Every finding on record at Harmony River Living Center

Based on observation, interview and document review the facility failed to develop and implement resident specific approaches to behavior for 1 of 3 residents (R1) diagnosed with dementia who displayed negative behaviors affecting himself and other residents in the facility. Findings include: R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1's care plan: Revised on 3/17/26, identified an alteration in mood or behavioral expression due to Alzheimer's and dementia. Targeted behaviors included exit seeking, wandering into other residents' rooms, sexual behaviors toward staff, delusions and hallucinations. Revised on 3/1/26, see behavior intervention care plan: Revised on 3/17/26, encourage activities of interest. Revised on 3/24/26, Therapeutic fibbing (bending the truth or telling small white lies to someone with dementia), redirection, reassurance, explain procedures, conversation, food, drink and toileting. Intervene as needed to protect the rights and safety of others. Approach and speak in calm manner. Revised on 4/17/26, had required 1:1 care due to sexual advancements toward others. Revised on 5/20/26, Utilize my favorite activities as opportunities for my behaviors: listening to personal music, going for walks, going outside, talking about hunting/fishing, ice cream, looking through picture books, watching television, calling family. The care plan identified potential to demonstrate verbally abusive behaviors related to cognitive impairment, dementia and poor impulse control. The care plan directed staff to observe for and document side effects of medication. When agitated, staff were directed offer photo album, busy board, and/or white noise machine. R1's care plan lacked evidence of comprehensive assessment of behaviors or resident specific interventions between 3/24/26 and 5/20/26 and lacked evidence of recommendations for non-pharmacological behavior interventions. R1's Progress Notes indicated the following: 3/4/26, R1 walked around the neighborhood several times during the shift. Pleasant with staff. Confused at times but was able to make needs known. 3/7/26, R1 was found naked in the doorway of his room exposing himself to another resident. The other resident was able to walk away from him. Staff intervened. 3/9/26. R1's family member expressed concerns for his demeanor and mood and said she had noticed R1 had been less cooperative and irritable since he moved to the secured unit. R1 had been refusing care from staff over the weekend. 3/11/26, Interdisciplinary team met to discuss R1's current status. R1 showed improvement in activities of daily living and mobility. 3/17/26, R1 had severe cognitive impairment, alert and oriented to self and family. Exhibits confusion, memory loss, impaired safety awareness and disorientation. Presented with minimal symptoms of depression. Targeted behaviors included exit seeking, wandering into other rooms, sexual behaviors toward staff. Behaviors often redirected by conversation, offer food/drink, escort to different location and allowing him to express feelings. R1 was generally pleasant and cooperative on a daily basis. 3/17/26, During assessments, R1 made sexual comments toward staff. 3/18/26. R1 admitted to hospice care. Medication changes implemented. 3/19/26, R1 awake at night, intermittently coming out of room and walking around common area. Staff assisted back to room several times. Offered snack and accepted. Sexual comments made to staff. 3/19/26, R1 was noted to have an increase in sexual behaviors and comments over the last week. 3/23/26, R1 stated he had to be somewhere tomorrow. Staff told him it was 1:00 a.m., R1 told staff they did not know how to read time and said staff knew nothing. Wandering in unit throughout shift. Assisted back to bed/room several times. Staff had been shutting R1's door to hear him exit due to wandering at night. R1 stated if door did not get opened, he would smash the window out. Staff opened door slightly to appease R1. 3/23/26, R1was agitated and asking to leave. Writer tried therapeutic fibbing and explained needed a few days to complete paperwork. R1 stated he was livid and would burn the place down then went back to his room. 3/23/26, R1 talked about enlisting in the Navy and that he had been told to wait and it had been days of waiting. 3/25/26, R1 self-transferred and stood in his doorway a couple times without a shirt on. Assisted back to wheelchair and refused food. Inappropriate remarks and gestures made to staff. 3/26/26, Nursing staff denied any new or worsening behaviors. 3/27/26, R1 continued to ambulate out of room, a few times without pants on. Mid-morning, R1 came out and reported to staff that staff in facility were drinking on the job and stated he needed to wake up staff laying on the floor. Also talked about enlisting in the Navy. 3/28/26, R1 continued to refuse care and declined to wear incontinent brief. 3/31/26, R1 was wandering on the unit looking for his wife and his car. R1 was seen showing affection toward another resident. Writer firmly told R1 to stop and separated the residents. 4/1/26, R1 awake throughout shift. Came out to common area looking for his wife and indicated he needed to get to work. Staff re-oriented him to time of day. Was offered a drink and snack which he declined. 15-minute checks performed per administrator. 4/1/26, R1 picked up phone and stated he was calling security because people were trying to break into his space. 4/1/26, R1 wandered around the unit looking for a way out. 4/1/26, Interdisciplinary team (IDT) discussion held regarding R1's escalating behavior and need for additional management strategies. Family member (FM)-C expressed hesitancy about using antipsychotic medications and questioned if behavior was related to new medication. It was explained that R1 was currently receiving one-on-one supervision which was not sustainable long term and if behavior continued or escalated without adequate symptom control through medication, a higher level of care may be necessary including potential hospital evaluation or alternate placement. 4/2/26, Staff had conversation with R1's FM-C regarding his care plan after recent incident. Facility staff requested family provide additional presence in the building by family or friends to manage R1 during periods of increased behaviors. Team would also be calling FM-A to request additional assistance. 4/3/26, Family meeting was held to discuss R1's care needs and ongoing challenges with care coordination. Family was informed that if hospice recommendations continued to be declined or over-ridden the facility may proceed with a 30-day discharge notice and assist with alternate placement. Family was also told if R1 were to reach out physically toward staff or other residents, the facility had been instructed to send him the emergency department. Agreement was reached to continue one-on-one supervision for seven days with the understanding that it was a temporary measure. 4/4/26, R1 was seen naked and urinating in the sink in his room. 4/5/26, FM-A arrived and took over the one-on-one staff assigned to R1. 4/6/26. R1 noted to be hallucinating. Thought FM-A was in his bed and reported seeing two dogs. 4/7/26, Care meeting held. Physician scheduled Buspirone and provided education to family about Seroquel. Plan in place to discontinue the one-on-one if medications start to work. 4/9/26, R1 agitated and wandering. Became upset when staff was following him in hallways and day room and commented, you better stop following me or else. Later talked about the woman who was following him. 4/10/26, IDT reviewed R1's overall mood and behaviors over the past several days. While there appeared to be a decrease in behaviors it did not mean behaviors had been resolved. The apparent reduction was largely due to the staff provision of one-on-one supervision which limited his ability to seek out or escalate behaviors. However, the behaviors were still present. 4/10/26, Hospice recommended the use of antipsychotic medications to address ongoing behaviors which family had declined. The IDT determined continued one-on-one supervision was required to maintain the safety of residents and staff. Family was provided with information on private long-term one-on-one staff that they would need to secure by Monday. Administrator advised family that if recommendations were not followed and behaviors continued, the facility would seek alternate placement. 4/10/26, Following ongoing discussion and IDT review a comprehensive evaluation of R1's clinical presentation, care needs and safety considerations was completed. Based on this review it was determined that the current care setting was no longer able to meet R1's long-term care needs. Conclusion was primarily due to progression and persistence of behavioral concerns that pose an increased risk to other residents and staff. 4/13/26, R1 left his room and walked to a recliner and sat down. Staff followed him and asked if he needed something to which he stated, what he wanted was to get away from staff. R1 went back to his room. Irritated that staff kept following him. Resident Occurrence Report dated 3/31/26, indicated R1 grabbed another resident's breast in a common area of the unit. Analysis of cause of incident indicated sexual disinhibition. Staff intervened and separated residents, and 15-minute checks were implemented. Facility document provided to family dated 4/10/26, indicated: Notice of discharge and indicated the facility was unable to meet R1's needs and required 1:1 supervision to meet R1's needs and ensure the health and safety of other residents and staff, and the facility was unable to provide the level of supervision R1 required. The documented indicated R1 would be discharged [DATE]. The discharge notice was rescinded 5/8/26, only after an appeal was filed on R1's behalf. Hospice visit note dated 5/15/26, indicated a care conference was held for R1. FM's expressed concerns related to anti-psychotic medications. [FM]'s have been given until 5:00 p.m. today to give consent or approval of hospice recommendations before going into the weekend. R1's behaviors indicated appropriate for situation, calm. The assessment lacked evidence of non-pharmacological behavioral interventions attempted. During observation on 6/4/26 at 1:05 p.m., R1 was lying in bed and appeared to be asleep. At 1:46 p.m., R1 was lying in bed and was snoring. During observation on 6/8/26 at 4:19 p.m., R1 was seated in a common area of the unit. R1 stood up and ambulated independently to his room. At 4:29 p.m., R1 came out of his room wearing a jacket. At 4:34 p.m., R1 went to his room to retrieve his walker, headed toward the exit doors of the unit then turned around and sat in a chair in the common area. At 4:41 p.m., staff attempted to get R1 to go to the dining room to eat, which was refused. Staff then assisted him to a recliner in the common area. R1 then got up from the chair and headed back to the exit door. At 4:50 p.m., R1 was ambulating, and staff asked him if he needed to use the bathroom. R1 replied he was trying to go outside and staff said he couldn't because everyone was eating. R1 swore quietly. During observation on 6/9/26 at approximately 7:30 a.m., staff was in R1's room talking to him. A medication cart was parked outside the door. Staff left the room and turned off the light. At 8:00 a.m., the same staff member was talking to licensed practical nurse (LPN)-A and said, I tried 129 [R1] but he wouldn't wake up. During interview on 6/5/26 at 7:31 a.m., licensed practical nurse (LPN)-A stated at one-point R1 had been placed on 15-minute checks, Maybe for being more sexual. I truly don't know. LPN-A stated when R1 first moved to the unit, he had exposed himself to R4, indicating he had his pants down and was facing R4. LPN-A stated R4 told staff about the incident the next day. During interview on 6/9/26 at 1:34 p.m., the household coordinator (HC) stated R1's discharge notice was given because he needed one-on-one staff supervision which was not a long-term solution. Essentially R1 needed more care than the facility could provide. Registered nurse (RN)-B was present and stated family had declined in-patient mental health placement. The one-on-one supervision was implemented after he had a physical touch situation with another resident. When asked about interventions for his behaviors, RN-B said staff diverted his attention with photo albums and music (not implemented until 5/20/26). When asked about psychiatric referrals, RN-B said because R1 was on hospice they would not normally reach out to psychiatry. RN-B said after the incident with the female resident, they needed some other interventions so R1 was placed on the one-on-ones. RN-B stated compared to other residents in the facility who also had dementia, R1 was impulsive and displayed sexual behaviors toward residents and staff. RN-B acknowledged no further incidents with other residents had occurred since 3/31/26. During interview on 6/9/26 at 3:23 pm., RN-A stated R1 displayed agitation and was always looking for items or family. The previous evening (6/8/26), staff was attempting to transfer another resident and R1 sat in the resident's chair and would not get up. The more staff attempted to talk to him, the more upset R1 got. RN-A said staff tried to distract R1 by offering him ice cream or toileting but said he had been refusing those things. During interview on 6/9/26 at 3:39 p.m., with the administrator and director of nursing (DON), the administrator stated the discharge was initiated due to the facility's inability to provide one-on-one staff supervision, which R1 required for the welfare of the staff and residents. R1's family declined in-patient mental health and medications. The administrator stated they asked family to help with one-on-one supervision. The family was provided with a list of organizations that could provide one-on-one care, but family did not want to pay for it. The DON stated R1's behavior was better when he was receiving one-on-one supervision. The DON acknowledged R1 had not sought out other residents since the incident on 3/31/26 and stated that it had been an isolated incident. When asked how the facility managed other residents' behaviors, the DON stated staff administered medications. Regarding non-pharmacological interventions, the DON said what worked was dependent on the day. The DON stated she had not observed staff interactions with R1, nor had she requested feedback from the staff in an effort to assess behavioral interventions. During interview on 6/9/26 at 4:26 p.m., nursing assistant (NA)-A stated R1 made some sexual comments and said he could be aggressive with staff. NA-A stated they had a class provided by the company regarding dementia and stated, I have been working here a long time, so I am pretty good at dementia. NA-A said she had not received any specific education related to R1. During interview on 6/9/26 at 4:31 p.m., NA-B said R1 would refuse toileting and would raise his voice but never touched anyone, he's just loud. NA-B said R1's behaviors were not present when he admitted to the facility and said they started when he moved to the secured unit. NA-B said when R1 was agitated or exit-seeking he had stuff in his room to distract him.

