Every finding on record at Guardian Angels Care Center

Based on observation, interview, and record review, the facility failed to complete a comprehensive bowel and bladder assessment and develop an individualized incontinence care plan with goals and interventions to maintain or improve continence status for 1 of 3 (R6) reviewed for urinary incontinence.Findings include:R6's diagnoses list dated 3/18/26 included surgical aftercare for right hip fracture, type 2 diabetes, repeated falls and dementia.R6's admission Minimum Data Set, dated [DATE] indicated R6 had moderate cognitive impairment. R6 was frequently incontinent of bladder and needed maximum assistance from staff for transfers and toileting hygiene. The urinary incontinence care area assessment indicated urinary incontinence would be addressed in the care plan with the overall objectives to include improvement and avoid complications.R6's bladder and bowel incontinence assessment dated [DATE] identified R6 did not have an indwelling catheter and did not have a urostomy. The following sections were not assessed or left blank: Incontinence symptoms, onset of incontinence, pattern of incontinence, bowel movement pattern, relevant physical factors, cognitive/emotional/communication status, current medication that may affect incontinence, overflow incontinence, physician order obtained for post-void residual, types of incontinence and care plan review. R6's care plan dated 2/27/26 identified R6 required assistance from one staff with a manual stand aid for transfers and toileting. The care plan did not address urinary incontinence that identified individualized goals and interventions that would maintain and/or improve incontinence.R6's urinary continence documentation from 2/28/26 through 3/18/26 identified R6 was incontinent of bladder fifty-one times and continent of bladder ten times.The nursing assistant care sheet for R6 had no information in the bowel and bladder column.On 3/18/2026 at 12:16 p.m., R6 was observed in his room sitting in a wheelchair with the call light within reach. Incontinent products were observed in the bathroom. During an interview, R6 stated he needed staff assistance to go to the bathroom. He wore an incontinent product and did not like when it was wet. R6 would use his call light to get help from staff to go to the bathroom or to change the incontinent product.During an interview on 3/18/2026 at 12:32 p.m., licensed practical nurse (LPN)-A stated assessments that need to be completed by the floor nurse would pop up on the treatment administration record (TAR). The floor nurse would complete and sign the assessment. Information would be gathered from the resident, report from the hospital nurse, and family members, if needed. LPN-A did not know who looked at the assessments after they were completed or who entered the information into the care plan. LPN-A stated toileting and incontinence information would be found on the resident's Kardex. LPN-A reviewed R6's Kardex and stated it did not indicate whether R6 was continent or incontinent of bladder and did not include a urinary toileting plan. During an interview on 3/18/2026 at 2:36 p.m., nursing assistant (NA)-A stated a resident's toileting information would be found on the Kardex or NA care sheet. Every resident was either checked for incontinence or offered to be taken to the toilet every two to three hours or as indicated on the Kardex.During an interview on 3/19/2026 at 2:08 p.m., NA-B stated R6's Kardex did not include a specific toileting plan. NA-B received information in report that R6 liked to sit on the toilet, but he was always incontinent of urine. R6 did not use his call light to request toileting so he was offered the opportunity to use the bathroom every 2-3 hours. During an interview on 3/19/2026 at 2:18 p.m., NA-C stated all residents are offered to go to the bathroom or checked for incontinence every two-three hours, as requested, and/or as indicated on the resident's Kardex.During an interview on 3/19/2026 at 4:34 p.m., the director of nursing (DON) stated a comprehensive bladder assessment was completed on admission to the facility, and a care plan focus would trigger if a resident was incontinent and individualized interventions would be added. DON further stated R6's comprehensive bladder assessment did not have all portions completed and the care plan did not address urinary incontinence nor was there a urinary toileting plan. The goal for an individualized toileting plan was for a resident to return to or maintain the continence level they were at prior to being at the hospital.The Bowel and Bladder Assessment policy dated April 2025 indicated all residents will receive a comprehensive bowel and bladder assessment upon admission, with ongoing reassessment and individualized interventions. Findings from the assessment must be used to develop an individualized bowel and bladder program and update the resident's comprehensive care plan. Care plans must include toileting schedules (prompted, timed, or scheduled voiding), bowel program (routine, medications, diet) and incontinence products and skin care, hydration and nutrition interventions, mobility and transfer assistance and monitoring parameters.

Based on observation, interview, and record review the facility failed to provide a dignified living existence for 3 of 3 residents (R1, R2, and R3) reviewed for call lights. Staff responded timely to the residents when the residents pressed their all lights for assistance; however, the staff would turn off the call light not providing services. This practice resulted in R1 and R2 soiling themselves and R3, a non-weight bearing resident attempted to transfer herself to the bathroom.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) of 15 indicating she was cognitively intact. R1 required substantial assistance with toileting hygiene, lower body dressing, personal hygiene, rolling from side to side in bed, transferring from a sitting to lying position and transferring from bed to chair. R1 was frequently incontinent of urine and stool and was not on a toileting program. R1's diagnoses included Type 2 Diabetes, cellulitis (a bacterial infection that enters the skin) of the right lower limb, morbid obesity, and lymphedema (swelling most often in the arm or leg caused by a lymphatic system blockage). R1's care plan report dated 7/10/25 indicated to make sure R1's call light was within reach and encourage her to use it for assistance as needed. R1 required prompt response to all requests for assistance. R1 used incontinent briefs, and staff was to change as needed and clean peri-area with each incontinent episode. R1's toileting need was one hand assistance from staff with a raised toilet set to assist with a safe transfer to the toilet. R1's call light detailed activity reported dated 9/8/25 at 3:30 a.m. indicated R1 pressed her call light. The call light response time was six minutes and fifty-nine seconds. R1's call light was again pressed on 9/8/25 at 6:05 a.m. and the response time was six minutes and sixteen seconds. Upon observation and interview on 9/8/25 at 11:55 a.m. R1 stated she pressed her call light around 4:00 a.m. and requested to use the bathroom. The light was answered and turned off. R1 soiled herself of urine in her brief waiting for the staff member to return. She fell asleep for a few hours and woke-up around 5:30 a.m. She waited for the morning shift to be on duty and pressed her light again at 6:05 a.m. stating she knew the a.m. staff would assist her. R1 was diabetic, her skin was a big concern. A few weeks ago, R1 developed a rash on her left thigh region just below her buttocks that was bleeding from sitting in soiled incontinent briefs. R1 was able to notify the staff when she needed to use the bathroom. She wore incontinent briefs for dribbling of urine and for when staff did assist her, and she soiled herself. She stated she was [AGE] years old, and she felt like she was [AGE] years old when she wet herself because of staff not assisting her timely. R1's skin was observed and revealed the inside of her left thigh under her buttocks was a macerated area (skin breakdown due to prolonged exposure to moisture). The area was approximately 12 centimeters in length x 4 centimeters in height. The area was covered with a barrier cream. There were no open areas and no bleeding was observed. R1's incontinent brief was dry. Upon interview on 9/8/25 at 12:15 p.m. nursing assistant (NA)-A stated R1 did turn her light on right away at the beginning of the shift and mentioned to her that in the night she requested to use the bathroom, and no staff member returned. R1's brief was soaked with urine. R1 was able to press her call light and request the use of the bathroom. NA-A stated she often found other residents soiled in the morning. NA-A stated her practice was to turn off a residents light when she answered it and would return when able to keep the call lights appear under 10 minutes. She hoped she never forgot about a resident with that practice. R2's MDS report dated 9/4/25 was in process at the time of the survey. R2's Care Plan Report dated 9/4/25 indicated R2 transferred with the assistance of two staff members. R2 did not walk. Staff was to ensure R2's call light was within reach and encourage R2 to use it for assistance. The resident required prompt responses to all requests for assistance. R2's face sheet dated 9/4/25 indicted R2's pertinent diagnoses were fracture of the left femur (hip), Type 2 Diabetes, and coronary artery disease. R2's BIMs score assessment dated [DATE] indicated R2 had a score of 15 indicating she was cognitively intact. R2's Functional Status Tracking dated 9/7/25 indicated R2 required maximum assistance with lower body dressing, rolling from side to side in bed, transferring from bed to chair and toileting hygiene. Upon observation and interview on 9/8/25 at 1:06 p.m. R2 was wheeling herself in a wheelchair to the bathroom. R2 had a boot cast on her left foot. R2 stated she was not supposed to transfer herself, but she was able to. She was aware she was not to bear weight on her left foot. R2 stated she transferred herself to the toilet because in only the few days she had been at the facility staff members would answer call light and not return for a long time. She had not soiled herself and would be horrified if she did. She stated she will have to transfer herself when she returned home, so may as well start in the facility. Upon interview on 9/9/25 at 11:21 a.m. physical therapy assistant (PT)-A stated R2 was ordered to have assistance of two staff members for transfers. She was not to self-transfer due to a non-weight bearing status. He had educated residents the importance of following the restrictions advised by physical therapy and to wait for staff for their own safety. He was not aware that R2 had been transferring herself. R3's MDS dated [DATE] was in process at the time of the survey. R3's face sheet dated 9/3/25 indicated her pertinent diagnoses were malignant neoplasm of the Pancreas, weakness, chronic lymphocytic leukemia, R3's Bladder/Bowel Incontinence assessment dated [DATE] indicated R3 did not have any incontinent symptoms. She was incontinent, the type of incontinent was overflow incontinence, however the previous questions indicated overflow incontinence was not suspected. R3 required assistance of one or two staff members for ambulation. R3 was oriented to time, person, and place. R3's BIMS assessment dated [DATE] indicated R3 had a score of 13 indicating she was cognitively intact. Upon observation and interview on 9/8/25 at 1:45 p.m. R3 stated she has been at the facility at the beginning of summer and felt staff was very attentive. Currently on this admission she felt staff were less attentive, R3 stated she had soiled herself waiting for staff to return after requesting assistance to the bathroom It has gotten all over my clothing, even though the pad. R3 stated she felt like baby when she sat in a wet incontinent brief. R3 was not certain if she had any skin breakdown but complained of anal pain. At 2:15 p.m. her skin was observed, between the folds of her buttocks was redness, no open areas. She was found to have a bulging hemorrhoid. Staff was notified of the finding. Upon interview on 9/8/25 at 2:12 p.m. R3's family member FM-A stated R3 had been at the facility in early May of 2025 for a rehabilitation stay. R3 had no complaints at that time. Currently she complained to FM-A about how long it took for her to receive assistance. She was not certain if the staff were turning off the light and not returning or just not answering the light in a timely manner. R3 was able to use the bathroom at home without becoming incontinent of urine or stool. She stated she had not reported her concern to the facility because R3 would soon be going home on hospice, and she did not want to cause a stir. Upon interview on 9/9/25 at 11:10 a.m. registered nurse (RN)-A the nurse manager stated she was not aware of any complaints that staff were turning off the resident call lights. She stated the facility process for answering call lights was any staff member could answer a call light. She stated it was unacceptable for staff to not return to a residents room for long periods of time or not at all. All staff carrier walkie talkies so if they needed an extra staff member, they should be using that to call for assistance. Upon interview on 9/9/25 at 12:25 p.m. the director of nursing, (DON) stated the process for answering call lights was to not turn off the light until the residents need are met. A facility policy titled Dignity dated 2/2025 indicated each resident shall be care for in a manner that promotes and enhances their sense of well-being, level of satisfaction with lift, and feelings of self-worth and-self-esteem.

Based on interview and record review, the facility failed to follow physician orders and ensure provider was notified of resident refusals for continuous positive airway pressure (CPAP) orders for 1 of 1 residents (R2) reviewed respiratory care. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses of pulmonary fibrosis (condition where the lungs become scarred and thickened, making it difficult to breathe), acute and chronic respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea (sleep disorder where breathing repeatedly pauses or slows down during sleep due to a blockage of the upper airway). Further, MDS revealed R2 had exhibited behavior related to rejection of care. R2's medication administration record (MAR) and treatment administration record (TAR) dated April 2025, revealed R2 had physician order's directing staff to record hours R2 kept his CPAP (a machine that uses mild alit pressure to keep breathing airways open while you sleep) on, chart when refuses every night shift dated 3/31/25. R2's MAR/TAR revealed on two occasions R2 had refused, and 10 occasions was documented as 0 hours worn. R2 also had an order to remove R2's CPAP at 8:00 a.m. which was documented as completed from 4/4/25 through 4/7/25. R1's care plan revised 4/21/25, identified R2 had a behavior problem as evidenced by increased agitation, restlessness, fidgeting, pulling off clothes, pulling at drainage tube, and self-transferring. R2's care plan directed staff when refusing cares or tasks to ensure safety, attempt to re-approach, offer alternate caregiver, offer choices, and notify charge nurse. Further, R2's care plan revealed R2 had an altered respiratory status and difficulty breathing. R2's respiratory interventions included CPAP use and R2 had the right to refuse but staff were to encourage use while in bed. On 4/23/25 at 11:14 a.m., licensed practical nurse (LPN)-A stated family member (FM)-A arrived at the facility on 4/7/25, and was upset R2 did not have his CPAP on and/or in his room. LPN-A stated this was her first time working with R2 and was not aware he required a CPAP, but LPN-A stated she would go look in R2's old room for it. LPN-A stated she found the CPAP and brought it to R2's current room. LPN-A confirmed she had observed R2 on the morning of 4/7/25, in bed without a CPAP on. Further, LPN-A stated she was informed R2 had a history of refusing the CPAP, but with R2's respiratory diagnoses he should have still been offered to wear it. On 4/23/25 at 12:05 p.m., FM-A stated R2 had end stage lung disease and tested positive for COVID-19 on 4/4/35, which R2 then had to move to the isolation unit into a private room. FM-A stated she arrived at the facility in the morning of 4/7/25, and noted R2 did not have his CPAP machine. FM-A stated R2's CPAP was not new for him, and he had an order to wear the CPAP at night while sleeping due to his sleep apnea, however when R2 moved rooms on 4/4/25, staff did not bring his CPAP to his new room. Further, FM-A stated R2 would often decline to wear the CPAP or remove it himself, but he should still be offered to wear it. On 4/23/25 at 1:54 p.m. nurse practitioner (NP) stated R2 had an order to wear his CPAP at night because he had a diagnosis of sleep apnea. NP stated she was not aware of R2 refusing to wear the CPAP. On 4/23/25 at 2:50 p.m., registered nurse (RN)-A stated R2 had an order to wear his CPAP at night, however R2 had a history of refusing to wear the CPAP or removing the CPAP himself during the night. RN-A stated staff would still be expected to offer R2 his CPAP and document all refusals in R2's MAR/TAR, and RN-A confirmed staff would be expected to notify the provider of consistent refusals. On 4/23/25 at 4:35 p.m., combined interview with director of nursing (DON) and administrator revealed R2 was moved from the 100 unit on the evening of 4/3/25, to the 500 unit. DON and administrator stated during the transition to the other unit, R2's CPAP was not transferred to the new room and was not available for R2. Further, DON and administrator stated there were reports from the 100-unit staff R2 would often refuse to wear his CPAP, however DON and administrator confirmed R2's provider had not been updated regarding R2's consistent refusals as expected. In addition, DON and administrator confirmed staff had documented in R2's MAR/TAR for CPAP completion 4/4/25 through 4/7/25, however R2 did not have his CPAP in his room at the time. DON and administrator stated staff had not been re-educated regarding following physician orders and updating provider related to consistent refusals. On 4/24/25 at approximately 12:50 p.m., requested facility policy related to refusal of physician orders and notifying physician from administrator and DON, however facility failed to provide a copy.

