. R3 was seen with the glass of liquid in her hand. After ten minutes, R3 was sleeping at the dining room table. 5:45 p.m., poison control was called due to R3 getting an unknown amount of high dose blood pressure medication, facility was directed to send R3 to the ED if her pulse dropped below 45 consistently. 6:30 p.m., pulse continued to decrease 42-44 BPM and at times dropped to upper 30's, R3 was sent to ED for hydration. R1's Emergency Department Note dated 3/25/26, indicated R3 was at the table in the dining room and took another residents medications: valproic acid (seizure medication) 125 milligrams (mg)/ 5 milliliters (mL); carbidopa/ levodopa (Parkinson's disease medication) 25/100mg; glycopyrrolate (peptic ulcer medication) 1mg; metoprolol (high blood pressure medication) 75mg; and Remeron (antidepressant) 7.5mg. R3 was lethargic and diagnosed with medication overdose. R3 was given intravenous normal saline 500 mL bolus with glucagon (diabetes medication) 5mg. R3's pulse had dropped to 37bpm consistent with metoprolol ingestion. During an interview on 4/22/26 at 4:13 p.m., registered nurse (RN)-A stated he got R4's medications ready in a glass of liquid and set the cup in front of R4 then RN-A walked away. R3 grabbed R4's glass of crushed medications and drank out of the glass. R3's pulse started to decrease so R3 was sent to the ED. RN-A stated he should not have left R4 alone with his medications. RN-A stated he should have stayed with R4 until all of his medications were taken. On 4/29/26 at 2:40 p.m., nurse practitioner (NP)- A stated if the facility would have followed the medication administration policy and procedure R3 would not have ingested R4's medications and would not have been sent to the ED. R3's pulse was normally around 60 bpm so a pulse of 37 bpm was concerning. On 4/29/26 at 3:01 p.m., consultant pharmacist (CP)-A stated R3's pulse being above 50 bpm would not have been concerning but a pulse of 37 bpm was concerning. Glucagon was given to R3 to reverse the effects of the metoprolol overdose. On 4/29/26 at 3:42 p.m., director of nursing (DON) stated staff would be expected to stay with the resident when taking medications unless they were assessed and had orders to take medications alone. RN-A should have never left R4's medications on the table, RN-A should have stayed with R4 until his medications were taken. On 4/29/26 at 4:07 p.m., administrator stated staff were expected to stay with residents when giving medications until they were taken, unless the resident was assessed and safe to take medications alone. R4 was not safe to take medications alone. The facility Medication Administration policy revised 3/30/26, indicated staff would not leave medications with a resident unless a specific physician order was in place to do so and the resident was evaluated for self- administration of medications. The facility implemented corrective action to prevent recurrence by 3/31/26, when the facility completed the following: provided education to all staff members responsible for medication administration, which included administration of medications and self-administration of medication, observed all residents with self- administration of medication orders and updated care plans, and completed medication administration audits. Verification of corrective action was confirmed by observation, interview, and document review on 4/22/26 through 4/29/26.

Based on interview and record review the facility failed to develop/implement the care plan to include vulnerabilities for 3 of 3 residents (R1, R2, R3) who's care plans were reviewed for comprehension.R1R1's Face Sheet dated 2/16/22, indicated R1 had dementia and mild cognitive impairment. R1's Minnesota Vulnerable Adult Assessment (MVAA) dated 2/19/26, indicated R1 was unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs. R1's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R1: unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.R2R2's Face Sheet dated 10/9/2023, indicated R2 had mild cognitive impairment.R2'S MVAA dated 2/27/26, indicated R2 was unable to defend self from verbal and physical attacks and was unable to manage financial affairs. R2's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R2: unable to defend self from verbal/physical attacks and manage financial affairs. R3R3's Face Sheet dated 10/23/25, indicated R3 had dementia, disorientation, and Alzheimer's Disease.R3's MVAA dated 4/8/26, indicated R3 was unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.R3's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R3: unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.During an interview on 4/23/26 at 12:30 p.m., nursing assistant (NA)-A stated she would look at the resident care plan or Kardex for needs a resident might have and how to meet those needs.During an interview on 4/23/26 at 1:23 p.m., NA-B stated on 4/11/26 around 10:00 p.m., she went into R1's room and found R2 in his wheelchair on the right side of R1's bed, with R1 lying in bed with R1's pants down and brief to the side. R2 was touching R1's vaginal area with his left hand. R1 had her eyes closed but R1's eyebrows were scrunched together. NA-B stated she was surprised by this observation. NA-B stated she left R1 and R2 in the room to get the nurse. NA-B did not stop the interaction. NA-B stated she would look in a resident care plan or Kardex for any resident needs or interventions.During an interview on 4/29/26 at 1:45 p.m., Social Services (SS)-A stated she would complete the MVAA and once complete she would address the findings in the care plan. SS-A stated there was nothing in the care plan about vulnerabilities specifically because it was assumed everyone was a vulnerable adult and the facility treated all residents as such.During an interview on 4/29/26 at 3:42 p.m., director of nursing (DON) stated SS-A would be responsible for completing the MVAA. All vulnerabilities should be care planned.The facility Comprehensive Care Plan policy revised 12/29/25, indicated the facility would develop a person-centered care plan that would meet the residents physical, mental, spiritual, and psychosocial well-being.

Based on interview and document review, the facility failed to notify the resident representative and the medical provider following discovery of a deep tissue injury (DTI) (pressure injury where damage occurs to the underlying tissue before becoming visible on skin surface) for 1 of 1 resident (R196) reviewed for notification of change. Findings include: R196's Face Sheet printed 7/2/25, included diagnoses of cerebral infarction (stroke), pressure ulcer of sacral region unstageable (a type of pressure injury where the depth of wound cannot be determined because the wound bed is obscured by slough or eschar [black or brown layer of dead tissue]). R196's admission (MDS) assessment dated [DATE], indicated R196 had intact cognition, understands and is understood, and had no behaviors. R196 required partial to moderate assist for bed mobility and transfers and substantial to maximum assist for walking 10 feet. R196 had no known weight loss or gain or chewing/swallowing issues. R196 was not at risk for pressure ulcers (PU) and had no current PU's but did have skin tears present. R196's care plan dated 4/24/25 included impairment to skin integrity on left lower leg, bruising, small openings; appears to be trauma related; skin is also very fragile with bruising upon admission. Interventions included keep skin clean and dry, use lotion on dry skin. Weekly skin observation by licensed nurse. R196's plan of care was updated on 5/9/25, to include the resident has a suspected DTI with open area of coccyx related to immobility and resident prefers to lie on back in bed and spend a large amount of time in wheelchair. Interventions included low air loss air mattress; Roho cushion (used to prevent/treat pressure ulcers PU's); encourage resident to reposition side to side in bed; encourage and assist to turn and reposition at least every 2-2.5 hours when in bed related to current PU and high risk for further skin injury; encourage resident not to be in wheelchair longer than 3 hours if can be avoided. A Skin Assessment by licensed practical nurse (LPN)-A dated 5/7/25, included coccyx and buttocks are reddened and top of coccyx has a dark red area that is still blanchable. A Wound Data Collection by registered nurse (RN)-A dated 5/9/25, included initial data collection on the coccyx. No dressing present with area dark purple surrounding open area; red and excoriated skin distal to open area with bleeding this a.m. A Wound RN Assessment by RN-A 5/9/25, included physician was notified regarding wound status. A provider order signed by nurse practitioner (NP)-B included wound care for coccyx: cleanse area well and pat dry. Apply skin prep to surrounding skin. Warm 2x2 hydrocolloid dressing (2 layer dressing that absorbs drainage to form a hydrated gel over the wound to create a moist environment to promote healing) in hands a few seconds and apply dressing over wound. One time a day every 3 days for coccyx wound. The electronic medical record (EMR) did not include notification of family until 5/21/25, by RN-A. A progress note 5/21/25, by RN-A included wound was open on coccyx, and R196 had decreased progress in therapy over past week, increased weakness, decreased response during conversation and decreased appetite. Explained that condition of wound has quickly deteriorated and may need procedures that facility wound nurse is not able to complete. Explained that wound condition suggests further deep tissue injury under visible wound surface that may lead to bone resulting in infection, sepsis, and death. But also explained that even with a wound clinic treatments/routine visits, the potential of wound healing without adequate nutrition (calories, protein,vitamins/minerals) would still be slim. FM-B verbalized understanding; RN-A explained that all of the above information has also been discussed with R196 but R196 was not able to give an answer on how she would like to move forward. On interview 7/1/25 at 3:18 p.m., family member (FM)-B indicated the family was not notified until 5/18/25, when her family member was at the facility and saw the wound. FM-B stated a phone call was was made to the facility on 5/22/25, and RN-A ensured the facility had the wound under control. FM-B stated she requested to be notified if the wound worsened prior to a wound care clinic appointment on 5/29/25, but was never notified. FM-B stated when R196 arrived at the wound care clinic, the wound had worsened to the point R196 had to be hospitalized because the wound was infected. A Wound and Hyperbaric Healing Center note by NP-D on 5/29/25 at 12:30 p.m., included acute cellulitis (bacterial infection of the skin and underlying tissues) present along with unstageable sacral pressure ulcer requiring hospitalization for stabilization and planning of further care. Discussed with family that this is a very serious ulcer and prognosis. During interview on 7/2/25 at 10:56 a.m., LPN-A indicated she doesn't remember notifying the family or provider on 5/7/25 when the dark red spot was initially identified. LPN-A added if it wasn't documented they likely were not notified. During interview 7/2/25 at 11:37 a.m., RN-A stated there was no documentation family was notified until 5/21/25 regarding the coccyx wound adding the wound progressed very rapidly. RN-A stated she notified the provider on 5/9/25, regarding coccyx ulcer and got orders for treatment. On interview 7/2/25 at 12:16 p.m., FM-A stated a nurse (was unable to identify which nurse) contacted him about the wound initially when it was the size of a quarter and was open, when they were requesting to make an appointment with the wound care clinic. FM-A stated this was about a week before R196 went to the wound clinic (5/29/25) (could not give an exact date). On interview 7/2/25 at 1:14 p.m., medical doctor (MD)-C stated he was not sure when first notified of R196's wound but EMR first noted orders were given on 5/9/25. On interview 7/2/25 at 12:58 p.m., the director of nursing (DON) stated the family and provider should have been notified when initially discovered the dark red spot on the coccyx and then again by the RN when the wound opened. Facility Notification Of Change policy dated 12/21/24, indicated a facility must immediately inform the resident, consult with the resident ' s physician and notify, consistent with his or her authority, the resident representative(s) when there is: 1) An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. 3) A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment.