Based on interview and document review the facility failed to report an allegation of sexual abuse to the state agency (SA) for 2 of 3 residents (R4, R5) reviewed for reporting of alleged violations when R1 displayed sexual behaviors towards R4 and R5. Findings include: R1 R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1's care plan dated 4/13/26, identified limited physical mobility and indicated he required assistance from one staff for transfers and ambulate. The care plan revised on 3/17/26 indicated a history of requiring one-to-one staff supervision due to sexual advancements toward others. Interventions included: Intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention and move to an alternate location as needed. R1's Progress Note dated 3/7/26, indicated R1 was found naked in his doorway, exposing himself to another resident (R4). The other resident was able to walk away. R1 was redirected. Resident Occurrence Report dated 3/31/26, indicated R1 grabbed another resident's breast (R5) in a common area of the unit. Analysis of cause of incident indicated sexual disinhibition. Staff intervened and separated the residents and 15-minute checks were implemented. R1's Progress Note dated 3/31/26, indicated R1 had been seen showing affection toward another resident and indicated the other residents was not affected by it. R1 was removed from the area and brought back to his room. During interview on 6/5/26 at 7:31 a.m., licensed practical nurse (LPN)-A stated when R1 first moved to the unit, he was seated in the common area and had exposed himself to R4. LPN-A said R4 told staff and other residents about the incident and continued telling staff about it the next day. R4 R4's admission Record printed 6/11/26, indicated she was admitted to the facility 9/23/25. R4's diagnoses included altered mental status, mild cognitive impairment and anxiety. R4's significant change MDS signed 4/23/26, indicated R4's vision was adequate with corrective lenses, had severe cognitive impairment and had no behaviors. R4 required supervision with transfers but was independent with ambulation with use of walker. R4's care plan dated 4/22/26, identified an alteration in mood and behaviors and indicated she self-transferred, wandered into other residents' rooms and enjoyed being able to navigate her way around the unit. R4 was not able to be interviewed. R4's record failed to include information regarding the incident with R1. R5 R5's admission Record printed 6/11/26, indicated she was admitted to the facility 7/30/19. R5's diagnoses included vascular dementia and anxiety. R5's quarterly MDS signed 3/23/26, indicated R5 had severe cognitive impairment and had no behaviors. R5 required supervision with transfers and ambulation. R5's care plan dated 5/31/26, identified limited physical ability and indicated she required staff assistance to and from all destinations. R5 was not able to be interviewed. R5's progress note dated 4/1/26, indicated on 3/31/26, staff observed a male resident (R1) touch her on the breast, over her clothing. Staff intervened and redirected the male resident without incident. R5 appeared unaffected and had been holding the male resident's hand at the time of the incident. During interview on 6/5/26 at 7:31 a.m., licensed practical nurse (LPN)-A stated at one-point R1 had been placed on 15-minute checks, Maybe for being more sexual. I truly don't know. LPN-A stated when R1 first moved to the unit, he had exposed himself to R4, indicating he had his pants down and was facing R4. LPN-A stated R4 told staff about the incident the next day. During an interview on 6/8/25 at 12:51 p.m., with the administrator and director of nursing (DON), the administrator stated he was aware of the incident between R1 and R5 and said staff had intervened and separated the residents. The administrator stated R5 had been unaffected by the incident but R5's family member (FM)-A, had been very upset about the incident. The administrator stated the incident between R1 and R5 had not been reported to the SA because R5 had not been affected by it. The administrator and DON stated they had no knowledge of the incident between R1 and R4. During interview on 6/9/26 at 5:44 p.m., FM-A stated if R5 had been able to understand what happened when R1 touched her breast she would have been extremely uncomfortable. FM-A stated R5 was a very private and quiet person and would not have been okay with the situation. FM-A said R5 would have felt sexually harassed. Facility policy Vulnerable Adult Abuse Prevention Plan dated October 2025, identified sexual assault as sexual contact that resulted from force, threats or the inability of the person to give consent and included any sexual activity that occurred when and individual could not give consent. The policy indicated allegations of abuse will be reported immediately within state and federal guidelines and indicated if the allegation involved abuse the report must be made no later than two hours after the allegation was made.

Based on interview and document review the facility failed to ensure pharmacy recommendations were addressed to include a clinical rationale for declined recommendations and failed to identify and address medications as a contributing factor for falls for 1 of 3 residents (R1) reviewed who sustained multiple falls following the implementation of hospice prescribed medications. Findings include: R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1 received scheduled and as needed medication to relieve pain as well as non-medication interventions. R1 denied having, pain or hurting, during the assessment period. R1's care plan included: Revised on 3/17/26, history of requiring one-on-one staff supervision due to sexual advancements toward others. Interventions had been implemented along with extensive conversation to manage behaviors. Interventions included: Intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention and move to an alternate location as needed. Revised on 3/18/26, R1 entered hospice care. Revised on 4/13/26, identified limited physical mobility. R1 required assistance from one staff for transfers and ambulation. The care plan Revised on 4/23/26, behavior required intervention evidenced by sexual behaviors toward staff. R1 would comment on staff's appearance and voice sexual desires toward that staff member. R1 was often redirected through conversation. R1 had a history of masturbating in private room and being observed with hands inside pants in common areas, creating potential discomfort for others and need for redirection. Refer to Hospice regarding medication adjustments for behaviors. The care plan further identified a risk for falls related to weakness, Alzheimer's and a history of falls. Interventions included alert R1 to changes in environment, call light in reach, appropriate footwear, wheelchair out of path in room and review of information on past falls to determine cause and remove any potential causes of falls. Occurrence Report dated 2/11/26, indicated at 3:30 a.m., R1 fell in his room. Analysis indicated he was confused and may have fallen when returning from using the bathroom. Reminder to use the call light. R1's progress notes reviewed 3/16/26 through indicated: 3/18/26, indicated R1 admitted for hospice services. Hospice orders included: Start Lexapro (used to treat major depressive disorder and generalized anxiety. Typical side effects include nausea, fatigue, sexual dysfunction, and sleep changes) 5 milligram (mg) tablets. Take 5 mg daily for seven days then re-evaluate. Start Seroquel (typical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder. Potential side effects included heavy sedation and dizziness) 25 mg tablet. Administer 25 mg every four hours as needed for inappropriate sexual behaviors, agitation, and delirium. Mood disorder/ Discontinue after 14 days. Start Dilaudid (opioid analgesic used to manage severe pain that does not respond to other medications. Potential side effects included dizziness and drowsiness) 1 mg tablet, administer 1 mg every hour as needed for pain or shortness of breath. 3/19/26, Seroquel placed on hold at this time. 3/24/26, No pain noted, R1 reported feeling tired and family member (FM)-B reported R1 had been sleeping all the time. Order was received to increase Lexapro. 4/1/26, hospice orders: Start Rivastigmine (used to treat mild to moderate dementia caused by Alzheimer's or Parkinson's disease. Potential side effects included dizziness and fatigue) 1.5 mg by mouth three times daily for dementia. Buspirone (used primarily to treat generalized anxiety disorder. Potential side effects included dizziness, drowsiness, lightheadedness and excitement) 5mg tablet by mouth three times daily for anxiety. Haloperidol (antipsychotic medication used to manage sever behaviors. Typical side effects included drowsiness, dizziness and restlessness)1 mg Solu tab every four hours for agitation, hallucinations and delirium. 4/2/26, FM-C denied consent for Haloperidol. 4/4/26, R1 was seen naked and urinated in the sink in his room. Buspirone given. 4/7/26, care meeting, Buspirone scheduled twice daily and R1 could still have as needed. Education provided related to Seroquel. 4/8/26, indicated R1 fell on his right side at 4:04 p.m. Intervention indicated weakness, medication changes and hip pain. Occurrence Report dated 4/8/26, indicated at 4:04 p.m., R1 fell in the hallway. Suggestion included therapy assessment and assistance with transfers and ambulation. Occurrence Report dated 4/15/26, indicated at 7:15 p.m., R1 fell near the desk. Suggestions included when R1 displayed behaviors, avoid bringing him out where he could see other residents coming and going. Occurrence Report dated 4/19/26, indicated at 12:30 p.m., R1 was observed on the floor in his room. Suggestions included continue 15-minute checks and ensure needs were met. Occurrence Report dated 4/20/26, indicated at 3:40 a.m., R1 was observed crawling out of his room into the hallway. Suggestion included promote sleep, how do we get this man to sleep. Pharmacist's Recommendation to Prescriber dated 4/23/26, indicated R1 had experienced multiple falls, is at high risk for falls and received the following medications known to increase falls: Buspirone 10mg three times daily. Hydromorphone 1 mg every four hours as needed. Handwritten note on form indicated on hospice- meds [medications] effective. Check box on form indicated benefits outweigh risk and deemed necessary for R1. No changes. The recommendation lacked a clinical rationale for continuing the medications as prescribed and was signed by the physician on 5/19/26. Occurrence Report dated 4/25/26, indicated at 6:30 a.m., R1 fell in his room. Suggestions included medication review and getting him dressed for the day. R1's MAR dated April 2026 indicated he received the following medications: Buspirone 5 mg twice daily from 4/7/26 through 4/16/26 and as needed doses on 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/8/26, 4/9/26, 4/10/26 x 2, 4/11/26, 4/13/26, 4/15/26 and 4/16/26. Buspirone 10 mg three times daily from 4/16/26 through 4/30/26 and as needed doses received on 4/18/26, 4/19/26, 4/24/26 x 2, 4/25/26, 4/28/26 x 2 and 4/29/26 x 2. Hydromorphone (Dilaudid) 1 mg three times daily from 4/2/26 through 4/9/26. Hydromorphone 1 mg every four hours (six times daily) from 4/9/26 through 4/30/26. Hydromorphone 1 mg as needed doses administered 24 times. Occurrence Report dated 5/4/26, indicated at 10:20 a.m., R1 fell in the dining room. Analysis indicated R1 had not slept well over the weekend, contacted hospice and requested nurse visit. Occurrence Report dated 5/29/26, indicated at 3:12 a.m., family observed resident fall (via camera in room). R1 got himself up off the floor. Second incident at 7:57 a.m., family again observed R1 on the floor via camera. Suggestions included management of bowel status and restlessness. R1's May 2026 Mar indicated he received the following medications. Buspirone 10 mg three times daily. As needed doses were administered 19 times. Hydromorphone 1 mg every four hours (six times daily) from 5/1/26 through 5/27/26. As needed doses were administered 12 times. Hydromorphone 1 mg five times daily from 5/27/26 through 5/31/26. Occurrence Report dated 6/1/26, indicated at 6:23 p.m., R1 was observed on the floor by family via video footage. Suggestions included staff to perform one to one. Progress Note dated 6/2/26 indicated that FM called around 12:15 a.m. and reported R1 had fallen at approx. 6:23 p.m. on 6/1/26. Occurrence Report dated 6/3/26, indicated at 12:00 a.m., R1 was observed on the floor. Suggestions included an increase in dose of anti-anxiety medication and one to one care. Progress Note dated 6/4/26, indicated orders from hospice. Increase Hydromorphone to every four hours (six times daily) and may also have every hour as needed. Start Seroquel 50 mg at bedtime and 25 mg every four hours as needed. During interview on 6/8/26 at 2:38 p.m., the consultant pharmacist (CP) stated concern for R1's medication included: dilaudid caused drowsiness and dizziness; seroquel caused increased hallucinations and agitation especially in the elderly and also caused dizziness and sleepiness; buspirone could also cause drowsiness. The CP said concerns with R1's medications included falls and the recently added Seroquel dose. During interview on 6/9/26 at 11:34 a.m., medical doctor (MD)-A stated R1 was at risk for falls. The dilaudid was started for hip pain, MD-A was not sure if it was scheduled or as needed but said it was not a medication he would use for pain management. MD-A did not remember what dose R1 was receiving and said, it was just his preference, but he would have used something else. During interview on 6/10/26 at 11:38 a.m., the assistant director of nursing (ADON) stated falls were discussed with the interdisciplinary team and during weekly fall meetings. The ADON said any discussion of high-risk medications contributing to falls done through the coordination with hospice and said they collaborated with them. The ADON said hospice had access to the medical record and could read the notes. The ADON said they always talked about medications and said they discussed the whole resident but said she did not document any medication review and/or adjustments as part of R1's falls discussions. Facility Unnecessary Medication Use policy dated March 2025, indicated residents receiving medications for an undocumented reason or without clear indication for the medication requires the facility to document if continuing the medication is justified by evaluating the condition, risks and existing medication regime. The medical record must reflect a rational for continued use of medications.