Based on observation, interview and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Influenza A and norovirus. In addition, the facility failed to ensure infection control measures were implemented to reduce the spread of Norovirus when the dishwasher temperature did not rise high enough to sanitize the dishes during the norovirus outbreak. As a result, the facility developed an influenza outbreak which included three residents (R26, R29, and R71) who tested positive for Influenza A, and two residents who were suspected to have Influenza A (R54, and R216) as well as 10 residents (R87, R207, R346, R54, R84, R85, R23, R205, R216 and R209) who showed signs and symptoms and/or were confirmed to have norovirus. The facility failed to ensure 12 of 12 employees, (registered nurse (RN)-E, cook (C)-A, dietary aide (DA)-D, laundry aide (LA)-B, nursing assistant (NA)-D, housekeeping aide (HA)-C, DA-E, NA-E, RN-F, NA-F, NA-G, and NA-H) who displayed signs and symptoms of potential Norovirus were restricted from and returned to work per the Centers for Disease Control (CDC) criteria. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility to vulnerable residents and the staff of the facility resulting in an immediate jeopardy (IJ) which placed all 108 residents at a high likelihood to for serious illness and/or death by contracting a communicable disease, including but not limited to Norovirus and/or Influenza. The IJ began on 1/21/25 when R26 was observed to have influenza-like symptoms, and the facility failed to implement appropriate transmission-based precautions to prevent spread of infection and failed to implement infection control surveillance to identify trends or patterns of potential infectious outbreaks. In addition, after the facility placed residents in isolation, staff were observed to not use the appropriate PPE and/or perform appropriate hand hygiene practices. Norovirus outbreak started in December and continued to spread in facility at the time of the recertification survey. The IJ was identified on 1/23/25, and the administrator, director of nursing (DON), director of quality improvement (DQI), infection preventionist (IP) and executive business director were notified of the IJ on 1/23/25 at 5:45 p.m. The IJ was removed on 1/24/25, at 1:45 p.m., when the facility implemented actions to reduce/prevent the spread of illness, including Norovirus and Influenza A. However, noncompliance remained at the lower scope and severity, F, widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ. Findings include: The U.S. Centers for Disease Control and Prevention (CDC) identified Influenza is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. The Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities, dated 9/17/24, identified when there is influenza activity in the local community, active daily surveillance for influenza illness should be conducted among all new and current residents, healthcare personnel, and visitors of long-term care facilities, and should be continued until the end of influenza season. Healthcare personnel, and visitors who are identified with any illness symptoms should be excluded from the facility until their illness has resolved. Older adults and other long-term care residents, including those who are medically fragile and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of influenza virus infection, and may not have fever. Ill residents should be placed on droplet precautions with room restriction and be excluded from participating in group activities. Influenza testing should occur when any resident has signs and symptoms of acute respiratory illness or influenza-like illness. Implement standard and droplet precautions for all residents with suspected or confirmed influenza. Standard precautions are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard precautions constitute the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. Standard precautions consist of performing hand hygiene, using personal protective equipment (PPE) whenever there is an expectation of possible exposure to an infection material, follow respiratory hygiene/cough etiquette principles and properly handle, clean and disinfect patient care equipment and instruments/devices. Clean and disinfect the environment appropriately. The U.S. Centers for Disease Control and Prevention (CDC) identified Norovirus as a very contagious virus that causes vomiting and diarrhea, that sometimes is 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 (inflammation of the stomach or intestines). Most people with norovirus illness get better within one to three days; but they can still spread the virus for a few days after. A person usually develops symptoms 12 to 48 hours after being exposed to norovirus. Most common symptoms: diarrhea, vomiting, nausea, stomach pain with other symptoms that may include fever, headache. The virus can be introduced into healthcare facilities by infected patients, staff, visitors, or contaminated foods. Compared with healthy people, norovirus illnesses can be more severe and occasionally even deadly in patients in hospitals or long-term care facilities. Anyone can get infected and sick with norovirus and people of all ages get infected during norovirus outbreaks. Older adults and people with weakened immune systems are more likely to develop severe infections. Norovirus spreads very easily and quickly in different ways. You can get norovirus by having direct contact with someone with norovirus, eating food or drinking liquids that are contaminated with norovirus and touching contaminated objects or surfaces and then putting your unwashed fingers in your mouth. A person can still spread norovirus for two weeks or more after they feel better. Influenza R26 R26's admission record, dated 1/24/25, identified R26 was [AGE] years old, resided in the 300's unit, and had diagnoses that included monoplegia of upper limb following cerebral infarction affecting right dominant side (paralysis of limb following stroke), major depression disorder, gastrointestinal hemorrhage (bleeding in the digestive tract, from the mouth to the anus), unspecified dementia and hypertension. R26's progress notes, dated 1/20/25 at 6:00 p.m., identified R26 had complaints of a cough and emesis. Vital signs were per R26's normal. R26's progress note, dated 1/21/25 at 12:15 a.m., identified R26 continued to cough, had increased respirations of 24 breaths per minute, and had oxygen saturations of 90% on room air. Provider was updated and sent orders to repeat COVID test and to perform a triple swab test (COVID, RSV and Influenza) in the morning. R26 was complaining of back and rib pain from coughing and Tylenol was administered per R26's request. R26's progress note, dated 1/21/28 at 11:28 a.m., identified R26 had a hoarse voice and dry cough and R26 started coughing last evening (1/20/25) after supper. Rapid COVID test was negative, and a triple swab was obtained and sent to the lab. Provider recommended to utilize Guaifenesin cough syrup order and to update provider with worsening condition. R26's progress note, dated 1/21/25 at 8:06 p.m., identified R26 was tested for Influenza A earlier today due to symptoms of a hoarse voice and ongoing cough. Results were received for R26, positive for Influenza A. Daughter was notified and requested R26 be administered Tamiflu. Provider was contacted to request order. Note also identified isolation precautions were implemented earlier today. R26's electronic health record (EHR) indicated monitoring of Influenza symptoms and vitals, and respiratory assessments were not initiated until 1/22/25 at 7:00 a.m. Care plan was not updated until 1/22/25. R26's care plan indicated R26 had identified infection related to positive Influenza with the following inventions initiated on 1/22/25: - Administer anti-infective as ordered by MD/NP. Monitor for effectiveness and side effects. - Monitor breath sounds (wheezes, rales, rhonchi, cough (productivity), respiratory rate (rhythm, quality) oxygen saturation, shortness of breath, changes in LOC, anxiety, or mental status changes. Monitor/document/report new or worsening respiratory alterations to MD/NP. - Monitor for GI symptoms including watery foul-smelling diarrhea. Monitor/document/report new or worsening gastrointestinal alterations to MD/NP. - Monitor for skin for redness, purulence, tenderness, warmth, new or increased swelling. Monitor/document/report new or worsening integumentary alterations to MD/NP. - Monitor vital signs per facility protocol and as needed. R26's electronic treatment administration record (TAR) indicated the following orders: - R26 had a positive influenza test on 1/21/25 and R26 was in the contagious stage and required strict isolation as this is medically necessary at this time. Expected duration is at least through 1/28/25 @ 11:59 P.M., and 24 hours fever free. Treatment order was initiated on 1/22/25 at 3:00 p.m. R26's lab result report, dated 1/21/25, identified specimen was collected on 1/21/25 at 11:00 a.m., with lab receiving specimen on 1/21/25 at 4:58 p.m. Report also identified a reported date of 1/21/25 at 6:12 p.m., indicated R26 was positive for Influenza A. During observation and interview on 1/21/25 at 10:26 a.m., R26 stated he started coughing yesterday (1/20/25) and there was talk of sending him to the emergency room due to increased temperature but did not because his temperature went down. R26 was not on any precautions at the time of interview. During observation on 1/21/25 at 12:28 p.m., precautions outside R26's room were not in place. During interview on 1/21/25 at 12:32 p.m., registered nurse (RN)-A stated if a resident was exhibiting signs or symptoms of respiratory illness, the resident would be isolated right away. RN-A stated R26's symptoms started on 1/20/25 and confirmed there were no precautions in place for R26 at the time of the interview. During observation on 1/21/25 at 12:50 p.m., infection preventionist (IP) posted precaution signage outside of R26's room. R29 R29's admission record, dated 1/24/25, identified R29 was [AGE] years old, resided in the 300's unit, was receiving hospice services, and had d diagnoses that included Parkinson's disease without dyskinesia, mild cognitive impairment, acquired coagulation factor deficiency (rare condition that can lead to a bleeding due to a deficiency of a coagulation factor), hypertension, diverticulosis of large intestine (presence of one or more balloon-like sacs in the large intestine) and chronic kidney disease - stage three (condition characterized by a gradual loss of kidney function). R29's progress note, dated 1/21/25 at 3:28 p.m., identified R29 had signs/symptoms of runny nose, cough and malaise. Plan was to swab for COVID/Influenza and also obtain a triple swab for RSV/COVID/Influenza. R29 was isolated to room. R29's progress note, dated 1/21/25 at 4:43 p.m., identified rapid antigen influenza A&B and COVID test was conducted for symptoms of runny nose, cough and congestion which was negative. PCR was also obtained and sent to labs. R29 to be in isolation and on precautions while waiting for results. R29's electronic health record (EHR) indicated monitoring of Influenza symptoms and vitals, and respiratory assessments were not initiated until 1/22/25 at 7:00 a.m. R29's care plan indicated R29 had identified infection related to positive Influenza with the following inventions initiated on 1/22/25: - Administer anti-infective as ordered by MD/NP. Monitor for effectiveness and side effects. - Monitor breath sounds (wheezes, rales, rhonchi, cough (productivity), respiratory rate (rhythm, quality) oxygen saturation, shortness of breath, changes in LOC, anxiety, or mental status changes. Monitor/document/report new or worsening respiratory alterations to MD/NP. - Monitor for GI symptoms including watery foul-smelling diarrhea. Monitor/document/report new or worsening gastrointestinal alterations to MD/NP. - Monitor for skin for redness, purulence, tenderness, warmth, new or increased swelling. Monitor/document/report new or worsening integumentary alterations to MD/NP. - Monitor vital signs per facility protocol and as needed. R29's electronic treatment administration record (TAR) indicated the following orders: - R29 had a positive influenza test on 1/21/25 and R29 was in the contagious stage and requires strict isolation as this is medically necessary at this time. Expected duration is at least through 1/28/25 @ 11:59 P.M., and 24 hours fever free. Treatment order was initiated on 1/22/25 at 7:00 a.m. R29's lab result report, dated 1/22/25, identified specimen was collected on 1/21/25 at 4:09 p.m., with lab receiving specimen on 1/22/25 at 12:08 a.m. Report also identified a reported date of 1/22/25 at 1:05 a.m., indicated R29 was positive for Influenza A. R71 R71's admission record, dated 1/24/25, identified R71 was [AGE] years old, resided in the 300's unit, and had diagnoses that included type II diabetes mellitus, emphysema (long-term lung condition that causes shortness of breath), paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), hypertension (high pressure in the arteries (vessels that carry blood from the heart to the rest of the body) and pulmonary fibrosis (disease in which the lungs become scarred and damaged causing difficulty in breathing. R71's progress note, dated 1/18/25 at 7:02 p.m., identified R71 was not feeling well, was clammy, slow to respond, elevated blood pressure of 174/76 and an elevated temperature of 102.6. COVID test was negative. Provider was updated and sent orders for Ceftriaxone (antibiotic used to treat a wide variety of bacterial infections) 1 gram stat (immediately) and to repeat in 24 hours and to obtain a urine analysis and urine culture for presumed urinary tract infection. R71's progress note, dated 1/19/25 at 7:05 a.m., identified orders for COVID, RSV, and Influenza panel. R71's progress note, dated 1/19/25 at 8:24 a.m., identified R71 was having increased episodes of incontinence and increased weakness. Also identified that R71 was having episodes of coughing and barrier precautions were being used until lab results were received. Progress note did not specific which barrier precautions were in place. R71's progress note, dated 1/19/25 at 8:55 p.m., identified R71 had episodes of coughing during shift and also increased temperature of 100.1. R71's progress note, dated 1/20/25 at 2:56 p.m., identified R71 had episodes of coughing noted throughout shift and that UA/UC final results and COVID, RSV and Influenza results were still pending. R71's progress note, dated 1/20/25 at 3:49 p.m., identified rapid antigen combo Influenza A&B/COVID test was completed with a faint line that appeared on the Influenza A line which indicated R71 was presumed positive for Influenza A and PCR (test that detects genetic material from a pathogen or abnormal cell sample) results were pending. R71's progress note, dated 1/20/25 at 6:15 p.m., identified provider was updated on lab results, which indicated R71 was positive for Influenza A. Order was received for Tamiflu 75 mg twice daily for five days. R71's electronic treatment administration record (TAR) indicated the following orders: - Monitoring of Influenza symptoms and vitals were initiated on 1/21/25 at 11:00 p.m., respiratory assessments initiated on 1/22/25 at 7:00 a.m. and care plan was updated on 1/22/25. - R71 had a positive influenza test on 1/18/25 and R71 was in the contagious stage and required strict isolation as this is medically necessary at this time. Expected duration was through 1/25/25 @ 11:59 P.M., and 24 hours fever free. Treatment order was initiated on 1/22/25. R71's care plan indicated R71 had an identified infection related to positive Influenza with the following inventions initiated on 1/22/25: - Administer anti-infective as ordered by MD/NP. Monitor for effectiveness and side effects. - Monitor breath sounds (wheezes, rales, rhonchi, cough (productivity), respiratory rate (rhythm, quality) oxygen saturation, shortness of breath, changes in LOC, anxiety, or mental status changes. Monitor/document/report new or worsening respiratory alterations to MD/NP. - Monitor for GI symptoms including watery foul-smelling diarrhea. Monitor/document/report new or worsening gastrointestinal alterations to MD/NP. - Monitor for skin for redness, purulence, tenderness, warmth, new or increased swelling. Monitor/document/report new or worsening integumentary alterations to MD/NP. - Monitor vital signs per facility protocol and as needed. R71's lab result report, dated 1/20/25, identified specimen was collected on 1/19/25 at 11:49 p.m., with lab receiving specimen on 1/20/25 at 4:26 p.m. Report also identified a reported date of 1/20/25 at 5:27 p.m., indicated R71 was positive for Influenza A. During observation on 1/21/25 at 10:01 a.m., R71 had three signs posted on the wall outside of door in the hallway. Signs identified: 1. Isolation - precautions - PPE requires - Refer to Precaution sign for required PPE. Additional information in tasks or chart. Start date: 1/18/25 - End date: 1/25/25 at 23:59. 2. Stop - Droplet precautions - Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. 3. Stop - Contact precautions - Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. During observation on 1/21/25 at 10:04 a.m., activity aide (AA)-A entered R71's room without donning personal protective equipment (PPE). AA-A leaned against the back of R71's recliner, rested arms on top of recliner, and touched the over-the-bed table. AA-A left R71's room and did not wash or sanitize hands. AA-A proceeded into two other resident rooms without washing or sanitizing hands and assisted one resident down the hallway in his wheelchair. AA-A also did not have a face mask on when entering R71's room or any of the other resident's room. During interview on 1/21/25 at 12:11 p.m., AA-A stated when a resident is on precautions we should wears masks, if a resident is not sick, I am not going to gown up. AA-A stated when a resident is on droplet precautions, she would wear a mask but if she was going to be in the room for 10-15 minutes she would then gown up. AA-A stated staff are to sanitize hands between each resident. AA-A confirmed she did not don PPE when entering R71's room nor did she sanitize hands between residents. AA-A stated they are notified of residents on precautions via email from administration and an isolation cart would be in place outside resident's room. AA-A confirmed isolation cart and signs were outside of R71's room but stated she missed seeing them. During observation on 1/22/25 at 8:57 a.m., NA-B donned gown, mask and gloves and entered R71's room with his breakfast tray. NA-B came out of R71's room with her gown still on, had removed mask and gloves in room prior to exiting. NA-B donned a new mask and gloves and removed another breakfast tray off the cart and entered R29's room wearing the same gown that was worn in R71's room. NA-B was holding tray, so it was touching NA-B's right shoulder region of gown. During interview on 1/22/25 at 8:38 a.m., IP stated if a resident was displaying signs/symptoms of respiratory/GI illness, she expected the nurse to move on it right away which consisted of notifying the provider, testing the resident immediately, complete point-of-care (POC) testing, place resident on isolation. Precautions should be initiated at that time also. IP stated R71 symptoms started on Monday 1/20/25, the triple swab for RSV, COVID and Influenza was already completed before she found out. IP stated on 1/21/25, R26 and R29 were having symptoms, so both R26 and R29 were placed in isolation and precautions were initiated. IP stated she would consider this an outbreak and is implementing facilities Influenza protocol which included prophylactic treatment of Tamiflu to all residents, who consented, whether or not they displayed symptoms. IP stated for residents who had roommates, she placed a divider between the residents, updated the roommate and educated them on the importance of wearing a mask and performing hand hygiene, put in an EnvironKlenz filter and UV light to help the healthy roommate. IP stated R71, who was the first case, does leave the facility frequently and R26's daughter indicated that she was ill. IP failed to indicate attempts were made to identify initial source of Influenza. IP confirmed precautions were not initiated timely for R26 and stated they should have been initiated immediately with onset of symptoms. R35's progress note, dated 1/21/25 at 6:50 p.m., identified IP spoke with R35 (R71's roommate) regarding R71 being ill with a respiratory illness. IP explained single rooms were not available and encouraged resident to wear a mask in room and to keep the curtain drawn between areas. Identified an EnviroKlenz filter had been set up in room for further protection cleaning the air with a HEPA filter and UV light. IP also explained that additional cleaning would be conducted. IP asked R35 if he would prefer separating toileting activities with R35 stating that would not be necessary. During interview on 1/22/25 at 9:01 a.m., nursing assistant (NA)-B stated R26 started having symptoms when R71 did, which she believed was on Sunday 1/19/25. NA-B stated R26 is part of the group of men who sit together at meals where R71 also sat. NA-B stated precautions for R71 were put in place yesterday afternoon (1/21/25) when testing for Influenza A came back as positive. During interview on 1/22/25 at 11:03 a.m., IP stated facility was well stocked with PPE. IP stated she would expect staff to remove gown and gloves inside resident's room prior to exiting. Once outside of room, staff to remove mask and perform hand hygiene. IP stated staff should not wear gown outside of isolation room even if going into another isolation room due to the hallway being a public area and it was a way the illness could spread. IP stated staff could also get interrupted by needing to respond to an emergent issue and that would not be okay when wearing a contaminated gown from isolated room. R216 R216's admission record, dated 1/24/25, identified R216 was [AGE] years old, resided in the 500's unit, and had diagnoses that included hemiplegia affecting right dominant side, type 2 diabetes mellitus, morbid obesity, epilepsy (neurological disorder that cause seizures or unusual sensations and behaviors), hypertension, chronic diastolic heart failure (occurs when the heart muscle doesn't pump blood as well as it should), chronic kidney disease - stage three, and history of transient ischemic attack. R216's progress note, dated 1/23/25 at 8:16 a.m., identified a rapid antigen Influenza A&B/COVID test was obtained per provider's order for a new onset of cough and congestion. R216's progress note, dated 1/23/25 at 1:40 p.m., identified R216 had a new onset of cough and congestion with the provider recommended putting discharge on hold and ordered labs and chest x-ray. R216's electronic treatment administration record (TAR) indicated the following orders: - PCR COVID/Influenza A&B one time only for cough until 1/23/25 at 11:59 p.m. Treatment order was initiated on 1/23/25 at 11:00 a.m. - Outbreak monitoring - GI: temperature, presence/absence nausea, vomiting, diarrhea every shift. Treatment order was initiated on 1/23/25 at 3:00 p.m. - Outbreak monitoring - Respiratory: temperature, oxygen saturation, presence/absence of cough, congestion every shift. Treatment order was initiated on 1/23/25 at 3:00 p.m. R54 R54's admission record, dated 1/24/25, identified R54 was [AGE] years old, resided in the 500's unit, and had diagnoses that included metabolic encephalopathy (problems with your metabolism cause brain dysfunction), severe sepsis (serious condition in which the body responds improperly to an infection) with septic shock (serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis), heart failure, pulmonary edema (condition where fluid accumulates in lung tissues and causes shortness of breath, wheezing and coughing up blood), asthma (condition in which your airways narrow and swell and may produce extra mucus), chronic kidney disease - stage 3, sick sinus syndrome (abnormal heart rhythms resulting from the malfunction of hearts primary pacemaker) and adult failure to thrive (substantial decline in overall health and functional abilities). R54's progress note, dated 1/23/25 at 9:25 a.m., identified R54 had increased confusion and weepiness. R54's progress note, dated 1/23/25 at 11:46 a.m., identified R54 had signs/symptoms of increased confusion, elevated temperature and crackle sounds in lungs bilaterally. Provider was updated and orders were received to obtain a chest x-ray also obtain a triple swab for RSV/COVID/Influenza. R54 was isolated to room. R54's progress note dated 1/23/25 at 12:03 p.m., identified R54 was placed on droplet precautions when symptoms were reported, and testing occurred. R54's progress note, dated 1/23/25 at 12:04 p.m., identified chest x-ray was ordered and rapid antigen influenza A&B and COVID test was conducted. PCR was also obtained and sent to lab. R54's progress note dated 1/23/25 at 9:10 p.m., identified R54's functional status had declined and had declined supper. R54's progress note dated 1/23/25 at 11:44 p.m., identified R54 was diagnosed with Influenza A today. R54 lungs sounds were diminished at the bases and inspiratory wheezes were heard in the upper lobes. R54 had a small emesis following a few bites of yogurt. R54's progress note dated 1/23/25 at 12:04 p.m., identified chest x-ray was ordered and rapid antigen influenza A&B and COVID test was conducted. PCR was also obtained and sent to lab. R54's electronic health record (EHR) indicated monitoring of Influenza symptoms and vitals, and respiratory assessments were initiated on 1/23/25 at 3:00 p.m. R54's care plan indicated R54 had identified infection related to positive Influenza with the following inventions initiated on 1/23/25: - Adhere to droplet precautions. R54's electronic treatment administration record (TAR) indicated the following orders: - R29 had a positive influenza test on 1/23/25 and R54 was in the contagious stage and requires strict isolation as this is medically necessary at this time. Expected duration is at least through 1/30/25 and 24 hours fever free. Treatment order was initiated on 1/23/25 at 3:00 p.m. R54's lab result report, dated 1/23/25, identified specimen was collected on 1/23/25 at 11:30 a.m., with lab receiving specimen on 1/23/25 at 6:45 p.m. Report also identified a reported date of 1/23/25 at 7:46 p.m., indicated R54 was positive for Influenza A. Norovirus R87 R87's admission record, dated 1/24/25, identified R87 was [AGE] years old, resided in the 400's unit, and had diagnoses that included orthopedic aftercare following surgical amputation, type 2 diabetes mellitus, pain, motor and sensory neuropathy (damage to nerves), drug induced constipation, and hypertension. R87's progress note dated 12/17/24 at 2:26 p.m., identified R87 developed symptoms of nausea and had a large emesis. R87's progress note dated 12/18/24 at 10:14 a.m., identified R87 was awake all-night vomiting and having episodes of loose stools and had been outside room for fresh air. R87's progress note dated 12/18/24 at 8:35 p.m., identified R87 had not been nauseated or had any additional episodes of emesis since early morning. R87's care plan indicated Norovirus is suspected with the following inventions initiated on 12/20/24: - Actively promote adherence to hand hygiene (soap and water) for resident, staff and visitors. - Contact precautions: Resident is to remain in room for a minimum of 72 hours after the resolution of symptoms to prevent further exposure of susceptible patients. - Monitor for signs and symptoms of dehydration. Update provider with concerns notes. Pale in color, dry skin, dizziness, weak, skin turgor. - Resident and staff to use soap and water for hand hygiene after providing care, having contact, or leaving the room with residents suspected or confirmed with norovirus. R87's electronic treatment administration record (TAR) indicated the following orders: - R87 was on isolation and on enteric contact precautions (gown and gloves when entered resident's room) for suspected or confirmed Norovirus infection. Continue isolation and precautions for 72-hours after symptoms end. Clean high-touch surfaces, vital sign instruments, and lifts with bleach wipes every shift for infection monitoring. Discontinue order once Norovirus isolation has ended. Treatment order was initiated on 12/20/24 at 7:00 a.m. and discontinued on 12/24/24 at 10:52 a.m. - Monitor for fever, nausea, vomiting and/or diarrhea every shift for five days and to write a progress note whether resident had symptoms or not. Treatment order was initiated on 12/20/24 at 7:00 a.m., and was discontinued on 12/24/24 at 10:52 a.m. R87's EHR lacked documentation that any testing was completed during this time. R207 R207's admission record, dated 1/24/25, identified R207 was [AGE] years old, resided in the 400's unit, and had diagnoses that included hypertension, chronic pain, depression, dementia, gallbladder disease and rheumatoid arthritis (chronic inflammatory disorder that affects the lining of your joints and can damage other body systems). R207's progress note dated 12/19/24, identified R207 developed symptoms on 12/19/24. Progress note did not identify specific symptoms. R207's care plan, print date of 1/29/25, lacked documentation regarding Norovirus. R207's electronic treatment administration record (TAR) indicated the following orders: - R207 is on isolation and on enteric contact precautions (gown and gloves when entered resident's room) for suspected or confirmed Norovirus infection. Continue isolation and precautions for 72-hours after symptoms end. Clean high-touch surfaces, vital sign instruments, and lifts with bleach wipes every shift for infection monitoring. Discontinue order once Norovirus isolation has ended. Treatment order was initiated on 12/20/24 at 3:00 p.m. and discontinued on 12/27/24 at 5:52 p.m. - Lab order for enteric stool panel one time only for diarrhea until 12/19/24 at 11:59 p.m. and to discontinue once complete. Treatment order was initiated on 12/16/24 at 11:15 a.m., staff documented completed on 12/19/24 at 2:05 p.m. - Notify MD in AM of positive Norovirus result. Treatment order was initiated on 12/20/24 at 1:30 a.m., staff documented completed on 12/20/24 at 10:15 a.m. - Monitor for fever, nausea, vomiting and/or diarrhea every shift for five days and to write a progres[TRUNCATED]