Based on observation, interview, and document review the facility failed to ensure professional standards of practice were followed during administration of nasal spray for 1 of 1 resident (R19) observed for medication administration. Findings include: R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors or rejection of care, use of wheelchair, and independent with eating, hygiene, and dressing. R19's face sheet printed 7/1/25, indicated diagnosis of chronic rhinitis (stuffy nose) and dysphagia (difficulty swallowing). R19's care plan printed 7/1/25, indicated R19 had a self-care deficit and required supervision with occasional assistance for activities of daily living (ADLs). R19 required medication administration assistance and did not have a preference where in the facility his medications were administered. R19's physician's orders printed 7/1/25, included an order dated 12/15/22, for ipratropium bromide solution 0.03% two sprays in each nostril three times per day, wait at least five minutes between nasal sprays. During observation on 7/1/25 at 8:43 a.m., licensed practical nurse (LPN)-A administered two sprays of ipratropium bromide solution 0.03% (nasal spray) in R19's left nostril. LPN-A then administered two sprays of ipratropium bromide solution 0.03% (nasal spray) in R19's right nostril. LPN-A did not wait five minutes between sprays as directed by R19's physician's orders. During interview on 7/1/25 at 9:38 a.m., LPN-A stated she had trouble with the nozzle of the nasal spray, got distracted, and forgot to wait the five minutes as ordered. LPN-A stated she should have waited so the medication could be absorbed correctly into R19's nasal tissue. During interview on 7/1/25 at 11:28 a.m., director of nursing (DON) stated the order should have been followed as written by the provider, and if R19 did not want it administered that way, LPN-A should have reached out to the provider to ask if the order could be changed. DON viewed the medication administration record (MAR) and confirmed the order stated to administer the nasal spray with a five minute waiting period between spray one and spray two. Facility Medication: Nasal (Drops-Spray-Aerosol) policy dated 7/30/24, stated the following: Purpose: To administer nasal medication properly Policy/Procedure: 1. Verify physician's order 5. For nasal spray: Have resident sit up and tilt head slightly back. Insert tip of nasal spray bottle into one nostril, while using finger to hold other nostril closed. Resident should inhale through nose at the same time the bottle is being squeezed to administer spray into nostril and breathe through mouth. Repeat in other nostril. Encourage the resident to keep head tilted back for three to five minutes.

Based on interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 1 resident (R196) who developed an unstageable pressure ulcer to the coccyx (small, triangular bone located at the bottom of the spine) area. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Deep-Tissue Injury (DTI): Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. Unstageable pressure ulcer: (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.) R196's Face Sheet printed [DATE] included diagnoses of cerebral infarction (stroke), pressure ulcer of sacral region unstageable (a type of pressure injury where the depth of wound cannot be determined because the wound bed is obscured by slough or eschar (black or brown layer of dead tissue), atrial fibrillation with presence of cardiac pacemaker, unsteadiness on feet and back pain. R196's admission (MDS) assessment dated [DATE], indicated R196 had intact cognition, understands and is understood, and had no behaviors. R196 required partial to moderate assist for bed mobility, transfers and personal hygiene and substantial to maximum assist for walking 10 feet, toileting and dressing. R196 had no known weight loss or gain or chewing/swallowing issues. R196 was not at risk for pressure ulcers (PU) and had no current PU's but did have skin tears present. R196's care plan dated [DATE], included impairment to skin integrity on left lower leg, bruising, small openings; appears to be trauma related; skin is also very fragile with bruising upon admission. Interventions included keep skin clean and dry, use lotion on dry skin and weekly skin observation by licensed nurse. R196's plan of care was updated on [DATE], to include the resident has a suspected DTI with open area of coccyx related to immobility and resident prefers to lie on back in bed and spend a large amount of time in wheelchair. Interventions included low air loss air mattress; RoHo cushion (used to prevent/treat pressure ulcers PU's) to wheelchair and recliner; encourage resident to reposition side to side in bed; encourage and assist to turn and reposition at least every 2-2.5 hours when in bed related to current PU and high risk for further skin injury; encourage resident not to be in wheelchair longer than 3 hours if can be avoided. R196's activities of daily living (ADL) plan of care dated [DATE] included assist of 1 with bed mobility, dressing, toileting and transfer and set up assistance with personal hygiene. R196 is able to eat independently. R196's Braden scale assessments (tool used to predict pressure ulcer risk) included: (high risk score of 10-23, Moderate Risk 13-14, Mild risk 15-18). [DATE] - Mild risk score of 18. [DATE] - Mild risk score of 17. [DATE] - Mild risk score of 16. [DATE] - Mild risk score of 16. R196's Care Area Assessment for Pressure Ulcer/Skin dated [DATE], included R196 is at low to moderate risk for pressure injury. R196 ambulates with therapy and is able to reposition herself in bed or with minor assist from staff. No pressure injury present on admission however did admit with healing skin tear on lower left leg. Does have bladder incontinence with staff assist with all tasks related to toileting, transfers, clothing, incontinent pads and peri-care. R196 has intact cognition. Although she has a flat affect, she is alert and oriented and uses call light appropriately. Uses Tramadol 50mg BID due to history of compression fractures and osteoarthritis. Cerebral vascular accident (stroke) with decreased mobility and activities of daily living function and is no concerns for PU at this time; will address impaired skin due to healing skin tear. A progress note dated [DATE] at 12:56 p.m., registered dietician (RD)-E indicated R196 was at risk for malnutrition due to inadequate calorie intake and wounds including coccyx and buttocks reddened. R196 has not had significant weight loss but has inadequate oral intake related to recent acute stroke with variable intake with most meals at 0-50%. Will suggest discussion of possible nutrition interventions due to her history of weight loss and poor current intake at meals. Skin Assessments included: [DATE] (on admit): Sacrum is pink and intact, with right and left arm bruising present. Left lower leg bruising with multiple skin tears. [DATE]: Bruising and skin tears, left lower leg with healing and other bruising on bilateral lower arms, improving, face 1 cm scab present on left check with Band-Aid applied. [DATE]: Left lower leg with long bruise and small skin tear. Area cleansed and new dressing applied. Coccyx and buttocks are reddened and top of coccyx has dark red area that is still blanchable per licensed practical nurse (LPN)-A. [DATE]: Coccyx pink area, but no open areas. Left lower leg with several small scabbed areas 0.8 x 0.5 cm. Completed by RN-B. [DATE]: Coccyx - see Registered Nurse (RN) wound assessment, area with black center. Completed by RN-B [DATE]: Coccyx - see RN wound assessment for measurements. Area black with surrounding tissue red. Completed by RN-B. A Wound Data assessment dated [DATE] by RN-A included initial data collection on the coccyx. No dressing present with area dark purple surrounding open area; red and excoriated (red and inflamed showing signs of trauma or open wounds) skin distal to open area with bleeding this a.m. A Wound Data Collection form by registered nurse (RN)-A dated [DATE] included wound is 1.5 cm x 0.5 cm x 0.2 cm depth on coccyx. Moderate drainage, sanguineous (thin watery liquid that leaks out commonly seen in fresh wounds within 48-72 hours during inflammatory wound healing stages) no odor present. Wound margins with ecchymoses (skin discolorations from damaged blood vessels). Modification to interventions included repositioning/turning and wound treatment. Skin prep (protective barrier) to surrounding skin; hydrocolloid dressing (dressing made from gel-forming agent that helps to rehydrate the wound and absorb excess fluid) over wound. A notification to the provider, by registered nurse (RN)-A [DATE] included physician was notified regarding wound status. A provider order signed by nurse practitioner (NP)-B included wound care for coccyx: cleanse area well and pat dry. Apply skin prep to surrounding skin. Warm 2x2 hydrocolloid dressing (2 layer dressing that absorbs drainage to form a hydrated gel over the wound to create a moist environment to promote healing) in hands a few seconds and apply dressing over wound. One time a day every 3 days for coccyx wound. A physician visit from MD-C on [DATE] included no reported concerns from staff at the nursing facility. Skin was not assessed and no mention of coccyx wound on examination or assessment was present. A progress note on [DATE] at 2:59 p.m., by social worker (SW)-A included Mood/Behavior Note Text: 1 to 1 with res re: mood. Res was watching TV from her recliner, with a container of Boost at hand. Res was asked about her appetite; simply said, I'm not hungry. Res was asked about her long-range plan; she shrugged; indicated she didn't know if she is progressing (with therapy) or not. It seems kind of hopeless, R196 said. R196 was asked if she is purposefully not eating. There was a long silence and then R196 said, My good friend was here and she stopped eating and drinking and died after 22 days. R196 then added, I don't know if it was purposeful or not. R196 was given a little more information (verbally) about the option of stopping all intake; including the physician likely wishing to rule out depression first, and making sure the individual is of sound mind. R196 was encouraged to consider an antidepressant . She commented, My get up and go has got up and went. R196 was offered mental health professionals to talk to via tele-health. R196 looked thoughtful but did not respond. R196 was asked if she would like to discuss with her children . or her PCP .she would not respond. After considerable silence I stated I'd let her think about these options and then she said, ok, if that's what you'd like to do. An RN Wound assessment dated [DATE] at 12:42 p.m., by RN-A included suspected DTI, with full thickness loss. Deterioration of wound evidenced by all of necrotic tissue has opened up revealing larger wound; wound bed/margins remain dark purple in color. Increased drainage over past couple days. Debridement done using mechanical (removal of foreign material or devitalized tissue through physical means) and autolytic (use of moisture retentive dressing to cover the wound and allow devitalized tissue to self digest by enzymes present in the wound fluids). Interventions include repositioning/turning, support surfaces, friction/shear management and wound treatment. Physician was notified regarding wound status and care plan was updated. Physician notified of deterioration of wound (and overall condition) and updated on interventions that already have been and will be put into place. A Wound Data Collection dated [DATE], by RN-A included wound is 3 cm x 2 cm x 0.5 cm visible depth measurement; wound bed deep purple, suspected further deep tissue injury. Dressing present and intact with drainage. No drainage leaking around the dressing. Moist, soft edges. No complications. Resident does voice complaints of pain related to the wound and is tender to touch. Wound bed was not described. Moderate, serosanguinous drainage present with slight odor, with hydrocolloid dressing in place with large amount of drainage. Skin is macerated, deep purple wound margins extending out approx 1 cm to surrounding skin. No undermining or tunneling. Wound treatment included Calcium Alginate Silver rope packing (helps absorb moderate to heavy amounts of wound drainage); border foam cover. R196 continues with poor appetite/intakes with 5 pound weight loss since admission. Is on 4 oz house supplement BID in which she usually drinks. R196 chooses to sit up in wheelchair or recliner a majority of the day. Roho cushion to chair and low air-loss mattress applied. Physician was