Based on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs and care plan to eliminate/reduce the risk of an accident during cares in bed for 1 of 3 residents (R111). This resulted in actual harm to R111 when staff repositioned R111 on her side with one staff member instead of two staff members per care plan, causing R111 to roll out of the bed to the floor. As a result, R111 was admitted to the hospital on [DATE] for a fracture of the right femur and a closed fracture of the left hip. R111 had surgery on 12/6/25 on the right femur and surgery on 12/11/25 on the left hip femur. The facility had implemented actions to prevent recurrence prior to the survey on 4/6/26, therefore, the citation was issued at past non-compliance.R111's quarterly Minimal Set Data (MDS) dated [DATE], identified R111 as cognitively intact. R111 was dependent on staff for toileting, rolling to the left and right in bed, and lower body dressing and needed maximal assistance with upper body dressing. R111 had a diagnosis including fractures and diabetes.R111's care plan was revised on 8/28/24, identified R111 needed two staff for sling management and when moving up in bed.R111's care sheet, dated 11/26/25, identified R111 needed two staff for dressing, bathing, and transferring.R111's physical therapy Discharge summary dated [DATE], identified R111 needed moderate to maximal assistance from two caregivers for rolling to the left and right sides in bed.R111's incident report dated 12/1/25 at 7:40 p.m., identified R111 was assisted into bed with a full mechanical lift and the assistance from nursing assistant (NA)-A and NA-B. NA-B left the room to help another resident, and NA-A rolled R111 to change her brief. R111 rolled to the right side and fell from bed. R111 landed on the floor on her back, arms at her side, legs bent towards herself. Resident denied being hurt at the time of the fall. No medical attention required at the time of the fall. Medical provider notified on 12/1/25 at 8:25 p.m., sister notified 12/1/25 at 9:00 p.m., administrator notified, no time identified. The short term intervention was education for NA-A and NA-B to always use two staff for bed mobility. A note was made on the incident report that the resident and family did not want to go to the emergency department for evaluation. The medical doctor later gave orders to have R111 sent to the emergency room for evaluation. The evaluation at the emergency room showed a left femur fracture. State authority notified on 12/3/25 once facility received notification of the fracture diagnosis. On 12/3/25, electromagnetic waves (X-ray) revealed new displaced comminuted intertrochanteric/ periprosthetic fracture of the proximal left femur (fracture top of thigh bone). In addition, the x-ray revealed a displaced fracture of the right distal femoral diaphysis and metaphysis (fracture of the thighbone above the knee joint).On 12/6/25, surgical report revealed R111 had an insertion retrograde intramedullary nail placed in the right femur (treatment for fractures of the femoral shaft).On 12/11/25, surgical report identified removal intramedullary nail from left knee with replacement of an antegrade nail (used to stabilize fractures while maintaining alignment and length) to the left hip femur.R111's treatment medical record (TAR) identified staff to monitor R111's right hip, thigh, and knee surgical incision for any signs or symptoms of complications, from 12/16/25 until 1/7/26. Progress note dated 12/1/25 at 10:29 p.m., identified R111 fell in room at 7:40 p.m., R111 rolled out of bed. No injury noted. Fax sent to medical provider.Progress note dated 12/2/25 at 4:45 a.m., identified R111 complained of pain in her legs when being moved.Progress note dated 12/2/25 at 10:02 a.m., identified R111 complained of pain all over, especially her right arm, right leg, and left hip. Bruise seen on the right inner knee and top of right foot just below the great toe. R111said the pain is not alleviated with oxycodone.Progress note dated 12/2/25 at 10:05 a.m., identified R111 wanted the x-ray done in the facility, did not want to be sent to the emergency department. Provider was updated on the request.Progress note dated 12/2/25 at 10:17 a.m., identified R111's sister was provided an update on the increased pain and R111's request to have x-ray completed in-house versus seeking emergency evaluation. Sister was in agreement.Progress note dated 12/2/25 at 9:42 p.m., identified fax was received from medical provider recommending R111 to be seen in the emergency department. R111 was given this information. R111 continued not to want to be seen in person. Brother was in the presence of this conversation with R111. This information was passed onto the medical provider.Progress note dated 12/3/25 at 9:56 a.m., identified R111 was sent to the emergency room due to pain in left hip and right foot and knee pain.Progress note dated 12/3/25 at 2:40 p.m., identified R11 would be transferring to Methodist Hospital.Progress note dated 12/13/25 at 2:16 p.m., identified R111 returned from the hospital.Bed assist device assessment completed 10/7/24 for grab bars. R111 was deemed appropriate for having grab bars attached to the upper portion of the bed. Bed assist device informed consent signed 12/18/25. Bed system device assessment completed 12/18/25, for grab bars, R111 was deemed appropriate for grab bars being attached to the upper portion of the bed.During an observation on 4/7/26 at 8:00 a.m., NA-C and NA-D went into R111's room and informed R111 that they were going to get her ready for her bath. NA-C went to the left side of R111's bed, and NA-D went to the right side of the bed. NA-C instructed R111 to roll to the right side of the bed. NA-C and NA-D assisted R111 to lie on her right side and applied the lift sling for the mechanical lift under R111. NA-D and NA-C then assisted R111 to roll to her left side. Each time R111 rolled onto her side, she held onto the grab bars. NA-D positioned the lift straps between legs. R111 did not complain of pain or show any signs of anxiety during the rolling in the bed. Staff hooked the sling to the mechanical lift and lifted R111 out of bed and onto a shower chair. The lift sling was removed from under and behind the resident. NA-C brought the resident into the shower. At 8:23 a.m., NA-C and NA-D placed a mechanical sling under R111 and transferred R111 from the shower chair to the bed and lowered R111 onto the bed. NA-D went to the right side of the bed and NA-C was on the left side of the bed when rolling R111 in bed per care plan.During an interview on 4/6/26 at 1:21 p.m., R111 verified she fell out of bed and was injured. R111 indicated two staff were in her room, and one of the staff who was by the window left the room to help another resident. R111 rolled over to her right side, reached for the side table, and fell onto the floor. R111 indicated she used the mechanical lift before the fall. R111 indicated she feels safe having NA-A and NA-B provide care, as the fall was an accident.During an interview on 4/6/26 at 7:50 p.m., NA-B verified she was working the night R111 fell. NA-B indicated that she and NA-A laid R111 in bed using the mechanical lift. It came over the walkie that someone needed assistance. NA-B indicated she was not aware R111 was a two-assist for bed mobility and verified she did not read the nursing assistant care sheet at the start of the shift on 12/1/26. NA-B indicated she left the room to assist another resident. NA-B indicated R111 was recently changed to a two assist, as R111 had been a one assist with bed mobility. NA-B verified after the fall, she received education on R111 being a two-assist, and the need to read the nursing assistant care sheet before the start of the shift. NA-B indicated the facility took the grab bars away before the fall and was unsure why, but R111 now has the grab bars back on the bed. NA-B indicated R111 needed assistance with care and was a mechanical lift before the fall, and the fall has not changed her mobility. NA-B indicated R111 had two fractures from the fall. NA-B indicated R111 had more anxiety with rolling in bed right after returning from the hospital, but is back to her baseline.During an interview on 4/6/26 at 7:55 p.m., NA-A indicated on 12/1/25, NA-B assisted with transferring R111 into bed with the mechanical lift. When they were changing R111's brief, a call light went off, and it sounded on their pagers. NA-B left the room to answer the call light. NA-A went to roll R111 to the right, and R111 reached out for the nightstand because there were no grab bars on the bed and R111 fell on the floor. NA-A indicated R111's grab bars were taken away a few weeks before the fall and were put back on the bed after R111 returned from the hospital. R111 had some leg pain after the fall. NA-A indicated she was called to the office and had to complete refresher classes on nursing assistant responsibilities before returning to work. Education was also given on following the nursing assistant care sheet.During an interview on 4/7/26 at 10:37 a.m., TMA-A indicated R111 was a two assist for bed mobility, which started when the grab bars were removed a few weeks prior to the fall on 12/1/25. When R111 was changed to a two-assist, the nursing assistant care sheets were updated. When a change is made on the nursing care sheets, the changes are highlighted and placed on the communication clipboard and also hung up in the nurses station. TMA-A verified that she received education regarding the importance of following the nursing assistant care sheets when providing care, and that education was given to staff after R111's fall. During an interview on 4/7/26 at 10:50 a.m., NA-C indicated R111 required two staff to turn in bed prior to the fall on 12/1/25. NA-C indicated a mock survey was done at the facility a few weeks before the fall, and the mock survey results showed R111 grab bars should be removed. When the grab bars were removed, R111 was changed to a two assist when rolling in bed. NA-C indicated the nursing assistant care sheets were updated. NA-C indicated when the nursing assistant care sheets were updated, the changes would be highlighted and hung up on the wall in the nurse station, and written on the communication clipboard alerting staff to the changes. NA-C indicated R111 had anxiety and pain before the fall on 12/1/25. NA-C indicated R111 had increased anxiety right after the fall, but had returned to baseline. R111 required three staff to assist with bed mobility after returning from the hospital, as she had two fractures and her legs were kept straight. NA-C indicated R111 did not have rods put in, but had a procedure on both legs after the fall. NA-C indicated R111 grab bars were replaced after the fall, which R111 uses, and the grab bar helps R111 feel safe when rolling in bed. NA-C verified she received education regarding the importance of checking and following resident care sheets to ensure residents receiving the care they need.During an interview on 4/7/26 at 9:02 a.m., registered nurse care coordinator (RNCC)-A indicated R111 fell out of bed on 12/1/25 around 7:40 p.m., when NA-A rolled R111 on the right side towards the window and reached for the nightstand and fell out of bed. R111 had her nightstand between the bed and the window. After the fall, the nurse performed range of motion (ROM) without issues, and blood pressure was measured when lying and sitting. At the time of the fall, R111 did not report any pain. The doctor was updated on the fall with no injury by fax. During the night, R111 had pain. Family and R111 did not want R111 sent to the emergency room and wanted an X-ray done in-house. The doctor was updated by fax on the pain and the family's decision not to be sent out of the facility. The doctor did not want to have the X-ray done in-house and wanted R111 to be seen at the emergency room. After ongoing pain, the family and R111 agreed to be sent in for X-rays on 12/3/36. The X-ray showed R111 had two fractures. R111 had grab bars removed on 11/18/25, which R111 would sporadically use to assist in bed mobility. The facility had a mock survey, and since R111 did not initiate the grab bars, it was decided by staff to remove the grab bars. After the fall, an assessment was done, and it was determined R111 could hold onto the grab bars once staff turned her, and the grab bars were replaced after the assessment.During an interview on 4/7/26 at 9:22 a.m., administrator indicated R111 was a two assist for bed mobility when the grab bars were removed from the bed on 11/18/25. The nursing assistant care sheet was changed to reflect R111 was a two assist for turning in bed. Administrator verified that the nursing assistant care sheet was not being followed when resident fell out of bed. NA-A and NA-B transferred R111 into the bed, and NA-B went to help another resident. NA-A rolled resident on the right side. R111 reached for the nightstand and pulled on the nightstand, and fell. An investigation was completed. All care staff received education following the nursing assistant care sheets. Residents were interviewed about the care they received and if they had any concerns. Audits were completed on the nursing assistant care sheets to ensure they were accurate. Audits were completed ensuring care was done according to the nursing assistant care sheets. Administrator's expectation would be for staff to follow the nursing assistant care sheets to prevent accidents and ensure the safety of staff and residents.During an interview on 4/7/26 at 10:31 a.m., director of nursing (DON) indicated R111's fall occurred