Based on observation, interview and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwashers observed. This had the potential to affect all 108 current residents, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher. Findings include: On 1/21/25, at 9:32 a.m., during a brief initial tour with the interim culinary director (CD)-A and the certified dietary manager (CDM) an observation was made of completion of the dishwashing process. At that time, the temperatures for the morning cycle temperature check had not been logged. Dietary aide (DA)-B stated the wash temp was 150 degrees Fahrenheit, and the rinse temp was one hundred and eighty five-ish. DA-B stated the temperatures were to be 160 for wash, and 180 for the rinse cycle. Although able to state the desired temperatures for the wash and rinse cycle, DA-B stated she was unaware the temperatures were to be up to the desired temperatures before starting the dishwashing process and was unaware there were further interventions indicated if the machines did not reach the desired temperatures. CDM, who was present during the observation and interview, stated it appeared that staff were unaware of the need to run two or more racks through to bring the temperatures up to the desired temperatures prior to starting the dishwashing cycle, and instructed DA-B on this process. CDM stated if the dishwashing machine was not up to the required temperature when checked, the dishwasher would have to be run until the temp was up to the desired temp. If the temperature still did not get to the desired temp, the facility would have to reach out to the company and request a service call. CD stated if this could not be corrected, the facility would use the three section sink for cleaning of pots and pans, and implement use of Styrofoam plates. On 1/22/25, at 1:52 p.m. during a follow up observation, DA-C was observed as they completed the dishwashing process. A review of the recorded temperatures indicated the temp check for the wash temperature was 175, while the rinse cycle was at 178 degrees Fahrenheit. DA-C stated they were unaware of the need to run the racks through until the temperature met the desired temperatures of 160 for the wash cycle and 180 for the rinse cycle. CD-A was present and provided instruction to DA-C. A review of the dishwasher temps was completed for the period of 12/12/24 to 1/21/25. The facility documentation lacked logged results for the period of 1/1/25 through 1/7/25 (42 opportunities for documentation were missed). A review of the wash temps were completed and noted the temp was less than 160 on the following dates: 12/12/24: AM: 148 12/13/24: AM: 150, Supper: 155 12/14/24: AM: 152, Supper: 151 12/15/24: Lunch: 150 12/17/24: AM: 150 12/18/24: AM: 152 12/19/24: Supper: 152 12/20/24: Lunch: 148, Supper: 149 12/21/24: AM: 150 12/23/24: AM: 148, Lunch: 151, Supper: 162 12/24/24: AM: 150, Lunch: 147 12/25/24: Lunch: 150 12/26/24: AM: 152, Lunch: 150, Supper: 153 12/27/24: AM:150, Supper: 159 12/29/24: AM: 150, Lunch:151 12/31/24: AM: 150, Supper: 153 1/9/26: Supper: 100 1/11/25: Supper: 100 1/12/25: Supper: 150 1/13/25: Supper: 140 1/14/25: Supper: 148 1/16/25: Supper:148 1/17/25: Supper:148 1/18/25: Supper: 148 1/19/25: Supper: 148 The wash temperature was below the desired range on 36 occassions during the period of 12/12/24 to 1/21/25. The facility also lacked documentation for wash temperature checks on 27 opportunities during this period. This total, including the missing documentation for 1/1/25-1/7/25, would be 48 incidents when wash temperatures were not recorded. A review of the rinse documentation was noted to be less than 180 on the following dates: 12/13/24: Supper: 160 12/18/24: Supper: 169 1/8/25: Supper: 170 1/9/25: Supper: 170 1/10/25: Supper:170 1/12/25: Supper: 160 1/16/25: Supper: 150 1/17/25: Supper: 150 1/18/25: Supper: 154 1/19/25: Supper: 152 The rinse temperature was below the desired range of 180 degrees Fahrenheit on 10 occasions during the period of 12/12/24 to 1/14/25. The facility also lacked documentation for rinse temperature checks on 28 opportunities during this period. This total, including the missing documentation for 1/1/25-1/7/25, was 49 occasions where rinse temperatures were not recorded. On 1/23/25, at 8:50 a.m. the service representative (SR) for the dishwasher was present for a service call. At this time, the wash and rinse temps were checked three times. SR stated the required temp for washing of dishes was 160 degrees. SR went on to state The final rinse temperature can be no lower than one hundred and eighty degrees. SR stated it was recommended to run the dishwashing racks through a couple of times to get the temperature up to the appropriate temperature. SR stated the water has to be that hot to kill the bacteria, and stated If not sanitized properly, technically you're not washing. SR stated the potential implication of not having the correct temperatures was if temperatures are not at the 180 degrees People can get sick. That's the whole point of sanitizing. On 1/23/25, at 9:04 a.m. a review of the current logs was completed with CDM. CDM stated it appeared staff were not aware to run the dishwasher racks through the machine two or more times to get up to temperature. CDM stated the purpose of monitoring temperatures was to ensure the dishwasher was operating correctly to ensure that the dishes were cleaned and sanitized. CDM went on to state: If the dishes were not sanitized, and if the dishes were not clean, there was a risk, potential risk, for illness. CDM stated currently in the facility, she was aware of the presence of Covid and influenza, however, was unaware of any residents with Norovirus. CDM stated there were residents with Norovirus prior to January of 2025. CDM stated she was unaware of the length of time Norovirus could remain on dishes if not cleaned properly. On 1/23/25, at 9:54 a.m., CD stated he was not aware of any residents who require special precautions at this time. CD stated dietary is notified by infection preventionist of any new illnesses and if they need to use paper products to eliminate cross contamination. On 1/23/25, at 2:43 p.m., an email, dated 12/27/24 at 8:39 a.m., sent by the CD, was provided by the IP and administrator. The email stated In the event of instances like Norovirus that we have/had in the TCU, we would be using disposable items for meals wherever applicable. The email went on to state The [sic] reduces the amount of contact with items amongst the teams. As this surveyor had been told earlier by the CDM and CD there were no current cases which required disposable items, this was clarified with IP and administrator. The IP stated there was one case of Norovirus in the facility. IP stated use of disposable products was implemented when Norovirus was suspected. IP went on to state there were four total rooms where disposable dishes were being used. IP stated this was implemented upon suspicion of Norovirus. IP went on to state she was in contact with the CDM and CD and they were aware of people using paper products. Although paper products were used for those four residents as outlined by IP, the paper products were delivered on plastic trays which were washed through the communal dishwasher. On 1/24/25, at 10:13 a.m., surveyor stopped at the receptionist desk for directions. At that time, surveyor observed a credit card scanner on the counter top, and asked it's function. The receptionist stated it was for employees to pay for their meals when they eat the facility food. A facility policy, Dishwasher Temperature, undated, indicated the purpose of monitoring the dishwasher temperature was to ensure that proper infection control, cleaning and sanitizing of all dishware is achieved while using the automatic dish machine. The policy statement identified: The automatic dish machine will reach the appropriate temperature prior to washing and sanitizing to meet the guidelines. The procedure outlined prior to washing the dishes, the dish machine will be turned on and run through the cycles to identify wash and rinse temperatures. The procedure identified the wash cycle will reach and minimum temperature of 160 degrees and rinse cycle will reach and maintain a minimum temperature of 180 degrees. The procedure identified the dish machine will be monitored at each meal period to ensure proper wash and rinse temperatures are reached. If the temperature was below the specified temperatures for the wash and rinse cycle, the Engineering department will be notified immediately. The procedure went on to state dishes will not be washed until the dish machine reaches the appropriate temperature. The procedure further goes on to identify If needed, disposable dishes will be used until the proper repairs can be made, and the three-compartment sink method will be used for pots and pans. The policy lacked direction to staff to run multiple racks prior to starting the process to bring the cycles up to the desired rinse cycles prior to starting the dishwashing process. Additionally, the policy lacked instruction to the staff to record the temperatures obtained on the dishwasher temperature logs upon obtaining the temperatures. The manufacturer manual from American Dish Service for Model ADC-44 High Temp Conveyor Dishmachines [sic], last revised 4/28/21, was received from the facility. The manual indicated the requirement at the dishmachine is 180 F (degrees Fahrenheit). The manual identified for high temp sanitizing, the measurement is taken at the manifold for a minimum of 180 F, not in or at the sprays. The manual indicated the temperature for hot water sanitizing in the wash cycle should be 160 F and 180 F for the rinse cycle for the hot water sanitizing.

Based on observation, interview, and document review, the facility failed to provide activities of daily living (ADL's-dressing, grooming, bathing, eating, and grooming) for 4 of 4 residents, ( R57, R46, R16, R14) who were observed for assistance with eating. Findings include: R57: R57's significant change Minimum Data Set (MDS) assessment of 12/15/24 identified that R57 was rarely/never understood and had severe cognitive impairment. R57's medical diagnoses included Alzheimer's Disease/Dementia, anxiety disorder, metabolic encephalopathy (change in how your brain works due to an underlying condition), seizure disorder (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain)/epilepsy (a group of non-communicable neurological disorders characterized by recurrent seizures), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), dehydration (a lack of total body water that disrupts metabolic processes ( set of life-sustaining chemical reactions in organisms), hyperosmolality ( a condition of high osmolarity in the body, often caused by increased sodium or glucose levels), hypernatremia (a high level of sodium in the blood), fatigue, dysphagia (difficulty swallowing), contracture of the muscle of the upper arm, and failure to thrive. The MDS identified R57 is noted to have impaired functional movement of both arms and was totally dependent on staff for assistance with eating. R57's care plan, revised on 12/27/24, indicated R57 was unable to communicate her needs. Additionally, the care plan indicated R57 had a communication problem r/t (related to) dementia and indicated R57 was nonverbal and was unable to communicate needs. The care plan directed staff to anticipate R57's needs. The care plan also indicated R57 had an ADL self-care performance deficit r/t impaired cognition from early onset Alzheimer's. The care plan directed staff to assist R57 to have clothing protector at meals, and directed staff to provide assistance with eating. R46 R46's significant change MDS assessment of 11/12/24, identified R46 had severely impaired cognition. The MDS indicated R46 had the following medical diagnoses: non-traumatic brain dysfunction (brain damage caused by factors other than external trauma), arthritis, Alzheimer's disease/Dementia, malnutrition, age related macular degeneration (a condition that affects the middle part of your vision, and weight loss. The MDS indicated there were no limitations in range of motion. The MDS identified R46 required partial/moderate assistance with eating-which is identified as the helper does less than half the effort. R46's care plan, revised on 12/3/24, indicated R46 had a deficit with ADL performance related to rheumatoid arthritis (a type of arthritis where your immune system attacks the tissue lining the joints on both sides of your body. It may affect other parts of the body.), memory loss and dementia. Staff were directed to provide physical assistance to eat. The care plan also indicated R46 had a potential for communication problem related to dementia, memory loss, and trouble word finding. Staff were directed to allow adequate time to respond, repeat as necessary, and not rush client. R16 R16's significant change MDS of 11/18/24 indicated moderate cognitive impairment. Her medical diagnoses included other neurological conditions, gastroesophageal reflux disease ( a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus), thyroid disorder (a problem when your thyroid is either too active, or not active enough, which affects your metabolism), dementia, Parkinson's disease (a movement disorder of the nervous system that worsens over time), malnutrition, metabolic encephalopathy, and a vitamin deficiency. R16 was noted to have bilateral (both sides) impairment in her upper extremities. The MDS indicated R16 required substantial/maximal assistance with eating, requiring assistance with more than half of the effort. R16's care plan, revised on 8/12/24, identified R16 had a deficit in ADL performance related to weakness and impaired mobility from Parkinson's disease and directed staff to provide assist of one with eating, while staff encouraged resident to do what she was able to with eating. The care plan identified R16 had a communication problem r/t Parkinson's, slow processing verbal information and response, anxiety/behaviors, jerking movements at times and shaking of extremities. The care plan directed staff to allow adequate time to respond, repeat information as necessary, and instructed staff not to rush R16 as she attempted to communicate her needs and wishes. R14 R14's quarterly MDS assessment of 11/12/24 indicated R14 had severe cognitive impairment. R14's medical diagnoses included: Alzheimer's Disease (neurological disorder which involves irreversible worsening changes in the ability to think and remember. It is the most common cause of dementia), dementia (the loss of the ability to reason, learn new skills, and plan and prioritize to the point which it interferes with a person's daily life and activities), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), chronic pain, dysphagia (difficulty with swallowing). MDS indicated there was no functional impairment with range of motion and required supervision or touching assistance, providing verbal cues or touch steadying assistance as resident completes activity. R14's care plan, revised 9/16/24, identified R14 had an ADL self-care performance deficit r/t multiple medical diagnoses which included osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint), impaired cognition, glaucoma (an eye condition that damages the optic nerve which can lead to vision loss or blindness), The care plan directed staff R14 required assist of one staff members assistance staff to eat and was noted to eat slowly. The care plan identified R14 was able to communicate her needs and was able to hear with hearing aids. On 1/22/25, at 8:11 a.m. R57 and R57's tablemate's (R14, R16, and R46) were observed to have received their morning breakfast. R57 was served breakfast tray at this time. All residents (R57, R46, R14, and R16 were observed seated at the same table. There were no staff available at the table to assist with meals which were just served. Additionally, there were only two staff members observed in the dining room at the neighboring table assisting other residents. R16 was observed to pick up the sausage patty as a whole piece and took a bite. R16 then placed the sausage on the plate, and did not continue eating. While under constant observation, it was noted the staff had not arrived to provide any assistance to residents to eat. On 1/22/25, at 8:23 a.m. the residents continue to be seated in the dining room, with the food placed in front of them. There were no requests made by R57, R56, R14, and R16 for assistance with eating. The meals observed in front of the residents included cooked cereal, pureed eggs, pureed French toast sticks, solid French toast sticks, and one resident was served a solid sausage patty. On 1/22/25, at 8:27 a.m., 16 minutes after food was observed to be served, residents continued to sit at the table without assistance present. The food remained in front of the residents, uncovered. On 1/22/25, 8:28 a.m., it was observed room trays were set up for delivery, however, there were no additional staff available in the dining room to feed residents seated at the table. On 1/22/25, 8:31 a.m., registered nurses (RN)-C and RN-D arrived to aid residents R57, R56, R14, and R16 with their meals. This was 20 minutes after the initial service of the trays to these residents. RN's C & D proceeded to set up and begin to assist residents with meal without intervention due to length of time the food had been sitting out. A request was made by surveyor for trays to be temped due to the length of time food had been served, compared to the current time. The food was temped by the food production manager (FPM). Refer to citation 804 for further details. On 1/22/25, at 8:36 a.m. after fresh trays were served to the residents by FPM, RN's C and D proceeded to assist two residents. Upon interview after serving the fresh trays, FPM stated it was important to have staff able to assist residents prior to food being served as this was a quality concern and could impact the quality of life. FPM stated being served cold food starts off the day bad. FPM stated it was the expectation staff would be available to assist residents prior to the food being served. On 1/22/25, at 8:57 a.m. RN-C stated staff should be present to assist residents prior to service of the meals. RN-C stated residents should not be seated in front of their food without staff assistance. On 1/22/25, at 10:47 a.m. RN-D stated it is important to have staff available to aid with feeding residents prior to service of meal. RN-D stated if there was a delay with assistance of meal after it was dished, it would not be hot, and this would not be flavorful. If the staff were not here, the food should not have been served. On 1/22/25, at 12:04 p.m., Prep [NAME] (PC)-A stated the dietary staff are to serve the trays when the residents are seated at the table. PC-A stated she generally set up the residents who require assistance first. PC-A stated she served the residents requiring assistance, however, had not observed there were no staff available to assist the resident. On 1/22/25, at 1:55 p.m. the Certified Dietary Manager (CDM) stated it was her expectation that staff serve everyone at the table at the same time. If there were staff not available to assist the resident, the dietary staff should hold the plate until someone was able to assist them. On 1/22/25, at 3:18 p.m. the director of quality improvement (DQI), identified there were concerns with the residents sitting at the table, with food in front of them, where they can smell, and not be able to eat. DQI stated while the residents waited, and the food had been served, and was sitting uncovered, the food was getting cold. DQI stated it was necessary to determine a better prioritization of services provided at that time which delayed service of breakfast. On 1/22/25, at 3:24 p.m. clinical manager (CM)-A stated generally there were other staff members available to provide the residents assistance with the meal process. CM-A stated it did not go well this morning. CM-A expected dietary staff to wait until there were staff present before serving the meal. CM-A stated residents should not be served until staff are available to assist. On 1/24/25, at 4:00 p.m., the director of nursing (DON) stated she expected meals would not be placed in front of residents until there were staff available to provide assistance. A review of the facility policy, Assistance with Meals, dated February 2024, directed that facility staff will serve residents and will help residents who require assistance with eating. The policy further identified residents should receive the assistance with meals in a manner that meets the individual needs of each resident. The policy directed staff that residents who cannot feed themselves and need verbal cuing, or feeding assistance will be placed with staff for assistance, attention to safety, comfort, and dignity.