notified. New orders on [DATE] to include: Wound care for coccyx to include cleanse area well with wound cleanser; pat dry. Apply skin prep to surrounding skin. Pack wound bed with silver calcium alginate rope. Cover with silicone border foam dressing. Change dressing daily and as needed if becomes soiled or loose signed by NP-B. A progress note dated [DATE], by RN-A included wound was open on coccyx, and R196 had decreased progress in therapy over past week, increased weakness, decreased response during conversation and decreased appetite. Explained to FM-B that condition of wound has quickly deteriorated and may need procedures that facility wound nurse is not able to complete. Explained that wound condition suggests further deep tissue injury under visible wound surface that may lead to bone resulting in infection, sepsis, and death. Also explained that even with a wound clinic treatments/routine visits, the potential of wound healing without adequate nutrition (calories, protein,vitamins/minerals) would still be slim. FM-B verbalized understanding; RN-A explained that all of the above information has also been discussed with R196 but R196 was not able to give an answer on how she would like to move forward. A Physician Notification dated [DATE] by RN-B included R196 has wound on coccyx that is black colored. May we have a referral for the wound clinic. An order was received from CNP-F for wound care clinic and CNP also included please schedule exam of area at NH next provider rounds. An RN wound assessment dated [DATE] by RN-A included wound is unstageable with less drainage, odor improved, necrotic tissue slightly loose around edge, maceration improved. Damaged deep tissue now necrotic (dead tissue caused by injury, infection or lack of blood supply). Modifications include support surfaces, nutritional and wound treatment. Physician notified regarding: Requested order to change cover dressing for adequate drainage/moisture management; and will request Juven (drink to support wound healing in patient with inadequate nutrient intake) order if R196 likes Juven. A wound data collection tool dated [DATE] at 10:34 a.m., by RN-A included wound is 3 cm, by 2.6 cm with no depth documented. Dressing was present, and intact with drainage present but not leaking around the dressing. Surrounding tissue is pink and dry and intact. R196 has pain related to wound and is tender to touch. Slough 20%, eschar 80% (dead tissue that develops in severe wounds), moderate serosanguinous (fluids discharge light pink, thin and watery) drainage with odor present with slight foul odor improved over past 2 days. Wound margins are macerated and softened, with wrinkled tissue due to moisture. No undermining or tunneling. Dressing/Treatment: Calcium Alginate Silver rope packing and superabsorbent dressing instead of border foam. Low air loss mattress added. R196 has agreed to try Juven; if res likes supplement will obtain physician's order to give her routinely for wound healing. A provider notification dated [DATE] by RN-A included coccyx wound continues to have some excess of moisture related to drainage; can we DC silicone border dressing and change cover dressing to superabsorbent dressing to better manage drainage/moisture until wound clinic appointment on 5/29? CNP-F responded [DATE] to discontinue silicone border use superabsorbent dressing as cover dressing to coccyx wound daily. A wound data collection dated [DATE] by RN-B included Coccyx wound with dressing present with drainage. There is increased drainage present and complaints of coccyx pain. RN-B answered yes to presence of possible complications, increasing area of ulceration or soft tissue infection increased, redness, swelling around the wound and increased drainage from the wound. A Wound and Hyperbaric Healing Center note dated [DATE] at 12:30 P.M., by NP-D included open PU to the sacrum that family states present for 2-3 weeks. Unstageable PU with cellulitis of surrounding tissue. Wound measured 6 cm length by 3.5 cm width x 1 cm of unstable etiology and located midline coccyx. Large amount of sanguineous (bright red fluid that oozes from wound mainly consisting of blood) drainage noted. Wound margins are distinct with the outline attached to the wound base. There is no granulation within the wound bed. There is a strong malodor associated with the ulcer. There is a large amount of purulent (drainage that is thick from infected wound) brown drainage noted with the cleansing. There is superficial blistering noted along the left lateral border of the ulcer. The ulcer is covered with 100% soft black eschar. Peri wound showing induration (thickening and hardening of tissue) with erythema (redness) and warmth to the tough. Discuss with FM-B that R196 does have acute cellulitis (infection) and unstageable sacral PU and will need at least hospitalization locally for stabilization and planning of further care. Discussed with family that this is a very serious ulcer and prognosis. R196's admission history and physical dated [DATE] by MD-G included admitted to the hospital directly from the wound care clinic for cellulitis and unstageable pressure sore of sacral area with black eschar, not treatable without extensive surgical debridement which the patient and family refuse. A progress note dated [DATE] by RN-A included R196 returned from the hospital PU is present upon readmission, and is unstageable, with improved erythema since hospitalization. Deterioration of wound is present as evidenced by copious amt of drainage with necrotic tissue covering wound bed. Larger dimensions since 5/23 assessment from this nurse. Hospitalization 5/29-[DATE] related to cellulitis requiring intravenous antibiotic therapy and hydration. On interview [DATE] at 2:07 p.m., RN-B stated the DTI for R196 developed at the facility. RN-B stated R196 was sitting a lot and had no interest in doing anything. RN-B stated initially when R196 arrived at the facility she could have repositioned herself but R196 was not eating or drinking much and once the wound appeared she deteriorated rather quickly until a lift was needed to transfer her. On interview [DATE] at 2:19 p.m., RN-A stated R196 was mobile when she was first admitted and could pivot transfer and walk a few steps and was working with physical therapy. RN-A indicated R196 liked to stay sitting in her chair and staff had a difficult time trying to get her to lay down in her bed. RN-A confirmed R196 did not have a wound on coccyx upon admission. RN-A stated interventions were started on [DATE] that included a nutritional supplement, repositioning program every 2-2.5 hours, wound care and treatments, air mattress ordered and Roho cushion to chair and wheelchair. RN-A stated a lot of the problem was lack of nutrition and pressure as R196 was not active. RN-A stated the first wound assessment was done [DATE] by an RN but red area was initially noted on [DATE] and was unsure when the wound was first reported to her or what the delay was for initial assessment. RN-A confirmed the next wound assessment wasn't completed until [DATE], 11 days later due to her absence. The wound was sacral/coccyx and when it opened it progressed up and outwards so became more sacral area. On interview [DATE] at 8:11 a.m., NP-D, wound specialist stated when she first saw R196 at the clinic, she had an infection and was sent to the hospital. NP-D stated unfortunately the wound was extensive and if further intervention had been started earlier, the severity of the wound could have been prevented. NP-D indicated she could not say if the wound was preventable or not but added the severity could have been prevented. On interview [DATE] at 8:54 a.m., RN-A stated I don't believe this was preventable and felt this was related to an end of life ulcer. RN-B stated she hadn't seen the wound from 5/23 until [DATE], so was not sure if signs of infection were present or not but stated the wound on [DATE] prior to going to the wound care clinic was very red. On interview [DATE] at 11:05 a.m., RN-C, also identified as MDS nurse, stated she completed the initial MDS assessment and toileting habits, nutrition, history of skin issues, activity level and diagnosis are taken into consideration when determining if resident is at risk for PU injury. The first Braden scale was completed by RN-D and R196 had a skin tear but her coccyx area was fine without redness. RN-C stated R196 was in therapy and was moving, getting up our of her chair. RN-C stated however R196's appetite wasn't good. RN-C stated initially R196 did not have risk factors for developing a pressure ulcer. On interview [DATE] at 10:56 a.m., LPN-A stated she was unsure if any preventative measures were put into place after discovery of the red area on the coccyx but if nothing was documented no further preventative care was completed at that time. LPN-A stated she does remember R196 was not repositioning herself at the time and was rarely moving. On interview [DATE] at 11:37 a.m., RN-A confirmed there were no interventions to prevent further skin breakdown between [DATE] when red area was discovered until [DATE] when she assessed the area and the wound was open. RN-A stated the facility does not do tissue tolerance tests but rather do a repositioning assessment. RN-A was not able to find a repositioning assessment completed on R196 throughout her stay at the facility. On interview [DATE] at 12:03 p.m., nursing assistant, (NA)-A stated he cared for R196 a lot and she rarely wanted to do anything including therapy. NA-A stated R196 started to give up, and refused to eat. NA-A stated they were repositioning R196 every 2 hours once the wound started. NA-A stated they had to start using the EZ-stand when around the time the wound started and by the time R196 went to the hospital she required use of a lift and 2 staff. On interview [DATE] at 1:14 p.m., MD-C indicated he does not believe he saw R196's pressure ulcer at the facility when he saw R196 at the [DATE] visit. MD-C stated he would expect staff to have preventative cares and treatments in place especially for someone with a recent stroke like R196. MD-C was not able to determine if PU was preventable and stated the first mention of a PU in her medical record at the clinic was [DATE]. On interview [DATE] at 1:23 p.m., MD-G indicated the wound and surrounding area was infected and wound was extensive when he first saw R196 on [DATE] at the Wound Care Clinic. MD-G stated it is difficult to say if wound was preventable, but as soon as evidence of stage I PU (redness) was identified interventions should have been put into place to prevent further damage. On interview [DATE] at 12:58 p.m., the director of nursing (DON) stated if a red area is noted on the skin would expect staff to put preventative measures in place upon discovery. The DON stated she would expect staff to completed measurements on an open wound every 3 days but at least every 7 days until healed. The DON stated she would like an RN to do them more often than weekly especially if the wound is worsening like R196's was. Facility Skin Assessment Pressure Ulcer Prevention and Documentation Requirements, dated [DATE] included: 1. All residents will be identified for their risk of developing pressure ulcers on admission/readmission by a RN using the Braden Scale. Those residents determined to be at risk will have a Braden Scale completed weekly for the first four weeks following admission. 2. The RN will completed a Braden Scale on all residents quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning scheduled is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnosis mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation is a required tool that is used to determine an individualized repositioning plan. 3. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for treatment. Inquire whether physician/practitioner believes it is clinically necessary to see resident. 4. The pressure ulcer should be assessed/evaluated at least weekly and documented the Wound RN Assessment tool. Daily Wound Data Collection is completed daily for Medicare residents. 5. If the pressure ulcer is not determined to be clinically unavoidable, the ulcer should show signs of improvement within two to four weeks. Signs of improvement might include decrease in size of wound, decrease in amount of exudate and improvement in tissue type. 6. If the resident's ulcer is clinically avoidable, not showing signs of healing and the interdisciplinary team and/or the physician have made modifications to the treatments and interventions, consider a referral to a wound care specialist and discussion with the location's medical director.