when R111 was transferred into bed by NA-A and NA-B. R111 was a two assist for turning in bed at the time of the fall. NA-B left the room, and R111 was rolled to her side. R111 reached for the side table and fell to the floor. DON was unable to determine if having a second staff member present would have prevented the fall. DON verified R111 received two new fractures from the fall. DON verified the nursing assistant care sheet indicated two staff for bed mobility and the nursing care sheet was not followed at the time of the fall. DON verified that the staff called administration after the fall, and the staff was interviewed regarding the fall. Education was given to NA-A and NA-B and was removed from the schedule. Residents were interviewed regarding their care to ensure residents felt they were receiving the care they needed. All care staff were provided with education on the importance of following the nursing assistant care sheet. NA-A was provided with education in-house and received extra classes before returning to work. Audits were carried out to ensure nursing care sheets and care plans are updated when changes are received. Audits were done to ensure staff were following the care sheets.During an interview on 4/7/26 at 1:02 p.m., physical therapist (PT) indicated R111 was discharged from physical therapy on 9/30/25, with instructions for two staff members for bed mobility. PT indicated R111 had grab bars prior to a mock survey that was completed by presbyterian homes. The mock survey indicated the grab bars to be removed and R111 to be an assist of two with transfers and bed mobility. PT indicated R111 had a fall on 12/1/26. When R111 returned from the hospital, R111 received physical therapy three times a week. Occupational therapy (OT) saw R111 twice a week when R111 returned from the hospital, PT requested that the grab bars be reinstated on 12/17/26. PT changed R111 to an assist of three when turning in bed, two staff to assist with turning, and one staff member to assist with leg positioning. The assistance of three was discontinued on 1/20/26. PT stated they would expect staff to follow PT recommendations to ensure the safety of staff and residents.During an interview on 4/7/26 at 3:40 p.m., medical provider (MP) indicated she was aware of the fall on 12/1/26. MP indicated she was under the understanding that R111 was being rolled in bed for cares when the fall occurred. The facility sent a fax after the fall occurred, indicating no injury. Later that day, MP received a fax that R111 was having pain and requested the portable X-ray machine, as the family and R111 did not want to be seen outside of the facility. MD responded to facility that R111 needed to be seen, as without an assessment, MP-A would not know which joints or limbs would need to be x-rayed without an evaluation. The following day, MP-A was sent a third fax from the facility indicating R111 was refusing the in person evaluation. MP indicated she requested the facility to inform R111's sister that R111 needed to be evaluated in person for a trauma evaluation and the importance of having this evaluation. After the facility talked with the resident and sister, the facility then sent R111 to the emergency room. R111 had a new displaced fracture of the left femur and a right knee distal diaphysis and metaphysis. From the emergency room, R111 was sent to Regions Hospital in St. [NAME]. R111 was admitted later that night, around midnight on 1/4/26, and discharged on 1/13/26. The consultant orthopedic surgeon recommended what we call a palliative surgical repair to help R111 with pain and symptoms. On 12/6/26, a nail was placed into the right femur. On 12/11/26, a nail was placed into the left hip femur. MP-A was not aware that the staff was not following the care plan when R111 fell. MP-A indicated that two staff should have been providing care, but it would be speculative to say that having two staff would have prevented the fall. MP-A indicated R111 had anxiety and pain before the fall, which did increase after the fall, but R111's pain and anxiety have since returned to baseline.Verification of corrective action was confirmed by interview with facility staff and review of training documentation. The nursing assistant involved verified she was promptly re-educated on the importance of following the nursing assistant care sheets. Documentation showed the facility had developed, implemented, and completed a plan to ensure that any staff responsible for providing cares were trained. This was confirmed by review of training records and staff interview. Observation of care in bed observed and verified that staff were following the nursing assistant care sheets. Interviews were conducted with other residents in the neighborhood about the NA-A and NA-B performance, which indicated residents had no concerns with cares. Facility was able to demonstrate monitoring of the corrective action and sustained compliance.Review of policy titled Fall Prevention and Management Program Policy dated 1/26, identified, that upon admission, quarterly, annually and with significant change all residents will be assessed for their risk for falls. The Clinical Administrator is responsible for assuring implementation of this policy, for providing a safe environment, and for maintaining appropriate equipment in collaboration with facility equipment experts to aid in fall prevention. Clinical Coordinator or designee is responsible for implementation and oversight of individualized residents fall prevention care as follows: Assessing fall risk upon admission, quarterly, with significant change in condition. Determining risk for fall and establishing appropriate interventions in the care plan related to fall risk in the plan of care. Implementing the interventions specific to fall risk data collection. Supervising personnel in delivering safe and personalized care. Evaluating the effectiveness of interventions in relation to the resident specific plan of care. Collaborating with the interdisciplinary team in the prevention of falls. Appropriately managing residents who experience a fall by implementing interventions to prevent further falls. The facility will complete fall tracking with review every month. The information will be brought to the QAPI committee quarterly for review. A site and/or household root cause analysis will be completed by an interdisciplinary team. Action plans will be created as needed. The past noncompliance that began on 12/1/25. The deficient practice was corrected by 12/9/25, after the facility implemented a systemic plan that induced the following actions: immediate education on facility policy for all NA's and nurses to review the nursing assistant care sheet prior to the start of the shift. Interviews with staff on 4/6/26 and 4/7/26, confirmed understanding of reviewing the nursing assistant care sheet before the start of the shift for changes. Observation of transfers on 4/7/26 demonstrated compliance with transfers and bed mobility.

Based on interview and document review, the facility failed to report allegations of abuse to the state agency, immediately, but not later than 2 hours after the allegation is made, for one of three residents (R1) reviewed. R1 reported he was abused in his room multiple times during the night.Findings include: Minimum Data Set (MDS) dated [DATE] indicated R1 was admitted to the facility for treatment of osteoarthritis of the right knee. R1's relevant diagnoses included chronic pain, mild intellectual disability, anxiety, unspecified psychosis, and developmental disorders. R1 required substantial to maximal assistance with repositioning in bed. R1 used a wheelchair to ambulate. R1's Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had mild cognitive impairment. R1's care plan indicated he had a history of behavioral disturbances. R1's care plan indicated R1 experienced delusions and paranoid about people in his room intending to harm him. R1's care plan indicated R1 was at risk for abuse and had a history of making allegations against staff. R1's care plan indicated staff were to implement the buddy care system for all care tasks and during overnight cares. R1's care plan instructed staff to report any further concerns to the campus administrator for allegations. R1's care plan indicated staff should follow the facility vulnerable adult policy. A progress note dated 7/21/25 at 8:31 p.m. indicated R1 informed staff an unknown woman hit him on the top of his head. A progress note dated 9/23/25 at 9:22 p.m. indicated R1 informed staff someone had struck him on the head the previous night at about 1:00 a.m. A social services note dated 9/24/25 at 3:19 p.m. indicated social services staff followed up with R1 regarding his allegations of being struck on the head. The note indicated R1 had a history of paranoia, delusions, and conflict with others. A progress note dated 10/15/25 at 10:06 p.m. indicated R1 reported to staff that someone had been touching him down there, and staff reassured him because they use the buddy system for his cares, this could not have happened. During an interview on 10/28/25 at 1:08 p.m., trained medication aide (TMA)-A stated if a resident tells her they had experienced any abuse in the facility, she will inform the nurse so they can document it and follow the chain of command. During an interview on 10/28/25 at 1:14 p.m., registered nurse (RN)-A stated when residents report allegations of abuse, she must report it to the on-call administrator right away. RN-A stated when R1 makes an allegation of abuse, they must document it in the chart, then leave a voice mail for the clinical coordinator. RN-A stated if what R1 claims is serious, they should then call the administrator as well. RN-A stated R1 had not made any allegations of abuse to her. During an interview on 10/28/25 at 1:22 p.m., R1 stated he did not have any concerns with the care at the facility. During an interview on 10/28/25 at 1:39 p.m., TMA-B stated if a resident alleges any type of abuse, tell the charge nurse and the administrator as soon as they mention it. TMA-B stated R1 had never mentioned any type of abuse in the facility to her, and if he did, she would tell the nurse and the administrator immediately. During an interview on 10/28/25 at 2:08 p.m., TMA-C stated if a resident alleges abuse, they will use her walkie talkie device to notify the charge nurse right away. TMA-C stated this information would then go to the supervisor. During an interview on 10/28/25 at 3:00 p.m., RN-B stated if a resident reported abuse to her, she would notify the administrator right away. RN-B stated R1 told her on 10/15/25 someone was touching him down there in his private parts and abusing him. RN-B stated she then notified the clinical coordinator about R1's allegations. During an interview on 10/28/25 at 3:02 p.m., the household coordinator stated when she receives allegations of abuse, she tells the supervisor right away. The household coordinator stated because R1 has such a long history of making allegations against staff, they do not report all R1's allegations to the state agency, otherwise they would be reporting quite frequently. During an interview on 10/28/25 at 3:22 p.m., the clinical coordinator stated he contacts the director of nursing as soon as there is an allegation made and will begin investigating if he is in the building. The clinical administrator stated he investigates by speaking with the resident and any other staff present during the time of the alleged incident. The clinical administrator stated he then brings the information to the administrator who makes the report to the state agency. During an interview on 10/28/25 at 3:41 p.m., the assistant clinical administrator stated if a resident alleges abuse, they use two staff to enter the room and complete assessment to determine if the abuse was physically possible. The assistant clinical coordinator stated if they believe the allegation may have occurred, they report it to the administrator of the director of nursing. During an interview on 10/28/25 at 3:53 p.m., the administrator stated if nursing staff are expected to notify the director or nursing or himself if appropriate. The administrator stated allegations of abuse that would need to be reported to him are allegations of physical abuse, residents being yelled at, or residents being sexually abused. The administrator stated he then takes these allegations and vets them further based on the resident's plan of care and history making abuse allegations. The administrator stated if this is the resident's first instance of an abuse allegation, the administrative team would complete an investigation. The administrator stated if a resident reported sexual abuse, reporting would depend on their history and if the resident could recall specific details. The administrator stated if the resident has a known history of abuse allegations, the nurse will evaluate and determine if the situation possibly occurred. The administrator stated they need to report allegations of abuse if the resident's care plan was not followed, but if it was followed, the allegations are not reportable. The administrator stated there is a two-hour window for reporting to the state if the allegations pose risk for immediate harm to the resident. A facility policy titled Vulnerable Adult Abuse Prevention Plan, dated October 2025, the policy indicated the facility administrator, or designee will make a report according to federal and state requirements. The policy indicated allegations of abuse must be made within two hours after the allegation is made.