Based on observation, interview, and document review, the facility failed to ensure food was held at a steady temperature of greater than 140 degrees Fahrenheit for palatability, for 4 of 4 residents, ( R57, R46, R16, R14) observed during the dining process. Findings include: R57: R57's significant change Minimum Data Set (MDS) assessment of 12/15/24 identified that R57 was rarely/never understood and had severe cognitive impairment. R57's medical diagnoses included Alzheimer's Disease/Dementia, anxiety disorder, metabolic encephalopathy (change in how your brain works due to an underlying condition), seizure disorder (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain)/epilepsy (a group of non-communicable neurological disorders characterized by recurrent seizures), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), dehydration (a lack of total body water that disrupts metabolic processes ( set of life-sustaining chemical reactions in organisms), hyperosmolality ( a condition of high osmolarity in the body, often caused by increased sodium or glucose levels), hypernatremia (a high level of sodium in the blood), fatigue, dysphagia (difficulty swallowing), contracture of the muscle of the upper arm, and failure to thrive. The MDS identified R57 is noted to have impaired functional movement of both arms and was totally dependent on staff for assistance with eating. R57's care plan, revised on 12/10/24, indicated R57 was unable to communicate her needs. R57's care plan directed staff to assist with eating. R57's care plan indicated R57 had potential nutritional problem r/t (related to) the diagnosis Alzheimer's, low BMI (Body Mass Index), and a Mini Nutritional Assessment (MNA) indicating malnutrition. R57 continued to meet GLIM (Global Leadership Initiative on Malnutrition Statement-a framework to guide malnutrition diagnosis) criteria for severe protein-calorie malnutrition r/t moderate fat loss and muscle loss, a BMI below 18.5, unintended weight loss, and low meal intakes. Staff were directed to provide/serve the diet as ordered and, provide and serve supplements as ordered. R46 R46's significant change MDS assessment of 11/12/24, identified R46 had severely impaired cognition. The MDS indicated R46 had the following medical diagnoses: non-traumatic brain dysfunction (brain damage caused by factors other than external trauma), arthritis, Alzheimer's disease/Dementia, malnutrition, age related macular degeneration (a condition that affects the middle part of your vision, and weight loss. The MDS indicated there were no limitations in range of motion. R46 was noted to require partial/moderate assistance-which is identified as the helper does less than half the effort. R46's care plan, revised on 12/3/24, indicated R46 had a deficit with ADL performance related to rheumatoid arthritis (a type of arthritis where your immune system attacks the tissue lining the joints on both sides of your body. It may affect other parts of the body.), memory loss and dementia. Staff were directed to provide with one assist to eat. The care plan also indicated R46 had a potential for communication problem related to dementia, memory loss, and trouble word finding. Staff were directed to allow adequate time to respond, repeat as necessary, and not rush client. R46's care plan directed staff to provide diet as ordered. Staff were directed to consult with dietitian to seek a change in diet/textures if there were chewing/swallowing problems identified. In addition, the care plan, revised on 11/11/24, indicated the resident had the potential for altered nutritional status related to variable intake, dementia, with the MNA (mini nutritional screening-a screening to help identify elderly people who are malnourished) indicating malnourished status. The care plan identified R46 continued to meet GLIM criteria (Global Leadership Initiative on Malnuutrition-a screening for malnutrition based on clnical findings and cause) for moderate protein calorie malnutrition related to BMI below 22 for age over 70 and muscle loss in dorsal hand and clavicle regions. The care plan indicated a supplement appeared necessary as evidenced by decreased appetite. The care plan directed the Registered Dietitian (RD) to evaluate and make change recommendations as needed. Staff were directed to provide and serve supplements as ordered. R16 R16's significant change MDS of 11/18/24 indicated moderate cognitive impairment. Her medical diagnoses included other neurological conditions, gastroesophageal reflux disease ( a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus), thyroid disorder (a problem when your thyroid is either too active, or not active enough, which affects your metabolism), dementia, Parkinson's disease (a movement disorder of the nervous system that worsens over time), malnutrition, metabolic encephalopathy, and a vitamin deficiency. R16 was noted to have bilateral (both sides) impairment in her upper extremities. The MDS indicated R16 required substantial/maximal assistance with eating, assistance with more than half of the effort. R16's care plan, revised on 8/12/24, identified R16 had a deficit in ADL performance related to weakness and impaired mobility from Parkinson's disease and directed staff to provide assist of one with eating, while staff encouraged resident to do what she was able to with eating. The care plan identified R16 had a communication problem r/t Parkinson's, slow processing verbal information and response, anxiety/behaviors, jerking movements at times and shaking of extremities. The care plan directed staff to allow adequate time to respond, repeat information as necessary, and instructed staff not to rush R16 as she attempted to communicate her needs and wishes. R16's care plan also identified the resident had GERD. The care plan went on to identify resident had potential nutritional problems r/t inadequate energy and protein intake r/t acute illness AEB (as evidenced by) significant weight loss, history of mechanically altered diet, and needed assist to eat. The care plan identified the MNA indicating malnourished status, although indicated R16 did not meet GLIM criteria for protein-calorie malnutrition. R14 R14's quarterly MDS assessment of 11/12/24 indicated R14 had severe cognitive impairment. R14s medical diagnoses included: Alzheimer's Disease (neurological disorder which involves irreversible worsening changes in the ability to think and remember. It is the most common cause of dementia), dementia (the loss of the ability to reason, learn new skills, and plan and prioritize to the point which it interferes with a person's daily life and activities), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), chronic pain, dysphagia (difficulty with swallowing). MDS indicated there was no functional impairment with range of motion and required supervision or touching assistance, providing verbal cues or touching steadying assistance as resident completes activity. R14's care plan, revised 9/16/24, identified R14 had an ADL self-care performance deficit r/t multiple medical diagnoses which included osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint), impaired cognition, glaucoma (an eye condition that damages the optic nerve which can lead to vision loss or blindness), The care plan directed staff to R14 required assist of one staff members assistance staff to eat and was noted to eat slowly. The care plan identified R14 was able to communicate her needs and was able to hear with hearing aids. The care plan went on further to identify R14 had a potential nutritional problem d/t altered cognition/mood, diagnosis including CHF (congestive heart failure-potential for weight fluctuations), dysphagia with R14 need for assist/cueing needed at meals, Alzheimer's, advanced age. On 1/22/25, at 8:11 a.m. R57 and R57's tablemate's (R14, R16, and R46) were observed to have received their morning breakfast. R57 was served breakfast tray at this time. All residents (R57, R46, R14, and R16 were observed seated at the same table. At this time, there were no staff available at the table to assist with meals which were served. Additionally, there were only two staff members observed in the dining room at the neighboring table assisting other residents. R16 was observed to pick up the sausage patty as a whole piece and took a bite. R16 then placed the sausage on the plate, and did not continue eating. While under constant observation, it was noted the staff had not arrived to provide any assistance to residents to eat. On 1/22/25, at 8:23 a.m. the residents continue to be seated in the dining room, with the food placed in front of them. There were no requests made by R57, R56, R14, and R16 for assistance with eating. The meals observed in front of the residents included cooked cereal, pureed eggs, pureed French toast sticks, solid French toast sticks, and sausage patty. On 1/22/25, at 8:27 a.m., 16 minutes after food was observed to be served, residents continue to sit at the table without assistance present. The food remains placed in front of the residents, uncovered. On 1/22/25, 8:28 a.m., it was observed room trays were set up for delivery, however, there were no additional staff available in the dining room to assist residents seated at the table. On 1/22/25, 8:31 a.m., registered nurses (RN)-C and D arrived to aid residents with their meals. This was 20 minutes after the initial service of the trays. Once the staff were seated and prepared to begin meal service assistance, a request was made of food production manager, (FPM) , to perform a temperature check on the food items present at the table. The following temperatures were obtained at 8:33 a.m. (22 minutes after meals were observed to be served): Cooked cereal: 123 degrees Fahrenheit Pureed eggs: 103 degrees Fahrenheit Scrambled eggs: 100 degrees Fahrenheit French toast sticks (pureed): 107 degrees Fahrenheit Oatmeal: 112 degrees Fahrenheit Solid French Toast sticks: 76 degrees Fahrenheit Ground sausage: 96 degrees Fahrenheit Per FPM, the required temperature food is to be served at is 140 degrees Fahrenheit. The temperatures obtained, although not long enough to place a risk for food borne illness, would definitely affect the palatability of the food. The concern would be as to the quality of the food received. This would impact the quality of life. FPM went on to state cold food starts the day off bad. FPM stated it was the expectation that staff would be ready to assist residents before the food was served. On 1/22/25, at 8:36 a.m. after fresh trays were served to the residents by FPM, RNs C & D proceeded to provide assistance to residents. On 1/22/25, at 8:57 a.m. RN-C stated staff should be present to assist residents prior to service of the meals. RN-C stated if the food was sitting in front of the residents when the staff were not present to assist the food could be cold, and would need to be sent back to the kitchen. On 1/22/25, at 10:47 a.m. RN-D stated it is important to have staff available to aid with feeding residents prior to service of meal. RN-D stated if there is a delay in service of meal after it is dished, it is not hot, and this was not flavorful. If the staff were not here, the food should not have been served. On 1/22/25, at 12:04 p.m., Prep [NAME] (PC)-A stated the dietary staff are to serve the trays when the residents are seated at the table. PC-A stated she generally sets up the residents who require assistance first. PC-A stated she served the residents requiring assistance, however, had not observed there were no staff available to assist the resident. On 1/22/25, at 1:55 p.m. the Certified Dietary Manager (CDM) stated it was her expectation that staff serve everyone at the table at the same time. If there were staff not available to assist the resident, the dietary staff should hold the plate until someone was able to assist them. On 1/22/25, at 3:18 p.m. the director of quality improvement (DQI), identified there were concerns with the residents sitting at the table, with food in front of them in, where they can smell,and not be able to eat. DQI stated the while the residents waited, and the food had been served, and was sitting uncovered, the food was getting cold. DQI stated it was necessary to determine a better prioritization of services provided at that time which delayed service of breakfast. On 1/22/25, at 3:24 p.m. clinical manager (CM)-A stated it did not go well this morning. CM-A stated residents should not be served until staff are available to assist. CM-A stated the food sitting out may have been cold. CM-A stated it may not be that great. On 1/24/25, at 4:00 p.m., the director of nursing (DON) stated it was her expectation that meals would not be placed in front of residents until there were staff available to provide assistance. Additionally, it would be her expectation that the food served would be provided for assistance at the required temperature. A facility policy, Temperature and Time Requirements for Food, revised February 2024, identified: Guardian Angels Care Center utilizes the Minnesota Department of Health Food and Safety guidelines to ensure the proper and consistent monitoring, and temperature control of food. The document indicated Hot holding food was to be maintained at 135 degrees Fahrnheit or above.

Based on observation, interview, and document review the facility failed to provide assist with personal grooming for 1 of 1 residents, (R2), reviewed for personal appearance. Findings include: R2's quarterly Minimum Data Set (MDS) assessment of 11/16/24, identified R2 had brief interview for mental status (BIMS) score of 12. Although classified as moderate cognitive impairment, a score of 13 indicates intact cognition. A listing of R2's medical diagnoses included progressive neurological conditions, cerebral palsy (a group of conditions that affect movement and posture), dementia, and multiple sclerosis (MS-a disease that causes breakdown of the protective covering of nerves which can cause numbness, weakness, trouble walking, vision changes and other symptoms). The MDS indicated R2 had functional limitation of both upper extremities and was fully dependent of staff for all aspects of personal hygiene, including combing her hair, shaving, washing and drying face and hands. A review of R2's care plan, most recently revised on 6/3/24, indicated R2 had an ADL (activities of daily living-tasks of dressing, grooming, bathing, and mobility) self-care performance deficit r/t (related to) cerebral palsy. The care plan directed the staff to provide assist of one to complete personal hygiene. The care plan lacked description of what personal hygiene consisted of for R2. The care plan further identified R2 had a communication problem r/t aphasia (an impairment of person's ability to comprehend or formulate language because of damage to specific brain regions), slow speech, and no teeth. The care plan indicated R2 could be difficult to understand due to this. During observation and interview on 1/21/25, at 10:47 a.m. R2 was observed seated in her wheelchair in her room, watching television. R2's hair was observed to be neatly pulled back and she was neatly dressed. R2 was observed to have a patch of white whiskers under her chin which was approximately one inch in length, 1/4th inch in width, and 1/4th inch length of whiskers. R2 lacked dentures, and her speech pattern was difficult to understand due to difficulty with projection (ability to speak loudly/clearly) and when asked if she was bothered by her whiskers, R2 nodded her head yes. R2 stated staff offered to assist her with shaving her whiskers once in a while. R2 nodded her head yes when asked if she wanted to have her whiskers shaved by staff. On 1/23/25, at 12:32 p.m. R2 was observed in her room at this time as she was receiving assistance with her noon meal from nursing assistant (NA)-A. R2 was noted to have whiskers present, without shaving completed. NA-A stated she had provided R2 with assist to complete morning cares. NA-A stated personal grooming was completed by staff, and shaving was generally completed in the morning. NA-A stated she had not completed personal shaving, although acknowledged the whiskers were present and were long. R2 affirmed to NA-A she wished to have her whiskers shaved, and directed NA-A to the lower drawer in her dresser where her razor was stored. On 1/23/25, at 4:37 p.m. was observed to be up in her chair, watching television. R2 had her hair pulled up on top of her head. Her facial hair had been shaved and R2 appeared neat and well groomed. When asked if it felt good to have shaving completed, R2 responded yeah. On 1/23/25, at 4:54 p.m. clinical manager (CM)-A stated she was unaware R2 had facial whiskers present, and indicated this should have been addressed with routine morning/evening cares provided by nursing assistants. CM-A stated at times R2 has refused assistance from certain staff, however, stated if that occurred, she would expect staff to request the assistance of another staff member to complete the task. CM-A stated it was important to assist with removal of facial hair for the dignity of the resident. CM-A stated although some residents may not wish to have this completed, R2 would want to have facial hair removed. The facility policy, Dignity, dated February 2024, identified that each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feeling of self worth and self esteem. The policy indicated when assisted with care, residents are supported in exercising their rights, and are groomed as they wished to be groomed (hair styles, nails, facial hair, etc.).

Based on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 1 resident (R15) reviewed for MDS' accuracy. Findings include: The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, . Hospice Care, and outlined, Code residents identified as being in a hospice program . where any array of services is provided for the palliation and management of terminal illness . R15's quarterly MDS dated [DATE], identified diagnoses included progressive neurological conditions, neurogenic bladder, dementia, Parkinson's disease, depression, and manic disorder. At the time of survey, MDS failed to identify R15 received hospice care in section O- Special Treatments and Programs. R15's census report, printed 1/24/25, identified R15 was admitted to hospice services on 3/22/24. During interview on 1/23/25 at 4:36 p.m., director of reimbursement and MDS coordinator verified they had reviewed R15's MDS (dated 12/25/24) and stated hospice care should have been coded adding, That was a coding error. During interview on 1/24/25 at 2:40 p.m. the director of nursing (DON) stated MDS assessment accuracy was important because it needs to reflect the resident care needs and should be always submitted accurately. During interview on 1/24/25 at 11:08 a.m., regional clinical director stated facility did not have a policy on MDS and that they follow chapter two of the RAI manual.