Based on observation, interview, and document review the facility failed properly assess and monitor blood sugars, failed to identify signs and symptoms of hyperglycemia, and failed to follow continuous glucose monitor (CGM) manufacturer recommendations for placement and rechecking blood sugars for 1 of 4 residents (R1) who was admitted to intensive care unit with a blood sugar of over 1000 mg/dl (milligrams/deciliter). This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 1/29/25, when R1 was demonstrating symptoms of hyperglycemia but R1's blood sugar according to the CGM was 52 mg/dl and was administered glucose tablets without confirming blood sugar via finger stick. The administrator, director of nursing (DON) and regional nurse consultant (RNC) were notified of the IJ on 2/12/25 at 4:00 p.m. The IJ was removed and the deficient practice was corrected on 2/6/25, prior to the start of the survey, and was therefore issued at past non-compliance (PNC). Findings include: The American Diabetes Association defines low blood glucose (sugar) as when levels fall below 70 mg/dL (milligrams per deciliter) and recommends using the rule of 15 grams fast-acting carbs every 15 minutes to treat low blood glucose. Severe low blood glucose is an emergency. The American Diabetes Association identifies blood sugars should be less than 180 mg/dl 1-2 hours after a meal. Further informing hyperglycemia can be a serious problem and important to treat as it is detected. If hyperglycemia is not treated ketoacidosis, a life threatening condition, could occur. Symptoms of ketoacidosis includes shortness of breath, breath that smells fruity, nausea and vomiting, and very dry mouth. According to Mayo Clinic additional symptoms can be excessive thirst, being tired, and confusion. Mayo Clinic recommends to seek emergency care if sugar level is over 300 mg/dl. Review of R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated diagnosis of diabetes type 1. R1 had moderately impaired cognition and received insulin. Review of R1's physician orders, included the following: -apply and change Free Style Libre 3 (CGM) every 15 days, start date 11/15/24; -blood sugar checks four times daily with CGM, before meals and at bedtime, start date 11/15/24; -Glucagon emergency kit 1 milligram (mg) inject SQ for low blood sugars, start date 11/05/24; -glucose oral tablets 4 gram (GM), give four tablets by mouth as needed for low blood sugar of 51-70; start date 2/28/24. Facility policy Hypoglycemic Incidents dated 10/30/24, directed the following: 2. For residents with diabetes, the physician should be called immediately when blood glucose value is less than 70 mg/dl and is unresponsive or has consecutive blood glucose reading less than 70 mg/dl. 4b. Notify physician. 4c. monitoring may need to take place for several hours to days. 7. Document incident and actions taken in progress note health status and document the blood glucose testing in the weights and vitals tab. Free Style Libre 3 manufacturer's recommendations dated 4/24, included CGM's could replace blood glucose monitoring (BGM) except in the following situations. These are times when you need to do a blood glucose test before deciding what to do or what treatment decision to make as sensor readings may not accurately reflect blood glucose levels: 1- do a BGM if you think your glucose readings are not correct or do not match how you feel. Do not ignore symptoms that may be due to low or high blood sugars. 2- do a blood glucose test when you see the magnifying glass with a drop of blood symbol or when the sensor glucose reading does not include a current glucose number. R1's diabetic care plan dated 2/28/24, did not address R1's CGM. The care plan included R1 had history of hospitalization s related to fragile diabetic condition with the following interventions: -identify areas of difficulty in resident diabetic management. Provide and document teaching to resident/family to address identified roadblocks to good diabetes management, start date 2/28/24. R1's January 2025 medication administration record (MAR) identified R1's CGM was changed on 1/26/25, by LPN-H. During interview 2/12/25 at 9:25 a.m., LPN-H stated she had personal experience with CGM but no formal training. Review of R1's blood sugar records in conjunction with progress notes between 1/29/25 through 2/3/25 identified although R1's CGM showed blood sugars below 70 mg/dl, no finger sticks were done to confirm the values of CGM displayed values, the record did not include comprehensive assessments and monitoring for hypo/hyperglycemia, nor include monitoring of the effectiveness of the glucose tabs after administration. Further, it was not evident the physician was notified when R1's blood sugars were low. R1's blood sugars for 1/29/25, included the following: -Blood sugar (BS) record at 4:20 a.m., identified R1 had BS of 44 mg/dl; R1's record did not include any further documentation. -BS record at 5:00 a.m., identified R1 had BS of 54 mg/dl; R1's record did not include any further documentation. -BS record at 5:40 a.m., identified R1 had BS of 60 mg/dl. Corresponding progress note documented at 10:31 a.m. identified staff were alerted by the CGM beeping and R1 was given a snack. -BS record at 8:10 a.m. identified R1 had a BS of 248 mg/dl. Progress notes at 9:52 a.m. indicated R1's insulins were held because R1 did not eat breakfast. -BS record at 12:54 p M., identified R1 had a BS of 199 mg/dl; -BS record at 3:54 p.m. identified R1 had a BS of 262 mg/dl; -BS record at 8:23 pm. identified R1 had a BS of 305 mg/dl. Progress note identified R1 received 2 units of sliding scale insulin. R1's blood sugar record for 1/30/25, included the following: -BS record at 12:00 a.m., identified R1 had BS of 45 mg/dl. The BS record identified the next check at 1:15 a.m., R1's BS was 52 mg/dl. Corresponding progress note written at 1:35 a.m. indicated at 11:55 p.m. staff alerted by R1's CGM beeping with a reading of Lo (no value was given). Staff administered 8 oz of high calorie/high protein drink. Rechecked blood sugar at 12:00 a.m. and was 45. Staff gave a 1/2 of peanut butter sandwich and 6 oz of grape juice and 8 oz of orange juice. Blood sugar recheck at 1:15 a.m. (1.25 hours later) was 52. R1 ate the sandwich but required much prompting/cuing/encouragement. -BS record at 4:00 a.m., identified R1 had a BS of 279 mg/dl; -BS record at 8:46 am and 9:15 a.m.; identified R1 had a BS of 218 mg/dl; -BS record at 11:16 a.m. was 89 mg/dl; identified R1 had a BS of 89 mg/dl; -BS record at 2:04 p.m. was 89 mg/dl; the medication administration record indicated R1's insulin was held, with no other information in the record. -BS record at 4:33 p.m., identified R1 had a BS of 199 mg/dl; -BS record at 7:48 p.m., identified R1 had a BS of 124 mg/dl. R1's BS record for 1/31/25, included the following: -BS record at 2:50 a.m., identified R1 had a BS of 60 mg/dl; -BS record at 2:53 a.m., identified R1 had a BS of 52 mg/dl; R1's progress note at 4:08 a.m. indicated R1's CGM read Lo, R1 was administered 4 glucose tablets (16 G total) along with glucose control drink, pudding, and small cup cake. -BS record at 4:15 a.m., identified R1 had a BS of 109 mg/dl. -BS record at 11:55 p.m., identified R1 had a BS of 54 mg/dl. R1 shift summary for 1/31/25 at 6:26 a.m., summarized R1's CGM was alarming during the night. BS was 60. Prior to entering room, BS had dropped to 52. Staff got glass Boost Glucose Control and pudding which resident ate. BS recheck was 79, but later staff heard the CGM alarm again, and CGM reading was Lo. R1 was given 4 glucose tablets and wanted a cookie but not available. R1 ate a cupcake. BS recheck was 109. R1's blood sugars for 2/1/25, included the following: -BS record at 2:20 a.m., identified R1 had a BS of 53 mg/dl; corresponding progress note at 2:19 a.m. included R1 received four glucose 4 GM tablets for reading of 53 mg/dl. -BS record at 2:55 a.m., identified R1 had BS of 61 mg/dl; no further information documented. -Progress note at 4:21 a.m. indicated glucose tablets were effective. No other information documented. -BS record at 5:42 a.m. R1 had a BS of 283 mg/dl; no further information documented. -BS record at 12:47 p.m., R1 had a BS of 52 mg/dl; Progress note at 12:57 p.m. included R1's CGM was beeping with a reading of 53. Staff gave R1 4 oz orange juice, 1/4 peanut butter sandwich and 4 oz sugar free vanilla and yogurt. -BS record at 1:30 p.m., 83 mg/dl. No further information was documented. R1's blood sugars for 2/2/25, included the following: -BS record at 2:55 a.m. R1 had BS of 53 mg/dl; Progress note at 3:00 a.m. indicated R1 received four glucose 4 gm tablet for a reading of 53. -Progress note at 4:30 a.m. indicated the glucose tablets were ineffective. R1's record did not identify R1's BS level was prior to the administration of the second dose of four glucose tabs. No further information was documented. 2/2/25 6:31 a.m. 64 mg/dl; Progress note at 6:30 a.m. indicated the glucose tabs were effective even though the record identified a BS of 64 mg/dl. R1's BS throughout the the day, ranged from 180 mg/dl at 11:15 a.m. to 145 mg/dl at 10:55 p.m. R1's progress notes on 2/2/25 at 7:14 p.m., indicated R1 was sleepy, needing more queuing for activities of daily living (ADL's). Insulin held due to history of declining rapidly throughout the night. R1's progress notes on 2/2/25 at 9:02 p.m., indicated R1 appeared more confused than normal. Very sleepy through the afternoon. Only ate 1/2 her supper and then went back to her room, where she was asking staff about what she should do next. R1 was half undressed and wanted to get dressed for supper. Staff reminded R1 that she just finished supper and assisted R1 into her nightwear. BS monitored through shift were within range. Review of R1's BS record on 2/3/25 indicated the following: -BS record at 3:35 a.m., indicated R1 had a BS of 190 mg/dl; -BS record at 7:39 a.m., indicated R1 had a BS of 134 mg/dl. R1's progress notes on 2/3/25 at 9:10 a.m., R1 stated she was not feeling well, I feel icky, like I was going to throw up when I saw food. Did not eat well for breakfast. Insulin held for this reason. Taking sips of lemon/lime soda. CGM is 154 mg/dl. -BS record at 11:22 a.m., indicated R1 had a BS of 108 mg/dl; and -BS record at 4:10 p.m., indicated R1 had a BS of 120 mg/dl. R1's progress notes on 2/3/35 at 1:24 p.m., indicated NP-A was notified and orders were received. R1's progress notes on 2/3/25 at 7:53 p.m., indicated R1 was sent to the emergency room for evaluation via family vehicle. R1's progress notes on 2/3/25 at 9:18 p.m., indicated that at 5:00 p.m., BS CGM was reading 67 mg/dl. R1 was given orange juice but needed assistance with drinking it without spilling as R1 was lethargic and unable to hold drink without spilling. Staff checked a manual blood sugar and it read Hi. Staff had another staff nurse re-check manual BS on other hand and read Hi again. Called on call physician at 5:50 p.m., left message for return call. At 5:55 p.m. attempted to call first family contact, message left. At 6:10 p.m., contacted second family contact and updated on R1's condition. At undocumented time, on call physician called back and wanted R1 to go to ED for evaluation. Family transferred R1 via private vehicle at 7:00 p.m. Staff called ED at 9:00 p.m. and was told that R1 was very ill with blood sugars greater than 1,000 mg/dl and was being transferred to a ICU for further care. Review of R1's hospital records from 2/3/35 through 2/11/25, indicated R1 presented to the emergency department via private vehicle from skilled nursing facility (SNF) with abnormal sugars. Family reported R1 had increased confusion and somnolence over the past 2-3 days. R1's mucus membranes were dry, appeared listless and her speech was delayed and slow. Initial impression was diabetic ketoacidosis (DKA) with insulin drip (medication given through vein to help lower sugar) and fluid resuscitation started. R1 was transferred and admitted to a hospital intensive care unit (ICU) from emergency department on 2/4/25 with a BS of 1245 mg/dl. R1 was in the ICU until 2/6/25 and was transferred to the medical floor. Review of R1 medication administration record (MAR) indicated R1 received her scheduled doses of long acting insulin twice on 2/1/25 and doses were held on 2/2/25 and am of 2/3/25. R1 received sliding scale short acting at 8:30 a.m. and 6:30 p.m. on 2/1/25 and other doses were held 2/2/25 and 2/3/25. During an interview on 2/11/25 at 7:15 p.m., emergency room registered nurse (RN-G) stated on 2/3/25, R1 presented to the emergency department (ED), very lethargic and incoherent. RN-G stated she had not received a report from the nursing home, and the family stated R1 had not been feeling good the past couple of days with lower blood glucose. RN-G checked finger stick with ED meter and read Hi. R1's ED lab work showed a BS of 1245 mg/dl. RN-G was told to remove the CGM from R1's left arm. When she did this RN-G stated the site was infected with a thick tannish fluid leaking from the site. RN-H cleaned to site. During an interview on 2/11/25 at 8:15 p.m., emergency room nurse RN-H stated she has been trained in putting on CGM's and R1's CGM was located almost on her shoulder over a bone. CGM needed to be in the fleshy part of the back of the arm. RN-H further stated that when the sensor was removed, the site had a thick gray/tan drainage from the site. This drainage was foul smelling. The area was reddened and raised to the size of a quarter. During interview on 2/12/25 at 10:08 a.m. licensed practical nurse (LPN)-B indicated R1 was a fragile diabetic with blood sugars swinging from high to low and had a CGM. LPN-B stated she worked day shift on 2/3/24. R1 had complained of nausea, she had fatigue, did not want to eat, and demonstrated confusion. LPN-B explained since R1's blood sugars per the CGM had low readings, she did not identify R1's symptoms as hyperglycemic and did not confirm the meter readings with a finger stick. LPN-B indicated at the time she was not aware of the manufacturer's recommendations to follow-up with a finger stick if the meter was reading Lo or Hi so a finger sticks were not performed. During an interview on 2/12/25 at 10:40 a.m., LPN-G stated she worked the evening shift on 2/3/25. R1 was