Based on interview and document review, the facility failed to conduct a formal investigation into the allegations of physical and sexual abuse for one of three residents reviewed (R1) for abuse.Findings include: Minimum Data Set (MDS) dated [DATE] indicated R1 was admitted to the facility for treatment of osteoarthritis of the right knee. R1's relevant diagnoses included chronic pain, mild intellectual disability, anxiety, unspecified psychosis, and developmental disorders. R1 required substantial to maximal assistance with repositioning in bed. R1 used a wheelchair to ambulate. R1's Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had mild cognitive impairment. R1's care plan indicated he had a history of behavioral disturbances. R1's care plan indicated R1 experienced delusions and paranoid about people in his room intending to harm him. R1's care plan indicated R1 was at risk for abuse and had a history of making allegations against staff. R1's care plan indicated staff were to implement the buddy care system for all care tasks and during overnight cares. R1's care plan instructed staff to report any further concerns to the campus administrator for allegations. R1's care plan indicated staff should follow the facility vulnerable adult policy. A progress note dated 7/21/25 at 8:31 p.m. indicated R1 informed staff an unknown woman hit him on the top of his head. A progress note dated 9/23/25 at 9:22 p.m. indicated R1 informed staff someone had struck him on the head the previous night at about 1:00 a.m. A social services note dated 924/25 at 3:19 p.m. indicated social services staff followed up with R1 regarding his allegations of being struck on the head. The note indicated R1 had a history of paranoia, delusions, and conflict with others. A progress note dated 10/15/25 at 10:06 p.m. indicated R1 reported to staff that someone had been touching him down there, and staff reassured him because they use the buddy system for his cares, this could not have happened. During an interview on 10/28/25 at 1:14 p.m., registered nurse (RN)-A stated when residents report allegations of abuse, she must report it to the on-call administrator right away. RN-A stated when R1 makes an allegation of abuse, they must document it in the chart, then leave a voice mail for the clinical coordinator. RN-A stated if what R1 claims is serious, they should then call the administrator as well. During an interview on 10/28/25 at 3:00 p.m., RN-B stated if a resident reported abuse to her, she would notify the administrator right away. RN-B stated R1 told her on 10/15/25 someone was touching him down there in his private parts and abusing him. RN-B stated she then notified the clinical coordinator about R1's allegations. During an interview on 10/28/25 at 3:02 p.m., the household coordinator stated when she receives allegations of abuse, she tells the supervisor right away. The household coordinator stated her investigation would depend on what the administrator tells her to do next. The household coordinator stated after the allegations, she educated R1 to tell staff about his concerns immediately, rather than waiting multiple hours or days prior to notifying staff. During an interview on 10/28/25 at 3:22 p.m., the clinical coordinator stated he contacts the director of nursing as soon as there is an allegation made and will begin investigating if he is in the building. The clinical administrator stated he investigates by making a timeline of events, looking at the psychiatric diagnoses of the residents making the allegation, and determining if they have a past history of abuse allegations. The clinical administrator stated he when he spoke with R1 following his allegations on 10/15/25, R1 was unable to give a consistent account of what the alleged perpetrators looked like. During an interview on 10/28/25 at 3:53 p.m., the administrator stated if nursing staff are expected to notify the director or nursing or himself if appropriate. The administrator stated he then takes these allegations and vets them further based on the resident's plan of care and history making abuse allegations. The administrator stated if this is the resident's first instance of an abuse allegation, the administrative team would complete an investigation. The administrator stated if the resident has a known history of abuse allegations, the nurse will evaluate and determine if the situation possibly occurred. The administrator stated investigations are mostly managed by himself or the director of nursing, however he was not available when R1 made allegations to staff on 10/15/25, and the concern would have been brought to the interdisciplinary team. The administrator stated the interdisciplinary team determined because R1 had a history of making allegations, there were no residents who would have wandered into R1's room, and they had buddy care in place on his care plan, a formal investigation was not necessary. A facility policy titled Vulnerable Adult Abuse Prevention Plan, dated October 2025 indicated the facility must review of each allegation. The policy indicated internal investigations should contain an Investigation Form and Staff Interviews document. The policy indicated the administrator, or designee will complete a full review of investigative documentation to determine if trends exist.

Based on interview and document review, the facility failed to ensure medications were administered according to physician orders for 1 of 3 residents (R1) reviewed for significant medication errors. This failure resulted in actual harm when R1 did not receive twelve doses of a medication for treatment of congestive heart failure and subsequently required a two-day hospitalization. The facility implemented appropriate corrective action prior to the onsite investigation; therefore, the deficiency is being cited at past non-compliance. Findings include:R1's admission Minimum Data Set, dated [DATE], identified diagnoses of congestive heart failure (CHF) and renal insufficiency, R1 used diuretic medications (helps the body get rid of excess water).R1's care plan initiated 8/5/25, indicated R1 had an alteration in cardiovascular status related to atrial fibrillation (irregular heartbeat), CHF, and high blood pressure with a goal to receive medication per physician orders. Interventions included to observe for electrolyte imbalance which may include weak pulse, changes in cognition, changes in blood pressure.R1's Order Summary Report, with active orders, dated 9/1/25, directed staff to administer one Bumex three milligram (mg) tablet to R1 two times a day related to chronic diastolic (congestive) heart failure and four potassium chloride ten milliequivalents (MEQ) tablets two times a day for hypokalemia (low potassium).R1's September 2025 Medication Administration Record (MAR) identified an order was entered on 7/28/25, for Bumex oral tablet and directed to give 3 mg by mouth two times a day related to chronic diastolic (congestive) heart failure. The Bumex was scheduled daily at morning and at noon. The MAR revealed that the facility did not administer Bumex to R1 starting with the noon dose (second dose) on 9/10/25 continuing until the 9/16/25 noon dose due to the medication not being available. R1 missed 13 doses of Bumex. The facility continued to administer the potassium as ordered by the physician.According to Mayoclinic.org, Bumex is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. The medicine may cause you to lose more potassium from your body than normal. Your doctor would monitor the potassium in your blood while you are on this medicine.According to the American Heart Association, www.heart.org, hyperkalemia is defined as too much potassium in your blood. Severe cases can cause abnormal heart rhythms and need emergency treatment.R1's progress notes identified the following:9/11/25 at 9:27 a.m., there was no supply of Bumex and would call pharmacy.9/12/25 at 9:17 a.m., Bumex not available.9/14/25 at 1:32 a.m., R1 complains of SOB (shortness of breath), feeling nauseated, restlessness, confusion, and agitation.9/14/25 at 3:04 a.m., R1 complaining of feeling short of breath, feeling nauseous, noted to have mild expiratory wheezes, and using accessory muscles upon return to bed. Charge nurse updated on resident condition.9/14/25 at 7:45 a.m., R1 complaining that she could not breath and requesting to see a doctor R1 appeared very anxious. Supplemental oxygen was applied to R1 and seemed to help. R1's family member was notified.9/14/25, at 11:47 a.m., Bumex not available.9/15/25 at 10:40 a.m., physician notified and indicated R1 needed evaluation in urgent care or ER (emergency room). R1's family declined transfer at that time and will notify of any changes.9/15/25 at 12:28 p.m., physician requested facility's rounding physician evaluate R1 on 9/16/25.9/16/25 at 2:49 a.m., R1 was exhibiting increased confusion, weakness, and muscle movement while asleep. R1 was not at previous baseline and would be seen that day by a physician.9/16/25 at 6:48 a.m., Bumex not available-follow up pharmacy and nurse notified.9/16/25 at 1:23 p.m., physician saw R1 regarding weight increase and increased SOB. New orders to give Bumex 3 mg today when it arrives then continue BID (twice daily) dosing. Labs ordered.9/16/25 at 4:25 p.m., physician order note lab results received. On-call physician notified of critical potassium level and advised to send to ER. Faxed to primary physician.9/16/25 at 5:10 p.m., telephone order received by physician to send to the ER.R1's progress note lacked evidence the physician was notified of the unavailability of Bumex for administration to R1 until 9/16/25.R1's Lab Communication dated 9/16/25 at 5:58 p.m., identified R1 had a critical high potassium level of 7.4 mmol/L (Ref. (reference) range: 3.5 -5.1.R1's Physician Order dated 9/16/25, ordered to send R1 to the ER due to critical K (potassium) level of 7.4 today.R1's Hospital Progress Note dated 9/18/25 at 8:41 a.m., identified R1 was admitted for acute and chronic CHF and hyperkalemia. R1 had not received her Bumex dose for the last five (5) days; however, had received her potassium as ordered. Acute hyperkalemia management on admission. Required fluid bolus of 500 cc's (cubic centimeters) the first night for somnolence (abnormal drowsiness) and hypotension (low blood pressure).R1's Hospital Discharge Summary indicated R1 had a ten-pound weight gain over the past month and was having issues with shortness of breath (SOB). [R1] was seen by clinician at the facility and medication review found [R1] had missed her Bumex dose the past five days due to a pharmacy issue but was still getting her increased dose of potassium. R1 was admitted for management of CHF thought secondary to her not receiving Bumex for last five days prior to hospital admission.During an interview on 10/14/25 at 1:08 p.m., family member (FM)-A indicated the facility did inform FM-A that R1 did not receive one of her medications for a week. FM-A thought R1's was just displaying anxiety symptoms. If FM-A would have known that R1 was not receiving that medication she would have had R1 seen by a physician earlier.During an interview on 10/14/25 at 1:43 p.m., trained medication assistant (TMA)-B indicated she discovered the Bumex for R1 was not in the med cart, made a note in R1's chart, told the nurse, finished the med pass, filled out a reorder form, and sent it to the pharmacy. TMA-B stated she later followed up with the pharmacy and was told that it had been sent but later found out it had not been sent. TMA-B did not know if any more follow up was done. During an interview on 10/14/25 at 1:55 p.m. p.m., TMA-C stated she worked two of the days that the Bumex was not available but let the nurses know. TMA-C could not recall what nurse she reported to.During an interview on 10/15/25 at 10:17 a.m., TMA-A indicated when she worked on 9/11/25, she was unable to locate R1's Bumex but knew the pharmacy had been faxed. TMA-A stated she reported it to licensed practical nurse (LPN)-A but did not know what was done after that. TMA-A stated she meant to call the pharmacy to check on the Bumex, but the shift got crazy and did not get them called. During an interview on 10/15/25 at 2:04 p.m., registered nurse (RN)-A stated when she noted R1's Bumex was not available for administration, RN-A checked the backup storage and the pharmacy reorder sheet and noted it was reordered. RN-A then stated, my downfall was that I did not follow facility protocol. RN-A identified the facility protocol was to check all the backup storage, call the pharmacy, notify the clinical coordinator, and then notify the physician.During an interview on 10/15/25 at 2:15 p.m., TMA-D stated R1's Bumex was not available, and she checked the backup cupboard and charted not available. TMA-D stated she noticed other staff had the same problem but did not notify the charge nurse, look at the pharmacy order sheet, or call the pharmacy.During an interview on 10/15/25 at 11:05 a.m., RN-B indicated the rounding physician evaluated R1 on 9/16/25 and was reviewing the medication administration record (MAR) and identified R1 had missed twelve doses of Bumex. The physician ordered labs and a dose of Bumex to be given when it arrived.During an interview on 10/15/25 at 10:39 a.m., registered nurse care coordinator (RNCC) indicated he was not notified R1's Bumex was not available until 9/16/25. RNCC identified it was the TMA's responsibility to monitor the resident medication supply and reorder. When a medication was not available the expectation was staff notify the pharmacy, notify the floor nurse and the floor nurse would follow up on it. If the medication was still not available, the floor nurse should be calling the RNCC on call. RNCC further stated R1's hospitalization was due to the omission of the Bumex.During an interview on 10/15/25 at 11:30 a.m., the director of nursing (DON) identified she was not aware of the significant medication error until R1's hospitalization on 9/16/25. The DON also stated the facility had a protocol for an unavailable medication and it was not followed. It was the DON's expectation that TMA's and nurses follow the facility protocol.The following facility's corrective actions dated 9/20/25 were verified as implemented prior to the survey: -The facility completed a thorough investigation that identified the Medication Administration Policy was not followed and provided coaching and corrective action to staff involved.-Notified the medical director.- Conducted medication administration audits on all residents for medications marked unavailable and followed up on their findings. Continued weekly audits. -Provided education to all staff on the facility Medication Administration Policy and Procedure with emphasis on directions to follow if a resident medication is unavailable. Also, conducted random audits of staff knowledge of steps to take if a medication is not available.-Created laminated instruction cards for all medication carts. A facility policy, Medication Administration Policy last modified May 2021, identified it was the policy to ensure safe, effective, and timely drug therapy, to provide for an accurate and concise documentation system. RN's LPN's and TMAs would administer medication as ordered by the attending physician/NP (nurse practitioner). Medications will be prepared and administered as near the scheduled times as possible. If a medication is not available, the emergency kit may be used according to policy.The facility Medication Administration Error Policy last modified May 2021, defined a significant medication error as on which causes the resident discomfort or jeopardizes his or health or safety. A medication error occurs when a prescribed medication is not available to be administered. If the above errors occur, the following action is taken: the employee who discovers the error must assess resident for any adverse effect and if needed contact emergency services; notify provider (MD/NP); notify the charge nurse, clinical administrator and or on-call nurse; notify resident representative; document in medical record.