Based on interview and document review, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R21) reviewed for bowel management. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and required assistance with all activities of daily living (ADL)'s except upper body dressing, eating and oral hygiene. R21's diagnoses included neuromyelitis optica, hypertension, multi-drug-resistant organism (MDRO), paraplegia, malnutrition, cutaneous abscess of buttock and osteomyelitis. During review of R21's electronic medication record (EMR), R21 had an order for senna-docusate sodium oral tablet 8.6-50 mg (milligram) one tablet twice daily to prevent constipation, oxycodone 5 mg one tablet by mouth every four hours as needed for pain, and senna-docusate sodium oral tablet 8.6-50 mg one table by mouth as needed for constipation twice daily - take one or two tablets. R21's bowel record indicated R21's last bowel movement was on 1/16/25, indicating R21 had not had a bowel movement in six days. The facilities house standing orders indicated: Bowel: constipation (perform steps sequentially) 1. Consider rectal check to determine if impaction is present. 2. Encourage 2,000 ml (milliliter) daily fluid intake unless contraindicated. 3. Consult nutrition services for dietary recommendations. 4. Sennoside 8.6 mg, two tablets PO (my mouth) at HS (bedtime) prn x three days. If no bowel movement in three days - if not results, perform rectal check to determine if impaction is present - If no results within 24 hours, Bisacodyl suppository 10 mg PR (per rectum) daily PRN. 5. Administer MOM (milk of magnesia) 30 cc (cubic centimeters) (do not use magnesium-based products in patients with renal failure) PM day four if no results reattempt Sennoside 8.6 mg or Bisacodyl if no results after 24 hours and notify provider. 6. Monitor and record results from treatment. During review of R21's electronic health record (EHR), EHR lacked evidence of bowel management program being followed for R21. During interview on 1/21/25 at 1:22 p.m., R21 stated she was constipated due to the pain medication that she had been receiving. R21 stated she received scheduled Senna, but it was not working very well. R21 stated she had not had a bowel movement in several days. During interview on 1/22/25 at 2:37 p.m., registered nurse (RN)-B stated the night nurse runs a bowel movement report every night which indicated which residents did not have a bowel movement in a couple of days. RN-B stated if a resident is going on day three with no bowel movement, the facilities standing orders would be initiated which consisted of either as needed (PRN) Senna or MiraLAX. RN-B stated if a resident is going on day four with no bowel movement, the facilities standing orders would be initiated which consisted of PRN Dulcolax suppositories. RN-B stated R21 had scheduled senna and also had an order for one or two additional tablets PRN for constipation. RN-B confirmed R21's last bowel movement was on 1/16/24 at 7:43 p.m. RN-B stated R21 had not received any PRN medications since 1/16/24. During interview on 1/22/25 at 2:56 p.m., nurse manager (NM) stated if a resident did not have a bowel movement in three days, an PRN medication would be offered. NM stated if the resident did not have an order for a PRN medication the provider would be contacted. NM stated if resident had not had a bowel movement in several days, she would expect nursing to listen to bowel sounds and to perform a rectal check if resident would allow. NM reviewed R21's record and confirmed R21's last bowel movement was on 1/16/25 and last PRN medication was administered on 1/16/25. NM stated the night nurse reviews the bowel information and gives that information to the day nurse to administer medications. NM stated R21 should have been offered PRN Senna and other PRN medications per the standing orders as she is at a higher risk for constipation due to R21 receiving pain medication. NM stated it was important to monitor and administer PRN medications, so the resident does not get bloated, does not get a new diagnosis and especially for the resident's comfort. During interview on 1/24/25 at 2:35 p.m., director of nursing (DON) stated the aides chart resident's bowel movement in the point of care charting which relays that information to the nurses if it has been three days with no bowel movement. DON stated the nurse managers also oversees this. DON stated she would expect nursing to follow the protocol and offer PRN medications from the standing house orders which consisted of senna, MiraLAX, suppositories and/or edema. DON stated it was important so a resident does not get constipated and/or worse case scenario is they could end up with a small bowel obstruction. The facility Bowel Management policy, dated 11/24, indicated the facility will ensure that residents experience adequate bowel elimination. Bowel records will be reviewed by nursing. Residents will be monitored for lack of sufficient bowel movement. Upon identification of constipation, the nurse will conduct a GI assessment, implement PRN medication and/or implement house standing orders, and monitor for effectiveness.

Based on observation, interview, and document review, the facility failed to ensure the call light was accessible for 1 of 4 residents (R4) reviewed for accommodation of needs. Findings include: R4's quarterly Minimal Data Set (MDS) dated [DATE], had diagnoses of anxiety, depression, and was cognitively intact. R4 was noted to have lower extremity impairment on both sides. R4's care plan dated 8/10/23, indicated R4 had a mobility deficit due to adult failure to thrive, was non-ambulatory, and was dependent on staff for wheelchair mobility. On 9/11/24 at 4:11 p.m., upon entering R4's room, R4 stated I don't have my call light. R4 was observed sitting in her standard wheelchair next to her bed, facing the window and her back was to the door. R4's call light was observed on the bottom right-hand corner of her bed next to the wall. R4's bedside table was to the right of her in between her and the bed. R4 stated she was unable to self-propel in her wheelchair and depended on staff to assist with mobility. R4 stated this happens all the time, I would have to wait until staff comes into the room again. On 9/11/24 at 4:21 p.m., nursing assistant (NA)-A knocked and entered R4's room and R4 requested to be assisted out into the commons area by the nurses' station. NA-A confirmed R4 did not have access to her call light and was unable to reach it. NA-A stated she was unsure why the call light was out of reach and which staff assisted R4. On 9/12/24 at 9:33 a.m., licensed practical nurse (LPN)-A stated R4 required total assistance from staff with mobility in her wheelchair. Further, LPN-A stated R4 was alert and able to make needs known by using her call light. On 9/12/24 at 12:12 p.m., NA-B stated R4 was completely dependent on staff for all activities of daily livings and was unable to self-propel herself in her wheelchair. Further, NA-B stated R4 would utilize her call light if she needed anything. On 9/12/24 at 1:46 p.m., registered nurse (RN)-A stated R4 was dependent on staff for mobility and would utilize her call light for any needs. RN-A stated if R4 did not have her call light, R4 would ask her roommate to call for assistance. On 9/12/24 at 2:19 p.m., director of nursing stated staff were expected to ensure each resident had access to their call light before exiting the room. Review of facility policy titled Call Light Policy dated 09/23, staff were directed to position the call light conveniently for the resident to use and tell the resident where the call light was.

Based on interview and document review, the facility failed to ensure residents with food allergies received the appropriate meal tray for 1 of 3 residents (R1) reviewed for food allergies. This resulted in an Immediate Jeopardy (IJ) when R1 ingested an allergen, and was hospitalized in an intensive care unit (ICU). The provider had already implemented corrective action prior to the investigation, so the deficiency is issued as past non-compliance. The IJ began on 7/10/24, at 5:04 p.m., when R1 was served and consumed food she was known to be allergic to. The administrator and director of nursing (DON) were informed of the IJ on 7/17/24 at 4:05 p.m. The facility implemented corrective action on 7/11/24, prior to the start of the survey and was therefore Past Non-compliance. Findings include: R1's Face Sheet indicated she was admitted to the facility at 2:00 p.m. on 7/10/24. R1's care plan dated 7/10/24 indicated she had an allergy to shellfish. R1's meal tray ticket dated 7/10/24 indicated she had an allergy to shellfish. On 7/10/24, at 5:04 p.m., R1 was served a dinner tray by nursing assistant (NA)-A which included shrimp pasta salad. On 7/10/24, a progress note indicated at approximately 6:20 p.m., after eating the shrimp pasta salad, R1 began feeling diaphoretic and nauseous. R1 reported stomach pain and was unable to take a deep breath. Licensed practical nurse (LPN)-A determined R1 had consumed shrimp pasta for dinner. LPN-A administered epinephrine (medication used to treat serious allergic reactions), administered oxygen, and called 911. On 7/16/24, at 12:31 p.m., R1 was interviewed and stated she arrived at the facility earlier on 7/10/24. Her supper tray was delivered to her on 7/10/24 with her name on it. It was a cold pasta salad, which she thought had chicken in it. After she finished eating her supper, she began feeling very hot. She rang her call light, and the aide came in. The aide called for the nurse, who quickly realized R1 had consumed shrimp and had a shellfish allergy. The nurse administered her epinephrine shot, and called 911 right away. The ambulance arrived quickly and she was transported to the hospital where she spent a few days in the ICU. 07/16/24, at 2:05 p.m., dietary aide (DA)-A stated she plated R1's food in the kitchen, and she did not put the pasta salad on her tray. The cook pointed out R1's allergy, and directed her to give R1 a sandwich, not the pasta. On 7/16/24, at 2:51 p.m., nursing assistant (NA)-stated she served R1 her tray, which included shrimp pasta. She looked at the meal ticket, and it did not indicate R1 had any allergies. Later, she went to check on R1 and found her to be sweating profusely. R1 told her she didn't feel well and felt like she might throw up. She got LPN-A to come assess R1 at that time. On 7/16/24, at 3:22 p.m., the director of dining (DOD) stated DA-A prepared the trays for R1's unit on 7/10/24 for supper. He directed DA-A to provide R1 with a sandwich due to her shell fish allergy. All trays are provided with a meal ticket, and R1's meal ticket on 7/1024 indicated her shellfish allergy. On 7/16/24, at 3:48 p.m., registered nurse (RN)-A stated he conducted interviews with the nursing staff immediately following the medical emergency due to R1 ingesting the shrimp pasta on 7/10/24. He spoke with NA-A who stated she delivered the supper tray, but did not remember seeing a meal ticket on the tray. LPN-A provided R1 with appropriate medical interventions. RN-A stated immediate education was provided to all staff working at that time. On 7/16/24, at 4:08 p.m., RN-B stated he was notified of the event immediately after it happened. He notified the physician, the medical director, the director of nursing (DON), the administrator, the state agency (SA), and family. The facility began auditing process of trays, and education for nursing and dietary department on 7/11/24. On 7/17/24, at 7:52 a.m., the administrator stated the facility finished their investigation and were unable to determine what happened. It was inconclusive. Dietary staff said they prepped the tray correctly. NA-A stated she didn't remember if there was a meal ticket on the tray or not. On 7/17/24, at 10:42 a.m., LPN-A stated NA-A informed her R1 was dripping with sweat and didn't feel well around 6:20 p.m. R1's color did not look good. LPN-A stated she had received R1's medications from the pharmacy approximately 15 minutes earlier. She recalled an epinephrine pen indicated for a shell fish allergy. That's when she asked if R1 ate the shrimp pasta salad for supper. She administered the resident's albuterol inhaler, epinephrine, and applied oxygen, while another nurse called 911. R1 was sent to the hospital via ambulance. On 7/17/24, at 10:58 a.m., the DON stated the internal investigation was inconclusive. The facility had been auditing of meal trays and education has been in process since 7/11/24. EpiPens were available in the emergency kits, and the nurses were knowledgeable on how and when to use them. A facility document Dinner Menu dated 7/10/24, indicated main dinner meal was shrimp pasta salad on lettuce leaf, cucumber slices, dinner roll, diced peaches. The alternative dinner for 7/10/24 was BBQ pulled pork sandwich, coleslaw, chef salad. A facility document Resident/Patient Safety Policy dated 7/16/24, directed all disciplines participate in risk reduction. Including: 1. Dietary a. Serving correct diet and texture, including fluid consistency The facility implemented corrective action to prevent recurrence by 7/11/24, when the facility implemented a systemic plan that included the following actions: On 7/11/24 immediate education was done for nursing and dietary staff on tray tickets, food allergies, and double-checking the correct meal/diet to the resident. On 7/11/24 meal tray audits were implemented for all four care units to be conducted by nursing for each meal time. This audit consisted of ensuring the right resident received the right meal, consistent with the consistency and meal type ordered by their physician, allergens, and likes and dislikes were honored. The audits did not result in further discrepancies. This was verified through observation, interview and document review.