more confused than usual at start of shift. At 5:00 p.m., LPN-G responded to R1's CGM beeping with a reading of 67. LPN-G followed the protocol for low blood sugars and gave R1 orange juice and glucose tabs. LPN-G stayed with R1 and rechecked her blood sugar an undocumented amount of times, but the CGM kept reading that R1's blood sugar was going down. LPN-G then did a couple of finger sticks which resulted in Hi readings from that meter. LPN-G then called and left a message for the on-call physician who replied 30-minutes later with an order to send R1 to the emergency room . R1 left facility at 7:00 p.m. per private vehicle. On 2/3/25, LPN-G was not aware of the manufacturer's recommendation to confirm the blood sugars with the finger stick method after each Lo reading so LPN-G did not confirm blood sugars via finger stick nor aware when the physician should be notified when residents had low blood sugars. During an interview on 2/12/25 at 10:51 a.m., LPN-F stated prior to 2/3/23 he had not received education on CGM's. LPN-F would have given nutritional supplements or glucose tabs based on the CGM readings, would not have confirmed with a finger stick and/or symptoms. LPN-F also indicated he was not aware prior to 2/3/25, when to notify the physician if residents required administration of glucose tabs or Glucagon. During an interview on 2/12/25 at 11:30 a.m., nurse practitioner (NP) stated she saw R1 on 2/3/25 but was not made aware of R1's low blood sugars or holding of R1's insulin doses on 2/1/25 and 2/2/25. NP-A stated her expectation was that facility would contact her with readings on CGM out of the parameters of, less than 60 or greater than 400. NP further expected the facility staff perform a finger stick BGM to verify the reading During an interview on 2/12/25 at 12:50 p.m., director of nursing (DON) stated she had reviewed a slide deck about how to use and placement of Freestyle Libre system on 1/28/25. It was her expectation that anyone who ever did not come to the meeting, would read the PowerPoint at the nurses station and then sign that they have read it. On 2/6/25, DON has placed notes on medication carts to check a finger stick per manufacture recommendations with blood sugars below recommendation of 70 or if resident was showing signs of symptoms of hypo/hyper glycemia. It was her expectation that staff would report to provider anything under 60 or higher than 400, unless the provider has a different parameter. Expectation to re-check BS, normally would be 5 minutes. During an interview on 2/12/25 at 9:11 a,a.m., customer service representative (CS-B) stated the sensor should be applied to the back of the upper arms and remains for 14 days. After 14 days the sensor shuts off and will no long give a reading. The sensor will not read a correct reading, if not placed in the recommended placement on back of either upper arm. If the sensor was applied a little bit high or low it should not be affect the reading. If the site becomes infected at the site of insertion, or if the site bleeds, both may affect the readings. Manufacturer further recommends if there is pain at the insertion site, the customer takes the sensor off and applies a new one. The high and lows alarms are set up with default parameters of 70 and 250. The extreme low is mandatory by law and can not be turned off by law. Review of facility policy Blood glucose monitoring, disinfecting, and cleaning policy dated 9/25/24, did not indicate the use of CGM's for blood sugar monitoring. The PNC IJ began on 1/29/25. The immediate Jeopardy was removed, and the deficient practice corrected on 2/6/25 after the facility implemented the following prior to start of survey: -Review policy on blood sugar monitoring to include the use of CGM's and management of CGM's per manufacturer's recommendations -Educated staff on correct placement of CGM's that the facility uses -Educated staff on the signs and symptoms of hyper- and hypo- glycemia -Educated staff on when to do a finger stick BGM to verify the CGM's readings -Reviewed with staff when to alert the physician of low and high blood sugars.

Based on observation, interview, and policy review, that facility failed to ensure beverageware and metal pans were completely dry before storing to prevent bacterial growth. This had potential to affect all 47 residents who resided in the facility. Findings include: During an observation and interview on 6/24/24 at 11:37 a.m., with cook (C)-A observed multiple metal steam table pans stacked upside down, one on top of the other, on a wire shelving rack. When C-A removed the top pan, it had visible water on the inside surface. C-A acknowledged staff should not have put pans away while still wet as that could promote bacterial growth. During an observation and interview on 6/26/24 at 9:35 a.m., with C-B on a plastic cart with wheels were multiple drinking cups stacked upside down on a solid plastic tray waiting to be taken to the dining room for storage. Condensation was visible in the clear tumblers. C-B lifted three tumblers and showed condensation inside the tumblers and water pooling and creating water rings on the tray. C-B acknowledged staff should have let the tumblers dry completely before stacking them to be stored. C-B was asked to lift a stacked metal steam table pan which was upside down on top of other steam table pans on a shelving unit. C-B verified the pan had moisture in it and should have been completely dry before being stacked for storage to prevent bacterial growth. The facility Warewashing-Mechanical and Manual-Food and Nutrition policy revised 3/25/24, indicated that dishes are to air-dry before storage or use.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R196) observed to have medications at bedside, had been appropriately assessed and deemed appropriate to self-administer medications. Findings Include: R196's facesheet printed on 6/26/2024, indicated diagnoses of malignant neoplasm of colon (colon cancer), polyneuropathy (nerve pain), and pain. R196's admission Minimum Data Set (MDS) assessment dated [DATE], indicated an admitted [DATE], and no cognitive impairment. R196's care plan on 6/24/24, did not indicate R196's ability to self-administer medications. R196's physicians orders on 6/24/24 did not indicate R196 could self-administer medications. During an observation and interview on 6/24/24 at 1:15 p.m., R196 stated a nurse came to her room and told her that she could not have her diclofenac gel (generic topical pain gel) on her bathroom sink and put it away in her bathroom cupboard. R196 stated that she kept Voltaren (topical pain gel) and Tylenol in her room and used them for years prior to coming to the facility. One tube of diclofenac gel was found in her bathroom cupboard. Medications found in a drawer next to her bed included two bottles of Tylenol 650 milligrams (mg) tablets, one bottle of Systane eye drops, one tube of Voltaren gel, and one tube of Neosporin antibacterial ointment. During an interview on 6/24/24 at 7:13 p.m., registered nurse (RN)-A stated that she knew R196 had Tylenol in her room but did not know if she had an order for self-administration. RN-A stated if R196 had medications in her room there should be a self-administration assessment completed and an order for self-administration of medications. No assessment or order was found by RN-A. During an interview on 6/25/24 at 8:37 a.m., licensed practical nurse (LPN)-A stated that she was aware of the Voltaren gel in R196's room. In addition, LPN-A confirmed that there was Tylenol, Systane eye drops, Voltaren gel, and Neosporin ointment in R196's room. LPN-A verified there should be an order for self-administration of medications if medications are kept in a resident's room. LPN-A stated there was not a current order for self-administration of medications and removed the medications from R196's drawer and cupboard. During an interview on 6/25/24 at 9:43 a.m., the director of nursing (DON) stated that she would expect a self-medication administration assessment would have been completed prior to R196 having medications in her room and that R196 should have had an order for self-medication administration. DON verified that R196 did not have an assessment or order for self-medication administration. The facility Resident Self-Administration of Medication policy revised 10/30/2023, indicated the interdisciplinary team should determine that the resident can safely self-administer medications, and this must be documented. A physician's order must be obtained prior to the resident self-administering medications. The care plan must indicate which medications the resident is self-administering and where they are kept.

Based on observation and interview, the facility failed to ensure professional standards of practice were followed during administration of eyedrops for 2 of 3 residents (R197 and R7) observed for medication administration. Findings include: R197's facesheet printed on 6/26/24, indicated an admitted [DATE], and a primary diagnosis of pancreatitis (inflammation of the pancreas). R197's admission Minimum Data Set (MDS) assessment was not completed. R197's care plan printed on 6/26/24, did not indicate any care needs related to her eyes. R197's physician's order initiated on 6/14/24, indicated R197 was to receive Alphagen P ophthalmic solution eye drops, one drop in both eyes three times a day to reduce eye pressure. During observation on 6/25/24 at 8:45 a.m., R197 was sitting in a recliner in her room. Licensed practical nurse (LPN)-A informed R157 she had her eye drops. LPN-A placed the tip of the eye drop bottle at the inner corner of each eye to instill drops. LPN-A did not ask R197 to tilt her head back, nor did LPN-A attempt to place the drop in the pocket of the lower lid (conjunctival sac). R7's facesheet printed 6/26/24, indicated an admitted [DATE], and a diagnosis of unspecified macular degeneration (an eye disease that causes vision loss). R7's admission MDS assessment was not completed. R7's care plan printed on 6/26/24, did not indicate any care needs related to his eyes. R7's physician's order initiated on 6/16/24, indicated R7 was to receive brinzolamide ophthalmic solution eye drops, one drop in both eyes two times a day for glaucoma. During observation on 6/26/24 at 8:05 a.m., R7 was seated in his wheelchair in the dining room. LPN-A assisted R7 to the side of the room and informed him she had his eye drops. LPN-a did not ask R7 to tilt his head back. LPN-A instilled the eye drop in the inner corner of each eye and did not attempt to place the drop in the pocket of the lower lid (conjunctival sac). During interview on 6/26/24 at 10:30 a.m., LPN-A verified that she instills eye drops in the inner corner of the eye. LPN-A further stated this is how she was taught and has not had any education from her employer on eye drop instillation. During interview on 6/26/24 at 8:44 a.m., director of nursing (DON) stated that she would expect nurses to gently pull down the lower lid and instill eye drops in the pocket formed in the center of the eye. DON would not train nurses to instill eye drops in the corner of the eye due to risk of infection or the eye drop not getting fully into the eye. DON stated she does not believe they have completed any training on eye drop instillation. The facility provided an untitled and undated document printed from Elsevier online training. This document educated on administration of eye drops and stated ask the patient to look at the ceiling.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R36) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R36's face sheet dated 6/26/24, indicated she was [AGE] years old. The immunization record, dated 6/26/24, indicated she received a PPSV23 on 10/15/2008 followed by the PCV13 on 10/2/2014. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R36 was offered or received PCV20. During interview with infection preventionist (IP), on 6/25/2024 at 11:18 a.m., the IP indicated immunizations are reviewed upon admission to determine if resident is eligible for any immunizations. If resident is eligible for an immunization, it is reviewed with the resident and/or representative upon admission to see if they were interested in receiving immunization. IP verified R36's pneumococcal immunizations as listed above and stated that she was unable to find any documentation stating that resident was offered and declined the PCV20. IP verified there had been no shared clinical decision making with the provider regarding pneumococcal immunizations for R36. IP stated it was important to ensure residents are offered all available vaccinations to prevent the risk of developing symptoms to lead to acute illness. During interview on 6/25/24 at 1:55 p.m., R36 stated that she does not recall any facility staff discussing available immunizations when admitted . R36 stated she would be interested in receiving the PCV20 as she usually receives all recommended vaccines that are available. During interview on 6/26/24 at 8:27 a.m., director of nursing (DON) stated IP reviewed immunizations upon admission and eligible immunizations are offered to resident and then we either administer immunization or have resident sign a declination page. DON confirmed that documentation was lacking on if R36 was offered the PCV20. DON stated it was important for residents to know what immunizations are available to them as it is there right and would help prevent illness. The facility Immunizations/Vaccinations for Residents, Pneumococcal policy dated 9/21/23 indicated the facility to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals. The facility would provide guidance for the location's immunization program including recommended vaccinations. a) Upon admission, each client, resident and/or resident representative will receive the Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines and the VIS or Face Sheet for Recipients and Caregivers for the COVID-19 vaccine. b) If the client, resident and/or the resident representative consent to vaccination, obtain written consent if required by state regulation. If written consent is not required, obtain and document verbal consent. c) If the resident and/or resident representative chooses not to be vaccinated after discussion of benefits, document declination.