Based on interview and document review, the facility failed to create a comprehensive care plan for a resident with a history of respiratory conditions for 1 of 1 residents (R102) reviewed for care plans. Findings include: R102's Medicare 5-day Minimum Data Set (MDS) dated [DATE], indicated R102 cognitive impairment could not be decided. Diagnoses included pneumonia and respiratory failure. R102's comprehensive care plan undated, lacked a patient specific care plan or interventions related to R102's history of pneumonia and respiratory failure. During an interview on 2/20/25 at 1:16 p.m., registered nurse (RN)-B stated the care plan was updated either when there was a change in the resident's condition or when a new MDS assessment performed. RN-B reviewed R102's MDS and 5-day care plan. She acknowledged the respiratory conditions listed in the MDS but were not found on the care plan. RN-B stated the care plan should have been updated with a respiratory care plan, goals, and interventions when the MDS was updated on 1/22/25. During an interview on 2/20/25 at 1:43 p.m. the director of nursing (DON) stated an expectation the care plan would be filled out as appropriate based on resident needs. Facility policy Care Plan Policy and Procedure last modified 11/22, indicated the care plan would be reviewed at least with each MDS assessment period and with any significant change. The care plan would be changed and updated as the care changes for the resident and as the resident changes occurred. The care plan was to be current at all times.

Based on observation, interview and document review facility failed to provide activities of daily living (ADL) assistance for 1 of 1 resident (R38) who required assistance with eating. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R38's diagnoses included progressive neurological conditions, seizure disorder/epilepsy, bipolar disorder and other drug induced secondary parkinsonism. MDS did not indicate R38 exhibited any behaviors. R38's care plan dated 12/16/23, identified R.8 required assistance of 1 for eating due to extensive tremors. During observation on 2/18/25, at 5:19 p.m., R38 was seated at dining room table with two other residents. Staff served the other two residents their plates, who started eating, R38 sat there watching the other residents eat. At 5:25 p.m., R38 continued watching other two resident eat. At 5:28 p.m., staff brought R38's plate to table and sat down and started to assist R38 with eating. R38 ate food when staff assisted. During observation on 2/19/25, at 5:21 p.m., R38 was seated at dining room table with two other residents. Staff served the other two residents their plates, who started eating, R38 sat watching the other residents eat. At 5:33 p.m., staff brought a bowl of soup and a plate of food and set it down in front of R28. At 5:34 p.m., staff sat down and started to assist R38 with eating. R38 ate food when staff assisted. During interview on 2/20/24 at 2:54 p.m. nursing assistant (NA)-C stated R38 needed staff assistance with eating. NA-C stated they would serve the independent residents first and then would serve the residents who needed assistance eating. During interview on 2/20/25 at 3:01 p.m., director of nursing (DON) and administrator stated residents who require assistance with eating are served last as they need staff to assist them with eating. DON stated it would be important for all residents who are seated at the same table to eat at the same time for a more pleasurable dining experience and also for the resident's dignity. During interview on 2/20/25 at 3:22 p.m., director of nursing (DON) and administrator stated they spoke with dietary who confirmed R38 was served at the end due to him needing assistance with eating. The facility Dining Room Protocol policy, dated 1/13, indicated staff will participate in the delivery of meal service. Staff to provide dignified, prompt meal service. After all residents are served, proceed to assigned tables to provide eating assistance, as indicated or as appropriate.

Based on observation, interview and document review, the facility failed to follow provider orders for a resident on mild thickened liquids for 1 of 2 residents (R102) reviewed for diet changes. Findings include: R102's Medicare 5-day Minimum Data Set (MDS) dated [DATE], indicated R102 cognitive impairment could not be decided. Diagnoses included pneumonia and respiratory failure. R102's Order Summary Report dated 1/16/25 indicated R102 had an active diet order for level 6 soft and bite sized texture with mild thick consistency liquids. R102's care plan revised on 12/29/24, indicated R102 had a nutritional problem and diet was to be served as ordered. R102's therapy interdepartmental team (IDT) communication dated 2/3/25, indicated nursing and dietary was notified by speech therapy (ST) R102 was on mild thick liquids. Facility care sheets undated, indicated R102 was suppose to have mild thickened liquids. On 2/19/25 at 2:47 p.m., R102 was observed with a plastic glass half full of non-thickened water that was drank from and then placed on the over table cart. Next to the plastic cup was a large gray mug with a lid on it. During an interview on 2/19/25 at 2:52 p.m. nurse assistant (NA)-D stated floor staff were aware of resident specific diets based on the facility care sheets that are reviewed every shift. The facility care sheet was reviewed and confirmed R102 needed mild thickened liquids. NA-D entered R102's room and confirmed the water in the plastic cup and in the large gray mug was unthickened water and should have been thickened prior to it being given to resident. NA-D then removed the glass and mug of water. NA-D had also been notified that R102 had been observed taking a drink out of the plastic cup. During an interview on 2/19/25 at 2:58 p.m., the speech language pathologist (ST) stated R102 had been placed on mild thickened liquids as of 2/3/25 because R102 showed increased high risk signs of aspiration when R102 drank thin liquids. During an interview on 2/20/25 at 1:16 p.m. registered nurse (RN)-B stated the care plan and the facility care sheets that the NA's use every day to guide resident care are updated when changes occurred. During an interview on 02/20/25 at 1:43 p.m., the director of nursing (DON) stated staff should follow the prescribed diet orders from the provider or ST to protect the resident from adverse effects. The facility policy Diet Policy last revised 3/23 indicated thickened liquids may be recommended for residents with swallowing difficulty to decrease the risk of chocking or coughing on liquids. All liquids would be thickened to appropriate consistency before served.

Based on observation, interview and document review, the facility failed to ensure medication carts were properly secured for 4 of 8 medication carts observed. Findings Include: On 1/8/24, at 8:50 a.m. during medication observation trained medication aide (TMA)-A stepped away from medication cart, entered nursing office out of view of medication (med) cart with lock button observed to be in extended position. TMA-A returned to cart, continued with medication administration When interviewed on 1/8/24, at 9:03 a.m. TMA-A stated when lock button in extended position the medication cart was unlocked. TMA-A demonstrated entering code into touchpad on top surface of cart locked med cart by pulling lock button into cart. TMA-A then re-entered code demonstarting lock button extended out from cart then opening drawer demonstrating med cart was unlocked. On 1/8/24, at 9:04 a.m. observed TMA-A step away from med cart with lock button extended out. TMA-A went into nurse office dropped blood pressure machine into office, then assisted a resident around the [NAME] from the [NAME] cart, TMA-A was out of view of med cart On 1/8/24, at 9:07 a.m. TMA-A returned to med cart, TMA-A stated when walking away from med cart they should try to remeber to lock med cart so nobody could open the cart and remove items. TMA-A further stated the med cart would self lock, first beeping several times, but was unsure how long cart remaind unlocked prior to self locking. On 1/9/24, at 2:50 p.m. TMA-B was observed to walk away from med cart, lock button in outward position. When interviewed TMA-B stated the medication cart self locked, stated about 30 seconds but was not sure how long until med cart self-locked. On 1/9/24, 2:56 p.m. observed med cart outside of nurse office, no staff around. Med cart beeped loudly several times then self locked. On 1/9/24, at 2:58 p.m. licensed practical nurse (LPN)-A was observed to walk away from med cart with lock button in outward position. When interviewed LPN-A stated when she walked away the med cart should have been locked to keep people from opening the cart. LPN-A stated unsure how long med cart remained unlocked before it would self lock, the med cart was newer and they had not timed how long the cart remaind unlocked. On 1/9/24, at 3:27 p.m. LPN-B was observed to walk down the hallway with med cart unlocked. When interviewed LPN-B stated the cart locked itself but was unsure of how long the cart remained unlocked before locking itself. LPN-B stated the cart should be locked, don't want anobody to get into the cart. When interviewed on 1/9/24, at 3:46 p.m. director of nursing stated the med carts stay unlocked for 5 minutes and 13 seconds. The time the cart is unlocked is a factory preset, staff were trained to lock immediately. Undated Medication Ordering and Receiving Policy identified medications and biologicals are stored safely, securely and properly, following manufacturers recommendations or those of the supplier.

Based on interview and document review, the facility failed to ensure 3 of the 5 residents (R16, R63, R89) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R16's face sheet, dated 1/9/2024, indicated she was [AGE] years old. The immunization record, dated 1/5/2024, indicated she received a PPSV23 on 9/25/2018 and a PCV13 on 8/26/2015. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R16 was offered or received PCV20. R63's face sheet, dated 1/8/2024, indicated he was [AGE] years old. The immunization record, dated 1/8/2024, indicated he received a PPSV23 on 1/1/1998, a PPSV23 on 12/18/2013 and a PCV13 on 11/25//2015. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R63 was offered or received PCV20. R89's face sheet, dated 1/9/2024, indicated he was [AGE] years old. The immunization record, dated 1/8/2024, indicated he received a PPSV23 on 7/11/1997, a PPSV23 on 3/18/2009 and a PCV13 on 1/15/2016. The record indicated R89 was provided education and consented to receiving a PCV20 on 12/6/23 but had not yet received it. During an interview with infection preventionist (IP), on 1/9/2024 at 10:27 a.m., IP indicated immunizations are verified upon admission through MIIC (Minnesota Immunization Information Connection). IP stated vaccine education is done with residents and families at council meetings. IP stated IP would ask residents and/or their families if immunizations were desired and consents were obtained if immunizations were needed. IP stated if a resident consents to a vaccine an order would then be obtained from the provider, and it could be administered in the facility. IP verified R16's, R63's, and R89's pneumococcal immunizations as listed above. IP stated the facility policies were followed to determine resident eligibility for all vaccines. IP verified R16 and R63 had not been offered or provided education on PCV20. IP verified R89 had been offered, provided education, and consented to the PCV20 on 12/6/23, but had not yet received it. IP verified there had been no shared clinical decision making with the resident providers regarding pneumococcal immunizations for R16, R63 and R89. The plan to educate and obtain consents for the PCV20 had recently been implemented six to eight weeks ago for new admits only and a process to determine eligibility, educate and obtain consents for all other residents had not yet been started. IP indicated residents and families were recently informed through a facility Winter 2024 newsletter that a process for reviewing current guidance and eligibility for pneumococcal vaccinations was coming and residents and families would be contacted. A facility policy titled Pneumococcal Vaccination dated July 2023 identified, residents should be vaccinated in accordance with the CDC's pneumococcal vaccine recommendations.

Based on interview, and record review, the facility failed to ensure a resident with [CONDITION(S)] medications was monitored for side effects, adverse reactions of the medications, and/or behaviors for 1 of 5 residents (R83) reviewed for unnecessary medications. Findings include: R83's Face Sheet, indicated admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R83's Physician Orders, dated 3/29/22 indicated: -[MEDICATION(S)] ([MEDICATION(S)]) 5 milligrams (mg). The directions were to give one tablet by mouth two times a day for anxiety. -[MEDICATION(S)] ([MEDICATION(S)])7.5 mg by mouth at bedtime for [CONDITION(S)] and depression. -[MEDICATION(S)] ([MEDICATION(S)]) tablet 5 mg. and to give by mouth one time a day for agitation, hallucinations, and restlessness. R83's Care plan, dated 3/24/22, indicated: -I use an antidepressant medication and administer my medication as ordered. Monitor/document for side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, [CONDITION(S)], and [CONDITION(S)]. -I use an anti-anxiety medication and administer my medication as ordered. Monitor/document for side effects and effectiveness. Anti-anxiety side effects: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation. -I use an antipsychotic medication related to Alzheimer's Disease, wandering behavior and restlessness and monitor/document/report to my physician as needed in regards to side effects and adverse reactions of anti-psychotic medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R83's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/22 at 9:24 AM, the Clinical Administrator confirmed the [CONDITION(S)] medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were not being monitored for R83 after they were prescribed by the physician. R83 was not being monitored for the side effects or adverse reactions to the [CONDITION(S)] medications ordered and/or the behaviors of the resident. Review of the facility policy titled [CONDITION(S)] and Unnecessary Medication Use Policy, reviewed September 2021, revealed the procedure for initiation of [CONDITION(S)] medication use included initiation of monitoring for targeted behaviors and side effects.