Based on observation, interview and document review, the facility failed to provide care planned supervision to prevent falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R1 when she sustained a right femur (leg) fracture during a fall that required surgical intervention while attempting to self-transfer unsupervised in the bathroom. The immediate jeopardy began on 5/6/24, when nurse aid (NA) assisted R1 to the bathroom, left her on the toilet, and exited the bathroom. While R1 was in the bathroom alone, she stood up and fell to her right side which resulted in a two-inch laceration to left forearm, two skin tears, two centimeters (cm), on right knee, and two skin tears above right knee. R1 rated right hip/leg pain at 8/10 (0-to-10 Pain Scale, this scale uses numbers from 0 to 10. A score of 0 means no pain, while 10 represents the worst pain a person has ever experienced) and unable to move right leg. R1 was transferred to the hospital and was diagnosed with an intertrochanteric (area located between the hip joint and the upper portion of the femur) fracture which required surgical intervention. The director of nursing (DON) and administrator were notified of the IJ on 5/15/24, at 6:40 p.m. The IJ was removed on 5/16/24, at 3:45 p.m. following verification of an acceptable removal plan however, noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. R1 required substantial to maximal assistance for toileting hygiene and was dependent on staff to safely stand from a sitting position, and all transfers. R1 was frequently incontinent of bowel and bladder. R1's medical diagnoses included hypertension (HTN), atrial fibrillation (AFIB) (abnormal rapid heart rhythm), fracture with multiple trauma, renal failure, obstructive uropathy (flow of urine is blocked), arthritis, depression, past history of falls, and recent surgery for fracture repair. R1 received diuretics (increases urine output), anticoagulant (thins the blood), and insulin. R1's Care Area Assessment (CAA) dated 4/27/24, identified R1 had hearing and vision impairment, confusion, disorientation, forgetfulness, complications of immobility such as contractures and incontinence. R1 had functional limitation in range of motion, increased risk for falls, shortness of breath upon exertion, and history of pain. R1's St. Louis University Mental Status (SLUMS) (detects mild cognition impairment and dementia) dated 4/23/24, identified a score of 19/30 and indicated dementia. R1's Fall Risk assessment dated [DATE], identified a fall with fracture occurred within six months prior to admission, weakness, gait impairment, and impairment of one side of lower extremity. R1's Fall Risk assessment dated [DATE], identified lack of safety and awareness due to new environment, impairment of both lower sides of extremities, wore a walking boot, weakness, and gait impairment. R1 had pre-admission fall which resulted in left foot fracture and recent fall at the facility which resulted in right hip fracture. R1 required manual stand assist (MSA) with assist of one per therapy. Staff were not to leave R1 alone unattended in bathroom. R1's care plan last updated 4/24/24, identified R1 had mobility and activities of daily living deficits due to previous left lower leg fracture, did not walk, required assist of one to stand, and transferred with walking boot on. Staff were directed to anticipate needs. R1 had a history of repeated falls. Staff were instructed to not leave R1 alone in the bathroom, fall risk. Review of R1's care plan dated 4/24/24, lacked evidence R1 preferred female care givers or was modest in the bathroom. R1's Kardex undated, identified transfer with assist of one, manual stand with walking boot. Need To Know section included: DO NOT LEAVE ALONE in Bathroom, Fall Risk!!! Resident does not walk. R1's progress note dated 5/6/2024, at 11:55 p.m. identified at 10:00 p.m. nursing assistant (NA) reported to nurse R1 had fallen on right side while she was being assisted in bathroom. R1 reported she stood up off toilet by herself and then suddenly she was on her right side. R1 sustained a two-inch laceration to left forearm actively bleeding, two skin tears two centimeters (cm) circular shape on right knee, and two circular shape skin tears above right knee. R1 rated right hip/leg pain at 8/10 and was unable to move right leg. No bruising or bleeding noted. On call triage provider notified with new orders to be sent to emergency department. R1 was hesitant to go, refused at first, but then decided was best to be seen right away. Emergency medical system (EMS) transferred R1 at approximately 11:00 p.m. to local hospital. R1's x-ray of pelvis dated 5/7/24, identified intertrochanteric (hip) fracture. R1's hospital discharge date d 5/11/24, identified principal diagnosis closed intertrochanteric (IT) fracture of the right femur with routine healing. R1 had a recent ankle fracture on 4/2/24. Per report, R1 had a witnessed fall at her nursing home facility while transferring to the toilet. R1 was on Coumadin, imagining revealed a right IT fracture, right psoas (deep within the body near the pelvis and spine) muscle and iliacus (triangle shaped muscle located in pelvic bone) muscle hematoma (an abnormal pooling of blood under the skin that resulted from broken or ruptured blood vessels). T6 and T7 and sacral fractures. R1 demonstrated profound anemia, hgb 5.2. at admission due to trauma and received three units of blood (packed red blood cells) transfusions. R1 had a right hip intramedullary (IM) (a rod placed into the hollow center of the femur/bone) surgical procedure on 5/8/24. R1's facility incident/fall risk management report dated 5/6/24, identified R1 had been assisted to the bathroom and then fell in bathroom onto her right side. R1 sustained a right trochanter fracture, laceration of left forearm and right forearm, and skin tear of right knee. R1's hemoglobin (measures amount of oxygen carried in the red blood cells to the body's organs) 5.2 grams per deciliter (gm/dl) (normal range for woman 11.6 to 15 gm/dl) was extremely low. Contributing factor identified as NA having left R1 unattended in the bathroom, impulsivity, and history of repeated falls. Review of State Agency report dated 5/7/24, indicated on 5/6/24, at approximately 11:00 p.m. NA-A reported to licensed practical nurse (LPN)-A that R1, while being assisted in bathroom, stood up off the toilet by herself and then suddenly was on her right side. R1 had right hip/leg pain of 8/10 and unable to move leg. R1 was transferred to local hospital via EMS. Per R1's care plan and Kardex was not to be left unattended in the bathroom. Upon initial incident interview, LPN-A's perspective was R1 was not left unattended in the bathroom. On 5/7/24, at 5:00 p.m. NA-A was interviewed again by director of nursing (DON) and indicated R1 asked him to step out of the bathroom because she felt embarrassed. NA-A stepped outside the door, did not see what happened, and heard R1 fall, and quickly entered the bathroom. NA-A presumed she stood up by the sink to brush her teeth and then fell . NA-A failed to follow R1's care plan and was suspended from work until investigation was completed. NA-A stated he understood R1 was care planned to have staff stay in the bathroom with R1 as a fall intervention and it was listed on the Kardex. Review of facility investigation five-day report dated 5/13/24, identified R1's care plan was correct, up to date, and indicated staff were instructed to not leave R1 unattended in bathroom alone. NA-A admitted he left the bathroom, felt R1 was embarrassed, did not supervise through the open door. Later when NA-A was interviewed, he corrected his story indicating he brought R1 to bathroom, was asked to step out by the resident, he exited bathroom, closed door, stood outside of door and heard R1 fall onto the floor. NA-A confirmed during interview he was aware R1 was not to be left alone in bathroom. Report identified facility wide nursing education would be given. Review of a handwritten document provided by nurse manager (RN)-A on 5/15/24, identified nine staff had documented they worked directly with R1 under the cares section in PCC from 5/11/24, through 5/14/24. -5/11/24 NA-F -5/12/24 NA-G, NA-H, NA-I -5/13/24 NA-J, NA-K, NA-L -5/14/24 NA-E and NA-M Review of facility On the Spot Education on 5/15/24, revealed seven out of nine staff provided direct care for R1 and had not received the required re-education related to supervision after R1 had fallen in bathroom and fractured her right hip on 5/6/24, and prior to her return to facility on 5/11/24. During an interview on 5/14/24, at 9:00 a.m., R1 stated she fell at home, had surgery to repair left lower leg and shattered parts of left foot, adding, a walking boot was worn to protect the foot. R1 stated she had a fall at the facility in the bathroom not too long ago. R1 indicated she required assistance in the bathroom and was aware she was not to be left in there alone. R1 also stated she had fallen many times in bathroom prior to admission to nursing home and felt comfortable having a male in there with her. R1 indicated she did not ask NA-A to leave the bathroom the night that she fell , and she was unsure if the door was closed or open. R1 stated she informed NA-A she planned on using the toilet since she was already in the bathroom. R1 verified she stood up from toilet, in front of her wheelchair, pivoted to sit down, and then fell to the floor. R1 shared that the feeling was awful to be in the bathroom alone after the fall but once NA-A found her, he hollered for help. R1 indicated when her right leg was moved, she yelled out a lot and they took her to the hospital. During an observation on 5/14/24, at 11:05 a.m. R1 sat in wheelchair in her room. NA-D and NA-E entered R1's room and assisted her to the bathroom using the mechanical stand lift machine. NA-D and NA-E were observed to lower R1 onto the toilet and then proceeded to exit the bathroom and closed the door. NA-D and NA-E stood in the bedroom and conversed with R1's daughter for approximately seven minutes. After approximately four minutes NA-E asked R1 while door was still closed if she needed help. R1 responded no. Seven minutes had passed and then NA-E and NA-D opened the door and R1 remained sitting on toilet. Once R1 was finished using the bathroom, NA-D and NA-E assisted R1 back to her bedroom using the mechanical stand lift. During observation facility staff failed to follow care planned intervention to stay in the bathroom with R1 for safety. During interview on 5/14/24, at 2:00 p.m. NA-E stated R1's short term memory was not the best. NA-E stated R1 needed assistance of at least one in bathroom to get on and off toilet. NA-E stated prior to working with residents today she had reviewed Kardex but was unaware R1 was not to be left alone in the bathroom. NA-E stated she did not stay with R1 in the bathroom earlier today when she was in the bathroom, closed the door, and waited in the bedroom. NA-E stated had seen R1 become impulsive, get up on her own when with her. NA-E indicated would have been important to remain in the bathroom for safety to avoid falls. NA-E stated had not received education since her fall or prior to assisting her to the bathroom today. Follow up interview on 5/14/24, at 2:40 p.m. NA-E stated later today she was approached by management and read a training document, and signed to acknowledge she received the education regarding R1 who should not be left alone in bathroom. During an interview on 5/14/24, at 2:43 p.m. NA-D stated R1 required assist of one to two and a manual stand lift to transfer, depending on her strength that day. NA-D verified she had looked at R1's Kardex and transfer sheet prior to the start of the shift. NA-D stated R1 could be in the bathroom alone, with door closed but was not sure and wished the Kardex was posted in the room so that staff would know for sure. NA-D indicated she felt uncomfortable when they left R1 in the bathroom alone earlier, was not aware at that time she was not to be left alone and probably should have opened the bathroom door but chose not to and relied on the other NA. NA-D verified she had received and signed a document of On the Spot Training today, but was not sure if it was before or after R1 was transferred to and from the bathroom. During an interview on 5/14/24, at 3:39 p.m. nurse manager (RN)-A stated nursing staff were expected to help and answer resident call lights in other rooms besides those assigned to them. RN-A stated prior to each shift worked, staff were expected to read and review the resident Kardex to verify their care and how they transferred, because changes occurred frequently on the transitional care unit (TCU). RN-A stated the Kardex was considered the road map on how to care for residents and was important to know to ensure accommodation of needs and safety. During a follow up interview on 5/15/24, at 12:06 p.m. RN-A stated R1 was impulsive and a high risk for falls. RN-A verified R1 never indicated she was uncomfortable with male caregivers and, if that were the case, NA-A could have called another staff on the walkie to assist R1. RN-A indicated NA-A left R1 alone in the bathroom, she fell , and sustained a fractured right hip. RN-A verified all staff were expected to work together to verify the education was received, no date was determined to assure all staff were educated on this incident, expectation would have been prior to their next shift worked. RN-A stated it had been more than a week, a questionnaire regarding this incident was placed on a clip board at the nurse's station and staff filled them, placed them face down, and were collected periodically. RN-A verified NA-D and NA-E were educated early this morning, unsure as to what time. During an interview on 5/15/24, at 8:30 a.m. family member (FM) stated R1 was ok with having all (including male) staff in the bathroom with her because she was afraid of falling. FM also stated R1 had fallen many times and required assistance while in the bathroom. FM indicated R1 most likely would not ask staff to step out of bathroom. FM verified without a doubt R1 was very determined to go home and knew she would try to get up by herself once she could bear weight. During an interview on 5/15/24, at 8:45 a.m. physical therapist (PT) stated R1 had some cognitive deficits especially with memory. PT stated R1 was reassessed on 5/13/24, after she returned from hospital and was manual assist of one but required max assistance of two, unable to pivot. PT recommended the manual stand with one be used to assist R1. PT stated staff were expected to stay in the bathroom with R1 since she had fallen once. PT indicated R1 was not cognitively intact had already demonstrated that self-transferring leads to a fall, and now required one to two staff and the manual stand lift, to stand up. During an interview on 5/15/24, at 9:17 a.m. occupational therapist (OT) stated R1 was forgetful, distractible, impaired cognition with poor decision making and does not always stop to think about what the consequences are, and therefore was a high risk for falls. OT stated R1 required assistance with peri cares and dressing. OT stated R1 required assistance of two but always a possibility to get up by herself out of the chair especially if she had to go to the bathroom. OT stated since R1 had fallen in bathroom the expectation for staff would be stay with her in the bathroom to help minimize fall risk. OT verified R1 required transfers with the manual stand lift and assistance of one, difficult to stand up by self without assistance, but would be possible. During an interview on 5/15/24, at 10:36 a.m. director of nursing (DON) stated R1 was a high risk for falls, had at least three falls at home, admitted to nursing home with a lower leg/ankle fracture and walking boot. DON stated R1 used a wheelchair and wanted to be more independent. DON verified staff were expected to review each resident's transfers on transfer sheet, care plan, and Kardex prior to assisting them. DON also verified R1 had decreased mobility and had an intervention to not leave alone in bathroom. DON stated NA-A admitted he was aware of this intervention, R1 felt embarrassed to have him in the bathroom with her. DON stated had been identified R1 has had many falls, a fall risk, and the bathroom had hard surfaces, tile, toilet, and sink that are all very hard to fall onto and should have not been left alone in the bathroom. DON stated daily reminders were given to staff to ensure care plan interventions were being implemented and staff were expected to follow the plan of care for each resident. DON stated the floor nursing managers were responsible for education and the education for this incident needed more attention. DON indicated house wide education should have been done and was not completed in entirety and was resumed yesterday 5/14/24. DON stated all nursing staff should have received the education prior to the next day worked. During a telephone interview on 5/16/24, at 11:20 a.m. NA-A stated on 5/6/24, he answered R1's call light, she requested assistance to get ready for bed. NA-A verified he handed her a gown (night clothes) while she was in the bathroom, and asked him to step out while she changed clothes. NA-A exited the bathroom, left the door ajar (cracked open), and waited in the bedroom. NA-A indicated R1 did not want him to see her body, he encouraged independence, and once she was ready planned on assisting to bed. NA-A also stated R1 was not on the toilet rather positioned in the wheelchair in front of the bathroom sink for approximately three minutes and then shouted out for help. NA-A stated it happened all so quickly, R1 sat on the floor next to the wheelchair faced the sink and held onto the wheelchair arm with her one hand. NA-A indicated R1 had bruises on her knee and hand and notified the staff nurse right away. NA-A stated he had taken R1 to the bathroom many times such as three to four times a shift prior to this incident, cracked the door so he could hear her, and left her alone in the bathroom to provide privacy. NA-A verified was aware of R1's care plan and intervention do not leave alone in bathroom. NA-A stated R1 had tried to self-transfer in the past but privacy was important. NA-A indicated if he had been in the bathroom with her, tried to stand up he could have intervened, offered to help, and possibly prevented a fall. Facility policy titled Fall Management Protocol dated April 2024, identified all residents who were assessed as being at high risk for falls will be identified and individualized fall precautions will be developed for that resident. Preventive measures shall have been taken to decrease the number of falls whenever possible. Potential and actual risks for falls will be placed on the resident care plan along with identified individualized interventions. Facility policy titled Care Plans - Comprehensive/Baseline/discharge date d 9/2023, identified care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Facility policy titled Care Plan/Kardex Development/Use, dated 5/16/24, identified a plan of care will be developed and individualized based on comprehensive and subsequent assessments performed for each resident aimed at directing resident care/needs by all members of the interdisciplinary team. The Kardex is developed directly as a subset of the resident plan of care including specific information for the NA providing direct care to the resident. The Kardex will be reviewed daily by nursing staff prior to providing care for the resident. The IJ which began on 5/6/24, was removed on 5/16/24, when the facility successfully implemented a removal plan which included: All nursing staff on duty will be trained on the current Kardex/Care Plan and interventions for R1 by 12:00 p.m. on 5/16/2024. All nursing staff not on duty will be trained at the start of their next shift, prior to beginning duties on unit. All nursing staff on duty on 5/16/2024 will be trained by 12:00 p.m. on the procedures for Kardex/care plans with emphasis placed on the need to regularly and comprehensively review these documents to ensure that appropriate care is provided. Nursing staff not on duty will be trained on the same at the start of their next shift, prior to beginning duties on the unit. The policy and procedure for resident care plans has been reviewed/revised. On 5/16/24, between 9:30 a.m. and 3:30 p.m. interviews with DON, nursing staff and management verified training procedure for Kardex/care plans and need to regularly review those documents to ensure appropriate care was provided to help prevent falls. The facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift.

Based on interview and document review, the facility failed to ensure advanced directives were accurately documented on the resident's electronic health record (EHR) banner, physician orders and Physician's Orders for Life Saving Treatment (POLST) which affected 2 of 32 residents (R24 and R79) reviewed for advance directives. This resulted in an immediate jeopardy (IJ) for R24 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations and for R79 who would have received CPR contrary to their wishes in the absence of a pulse or respirations. The administrator was notified of the IJ on [DATE] at 2:33 p.m. The IJ was removed on [DATE] at 8:00 p.m., when the facility implemented their removal plan, but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with diagnoses of dementia and stroke. R24's EHR banner reviewed on [DATE] at 7:20 p.m., identified R24 was full code. R24's Order Summary report dated [DATE], indicated full code status. R24's most current Physician's Orders For Life Sustaining Treatment (POLST) located in the scanned EHR, signed by R24's family member (FM)-A and medical doctor (MD)-A on [DATE] identified R24's wishes were do not resuscitate (DNR). R79's quarterly MDS dated [DATE], identified severe cognitive impairment and a diagnosis of Alzheimer's Disease. R79's EHR banner reviewed on [DATE] at 7:38 p.m., identified R79 was DNR. R79's most current POLST located in the scanned EHR, signed by R79's family member (FM)-B and certified nurse practitioner (CNP)-A on [DATE] identified R79's wishes were DNR. R79's Order Summary report dated [DATE], indicated DNR status. R79's POLST located in hard chart dated [DATE], indicated full code status. On [DATE] at 8:22 a.m., FM-B stated R79's wishes were to be DNR and should not have cardiopulmonary resuscitation (CPR). On [DATE] at 7:14 p.m., licensed practical nurse (LPN)-A stated he would check the hard chart for the POLST and/or code status on the banner in EHR, whichever was fastest or closest and would instruct staff on how they could assist. In this case, if the banner in EHR was closer, R24 would have received CPR and R79 would not have received CPR. If the hard chart was closer, R24 would not have received CPR and R79 would have received CPR. On [DATE] at 7:18 p.m., RN-B stated she would check the hard chart for the POLST and/or code status on the banner in the EHR, whichever was fastest or closest. In this case, if the banner in EHR was closer, R24 would have received CPR and R79 would not have received CPR. If the hard chart was closer, R24 would not have received CPR and R79 would have received CPR. On [DATE] at 7:37 p.m., RN-E stated she would first look at the banner in the EHR for the code status, but it was also located in the hard chart. According to the banner in EHR, R24 would have received CPR and R79 would not have received CPR. On [DATE] at 7:40 p.m., RN-F stated she would look at the banner in the computer for resident's code status. According to the banner in EHR, R24 would have received CPR and R79 would not have received CPR. On [DATE] at 8:40 a.m., RN-G stated she would look at the POLST in the hard chart. RN-G stated code status is generally located in the banner in the EHR but in the hard chart it is up front and if it didn't match, they would follow the POLST as that is the signed order. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 8:42 a.m., RN-H stated he would look at the front of the hard chart as that is what is signed. RN-H stated we try to have it on the banner too, but it seems like the banner isn't always right. RN-H stated when a resident goes to the hospital, the hospital will change it to whatever they had at their last admission, so then our order gets changed but they are not correct. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 8:48 a.m., RN-C stated she would look at the hard chart for resident's code status on the signed POLST. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 8:55 a.m., clinical manager (CM)-B stated she would look either on the banner in the EHR or in the front of the hard chart for a copy of the POLST. CM-B stated if orders are different, then they should always follow the paper POLST as that is what is signed by the provider. CM-B stated if code status changed, the old POLST would be removed from the hard chart and sent to medical records with the new POLST placed in hard chart. On [DATE] at 9:00 a.m., RN-D she would look in the hard chart for resident's code status on signed POLST by the provider. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 9:03 a.m., LPN-B stated she would look at the banner in the EHR and have it verified with the POLST in the hard chart. On [DATE] at 8:50 a.m., registered nurse (RN)-A stated we would check the hard chart or the banner in EHR, whichever one is closest. RN-A verified that R24's EHR indicated Full Code and R79's EHR indicated DNR. RN-A then went to hard chart and verified that the POLST identified R24 was DNR and was dated [DATE] and R79 was full code and was dated [DATE]. RN-A verified the discrepancy and attempted to located what the actual order should be for both residents. RN-A stated she would have followed the signed POLST that was located in the hard chart. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 9:14 a.m., CM-A stated upon admission or readmission from the hospital we would determine what the code status order is and would confirm with the resident and/or representative what their wishes are. CM-A stated her expectation would be for staff to refer to the hard chart for the signed POLST form. If code status changed, a new POLST is completed and placed in hard chart with the old POLST being removed. On [DATE] at 9:40 a.m., medical records (MR)-A stated upon admission or readmission if there is a discrepancy she would highlight it on an internal clarification of admission orders checklist and will give to the floor nurse to clarify with resident, representative and provider. MR-A stated she would leave the code status order blank in EHR, until clarified by nursing. On [DATE] at 9:54 a.m., director of nursing (DON) stated his expectations would be to look at the hard chart at the actual signed POLST for code status. If code status orders do not match, there would be a high risk of initiating the wrong life-saving treatments. The DON stated that referring the hard chart for code status is the fastest. According to the POLST in R24's chart, R24 would not have received CPR. According to the POLST in R79's chart, R79 would have received CPR. On [DATE] at 8:48 a.m., the facility medical director (MD)-G stated best practice was to have a resident's code status in one location of the residents' EHR and acknowledged the potential for mistakes to be made in an emergency situation. The MD-G stated if a resident did have conflicting code status orders, his is expectation was for nursing staff to clarify wishes with the resident or resident representative and obtain new orders from the resident providers if necessary. The facility policy Cardiopulmonary Resuscitation (CPR) dated [DATE], identified at the time of admission the resident and/or resident representative will be asked about the resident preference for CPR or do not resuscitate (DNR). The resident and/or resident representatives' response will be compared to physician orders issued at the time of admission. Where necessary, orders will be obtained to be consistent with the resident's wishes. The facility policy Advanced Directives POLST dated [DATE], identified all staff members and medical team will refer to the POLST form indicating the patient/resident's wished prior to initiation or discontinuation of any treatment and all treatments must be in keeping with the resident's wishes. The IJ was removed on [DATE] at 8:00 p.m., when the facility developed and implemented a systematic removal plan which was verified by interview and document review. On [DATE] at 6:35 p.m., the facility completed an audit of all residents' code status, reviewed the policy regarding code status and updated the policy, which outlined where the staff would locate the code status. On [DATE] at 8:00 p.m., oncoming licensed staff were educated regarding the updated POLST procedure and where to find a residents' code status. and continued for staff prior to their next shift. 48013

Based on observation, interview and document review, the facility failed to assess residents for the ability to self administer nebulizer treatments after nurse set up for 1 of 1 residents (R270) observed self administrating a nebulizer treatment. Findings include: R270's admission Minimum Data Set (MDS) date 4/9/24, indicated R270 was cognitively intact. R270's self-administration of medication evaluation dated 4/8/24, indicated R270 did not self-administer medications which included nebulizer medications after nurse set up. R270's order summary report dated 4/11/24, directed staff to administer albuterol sulfate (medication to open airways, and treat air flow blockage) nebulization solution 2.5 milligrams(mg)/3 milliliters (ML) 1 vial via nebulizer four times daily. However R270's orders failed to include a provider order to self-administer albuterol sulfate. When interviewed 4/8/24 at 1:55 p.m. R270 stated staff did not observe him while Albuterol nebulizer was administered. On 4/11/24, at 9:35 a.m. observed R270 sitting in chair in room self-administering nebulizer, resident stated nurse put the medication in the reservoir of the mask and left. Door was closed with no staff in room. When interviewed on 4/11/24, at 10:29 a.m. licensed practical nurse (LPN)-A stated residents could self-administer medications if they had an order and were assessed. LPN-A checked R270's chart, was not able to locate an assessment with ok to self-administer medications, LPN-A was not able to locate order in medical record to self-administer nebulizer. When interviewed on 4/11/24, at 11:11 a.m. director of nursing (DON) stated there should be an assessment for self-administer form completed by the nurse with the ok to self-administer added to the medication order. DON was not able to locate an assessment or provider order that identified R270 was able to safely self-administer nebulizer medications. Self-administration of medications policy was requested, however was not provided.