Based on interview and observation, the facility failed to ensure proper food safety practices when dietary aide (DA)-A was observed assembling sandwiches with bare hands. This practice had the potential to affect all 43 residents who resided at the facility. Findings include: During an observation and interview on 8/15/23 at 4:07 p.m., DA-A was observed standing at a metal counter toward the back of the kitchen assembling a ham and cheese sandwich with bare hands. DA-A held a piece of wheat bread in bare left hand and buttered it with right hand. Using a bare hand, DA-A removed a slice of ham from a plastic container and set it on top of a piece of bread with cheese that was on a plate. DA-A placed the buttered piece of bread from left hand on top of the ham to complete the assembly. DA-A picked up and placed the whole, uncut sandwich in a small plastic bag. Butter had oozed over the edges of the bread and smeared on the inside of the plastic bag. Further, DA-A was observed to pick up a piece of wheat bread with bare left hand and spread peanut butter on it with right hand. DA-A then folded the one piece of bread in half and placed it in a bag; the sandwich had not been cut in half with a knife. When approached, DA-A stated he did not need to wear gloves since he had washed his hands prior to assembling the sandwiches. During an observation and interview on 8/15/23 at 4:14 p.m., observed dietary manager (DM)-B talk to DA-A. After that, DM-B stated cook (C)-C had also observed DA-A assembling sandwiches with bare hands and had immediately informed her. DM-B stated she told DA-A to start over and to wear gloves. DM-B acknowledged start over meant DA-A had thrown the sandwiches in a wastebasket and was to assemble more sandwiches. During an interview on 8/15/23 at 4:17 p.m., DA-A stated he had received training on food safety practices and stated he should have worn gloves, but today, It just went over my head. During an interview on 8/15/23 at 4:21 p.m., DM-B admitted she did not stay in the kitchen to observe DA-A remake the sandwiches and provide coaching, adding she thought C-C had been going to do that. DM-B was informed C-C did not observe DA-A remake the sandwiches. DM-B acknowledged she was responsible for ensuring proper food handling and ensuring staff provided visually appealing food. During an interview on 8/15/23 at 7:35 p.m., the administrator stated she had been made aware of a DA-A handling food with bare hands and stated she would have expected DA-A to be trained in proper food handling and for his performance to be monitored by DM-B. During an interview on 8/16/23, at 9:45 a.m., DM-B stated DA-A, who had been hired in January 2022, had completed an online food safety module. DA-A's transcript indicated the training titled Basics of Food Safety in Long Term Care Facilities had been completed on 2/8/22. The same training module was due to be completed by 8/31/23. DM-B stated DA-A would have been trained in the kitchen by other dietary aids and assumed was instructed on proper food safety practices, including not touching/handling resident food with bare hands. DM-B stated an orientation/training checklist had not been used to ensure DA-A had been informed how to execute proper food safety practices. DM-B stated she provided some of the orientation for new dietary aids, but not specifically about proper food safety practices. In addition, DM-B stated she did not observe or coach new employees for adherence to proper food safety practices; she relied on other dietary staff to do this. The facility Food Handling policy dated 7/21/23, indicated the purpose was to limit contamination of food served to a highly susceptible population. Food was handled in a manner that minimized the risk of contamination. Foods were never touched with bare hands. Proper utensils such as a tissue, spatula, tongs, and single use gloves were used for food handling. The facility Hand Washing and Glove Use policy dated 6/14/23 indicated employees would not touch any food with bare hands.

Based on observation, interview and document review, the facility failed to monitor the condition of food storage containers in the walk-in kitchen refrigerator resulting in mold growing on the outside of multiple containers. In addition, the facility failed to date-mark open containers of food stored in the walk-in kitchen refrigerator, and failed to ensure expired food was identified and removed. In addition, the facility failed to prevent cross-contamination when egg shells were stored with whole eggs. In addition, the facility failed to ensure the trained dietary manager oversaw and supervised all aspects of dietary services and ensured dietary cooks received comprehensive training upon hire and on-going. Furthermore, the facility ensure hand hygiene was performed by staff when plating food and delivering meal trays, failed to ensure proper infection control practices were followed when handling resident drinking cups. This had the potential to affect all 34 residents who were served food from the kitchen. Findings include: The initial kitchen observation and interview on [DATE], at 1:38 p.m. was provided by kitchen aide (KA)-B, as the dietary manager had been off duty and the cook had been on break. During an observation of the walk-in freezer, noted a large box of hamburger patties; the patties were inside a bag and the bag was open to the air. Observed the built-in freezer fans had ice on the grates and icicles hanging from them. During an observation of the adjacent walk-in refrigerator, noted the following: 1. [NAME] Honey Mustard dressing, 1 gallon. Written on top with black marker open ,d+[DATE]. Also written on cover was ,d+[DATE]. Moldy material - white, gray and fuzzy, was growing on the outside of the container trailing down, and on top of the cover. Manufacturer expiration date not seen. 2. Vinegar, 1 gallon, with manufacturer best by date of [DATE]. Written on side of container was open ,d+[DATE]. On top of cover, was written ,d+[DATE] with year of either 17 or 19. Product label was full of dark fuzzy mold, so much so that the label could not be read. KA-B stated there was vinegar in the container. In addition, the container had fine dots of black mold trailing down the side. 3. [NAME] brand Sweet and Sour Sauce, 1 gallon, had about 3 inches of product left in the container. Fuzzy white and black mold was growing on the outside of the container. The date written on the side with black marker was ,d+[DATE], with lines drawn through it. KA-B did not know what the lines through the date meant. Dried sauce and mold were trailing down the side of the container. 4. Real Lemon Juice, 1 gallon, had spotted mold over entire outside surface of the container. Written on outside of container in black marker was ,d+[DATE]. Manufacturer best by date was [DATE]. 5. Sysco Reliance brand Sweet Pickle Relish, 1 gallon. One of two manufacturer labels was covered with black mold and the other was partially covered. Date written on top with black marker was ,d+[DATE]. This container appeared full, possibly unopened. 6. Lea & Perrin's Worcestershire sauce, 1 gallon. Approximately half of manufacturer label had mold on it, as did areas of the container. The manufacturer best by date was [DATE]. 7. Mrs. Gerry's Dixie Coleslaw, 4 lb (pound) tub was observed in a box on an upper shelf, the plastic cover was ajar and contents were coming out. There was no date mark indicating when it was opened. Manufacturer expiration date was [DATE]. 8. Shredded cheddar cheese, 5 lb bag, open to the air. Bag of lettuce open to air. 9. Roast beef in a plastic container with green cover. Tape read rot [roast] beef ,d+[DATE]. 10. A small plastic bowl covered with plastic wrap with unidentified contents and no date. Tan in color. Texture was like pudding. 11. Mrs. Gerry's Deli Fresh Macaroni Salad, 5 lb tub, two dates were written on the cover with black marker: ,d+[DATE] OP and ,d+[DATE] -- KA-B did not know how long food in opened containers were good for. 12. Plastic container of leftover Veg soup dated ,d+[DATE], with about 3 inches of product left in the container. Observed two large plastic containers on wheels which KA-B stated held sugar and flour. Contents of containers not labeled or dated. In a double-door refrigerator by the pass-through window was a cardboard tray of eggs. There were 11 egg shells still in the tray, along side eight whole, pasteurized eggs. A small plastic bag of what appeared to be deli ham was also noted; contents of the bag were not identified nor was the bag dated. During a interview on [DATE], at 1:58 p.m., the administrator was asked to come to the kitchen to observe the findings from the walk-in refrigerator, specifically moldy containers, foods past facility and/or manufacturer expiration date, and from another refrigerator: egg shells with whole eggs. KA-B had removed the containers from the walk-in refrigerator to a stainless steel table in the kitchen. When shown the findings, the administrator stated oh, that's not good adding that the facility had been cited in the past for concerns in the kitchen. During an interview on [DATE], at 12:59 p.m., dietary manager (DM)-A was asked if she had been informed of finding from the walk-in refrigerator on [DATE], and she confirmed she had been, adding that the administrator had shown her photos. When asked how the containers got moldy and went unnoticed by staff, DM-A stated the mold occurred when staff didn't wash off containers before returning them to the refrigerator. DM-A stated she didn't know how the containers were overlooked by staff, and admitted she was the one who received in food orders and put them away, yet didn't notice the moldy containers either. When asked if contents of the refrigerators were inspected for facility and manufacturer expiration dates on a periodic basis, DM-A stated they were not. DM-A stated when a food product came into the facility it was date-marked with the delivery date. When a container was opened, it was date-marked when opened. When informed food containers were marked with a month and day, but not year, DM-A stated that was what she was told to do. When informed not all open food containers had a date-mark, DM-A stated the facility policy indicated food containers were to be dated when opened, including leftovers, and open containers of food were good for three days. DM-A stated cooks and kitchen helpers were responsible for monitoring this. DM-A stated the bulk containers of sugar and flour on wheels should have had a date on them, and the date must have washed off the lids. DM-A stated she did not review temperature logs to ensure staff were compliant. Together in the walk-in refrigerator, DM-A identified food that had been opened greater than three days and removed them from the refrigerator: - Tuna salad, 5 lb container, dated ,d+[DATE] - Leftover rot [roast] beef, dated ,d+[DATE] - Ham slices, dated ,d+[DATE] - Macaroni salad, 5 lb container, dated ,d+[DATE] - Turkey slices, dated ,d+[DATE] - Potato salad, 13 lb container, dated ,d+[DATE] - Cottage cheese, 3 lb container, dated ,d+[DATE]. DM-A opened this container, it was full and on top had a layer of pale yellow gel-like substance and gray fuzzy mold. - Bologna slices, dated ,d+[DATE] During an interview on [DATE], at 10:30 a.m., DM-A was asked when food in moldy containers, mostly condiments, were used last. Honey mustard dressing - couldn't recall. Real Lemon Juice - not often. Worcestershire sauce - used for baked beans which were on lunch menus on [DATE], and [DATE]. Sweet and Sour sauce was used for pork stir fry, but had not been able to get ground pork. Vinegar - used daily to clean the stove. DM-A stated I guess I missed it when referring to the moldy containers. DM-A stated she contacted the maintenance supervisor about the gasket around the walk-in refrigerator door, adding it had been a problem before, and also new fans had been installed, but didn't seem to make a difference. DM-A stated this could attribute to the mold. During an interview on [DATE], at 8:46 a.m., maintenance supervisor (MS)-A stated he heard there had been mold growing on containers in the walk-in refrigerator. MS-A stated the gasket around the door to the walk-in refrigerator needed to be replaced, and that he planned to replace the door latches to make sure the door always close behind the staff. MS-A stated he noticed the fan inside the walk-in freezer wasn't running so chipped the ice away and had been watching it closely. MS-A stated he called the refrigeration company and they were coming [DATE], to check it. During an interview on [DATE], at 11:20 a.m., with DM-A and the administrator, negative findings above were reviewed. When asked how the moldy food containers could go unnoticed, DM-A stated, I can't figure it out, none of the other staff noticed either. When asked what happened to the food items removed from the walk-in refrigerator on [DATE], the administrator stated she directed staff to throw away because it was moldy, expired, and might be served to residents which could cause foodborne illness. DM-A stated she discarded food containers on [DATE], because they exceeded the three-day maximum for open containers, and if served to residents could cause foodborne illness. When asked why routine duties in the kitchen were not being done, such as monitoring the condition of food containers, dates of food containers, manufacturer expiration dates, DM-A stated, training. DM-A stated she trained new kitchen staff, but did not utilize a tool such as a training checklist to ensure all elements of each role were addressed during training, nor did she monitor performance after completion of training. DM-A stated she was very behind on everything. The administrator stated it had been a long six months of advertising for a cook and getting no applicants; that DM-A had been burning the candle at both ends and working long hours. For some of these tasks, the administrator and DM-A agreed didn't required a cook to do them. DM-A stated she was ultimately responsible to ensure food safety for residents, and the administrator added that it was an accountability issue .holding staff accountable for their specific job duties. During the same interview, the administrator and DM-A were reminded about food service deficiencies with past inspections and asked what actions had been taken to ensure sustained improvements. DM-A stated they had done audits, and survey inspection findings had been added QAPI (quality assurance and performance improvement) plans. DM-A stated they shouldn't have stopped auditing and stated she would need to train dietary staff all over again. The administrator stated it seemed like they had done that every year with the same results. Both the administrator and DM-A acknowledged the findings in the kitchen were a significant concern and could result in foodborne illness to residents. During a telephone interview on [DATE], at 12:32 p.m., the registered dietician (RD)-F stated she worked in the facility two times per month, that most of the days were working with resident information and nutritional status. When asked if her role included any oversight for the kitchen, RD-F stated company policy said it did, but since returning to onsite visits after the Covid-19 pandemic in the spring of 2021, she had not done any kitchen audits. RD-F stated she checked in with the kitchen staff when she had questions, but had not done any inspections. RD-F stated she had been in the facility on [DATE], and had heard about cleanliness issues in the kitchen and stated had she been doing audits, it might have made a difference. When informed of findings, such as mold growing on the outside of condiment containers, RD-F stated that meant food had been left on the outside of the container. When asked about egg shells stored with whole eggs, RD-A stated that was a concern for cross contamination. RD-F stated they had work to do and would meet with the administrator and DM-A and put a plan in place. Training of new kitchen staff hired in 2022, consisted of on-the-job training with DM-A, however no orientation list/tool was used to verify the content of the training. In addition, new staff completed the following online module titled: Basics of Food Safety in LTC (long term care). Detail of the course included: Three types of hazards to food safety: physical, chemical and biological. Use proper hygiene to prevent contamination. Follow proper protocols to prevent cross-contamination. Maintain safe temperature ranges for food. Use cleaning and sanitizing methods to reduce risk of foodborne illness. Cook (C)-D was hired on [DATE], and completed the online course on [DATE]. Kitchen aide (KA)-B was hired on [DATE], and completed the online course on [DATE]. DM-A holds a certified dietary manager certification with expiration date of [DATE]. Job description for DM-A indicated supervising the quality of performance for employees on the team, assist in training new staff and the development of existing staff members, ensure department meets all regulatory requirements, advises on the appearance, taste and sanitation of food, delegates responsibilities, and supervises staff to be accountable to tasks. Hand Hygiene During observation on [DATE], at 5:26 p.m., dietary aide (DA)-A took out tray from enclosed cart and entered R14's room, with no observed hand hygiene completed. DA-A set tray down and touched bedside table and moved into position for eating. DA-A then left the room, did not complete hand hygiene and took out tray for R136 and left on table outside of the door and notified nurse the tray was outside of the room, did not complete hand hygiene. DA-A then took out tray for R134 and entered room, touching the bedside table and R134's water glass. DA-A exited room and did not complete hand hygiene. DA-A then took out R25's tray and delivered it to her room, again touching and moving the bedside table. DA-A exited the room and did not complete hand hygiene and returned to the kitchen. During interview on [DATE], at 5:36 p.m., DA-A indicated he does not complete hand hygiene between rooms and no one ever taught him to do that. During an observation in the kitchen on [DATE], from 5:36 p.m. to 5:42 p.m., cook (C)-B was observed handling multiple items and surfaces while wearing black gloves, and at no time during this observation did C-B remove gloves and perform hand hygiene. C-B was observed plating food while standing at the pass-through window. C-B handled multiple paper meal slips filled out by staff and residents, placed coleslaw on plates using a scoop, placed half sandwiches on the plates, then covered the plates with a plastic thermal cover and set the plate on the counter of the pass-through window. In addition, while wearing the same gloves, C-B placed food in the microwave to reheat, stirred food on the stove, then reached into a plastic container for the half sandwiches to add to plates. This process was repeated until all resident food orders had been filled. During an observation on [DATE], at 10:38 a.m., observed kitchen aide (KA)-C fill beverage cups for water, milk and juice, and set them on resident trays. When setting the filled cups on the tray or re-arranging the cups, KA-C held the cups by the rims with her bare hands. During interview on [DATE], at 11:10 a.m., the interim director of nursing (DON) confirmed hand hygiene should be completed if touching personal items such as water glass or bedside table in resident's room when delivering trays to residents. Upon request of hand hygiene education for DA-A, the dietary manager (DM) gave a Food and Nutrition Competency Checklist for Hand washing and Glove use competency form dated ,d+[DATE]. No name was present on competency. A rating of 3 (moderately skilled), completion date of ,d+[DATE] was present with no signature of who completed competency present. An Employee Roster indicated DA-A began employment at the facility on [DATE]. During interview on [DATE], at 12:40 p.m., human resources (HR)-A indicated she was trained by previous DON to complete hand hygiene observations on nursing department staff only and was never requested to complete them on dietary staff members. During an interview on [DATE], at 11:20 a.m., the dietary manager (DM)-A and administrator were informed of observations of KA-C holding the rim of drinking cups and of C-B wearing the same gloves for multiple tasks, then handling sandwiches. DM-A stated staff should know not to do that. When asked if dietary staff received infection control training related to their specific duties, DM-A stated she thought so, but didn't know who was responsible for providing this training. During an interview on [DATE], at 1:47 p.m., registered nurse (RN)-C stated there had been no residents with symptoms of foodborne illnesses. When asked if she had any involvement with infection control oversight in the kitchen, RN-C stated she had done mock surveys in the kitchen in the past, the last time being [DATE]. RN-C stated the human resource director had also helped with audits and had done one on [DATE]. These two audit results were reviewed and pertained primarily to equipment and environment. Facility policy titled Date Marking - Food and Nutrition, with revised date [DATE], indicated the policy provided guidelines for proper date-marking to ensure that food was handled and stored safely. Best if used by dates were not expiration dates. Refer to USDA (United States Department of Agriculture) guidance on Shelf Stable Food Safety. When TCS (time/temperature control for safety foods) were received in, employees date-mark the item with the delivery date. Use by date is an expiration date. As much as possible, food items should remain in original containers/packaging; if removed from original packaging, individual items were labeled and dated with date of receiving. Ensure that ready-to-eat TCS foods opened at the location were clearly date-marked for date/time the original container was opened. The date or day by which the food shall be consumed on premises, or discarded. TCS food prepared onsite and held in refrigeration for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Employees were to count the day of preparation as Day 1. At no time can a TCS prepared food be held more than seven days in a non-frozen state. Facility policy titled Food-Supply Storage, with revised date of [DATE], indicated food from approved food sources would be stored in sanitary conditions. Food opened or prepared were placed in an enclosed container, dated, labeled and store properly. Once meal service is over, cover, date and label individually-portioned items. Location-prepared time/temperature control for safety foods are discarded after three days in the refrigerator unless safe storage guidelines are available. In the refrigerator, the temperature was kept between 35 and 40 degrees Fahrenheit (F). In the freezer, the temperature was 0 degrees F or lower. Internal temperatures of all refrigerators and freezers are recorded twice daily. Facility policy titled Food Temperature Monitoring, with revised date of [DATE], indicated food was cooked, reheated or cooled to ensure proper holding temperatures before each meal services. Food temperatures were taken and recorded before each meal service. Periodically, temperatures were taken at other times during or at the end of meal service to ensure temperatures were held within acceptable ranges. Food was served at proper serving temperatures. Before meal service, the cook takes the cook-to and the serve temperatures of all TCS (time/temperature control for safety) menu items and records it on the Food Temperature Record. The cook monitors TCS foods throughout meal service. To correctly take temperatures, the food thermometer was inserted into the center or thickest part of the food for at least 15 seconds or per instructions on the thermometer. TCS hot foods should be served at 135 degrees F or higher. A chart of Minimal Internal Cooking Temperatures indicated a variety of foods and the required temperature prior to serving.

Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: When interviewed on 4/13/22, at 11:10 a.m., the interim director of nursing (DON) indicated staff initiate infection monitoring by documenting in the electronic medical record (EMR) which is then reviewed daily by her. The McGeer criteria is used. The interim DON indicated the EMR information including date of onset, date of end of symptoms, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interim DON indicated from the software program, reports are run and shared quarterly at quality assurance and performance improvement (QAPI) meetings, which includes the medical director and consulting pharmacist. The interim DON indicated nursing staff monitor resident's culture reports to make sure resident's prescribed antibiotics are on the correct medication. Upon request of reports shared at QAPI meetings, a monthly infection summary was received for January, February and March 2022. Information included on this report was resident name, start date, date symptoms resolved, type of infection (urinary tract infection, pneumonia), antimicrobial used, infection source (community or facility) and surveillance criteria met. Culture or x-ray results were not included. Antimicrobial included medication name and dosage but did not include length of use. The interim DON indicated she is not able to run a report that included chest x-ray and/or culture results that included antibiotic prescribed including length of use, symptoms and onset, and resolution of symptoms. Infection control meeting minutes were requested however the interim DON indicated she was not able to locate and unsure if meetings were held or just reported at QAPI meeting. The interim DON did indicate she has not attended a QAPI meeting since her interim employment began at facility. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated 48 hours after an order is received for an antibiotic, nursing staff are responsible to contact the provider using a form to determine if antibiotics should be continued. Upon request of this form or example of a completed form, none was received. The interim DON did indicate the providers are inappropriately starting antibiotics on residents even if minimal symptoms are present prior to culture results and she has discussed this with them but was unable to identify who, or when this occurred. Upon request, the QAPI meeting minutes were reviewed for 2/15/22, 11/11/21, 8/19/21 and 5/13/21. Infection Control portion included COVID-19 status, testing and vaccine updates. The QAPI meeting minutes did not include a summary of antibiotic use, infectious organisms or multidrug resistant organisms. The interim DON was unable to provide documentation that included a periodic review of antibiotic use, review of laboratory and medication orders, and a system of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data and prescribing practices. A policy titled Antibiotic Stewardship Rehab/Skilled dated 11/29/21 included: - Purpose is to decrease the incidence of multi-drug resistant organisms, promote appropriate use while optimizing the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) was discarded prior to leaving resident rooms, and failed to clean multi-use equipment between uses. The deficient practices had the potential to affect all 34 residents who resided in the facility. Findings include: Sanitizing re-usable equipment During observation and interview on 4/12/22, at 9:23 a.m., nursing assistant (NA)-C and NA-D came out of R31's room after using the mechanical lift to transfer R31 from wheelchair to recliner and went directly into R134's room with lift. NA-C and NA-D then used lift to assist R134 with transfer from wheelchair to the bed. NA-D, when asked if the resident lift was cleaned between uses, indicated Purell (hand sanitizer) was used to the clean the machine. When questioned when that was completed, NA-D then stated we run out of things all the time and there were no wipes on the machine. During interview on 4/13/22, at 11:10 a.m., the interim director of nursing (DON) indicated lift equipment should be cleaned using appropriate designated sanitizer, which is not Purell, between uses. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated training is occurring today on proper disinfection of equipment. Personal Protective Equipment: The Centers for Disease Control guidance CS 2-E, undated, indicated Remove all Personal Protective Equipment (PPE) before exiting the patient room except a respirator. During observation and interview on 4/11/22, 2:55 p.m., R25, R134 and R136 had cart with drawers present next to the door of the rooms with laundry basket full of uncovered yellow gowns on top along with gloves. A covered linen hamper was present on the other side of the cart. Contact Precaution signs were present on R25, R134 and R136's doors. During interview RN-A indicated the laundry basket has clean gowns in it and all three residents are on quarantine currently. RN-A indicated they take gloves off inside the room and then come out of room and remove gown and place in covered linen hamper. During observation on 4/11/22, at 3:08 p.m., NA-A put on gown, then gloves and entered R25's room and assisted her to restroom. NA-A then came out of room with gown on walking past uncovered clean gowns and removed and discarded contaminated gown in linen hamper. During observation on 4/11/22, at 4:02 p.m., registered nurse (RN)-A put on gown from the laundry basket, gloves and entered R133's room. RN-A came out of R133's room without gloves, walked past cart with gowns present on top in uncovered laundry basket and removed gown, discarding into covered dirty linen hamper. During interview on 4/14/22, at 9:01 a.m., RN-C indicated if the policy and procedure says to discard the gown in the work area, that would be inside the room, not in the hallway. During interview on 4/14/22, at 9:23 a.m., RN-E indicated she does the yearly training for staff on donning and doffing PPE. RN-E stated staff were taught to take all PPE off inside the room and dirty linen hamper should be inside the residents room/door even if the resident is only on quarantine. During interview on 4/14/22, at 11:19 a.m., the interim DON confirmed staff should not be coming out of the room to discard the gown. That should be done inside the room. A policy on Putting on/Taking Off Personal Protective Equipment (PPE) dated 2/15/22 included: -For safe donning and removal of PPE refer to the CDC and Prevention poster. -The Poster indicated Remove all PPE before exiting the patient room except a respirator. - Remove gown (perform gown removal per any isolation requirements) and perform hand hygiene before leaving the contaminated area.

Based on observation, interview and document review, the facility failed to ensure a sanitary environment in the kitchen when daily cleaning duties were not done, and 1 of 1 fans used in the dishwashing room was observed with dust and debris. This had potential to affect all 34 residents who consumed food prepared in the kitchen. Findings include: The initial kitchen observation and interview on 4/11/22, at 1:38 p.m. was provided by kitchen aide (KA)-B, as the dietary manager had been off duty and the cook had been on break. In the dishroom, a dirty fan was observed blowing on clean, plastic coffee cups that had come out of the dishwasher and were drying in a plastic crate. The fan was secured to a wall and dust was visible on the grate cover. KA-B was asked to shut the fan off, and dark, fuzzy material was observed on the outer edges of each fan blade. KA-B stated the fan was used for staff comfort as it got hot when doing dishes. On the left side of the stove, greasy material was observed on the flat surface underneath the cast iron burners. On the right side of the stove was a flat, stainless steel griddle. Between the stainless steel edge of the stove which was about four inches wide, to the lip of the griddle, there was a crevice which appeared to have food debris caked all along in the crevice which was approximately 18 to 24 inches long. A white, square drain under the three-compartment sink was observed with dark debris in it. The well-worn sheet vinyl flooring was dull, stained, with dark smudges. In the dry storage room was a three-door stainless steel refrigerator. The outside stainless steel doors were smudged, and the back side of the handle of one door had spongy, moveable material on it. The roll top, stainless [NAME] doors on the steam table were smudged with either hand prints or food splattering. Daily cleaning logs were observed posted in various parts of the kitchen and dining room for dates 3/28/22, through 4/10/22, and were rarely documented as being completed. Duties varied where identified, including but not limited to, polishing refrigerators and freezers, cleaning salt and pepper shakers, sugar and jelly containers, peanut butter containers. Cleaning the stove top, microwave, grill shelf, can opener, outside of steamer and handle, left oven, right oven, convection oven, sweep and mop. During an interview on 4/14/22, at 11:20 a.m., dietary manager, (DM)-A, stated all kitchen staff were assigned duties, depending upon their role and if they worked during the day or afternoon. DM-A acknowledged that many of the spaces on the forms were blank and she could not verify whether or not the cleaning duties had been carried out, as she did not monitor this. DM-A stated she did a lot of the cleaning herself, but often forgot to sign off that it had been completed. When asked about the food build-up in the crevice on the stove, DM-A stated she recently noticed that and was going to scrape it out. DM-A stated the square, white drain under the three-compartment sink was not hooked up to a drain and the debris in it was from sweeping in and around the drain. DM-A stated staff were responsible for maintaining cleanliness of the kitchen and dining room, and she was responsible to ensure cleaning duties were carried out. DM-A acknowledged that unclean surfaces had the potential for cross contamination causing foodborne illness to residents. Facility policy titled Cleaning Schedule - Food and Nutrition Services, with revised date of 2/15/22, indicated the purpose was to identify cleaning tasks to be completed. The director of food and nutrition was to post the cleaning assignments and employees were responsible for knowing their assigned duties and carrying them out during the designated work shift. Employees would initial the schedule after completing the cleaning duties. The supervisor was responsible for monitoring employees to ensure that cleaning duties were completed in a satisfactory and timely manner.

Based on observation, interview and document review, the facility failed to ensure infection control measures were implemented in a dignified manner for 1 of 1 resident (R25) who was reviewed for contact isolation precautions related to recent hospitalization for urinary tract infection. Findings include: Centers for Disease Control (CDC) guidance dated 2/2/2022, includes: Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility and for residents who have had close contact with someone with Covid-19 infection if they are not up to date with all recommended COVID-19 vaccine doses. In general, quarantine is not needed for asymptomatic residents who are up to date with all COVID-19 vaccine doses or who have recovered from Covid-19 infection in the prior 90 days; potential exceptions are described in the guidance. However, some of these residents should still be tested as described in the testing section of the guidance. R25 undated face sheet indicated initial admitted [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's Immunization Report indicated R25 received COVID-19 vaccine on 2/25/2, 3/25/21 and 11/5/21. R25's Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], indicated R25 was cognitively intact with no behaviors, required limited assist of one for transfers and toileting and was frequently incontinent of urine. A progress note dated 3/31/22, indicated R25 had blood in her urine, flushed and diaphoretic and was transferred to the emergency department for further evaluation. A progress note dated 4/5/2022, at 2:25 p.m., indicated R25 returned from the hospital and was alert and oriented. During interview and observation on 4/11/22, at 3:09 p.m., R25 was sitting in her wheelchair in her room. An isolation cart was outside of her room with a sign on her door indicating contact isolation. Nursing Assistant (NA)-A gowned and gloved and entered R25's room. R25 using a raised voice stated I don't belong in isolation and I have rights. NA-A indicated she would talk to the nurse. During interview on 4/11/22, at 3:17 p.m., R25 indicated she has been in and out of the hospital over the past month with frequent urinary tract infections ([CONDITION(S)]). Every time she is hospitalized she has to stay in her room and they quarantine her for a week, which is a rights violation. R25 indicated she is fully vaccinated and boosted and there is no reason she has to be in her room or have a sign on her door. R25 further added next time she will just refuse to go to the hospital. During interview and observation on 4/11/22, at 5:20 p.m., R25 was in the hallway in her wheelchair with a mask on the back of her wheelchair. R25 stated she was told she is all clear now and can be out and about the facility. R25 was smiling and joking with others around her. Cart remained outside of her door, but clean gowns bin was gone along with dirty laundry hamper. During interview on 4/11/22, at 7:17 p.m., registered nurse (RN)-A indicated R25 was on day seven of quarantine, was tested around 5:00 p.m. and was negative so is no longer in quarantine. RN-A indicated anyone out of the building for 24 hours or more at the hospital are quarantined for 7 days and are tested on admission and day 7 prior to releasing them from quarantine. During observation on 4/12/22, at 12:36 p.m., R25 was in the lobby waiting for the bus to take her to her infectious disease appointment and was smiling and talkative. During interview on 4/13/22, at 8:17 a.m., R25 indicated her appointment went very well yesterday. R25 indicated every time she goes to the hospital she has been quarantined to her room on return and complains to staff every time about it but the facility doesn't do anything about it except tell me the Centers for Disease Control (CDC) makes the rules and they have to follow it. R25 added being vaccinated and having had Covid-19 recently, she should not have to stay in her room. R25 stated it makes her feel like a three year old and other residents in quarantine indicated the same thing. R25 had to eat in her room, wasn't allowed to participate in anything like exercise classes, and was not allowed to go to the chapel. R25 stated she felt like a second class citizen. During interview on 4/13/22, at 10:09 a.m., RN-B indicated any new admission or resident who comes from the hospital are automatically quarantined for 7 days regardless of vaccination status. During interview on 4/13/22, at 11:14 a.m., with RN-C and interim director of nursing (DON) indicated an e-mail was received from the parent company which indicated new admission or residents that are hospitalized for 24 hours or greater are placed in quarantine and tested 7 days later. E-mail indicated it did not matter if the resident was vaccinated or not. The interim DON indicated she confirmed this information on the Centers for Medicare and Medicaid Services (CMS) website. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated upon further review of the e-mail received, it included the CDC recommendations from 2/2/22, which did not include fully vaccinated residents. The interim DON confirmed if residents are up to date on vaccines, they do not need to quarantine upon readmission to the facility and the practice will no longer be used. Requested policy on resident rights and received Combined Federal and state Bill of Rights, dated 2/1/17, included: - The resident has a right to a dignified existence, self-determination, and communication and access to persons and services inside and outside of the facility. -A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.