Based on observation, interview, and document review, the facility failed to ensure staff utilized proper infection control practices to prevent and control the transmission of a highly infectious spore forming bacterium (Clostridium Difficile, otherwise know as[DIAGNOSES REDACTED]) when caring for 1 of 1 residents (R19) who had a known case of this bacterium. The facility's lack of infection control precautions observed by nursing and housekeeping staff, resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury or death for the other 69 residents who resided on the facility's second floor of the facility. The facility's lack of infection control precautions observed by nursing and housekeeping staff, had the potential to affect 11 residents (R49, R80, R99, R16, R100, R205, R81, R82, R123, R37, R47) on the second floor, who were currently or had recently received antibiotics placing them at higher risk of contracting[DIAGNOSES REDACTED] infection. In addition, there were 4 residents (R20, R49, R80 and R111) on the second floor, received daily to four times per day blood glucose checks with a shared glucometer that was not cleaned with proper disinfectant to kill[DIAGNOSES REDACTED] infections. The Immediate Jeopardy (IJ) began on [DATE], when R19 was diagnosed with [REDACTED]. The administrator and director of nursing (DON) were notified of the IJ situation on [DATE], at 4:29 p.m. The IJ was removed on [DATE], at 3:03 p.m., but non-compliance remained at the lower scope and severity of (E) pattern with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: R19's admission record and Face Sheet, identified R19 was admitted to the facility in [DATE]. The Face Sheet, undated, identified admitting [DIAGNOSES REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) on the left buttock. The Face Sheet further indicated a secondary [DIAGNOSES REDACTED]. R19's significant change Minimum Data Set (MDS) and associated Care Area Assessment (CAA), dated [DATE], indicated a mild cognitive deficit. The CAA further identified limited mobility and a recent hospitalization , requiring increased staff assistance with cares, needing two plus staff for toileting, and was working with physical and occupational therapies. Further review of R19's medical record identified the following: R19's Medication Administration Record (MAR) indicated she took Align Capsule (a [MEDICATION NAME]) every morning since [DATE], for, Bowel management related Entercolitis Due To Clostridium Difficile. According to R19's progress notes, R19 was administered as needed [MEDICATION NAME] Suspension (antidiarrheal medication) on [DATE], at 3:15 a.m. and 5:09 a.m. with the indication for Loose stools. The notes further indicated R19 had a history of [REDACTED]. BM at 4:18 p.m. and the culture sample was sent. On [DATE], at 9:31 a.m. R19's stool sample was positive for[DIAGNOSES REDACTED], and a [MEDICATION NAME] precautions hangar (specific precautions used with infections spread through feces, like[DIAGNOSES REDACTED], for which alcohol based hand sanitizers are not effective) was placed on R19's room door. The notes further identified R19's medical doctor (MD)-A had been faxed with the results and for orders. A telephone order, dated [DATE], indicated R19 was prescribed [MEDICATION NAME] (antibiotic) three times a day and [MEDICATION NAME] (a [MEDICATION NAME]) four times a day for[DIAGNOSES REDACTED]. R19's progress notes indicated she continued to have loose stools, noting on [DATE], at 1:59 a.m. R19 had a smear of blood from anus after wiping; and R19's current MAR confirmed she continued to take [MEDICATION NAME] medication for[DIAGNOSES REDACTED]. R19's current care plan, last reviewed [DATE], identified an active[DIAGNOSES REDACTED] infection and further noted R19 was continent of bowel, but wore a brief to contain loose stools from an active[DIAGNOSES REDACTED] infection. The care plan directed R19 needed setup assistance with her walker for toileting, and to cleanse high-touch areas PRN (as needed). The care plan contained interventions which included administering medications, monitoring symptoms of infections, vitals signs, and to update R19's physician. R19's care plan was revised on [DATE], to include visitor, resident, and family education on contact precautions, and wipe down high touch surfaces using bleach wipes. During initial tour on [DATE], at 1:58 p.m. a sign was observed posted on R19's room door, identifying R19 was on [MEDICATION NAME] Precautions, with a diagram of protective personal equipment (PPE) to wear, which included gown and gloves. In addition, an isolation hanger was hanging over R19's room door. Gowns were in R19's isolation hanger; however, no disinfecting bleach wipes were observed in the isolation hanger. During observation on [DATE], at 8:20 a.m. the door to R19's room was opened, and trained medication assistant (TMA)-B was standing directly inside R19's room. On the outside of R19's opened door were hanging bins that held gowns, gloves, and signage that read: [MEDICATION NAME] Precautions- Stop- check with nurse before entering. The signage read, perform hand hygiene with either hand sanitizer or washing their hands prior to donning gloves. Visitors, staff, and physicians were to always wear a gown, and staff were to disinfect equipment with bleach wipes between resident use for multi-use equipment. Housekeeping was to terminally clean the room with bleach. Visitors, staff, and physicians were to have always washed their hands each time they left the room. During this time TMA-B was taking R19's blood pressure (BP) with an automated BP machine and administering medication to R19. TMA-B was not wearing any PPE (personal protective equipment such as gowns and gloves). Once TMA-B had finished her tasks, she pushed the automatic BP machine into the hallway, without first disinfecting the machine or cuff. TMA-B did not have any gloves or nor did she wash her hands before leaving R19's room with the automatic BP machine. The machine remained in the area, there were no attempts to clean the machine after leaving R19's room. During observation on [DATE], at 2:30 p.m. TMA-B knocked on R19's partially closed door, and immediately proceeded into R19's room, without performing hand hygiene, or donning any PPE. TMA-B was checking if R19 was in her room and was heard speaking to R19 outside the room. TMA-B then left R19's room without first performing hand hygiene or wearing any PPE. TMA-B contaminated her uniform by placing her soiled hand into her left pocket before returning to the nurses station. During interview on [DATE], at 1:51 p.m. licensed practical nurse (LPN)-A stated she was aware R19 was on contact precautions for[DIAGNOSES REDACTED]. Staff were to gown and glove when they provided care to R19. During observation later on [DATE], at 2:00 p.m. LPN-A proceeded to retrieve the automated BP machine that was still placed outside of R19's room, and rolled it down the hallway to be used on another unidentified resident. There was no indication this item was cleaned after leaving R19 room, and before being used in other resident rooms. During observation on [DATE], at 3:30 p.m. registered nurse coordinator (RNC)-A and LPN-B entered R19's room to perform a dressing change. Both staff failed to donn PPE (gown and gloves) prior to entering the room. Once in the room RNC-A set down her common-use IPad (used to access and document in the residents' electronic medical records in the facility) and a container of wound marker dot identifiers (mark wounds used in conjunction with IPad for accurate wound measurements) on the counter next to the sink located immediately inside R19's room adjacent to the door. RNC-A was wearing flip-flop sandals which fully exposed her feet and toes, not protecting herself. RNC-A walked up to R19 who was seated in her chair, and informed her of the dressing change touching the resident's shoulder with her bare hand. RNC-A then sanitized her hands and put on her gown and gloves. RNC-A's PPE gown did not cover her appropriately, leaving her back exposed. LPN-B put on her gloves and gown without first sanitizing or washing her hands. RNC-A picked up her IPad and wound marker container that was placed on the resident's counter near the door. R19 told the two nurses she needed to have a bowel movement (BM). LPN-B assisted R19 to walk to the bathroom with her walker, touching R19's back with her gloved hand. RNC-A brought the IPad into the bathroom and placed it on the counter by the sink in the resident's bathroom. While R19 was in the bathroom she complained of having continuous loose bloody stools. RNC-A removed R19's brief as the resident stood in front of the commode located directly over the toilet, with her hands on her walker. R19's was incontinent of a loose stool and BM was in the soiled brief. RNC-A placed the soiled brief in the garbage can, causing the garbage liner to collapse into the can. R19 then sat down onto the commode touching the seat and handles. Once R19 was finished, RNC-A assisted R19 to stand up and R19 steadied herself to stand with the use of her hands on her walker. RNC-A assisted R19 by wiping her perineal and rectal area. RNC-A retrieved the fallen garbage can liner from inside the can with her soiled hands, and re-placed it onto the garbage can. RNC-A placed the soiled wipes into the garbage can. There was a half-dollar sized loose BM on the commode seat. RNC-A removed her soiled gloves, washed her hands, and donned (placed on) a new pair of gloves. RNC-A opened the wound marker dot container and grabbed a marker out of the container. RNC-A then touched R19's buttocks with her gloved hands and placed the marker dot on R19's left buttocks, next to her open wound. RNC-A reached for her IPad and proceeded to take photos on her IPad for wound identification, touching the IPad with her soiled gloves. LPN-B was assisting RNC-A with these pictures, opening the residents buttocks with her gloved hands. Once RNC-A snapped her photos, she stood up and took a step backwards while the edge of her gown brushed across the loose BM on the toilet seat. The gown had visible BM on it. RNC-A placed the IPad back onto the bathroom sink counter with her soiled gloves, and applied a dressing to R19's wound. RNC-A's personal clothing touched the bathroom wall and the handicap handles that R19 touched while she backed up. RNC-A was going to apply a barrier cream but the cream was missing. LPN-B grabbed the walkie-talkie that was under her gown with her soiled gloves and called for another unidentified staff member to bring her the keys to the medication cupboard. The unidentified staff member alerted LPN-B she was entering R19's room. The unidentified staff member opened the medication cabinet in the room with her keys, without first donning PPE or sanitizing her hands. LPN-B retrieved the cream from the cabinet with her soiled gloves and locked the cabinet with the keys while using her soiled gloves. LPN-B placed the medication keys under her gown inside her uniform pocket with her soiled gloves. LPN-B then squirted the cream onto the glove of RNC-A, and RNC-A applied the cream to the resident's buttocks. RNC-A assisted R19 to pull the back of her brief up, while LPN-B pulled the front of the brief up. RNC-A's gown, which was still contaminated with R19's loose BM, brushed against the leg of her uniform several times. Once R19 was done in the bathroom, neither RNC-A or LPN-B reminded R19 to wash her hands before leaving the bathroom. R19 walked back to her recliner independently using her walker, and sat down in her cloth recliner chair. R19 touched the arms of her recliner chair and adjusted herself, touching her papers on the table next to her. LPN-B then retrieved the garbage and liner from the bathroom where R19's soiled brief was located, while still wearing her soiled gloves, tied it, brought it to the door of the room and placed it on the carpeted floor. LPN-B opened the cupboard door near the sink by touching the handles with her soiled gloves, and retrieved the garbage can inside the cupboard and set it on the floor. LPN-B then removed her gown and gloves, placed these items into the garbage can and washed her hands. LPN-B placed the garbage can back into the cupboard with her clean hands, touching the handles and closed the cupboard door. LPN-B then picked up the soiled garbage bag sitting on the floor with her bare hands, opened the door and walked out of the room. RNC-A retrieved her IPad from the bathroom. R19 informed RNC-A she was going to go eat supper soon. After talking with R19 for a short time, RNC-A placed the soiled IPad that was in the bathroom onto the counter by the sink near the door. RNC-A opened the cupboard door with her soiled gloves and removed her gown while still wearing her soiled gloves. RNC-A then removed her soiled gloves, washed her hands, and picked up her IPad. She then decided to disinfect the IPad. She set it back down on the counter and left the room. RNC-A went to the nurses station and returned to R19's room with a container of purple top Super Sani-Cloth wipes (which do not contain bleach, and are ineffective at killing[DIAGNOSES REDACTED] infection). With her bare hands she wiped off the IPad with and the dot identifier container with these wipes, set them back onto the counter, and placed the purple top Super Sani-Cloth wipes into the top cupboard with her bare hands. She then left the room with the IPad in hand. During interview on [DATE], immediately after the above observations at 4:02 p.m. with RNC-A regarding the dressing change and infection control practices indicated RNC-A confirmed she had not had specific training for[DIAGNOSES REDACTED]. RNC-A was not aware of what chemicals killed the[DIAGNOSES REDACTED] infections and if the previously used purple top Super Sani-Cloth wipes were effective or the correct chemical to