Based on observation, interview and record review, the facility failed to implement and maintain recommended restorative programming for 1 of 1 residents (R71) who were reviewed for treatment and services to prevent further decrease in range of motion (ROM). Findings include: R71's Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with a diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side and contracture (a shortening and hardening of muscles and rigidity in joints) of the left hand. R71's cognition was moderately impaired. R71's occupational therapy (OT) discharge summary dated 11/16/22, identified a prognosis to maintain current level of function as excellent with consistent staff support and the recommendation of a range of motion program to decrease risk of increased tightness. R71's Change in Functional Status/Nursing Rehabilitation Program form dated 11/11/22, identified the therapy recommendation to nursing to complete passive range of motion (PROM) exercises (the movement of a joint through the range of motion with assist) to the left upper extremity (LUE), up to 10 repetitions (reps) and up to seven days a week. R71's care plan dated 3/7/22, identified limited physical mobility related to hemiplegia affecting left non-dominant side and instructed staff to complete PROM per occupational therapy (OT). R71's order dated 11/6/23, identified per OT: left resting hand splint, nurse to perform PROM to LUE, 10 reps prior to donning left resting hand splint, leave the left hand splint on for up to an hour and after removing observe for any signs of redness as needed for weak hand. R71's January, February, March and April 2024 treatment administration record (TAR) identified OT's order dated 11/6/23 had been entered as per requested need (prn) with no scheduled frequency instruction for nursing staff and lacked documented evidence of completion or resident refusals to complete. R71's OT discharge summary dated 2/28/24, identified R71 requested the left hand splint be discontinued and recommended nursing continued with daily PROM to LUE to decrease risk of increased tightness. During observation and interview on 4/8/24 at 1:43 p.m., R71 was sitting in his room in his wheelchair with his left hand resting fist closed on his lap. R71 couldn't remember if staff were supposed to assist with PROM. R71 stated he could not recall the last time staff offered to assist him with PROM. During observation and interview on 4/9/24 at 3:06 p.m., R71 was sitting in his room with his hand resting closed fisted on his lap. R71 stated the nursing staff assisted with skin care but did not offer to assist with PROM to the LUE. When interviewed on 4/10/24 at 2:57 p.m., clinical manager (CM)-A stated PROM programs would be given to nursing after completion of treatment by the therapy department, the program would then be entered into the orders and trigger for the nursing staff to document completion. CM-A confirmed R71's therapy recommendation had been entered into the orders as prn and lacked documentation of completion or refusals on the TARs. When interviewed on 4/10/24 at 3:07 p.m., licensed practical nurse (LPN)-D stated R71's order for PROM was prn so he should ask for assistance with it. LPN-A stated she could not recall the last time staff offered to assist him with PROM but if they had he would most likely refuse it. LPN-A confirmed R71's electronic health record (EHR) lacked documentation of refusals. When interviewed on 4/10/24 at 3:15 p.m., registered nurse (RN)- J stated R71 should be offered PROM but sometimes refuses. RN-J stated refusals of care should be documented in the EHR. RN-J confirmed R71's EHR lacked documentation of refusals. When interviewed on 4/11/24 at 10:04 a.m., the occupational therapist (OT)-A and Rehab Director confirmed R71's PROM was recommended and ordered back in November of 2022 and had not changed after his most recent episode of therapy in February of 2024. The rehab director stated restorative programs including PROM were always recommended and ordered at a specific frequency and would never be recommended or ordered as prn. The rehab director stated the importance of regular PROM for R71 was to prevent increased contracture. OT-A confirmed R71's degree of contractures had not changed from first measurement on 11/10/22 to most recent measurement on 2/21/24. When interviewed on 4/11/24 at 11:39 a.m., the director of nursing (DON) stated therapy restorative program recommendations were documented on a Functional Change form and given to the nursing clinical managers who are in charge of updating resident care plans and entering the recommendation into the EHR to populate as a task that required staff documentation of completion or refusals. The DON could not confirm R71's PROM was being completed or attempted and refused as it was not documented in R71's TAR. The DON stated the importance of R71's PROM was to prevent increased contracture. The facility policy Therapy Rehabilitation Referrals dated 9/1/16, identified therapy staff would routinely screen all long term care residents a minimum of one time each quarter, between MDS assessment periods to determine if the resident might benefit from therapy interventions, and results of all screens would be reviewed with the nurse unit manager and physician where warranted.

Based on observation, interview, and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 1 residents (R40) reviewed for dialysis. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 had intact cognition and required partial/limited assistance with all activities of daily living (ADLs). R48's diagnoses included atrial fibrillation, coronary artery disease, orthostatic hypotension, end stage renal disease, arthritis, CVA/TIA (stroke) and malnutrition. R48 received dialysis treatment that was done outside of the facility. R48's care plan dated 2/20/24, indicated R48 required hemodialysis related to end-stage renal disease and had a shunt in their left arm for vascular access. R48's care plan lacked pre- and post-dialysis instructions for monitoring of access site for shunt bruit and thrill (when the nurses listens and feels the dialysis access site to ensure blood flow). R48's Medication Administration Record (MAR) for 4/1/23 - 4/11/24 lacked evidence of monitoring of shunt for bruit and thrill. R48's medical record lacked documentation of monitoring of shunt for bruit and thrill. During observation and interview on 4/8/24 at 2:48 p.m., R48 stated he went to dialysis three days per week on Tuesdays, Thursdays, and Saturdays and that nursing does not auscultate (listen to) or palpate shunt (feel) regularly. During interview on 4/10/24 at 2:58 p.m., licensed practical nurse (LPN)-E stated there is only one resident at the facility that has an order to auscultate/palpate for bruit and thrill and confirmed that R48 was not that resident. LPN-E stated it is important to monitor shunt to ensure that the fistula (dialysis access) remained open and doesn't close. During interview on 4/11/24 at 12:16 p.m., LPN-A stated that for dialysis residents, vitals and weights were obtained when they return from dialysis and site is visualized. LPN-A confirmed that R48 did not have an order to auscultate/palpate for bruit and thrill. During interview on 4/11/24 at 12:17 p.m., clinical manager (CM)-D stated R48 went to a dialysis center three days a week and that staff were aware of where residents' dialysis access sites are located. CM-D confirmed that R48 did not have an order for monitoring of shunt for bruit and thrill and that it was not documented on R48's care plan. CM-D stated it was important to monitor shunt to check for patency. During interview on 4/11/24 at 12:38 p.m., director of nursing (DON) stated their expectations for dialysis residents were for staff to complete fluid monitoring, vital sign monitoring when resident returned from dialysis and observation of the site that included skin inspection and checking for bruit and thrill. DON stated it would be important to ensure the shunt was functioning properly by monitoring the blood flow to ensure that there is no decreased blood flow through shunt. The Care for Residents with Hemodialysis policy dated 4/24 indicated residents with an internal shunt will have daily checks of shunt patency by auscultating/palpating for pulse, thrill, and bruit to assure adequate blood flow.

Based on interview and document review the facility failed to ensure resident protection pending an investigation into an allegation of abuse. Findings include: R1's Admission Record indicted he admitted to the facility on [DATE] and identified diagnosis that included anxiety. R1's care plan dated 3/1/24, indicated he was alert to person, place and time and identified intact cognition. A report to the state agency (SA) dated 3/12/24, indicated R1 alleged he was physically abused by staff on 3/9/24. The report indicated the alleged abuse caused R1 great fear and anxiety and indicated he was afraid to leave his room. A second report to the SA dated 3/12/24, indicated R1 sent an e-mail to registered nurse RN-A which stated there had been conduct issues with nursing staff and requested NA-A and RN-B not provide care for him. R1 reported to RN-A he had scratches on his forearm as a result of RN-B attempting to grab his phone out of his hand. R1 further reported NA-A had called him a fat ass and said all he did was ask for food. The report indicated R1 had light pink scratch marks on his forearm. R1 indicated he had reported the incident to RN-C on 3/9/24. During interview on 3/14/24 at 11:40 a.m., RN-A stated a nurse had approached him and said R1 showed her some scratches and reported a staff member had called him a fat ass. RN-A said R1 did not want RN-B or NA-A to take care of him. RN-A stated R1 did have scratch marks on his arm RN-A, further stated R1 did not have a history of making false accusations. Facility Shifts Scheduled Report dated 3/12/24, indicated NA-A worked both the morning and evening shifts that day. On 3/14/24, at 4:29 p.m. the administrator and director of nursing (DON) were interviewed. The administrator stated when an allegation of abuse was reported the facility removed the caregiver then gathered information to determine a course of action. The administrator stated neither staff had been removed from the schedule pending the investigation into the abuse allegation and said it seemed the like the story kept changing. The DON stated he had spoke to RN-A right away and she denied the allegation so they did not feel it warranted suspension. The DON stated he had placed a call to NA-A and had not realized she was working. Facility policy Abuse Prevention Plan dated March 2017, indicated each resident had the right to be free from abuse. The policy indicated if a staff member was alleged to be involved in the allegation of abuse the staff member would be suspended pending the outcome of the pending investigation.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R57, R86) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC's PneumoRecs VaxAdvisor identified: -based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 is administered, their pneumococcal vaccinations are complete. The CDC's Pneumococcal vaccine timing for adults identified: -together, with the patient, vaccine providers may choose to administer PCV20 to adults [AGE] years and older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSC23 at or after the age of [AGE] years old. R57's face sheet, identified she was [AGE] years old and admitted on [DATE]. R57 had no allergies to vaccines or contraindications to vaccine listed. R57's immunization report, identified R57 had previously received the PCV13 on11/16/2012 and the PCV13 on 12/14/2016. R57's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered or received. R86's face sheet, identified she was [AGE] years old and admitted on [DATE]. R86 had no allergies to vaccines or contraindications to vaccine listed. R86's immunization report, identified R86 had previously received the PCV23 on 6/16/2014 and the PCV13 on 6/23/15. R86's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered or received. When interviewed on 6/8/23 at 1:05 p.m., infection preventionist (IP) stated when a resident is admitted to the facility, she reviews their Minnesota Immunization Information Connection (MICC) for immunization record. IP stated that the MICC is sometimes not accurate, so she also interviews the resident to ensure that it is correct. If resident is eligible for vaccine, IP gives resident the Vaccine Information Sheet (VIS) and completes a consent/decline form. For pneumococcal vaccines, IP stated that she uses the CDC's PneumoRecs VaxAdvisor to see if resident is eligible and if so, vaccine will be administered within the first couple of weeks. IP stated she had not offered R57 and R86 the PCV20 as she considered them to be fully vaccinated. IP stated that she periodically reviews the resident's immunization record to ensure that they have all recommended vaccines. The Pneumococcal vaccine policy dated 11/30/2017, identified all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Center for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interview, and document review the facility failed to follow the comprehensive care plan for transfers for 1 of 1 resident (R1) reviewed for transfers. Findings include: Facility reported incident (FRI) submitted to the State Agency (SA) dated 4/30/23, indicted R1 requested assistance to use the bathroom and staff brought in EZ stand mechanical lift to transfer resident. R1 did not use the EZ stand for transfers per care plan. R1's admission Minimum Data Set (MDS) dated [DATE], indicated diagnoses of hemiplegia (weakness on one side of the body), atrial fibrillation (irregular heart rate), cognitive communication deficit and aphasia (speech impairment). R1 required extensive assist of two staff for bed mobility and transfers. R1 used a walker and wheelchair for locomotion. R1's care plan dated 4/13/23, directed staff to transfer R1 with assist of one staff and walker. During an interview on 5/10/23, at 6:14 a.m. nursing assistant (NA)-S stated R1 was a pivot transfer with assist of one to two staff staff and able to make needs known. NA-S did not remember ever using a mechanical lift to transfer R1. NA-S stated R1 sometimes used the bedpan. During an observation on 5/10/23, at 7:30 a.m. R1 was lying in bed with gripper socks on. Without putting on her call light for assistance staff assist, she sat herself up on the side of the bed. At 7:37 a.m. NA-M walked into R1's room and explained she was waiting for her partner to help R1 get ready. At 7:40 a.m. NA-N entered R1's room. NA-N applied the gait belt onto R1. Both aides assisted R1 to stand and pivot transfer into her wheelchair. R1 was pushed to the bathroom where both aides assisted R1 to pivot transfer to the toilet. At 7:48 a.m. after R1's cares were completed, both NAs assisted R1 to stand and pivot transfer R1 back to her wheelchair. All of the transfers were completed safely, without difficulty, and in accordance with R1's care plan. During an interview on 5/10/23, at 2:17 p.m. NA-W indicated on the 3rd day he worked with R1 he had transferred R1 to the bathroom and then back to bed with the EZ stand. During the transfer R1's face had turned red during the transfer back to bed, however R1 had not said anything. NA-W explained after the transfer, he checked R1's care plan and realized R1 was a pivot transfer with the gait belt. NA-W reported he did not follow the care plan and should have. During an interview on 5/10/23, at 12:13 p.m. nurse manager (NM)-A and director of nursing (DON) stated NAs had access to the Kardex (abbreviated care plan NAs use) on the iPhone they carry. The Kardex lets them know how to care for the resident. NM-A's and DON's expectation was if NAs were not familiar with resident, they would check the Kardex or ask another staff member. Facility policy Resident Assessment, Care Planning, Discharge Planning revised 3/17/2017, indicted the plan of care will include resident strength, goals, life history and preferences, and needs.

Based on interview and document review, the facility failed to ensure 1 of 2 allegations of abuse were reported to the state agency (SA) immediately, but not later than two hours, and 1 of 3 residents (R1) was subsequently free from physical abuse. This deficient practice resulted in an immediate jeopardy (IJ) for R1 who was noted to suffer physical injuries after an interaction with facility staff. The IJ began on 10/1/21, at 7:46 p.m. when R1 was heard screaming in her room when alone with nursing assistant (NA)-A. NA-A exited R1's room, did not respond to her screaming, and R1 was found bleeding with newly identified injuries to her elbow and forehead. The administrator and director of nursing (DON) were notified of the IJ on 10/7/21, at 1:32 p.m. The IJ was removed on 10/8/21, at 2:25 p.m. but non-compliance remained at the lower scope and severity of D - isolated scope and severity, which indicated no actual harm with the potential for more than minimal harm, that is not IJ. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had a severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required extensive assistance with transfers and grooming. A facility Discussion/Coaching form dated 3/31/21, indicated NA-A received coaching related to an allegation of rough care / going too fast during resident cares. There was no documented follow-up with NA-A. During an interview on 10/5/21, at 5:59 p.m. family member (F)-A reported she visited R1 on 8/24/21, and noted R1 was anxious and fearful. R1 was holding her arms close to her body and asked family not to leave because someone at the facility had hurt her and she was scared. F-A stated R1 verbalized a, Black male nurse threw her down on the bed roughly. F-A reported the allegation of abuse to a facility social worker and nurse manager on 8/25/21. R1 was placed on a buddy system (two caregivers) and female caregivers only, if possible. F-A stated since the alleged abuse on 8/24/21, R1 had increased anxiety and tearfulness. Further, prior 8/24/21, R1 did not differentiate staff, however, had subsequently made comments reflecting she did not want a African American males working with her. During an interview on 10/6/21, at 12:37 p.m. registered nurse (RN)-B confirmed, approximately one month ago, a complaint was received from R1's family regarding an allegation of abuse on 8/25/21. The facility investigated the allegation which included interviewing residents and staff. Further, R1's care plan was changed to reflect only female caregivers, when possible, and implemented a, buddy system. RN-B stated the allegation of abuse was not reported to the state agency SA as, nothing had happened. RN-B was unable to provide documentation of the investigation. During an interview on 10/6/21, at 1:18 p.m. social worker (SW)-A stated the facility interviewed staff and residents regarding a complaint received on 8/25/21, for R1. SW-A was unsure what the complaint involved or why an investigation was conducted. SW-A stated, I was told to ask residents if they felt safe at the facility and about their cares by RN-A. The above noted incident was not reported to the SA. A Nursing Home Incident Report (NHIR) dated 10/1/21, at 9:54 p.m. indicated on 10/1/21, at 7:55 p.m. R1 was heard calling for help and a staff-person entered R1's room. R1 was seated in a wheelchair and was noted to be bleeding from her forehead and right elbow. R1 had a 1.8 centimeter (cm.) by 2 cm. laceration on her forehead and two lacerations to her right elbow which measured 1.3 cm. by 0.7 cm. and 1.5 cm. by 1 cm. The NHIR indicated R1 verbalized, that short black man came up from behind me and picked me up and threw me on the floor. The alleged perpetrator, nursing assistant (NA)-A, was immediately removed from the floor, asked to provide a written statement, and told to leave pending investigation. Law enforcement arrived prior to NA-A leaving the facility and interviewed NA-A. Law enforcement requested NA-A's clothing as the officer felt there was, blood on his [NA-A] clothes. NA-A was arrested. Camera footage dated 10/1/21, revealed: - 7:41 p.m. NA-B exited R1's room. - 7:45 p.m. the rear handles of R1's wheelchair became visible at R1's door entrance. R1 was unable to be seen at this time. - 7:46:01 p.m. NA-A, an African American male with a stocky build, was visualized wearing a royal blue uniform. NA-A pushed the above noted wheelchair inside R1's room. - 7:46:10 p.m. R1 was heard screaming. - 7:46:32 p.m. NA-A exited R1's room and screaming was still audile. NA-A walked to and entered a supply room. Subsequently, NA-A exited the supply room and entered a resident room across the hall from R1. NA-A walked by R1's room as she continued to scream. - 7:48 p.m. R1 was visualized self-propelling her wheelchair outside of her room and licensed practical nurse (LPN)-A responded to R1 who continued to scream. R1 verbalized, That black man in the blue clothes did this. - At 7:51 p.m. NA-A was visualized looking out a doorway, in a room across the hall from R1, towards staff attending to R1. - At 7:55 p.m. R1 verbalized, A black man pushed me over to LPN-A and RN-A who were providing medical aide to R1. - 8:07 p.m. law enforcement were visualized arriving at the facility. A progress note dated 10/1/21, at 8:29 p.m. indicated R1 had an abrasion to her forehead and elbow. Further, blood was noted on R1's clothing when assessed by nursing staff. R1's medical record lacked indication R1 had the previously noted injuries prior to this medical record entry. During an interview on 10/5/21, at 2:51 p.m. NA-A denied entering R1's room, contrary to camera footage, on 10/1/21. Further NA-A denied consuming alcohol, being intoxicated while at work, or coming into contact with blood on 10/1/2. During an interview on 10/5/21, at 3:33 p.m. LPN-A reported NA-A was difficult to work with, at times, as he was disrespectful of authority. LPN-A, who worked evening shift on 10/1/21, sated she saw R1 going back-and-forth to her room throughout her shift and R1 had no blood on her forehead or arm. LPN-A stated she attended to R1 after she heard R1 screaming and observed blood on R1's forehead and R1's right arm. LPN-A cleaned R1 and noted R1 had two skin tears to her right elbow. R1 also had a bruise to the right side of her forehead which measured 1.8 cm. by 2 cm. LPN-A stated herself and registered nurse (RN)-A informed NA-A he was suspected of abuse (due to R1's allegation), however, NA-A continued to want to work on the floor. NA-A was informed NA-A law enforcement was called. LPN-A stated she did not observe blood on NA-A uniform, prior to him being suspected of abuse, and noticed it after law enforcement pointed it out. During an interview on 10/5/21, at 3:57 p.m. RN-A, who worked evening shift on 10/1/21, stated she observed R1 leave the dining room after supper and did not see blood on R1 at this time. RN-A stated NA-A denied he worked with R1 on 10/1/21. Further, RN-A did not notice blood on NA-A's uniform, prior to him being suspected of abuse, and noticed it after law enforcement pointed it out. RN-A stated NA-A had defiant behaviors with supervision. During an interview on 10/5/21, at 4:45 p.m. NA-B stated at approximately 6:00 p.m. on 10/1/21, she completed evening cares with R1 and assisted R1 to bed. R1 got up at approximately 7:00 p.m. and was put back to bed by her. At 7:33 p.m., R1 requested NA-B to lay out clothing for church and R1 was again assisted back to bed. NA-B stated, She [R1] had no bleeding or bruising and was in good spirits at that time. During an interview on 10/6/21, at 2:12 p.m. the DON denied having knowledge of a complaint received from R1's family or an investigation being completed regarding allegations of abuse on 8/25/21. It was expected staff report any allegations of abuse to the DON or administrator immediately. Further, the facility needed to file a report to the state agency within two hours. During an interview on 10/6/21, at 2:29 p.m. the administrator stated all reports of abuse should be reported immediately to the DON and the administrator. The administrator denied having knowledge of any allegations of abuse, regarding R1, prior to 10/1/21. Further, the administrator was not aware an internal investigation was conducted regarding the previous allegation of abuse for R1. During an interview on 10/8/21, at 10:52 a.m. law enforcement officer (LE)-A stated he was called to the facility on [DATE], regarding an allegation of abuse of a vulnerable adult [R1]. LE-A stated he observed blood on NA-A's uniform around his waist and shoes. Further, the smell of alcohol was noted on NA-A's breath. NA-A was escorted out of the facility and taken to jail. Further, NA-A's blood alcohol level was taken and resulted at 0.16 (consistent with alcohol intoxication). NA-A remained in jail until 10/3/21, and was criminally charged with a gross misdemeanor of assaulting a vulnerable adult on 10/8/21. The facility Abuse Prevention Policy and Procedure revised 1/15, indicated abuse was the willful infliction or injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Anyone who has information concerning an incident or alleged abuse or neglect of a resident or suspects that a resident has sustained an injury not reasonably explained by the resident's medical history, resident, report, witnessed resident or staff actions should report it immediately. The IJ which began on 10/1/21, at 7:46 p.m. was removed on 10/8/21, at 2:25 p.m. when it was verified through interview and document review facility implemented a systemic removal plan which included: - NA-A was suspended and the facility began an investigation on 10/1/21. - The facility Abuse Prevention Policy and Procedure was reviewed on 10/7/21. - The facility provided education to all staff who were working regarding abuse prevention and reporting on 10/8/21. - All facility staff, who had not worked, were notified abuse prevention and reporting training must be completed prior to their next scheduled shift.

Based on interview and document review, the facility failed to ensure medication to prevent blood clotting was administered in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings constituted actual harm for R1. Findings include: On 7/28/20, at 1:30 p.m. R1's family member (FM)-A was interviewed. FM-A explained R1 had sustained a medication error while residing at the nursing home when her physician ordered aspirin was not provided to her and she subsequently suffered a stroke. FM-A explained the nursing home had followed up with him about the error; and they voiced R1's ordered aspirin had been accidentally discontinued instead of just R1's listed aspirin allergy, which is what had been actually ordered. This caused R1 to miss several weeks of aspirin dosing. FM-A voiced he believed the error contributed to R1 suffering the stroke; and since the stroke, R1 is no longer able to live on her own and needs more help to complete basic cares. Further, FM-A expressed frustration about the situation and voiced the error made him think there was obviously a problem at the nursing home with their order processing. R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition and required extensive assistance with activities of daily living (ADLs). Further, R1 had no neurological diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . stroke, [CONDITION(S)], [CONDITION(S)]) and received anticoagulation medication(s) only on one (1) day during the review period. R1's post-hospitalization After Discharge Orders, dated 4/22/20, identified R1 was being discharged to the nursing home after being hospitalized due to a fall and fracture with a hematoma. R1's hospitalization was listed as being complicated due to [CONDITION(S)], and dictation directed to hold R1's [MEDICATION(S)] (an anticoagulant medication) for a set period. The report identified, May need discussion regarding continuation of [[MEDICATION(S)]] given high fall risk. R1's discharge medications to the nursing home were listed which included, aspirin 81 mg [milligrams] . 1 tablet by mouth once daily with a meal, along with a listed allergy to aspirin with dictation reading, . *patient tolerating daily dose of aspirin 12/14/16. A Physician's Telephone Orders, dated 5/4/20, identified an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Dx: [diagnosis] Afib [[CONDITION(S)]; an abnormal heath rhythm which causes rapid, irregular beating]. A subsequent Physician's Telephone Orders, dated 5/6/20, identified an order which read, OK to DC [discontinue] aspirin alergy [sic]. The order was provided by the nurse practitioner (NP). The order was signed by various staff members, including station secretary (SS)-B. However, a Discontinue Order report, dated 5/6/20, identified licensed practical nurse (LPN)-A discontinued R1's ordered aspirin 325 mg QD with dictation present, Per NP directive. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was provided aspirin 81 mg on 5/1/20, 5/2/20, 5/3/20, 5/4/20 and 5/5/20. Further, an additional order, started 5/6/20, was identified which directed to provide aspirin 325 mg by mouth one time a day for [CONDITION(S)]. A single dose was provided on 5/6/20; however, the order then listed a discontinue date of 5/6/20. No further doses of aspirin were provided to R1 according to the MAR. R1's progress note, recorded on 5/29/20, at 10:41 a.m. which recorded R1 as being alert and orientated and needing only assistance of one with her walker. A progress note on 5/29/20, at 2:37 p.m. listed an SBAR (Situation, Background, Assessment and Recommendations) note was completed. R1 was recorded as having developed left-sided weakness and left-sided facial droop while using the restroom. The nurse was unable to obtain a set of vital signs on R1, and R1 was recorded as saying, I don't know what is happening. R1's physician (MD)-A was contacted and R1 was sent to the hospital ED for evaluation via ambulance. R1's corresponding ED Admission History & Physical, dated 5/29/20, identified R1 presented with a chief complaint of weakness. R1 was recorded as being a poor historian upon presentation to the ED, . due to the acuity of her condition, with slurred speech, [CONDITION(S)] (loss of ability to understand or express speech) and left-sided weakness being recorded as present. The report identified R1 had been taken off her [MEDICATION(S)] due to having sustained multiple falls on 4/18/20, and she was given TPA (thrombolytic therapy to dissolve blood clots) in the ED. A section labeled, Preadmission Medications, listed all of R1's medications which were being administered by the nursing home; however, the list lacked any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *patient tolerating daily doses of aspirin 12/14/16. Further, the report listed R1's medical problems with subsequent plan(s) to address each one. This included, Acute stroke, which was listed as being caused by ischemia (inadequate blood supply) and left-sided weakness and left facial droop were present. R1 was admitted to the hospital. R1's Hospital Discharge Summary, dated 6/1/20, identified R1 was discharged from the hospital back to the nursing home with a principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was listed as having [CONDITION(S)] and dictation read, . [[MEDICATION(S)]] had been stopped recently because of fall with injury. Neurology consulted and feels she should remain off [[MEDICATION(S)]] at this time and to use ASA [aspirin]. Further, a series of discharge medications were listed which included new orders for, aspirin 325 mg tablet . Take 1 tablet by mouth once daily with a meal. Further, the outlined allergies on the report continued to list aspirin with the same dictation present which read, *patient tolerating daily doses of aspirin 12/14/16. On 6/1/20, a progress note identified R1 was readmitted to the nursing home from the hospital. The note outlined, Resident is a readmission due to a recent stroke. Resident has left sided facial drooping and weakness. Further, R1 was now listed as needing assist of two with all transfers using a mechanical lift. A completed State agency (SA) submitted investigation, dated 6/4/20, identified the facility' completed investigation into the incident. R1 admitted to the nursing home on 4/22/20, and the record identified R1 had been on [MEDICATION(S)]; however, the provider was concerned for bleeding so it was placed on hold. On 5/4/20, orders were received to increase R1's daily aspirin dosing from 81 mg to 325 mg beginning on 5/6/20. On the same date, R1's aspirin allergy was identified and an order was received to discontinue the allergy. These orders were given to the station secretary to process who removed the listed allergy and gave the orders to the nurse to confirm. However, the facility' electronic medical system (PointClickCare) did not allow for the nurse to confirm allergies had been removed resulting in the nurse inadvertently discontinuing the aspirin dose order instead of the allergy. The report outlined R1 then presented with a change of condition and subsequent thrombotic stroke on 5/29/20, and listed, [R1] has experienced a functional decline due to the incident . The report listed section(s) to describe action(s) taken to prevent reoccurrence to the subjected resident and other residents. The facility identified education was provided to the nurse, LPN-A, who committed the error; however, the field to write what actions had been taken to prevent reoccurrence to others was completed with only, N/a [not applicable]. The report lacked any actions or evidence of a systemic response by the facility to help alert or educate staff to their identified findings of the electronic health system not allowing nurses to confirm allergies are removed; nor was there evidence of any completed education to other staff not involved in the incident regarding ensuring orders are clarified if they are unclear. During interview on 7/28/20, at 7:57 a.m. registered nurse (RN)-C stated the nurses were able to view resident allergies in the computer system; however, voiced she did not know how to adjust allergy orders. RN-C explained a significant medication error would be one which included the incorrect administration or omission of insulin, [MEDICATION(S)] or other high risk meds. RN-C stated she was not sure on the facility' process for reporting or investigating significant medication errors and added she had not been provided any recent training or education on order transcription and processing. When interviewed on 7/28/20, at 8:47 a.m. RN-E explained the facility' process for order processing. The SS enters the orders into the electronic health system, and the floor nurse then completes a second check for accuracy. The order is then listed as active in the system. The orders are then passed to the night nurse for a final check. RN-E stated if they received an order to discontinue an allergy for a resident, they would act on the order and not question it, as they're not a physician; however, afterwards would then follow-up with the provider about the order. Further, RN-E stated she had not been provided any re-education or new guidance on order processing within the past several weeks. When interviewed on 7/28/20, at 9:20 a.m. SS-A expressed they (SS) had rights and access to change allergies within the electronic health system; however, SS-A voiced she was uncomfortable doing so. As a result, SS-A stated she would ask a nurse to change the order instead of her doing it. During subsequent interview, on 7/29/20 at 9:10 a.m., SS-A stated she could not recall receiving any new guidance or re-education on allergy or order processing within the past several weeks. During interview on 7/28/20, at 9:30 a.m. SS-B voiced she was unaware of any issues or errors involving the electronic health system when allergies are modified or removed. SS-B stated she was not aware R1 had sustained a medication error (despite being the SS who originally processed the order for R1 on 5/6/20 to discontinue the aspirin allergy) and verified she had not been given any re-education or new guidance on order processing regarding allergies or medication orders since R1's incident. On 7/29/20, at 9:57 a.m. R1's medical doctor (MD)-A was interviewed and verified she was R1's primary care physician while R1 resided at the nursing home. MD-A explained R1 admitted to the nursing home on 4/22/20, and upon admission, R1's [MEDICATION(S)] was on hold as R1 had sustained an internal hematoma (type of internal bleeding) due to a fall which is why she had been hospitalized . R1 had several heart issues including [CONDITION(S)], carotid artery stenosis and coronary artery disease (CAD), all of which increased R1's risk of stroke; so R1 had orders in place for a daily dosing of aspirin 81 milligrams (mg). MD-A stated she had numerous discussions with R1 and her responsible party as she was worried about R1's anticoagulation in general due to her frequent falls. As a result, a decision was made to start R1 on a full-strength aspirin and an order was provided on 5/4/20 to increase R1's aspirin dosing from 81 mg to 325 mg provided on a daily basis. MD-A explained a situation then arose where they identified R1's medical record had a listed allergy to aspirin; however, it was determined to not be accurate and a separate order was written on 5/6/20 to remove the listed allergy. MD-A verified the order written on 5/6/20 was meant to remove the aspirin allergy; however, not meant to remove the medication administration order. MD-A explained she was aware an error then occurred where the medication itself along with the identified allergy were both discontinued, which resulted in R1 getting little to no dosing of the ordered aspirin through 5/29/20. MD-A expressed on 5/29/20, she had seen R1 for a visit earlier in the day and R1 had no visible signs of distress outside of complaints of knee pain; however, afterwards R1 then developed difficulty speaking and left-sided weakness. R1 was subsequently sent to the ED and diagnosed with a stroke. MD-A stated when she learned R1 had been hospitalized for a stroke, she reviewed her medication list and discovered the aspirin was not being given. MD-A then e-mailed the nursing home and expressed concern about the error which MD-A voiced was likely the first time the nursing home had been notified an error had happened. MD-A explained if R1 had been provided the ordered aspirin everyday, as the order on 5/4/20 called for, it would have provided R1 some protection against stroke adding, I do think it increased her risk of stroke to have nothing [medication]. MD-A reviewed R1's risk factors and stated she felt the omitted aspirin would be considered a significant medication error for R1. MD-A expressed regret about the error and voiced there were multiple opportunities for staff, including herself, to notice the aspirin was not being provided and correct it adding, None of us saw it. Further, MD-A stated she was not aware of there being any direct request of the physician staff to modify any of their procedures to help prevent future errors with circumstances surrounding R1's incident; however, MD-A stated she was not sure what new procedures or policies the nursing staff may have been directed on since the incident to help avoid further errors. On 7/29/20, at 10:41 a.m. LPN-A was interviewed and verified he processed R1's order from 5/6/20, which called to discontinue R1's aspirin allergy. LPN-A expressed he was unable to recall specifics of the events surrounding the order entry and subsequent error; however, acknowledged he was aware an error had occurred as he had been educated on it. LPN-A explained the education the facility provided was merely a telephone discussion which they directed him to double check and clarify orders if unsure of them. LPN-A stated he had received no education or further instruction on how to ensure allergy orders are processed correctly to prevent errors or confusion in the electronic record system. LPN-A voiced he was unaware R1 had an aspirin allergy when he processed the order on 5/6/20; however, reiterated he could not recall specifics which happened with the order processing as it was so long ago. On 7/29/20, at 11:07 a.m. the administrator and director of nursing (DON) were interviewed. They explained R1's unit manager, whom was on vacation currently and not available for interview, received notification on 5/29/20 of a medication error involving R1's aspirin. As a result, a vulnerable adult (VA) report was made and the error was reviewed with the physician and corresponding staff involved. The DON explained the process used for order processing included multiple chart checks by the nurses after the orders are entered into the system by the station secretary staff. They expressed the incident with R1 as being isolated and didn't feel there was a widespread concern with their order check system; however, the DON acknowledged the process failed regarding the incident with R1's aspirin error. The interview continued and they explained the facility had completed an investigation pertaining to R1's medication error and discovered an issue with their electronic record system (PointClickCare) where it did not readily display when allergies were discontinued, so they notified the software developer and were trying to get that fixed. The DON added the bottom line of the error was the nurse mis-read R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At 11:15 a.m. the director of quality (DOQ) joined the interview and voiced the incident pertaining to R1's medication error was the true definition of an accident. R1 had been taken off [MEDICATION(S)] and it was changed to a daily aspirin regimen; however, there was a listed allergy to aspirin on R1's record so the nurse practitioner (NP) had written an order to discontinue the allergy. The written order was acted on by the station secretary whom discontinued the allergy in the system and the nurse, LPN-A, then followed behind later on to complete the process and final transcription. However, the electronic record system does not log or record when an allergy is discontinued; so this caused the nurse to read the order and, in error, the nurse thought the order meant to discontinue the medication itself as the allergy was no longer listed. R1 subsequently was not provided any aspirin and sustained a stroke on 5/29/20, which caused R1's physician to contact the unit manager about the error and an investigation was started into the incident which revealed those details. DOQ expressed that in the best of all [NAME] the NP could have re-worded the order to be clearer, and expressed regret as everyone involved was doing what they thought was the right thing. The interview continued, and, as a result of the error, DOQ expressed they had completed some re-education with the person(s) immediately involved with the error, including the NP and LPN-A; however, they had not conducted any re-education for the other staff members working in the facility who process orders as R1's error was a unique situation and they felt it didn't require whole-house education or alert. DOQ stated she felt the facility' systemic response to the incident was reviewing and affirming their overall system for order transcription was adequate; however, DOQ acknowledged the system had failed us with R1's incident and she reiterated had the electronic software system shown recently discontinued allergy orders, the error likely would not have ever happened. DOQ voiced they had reached out to the software company regarding their findings; however, had not received a response from them on how to proceed or amend the identified issue. When questioned on any stop-gap measures put into place to help ensure other similar errors did not occur until the software company provided feedback, they expressed the unit manager staff were asked to keep an eye on it going forward. The DOQ voiced she felt the facility had a solid order transcription process in place for check and balance to ensure order accuracy and their investigation identified there wasn't a flaw in the overall process. Further, the facility did reach out to the medical director of the campus; however, neither him or the facility had done any follow-up with the physician group(s), despite some questions on the clarity of the provider order, as the facility authored the order and not the provider. When interviewed via telephone on 7/29/20, at 4:35 p.m. the facility' consulting pharmacist (CP) expressed she had not been updated on any medication errors, including R1's error, since she started in April 2020, and verified she was the only CP the facility used. CP stated she had not been involved with any education processes for nurses or SS staff regarding medication orders or issues with transcription/order processing. CP reviewed R1's medical record and expressed if she had noticed R1's aspirin had been discontinued, it would have been something she would have questioned given R1's medical history. Further, CP voiced she was unable to comment on how R1's aspirin omission could have contributed to her subsequent stroke; however, verified she had not had any conversations or consultation from the facility regarding allergy order transcription and processing. A provided Medication Monitoring policy, dated 6/15, identified the facility employed a system to assure medication usage is evaluated on an ongoing basis, and when a significant medication-related problem is identified, the issue would be assessed, documented and reported, as appropriate to the physician, the QA (quality assurance) committee, the pharmacy and consulting pharmacist and the FDA, if needed. A procedure was provided to follow when a resident received a new medication order which directed to ensure the ordered specifics of the medication (i.e. dose, route, etc.) are in agreement with current clinical practice and guidelines, and ensure the resident has no listed allergies to the ordered medication. A facility policy on order transcription and allergy order transcription was requested, however, none was ever provided or received.