use on contaminated surfaces and multi-use resident items for[DIAGNOSES REDACTED]. RNC-A stated the facility followed CDC guidance. RNC-A stated her IPad was routinely taken into multiple resident rooms, office and was a portable source for her documentation into the facility's electronic medical record. LPN-B was also interviewed during this time and was unaware what chemicals were appropriate to use to disinfect items from[DIAGNOSES REDACTED]. LPN-B agreed the keys and anything else in her pocket were contaminated due to lack of appropriate infection control technique. RNC-A acknowledged she would go find an appropriate chemical to disinfect her IPad before it was used again. During interview on [DATE], at 1:08 p.m. the director of nursing (DON) stated RNC-A had come to her office the previous day directly after the interview with this surveyor. RNC-A advised the DON that she needed a bleach solution to disinfect the common-use IPad and wound dot marker container she carried in her hands. The DON stated she went to the kitchen to get bleach and disinfected the IPad and wound dot container for RNC-A. The DON was unaware staff were not using the correct chemicals to disinfect multiple-use resident items. The DON stated she immediately got the orange top Super Sani-Cloth's (which contained bleach, that was effective in killing[DIAGNOSES REDACTED]), and placed these in R19's room. The DON indicated the facility followed CDC guidelines and expected staff to wear appropriate footwear according to the employee handbook when providing resident care and especially in the presence of[DIAGNOSES REDACTED]. She also expected staff to wash their hands and donn PPE prior to entering R19's room. R19's room was located in Pleasant View neighborhood. There were approximately 17 residents residing on Pleasant View unit. The staff float to all four units as needed in the facility on the second floor, where 69 residents resided. The DON did not monitor staff to ensure appropriate infection control technique had been maintained. During interview on [DATE], at 3:45 p.m. with NA-J and RN-B indicated the infection control (IC) informational sheet related to[DIAGNOSES REDACTED] was the signage for the front door. Staff are told to ask questions if needed. No other additional training was provided. NA-J and RN-B were not told they needed to take any special precautions for[DIAGNOSES REDACTED]. R19's NA care plan made no mention of[DIAGNOSES REDACTED] or what special precautions were needed when toileting or providing cares. RN-B stated glucometer's are multi-use and shared by residents. Both staff float to the other 3 units in the facility from day-to-day dependent on where they are scheduled. HOUSEKEEPING During interview on [DATE], at 8:21 a.m. housekeeper (H)-A stated she in charge of cleaning two units on the second floor, while H-B was in charge of the other two units. H-A stated wore a full gown, mask, and gloves when cleaning any resident room. H-A further stated she usually sprayed down the toilet bowl first, to let the cleaner sit, then started cleaning the sink and surrounding area. H-A reported after she was done cleaning a resident room, with her protective personal equipment (PPE) still on, she opened a plastic bag, set it on the floor outside the resident room door, and doffed her PPE outside the room, putting the dirty PPE into the open bag on the floor. H-A reported the following doffing order, taking off her gown, then gloves, and then the mask. H-A stated she took off the PPE outside the room, regardless if resident was in isolation or not, stating she was taught that way. H-A explained they used Hillyard brand chemicals to clean resident rooms. H-A reported the Hillyard brand Re-Juv-Nal was their main disinfectant, which she used to clean hard surfaces, stating she sprayed everything with it as it killed on contact. H-A further stated the Hillyard brand Top Clean was used to clean the floors. H-A stated the Hillyard products were effective against MRSA (another type of antibiotic resistant bacteria), but was not aware if they were effective against[DIAGNOSES REDACTED]. H-A reported the same cleaning chemicals were used for all the resident rooms, regardless of isolation, stating with[DIAGNOSES REDACTED], just error on the side of caution and left the chemicals sit longer. During interview, H-A's cleaning products were observed on her cart, and none of the labels listed any chemicals effective against[DIAGNOSES REDACTED]. During interview on [DATE], at 10:12 a.m. H-B, regarding the cleaning of R19's room, stated she would put gloves on, but stated she did not need to wear a gown to enter and clean R19's room, further reporting R19 did not have an isolation hanger on her door. H-B stated R19's infection was only in her stool, so she just needed to be cautious and make sure to wear gloves when cleaning R19's bathroom. H-A explained she used the Hillyard brand Re-Juv-Nal for the sinks and hard surfaces in R19's room. H-B reported she used the Re-Juv-Nal to wipe down R19's recliner, but R19 also had a cloth chair that she can't really wipe down. H-B stated if the infection was very contagious, she would use the purple top Super Sani-Cloth wipes, because they had alcohol in them. H-B stated the Super Sani-Cloths were just an added measure used occasionally, but could use either the Super Sani-Cloth or the Re-Juv-Nal to clean hard surfaces like the bedside table. H-B further stated she used the Hillyard brand Liquid Swabby II for the toilet and the Liquid Enzyme cleaner if there were stains around the toilet. H-B then reported when cleaning the bathroom, If I wanted to go real hard, use the Super Sani-Cloth in addition. H-B thought the Liquid Swabby II and Liquid Enzyme were effective against[DIAGNOSES REDACTED], although neither label listed them effective against[DIAGNOSES REDACTED] infection. H-B then reported after cleaning R19's room, she would take off her gloves, and use the hand sanitizer to make sure she did not get any germs, and maybe go wash my hands. During interview, H-B's cleaning products were observed on her cart, and none of the labels listed the chemicals effective against[DIAGNOSES REDACTED]. Review of the facility housekeeping disinfectants indicated the following: - Product labeling for Hillyard Re-Juv-Nal identified its recommended use as a disinfectant with active ingredients of four different ammonium chlorides (QUAT). The label did not indicate it was effective against[DIAGNOSES REDACTED]. - Product labeling for Super Sani-Cloth Germicidal Wipes (Purple top) identified its recommended use as a disinfectant with active ingredients of ammonium chloride/compounds. The label did not indicate it was effective against[DIAGNOSES REDACTED]. - Product labeling for Hillyard Top Clean identified its recommended use as a general cleaner with active ingredients of ethoxylated alcohol. The label did not indicate it was effective against[DIAGNOSES REDACTED]. - Product labeling for Hillyard Liquid Swabby II Bowl Cleaner identified its recommended use as disinfectant toilet bowl cleaner with active ingredients of hydrogen chloride, further noting it was incompatible with bleach. The label did not indicate it was effective against[DIAGNOSES REDACTED]. - Product labeling for Hillyard Quick and Clean Liquid Enzyme II identified its recommended use as multipurpose drain cleaner with active ingredients of ammonium chloride. The label did not indicate it was effective against[DIAGNOSES REDACTED]. LAUNDRY During interview on [DATE], at 10:22 a.m. laundry aide (LA)-A stated the facility's laundry room only did residents' linens such as bath towels, washcloths and bed sheets. LA-A reported dirty linens from both isolation rooms and non-isolation rooms were bagged in the same bags and sent down together. LA-A reported linens were only bagged in special marked bags, like red bags, if they were soiled with blood. LA-A stated she would not know if any isolation linens were sent down to the laundry because all the linens were bagged together. Further more, LA-A was not aware of R19's [DIAGNOSES REDACTED]. assistants. During interview on [DATE], at 10:33 a.m. nursing assistant (NA)-F stated every resident room contained a white basket with a mesh liner inside, where dirty resident laundry was kept. During interview, R19's personal linens were observed in a white basket with a permeable mesh liner located in the lower left cupboard of R19's bathroom. NA-F stated they brought the mesh liner into the laundry room, sorted residents' soiled personal laundry on the countertop in the unit laundry room, and then wiped the counter down with a purple top Super Sani-Cloth wipe so clean laundry could be folded on the counter top afterwards. NA-F reported staff wore gloves to sort dirty laundry; however, did not wear gowns while sorting. NA-F further acknowledged there were no gowns in the laundry room for staff to wear. NA-F reported after sorting, one resident's dirty laundry was placed in the washing machine, which had two settings. She explained the washing machine setting F1 had just detergent while F2 had detergent with bleach. NA-F stated she had never used F2, further stating she did not know when to use the F2 setting, and just washed with the normal F1 setting which seems to work. NA-F stated the nursing assistants trained each other on using the wash machine, and on how to use separate loads. NA-F stated the clean personal laundry was stored in the unit laundry room until it was delivered. NA-F further stated R19's linens were bagged in a clear plastic bag (the regular linen bag), then put in a garbage bin labeled Laundry located in the unit's soiled utility room. During interview, the soiled linens were observed and noted all linens were bagged in the same clear plastic bags with no special identifiers. During interview on [DATE], at 10:33 a.m. the Pleasant Stream unit's laundry room was observed. A washing machine and drier were observed on the left side of the room, with a counter running across the back wall. To the right and next to the counter, a metal rolling rack with several clean shirts were hanging, uncovered. A purple top container of Super Sani-Cloths were sitting on the counter. To the right of the entry door, above the washing machine, untitled directions for washing clothes was posted. The posted directions stated: - Put clothes in washer. - Select appropriate settings on washer. - Press Start button on washer. - Select F1 or F2 on the wall E-Pert dispenser as appropriate. - Press Start on the E-Pert dispenser. The posting lacked direction for staff on when to use the appropriate setting with[DIAGNOSES REDACTED]. During interview on [DATE], at 11:12 a.m. NA-G stated she took resident soiled laundry to the unit laundry room in the mesh liner because then she did not have to take the whole container, and the mesh bags could be washed with the personal linens. NA-G further stated she just used the F1 detergent setting on the washing machine, unless otherwise specified or the laundry was really soiled; although, she would personally use the F2 setting with R19 it's just tougher I think. NA-G reported she sorted soiled laundry by setting the mesh liner on the floor while using the washing machine door to hang soiled laundry while sorting. NA-G stated she wore gloves while sorting, not a gown, unless their was a larger load. During observation of the facility's laundry services on [DATE], at 12:33 the director of maintenance (DM) stated all soiled linens were bagged; however, soiled linens from an isolation room should be bagged separately, using the identical bags as non-isolation linens, but marked by staff with an X using a sharpie or a resident label, as long as it did not come off the bag, to identify it was from an isolation room. He further stated all soiled linen bags, including isolation, were put in garbage-like covered bins, and brought down to the basement at night. The DM stated isolation linens, like those with[DIAGNOSES REDACTED], would be washed under setting 6, a heavy BM cycle which included detergent with bleach. During interview, LA-A interjected stating nursing staff were not marking or bagging isolation linens separately, stating she had not observed any marked soiled linen bags in the bins; however, LA-A stated she washed all linens using cycles with bleach. The DM reported the soiled isolation linens were suppose to be labeled, but acknowledged the staff did not receive training on that procedure. During interview on [DATE], at 1:19 p.m. the DON stated it was not the facility's policy to use gowns as PPE when sorting soiled laundry. The DON stated she did expect staff to keep the soiled laundry away from their uniforms and to sort the soiled personal laundry in the resident's room. The DON was not aware if separate bags were used to bag soiled linens from isolation, nor if the chemical disinfectants like Re-Juv-nal were effective against[DIAGNOSES REDACTED]. The DON stated she would need to re-look at their policy for PPE and the handling of soiled linens. During interview on [DATE], at 1:33 p.m. NA-H stated they did two residents' personal laundry each shift. NA-H reported she brought soiled personal laundry into the laundry room using the white basket, although she stated some units just bring it down in the mesh bag. NA-H stated she sorted the soiled laundry in the laundry room entryway using the washing machine door to hold soiled linens as she sorted them from the basket. NA-H stated she wore gloves while sorting but not a gown. NA-H reported she generally washed whites on the cold cycle while darks were always washed on a hot cycle. NA-H stated she always did the normal F1 cycle with just detergent, further stating she would not use the bleach with any dark or color loads. NA-H reported they were suppose to clean the washing machine after each resident using the F2 with bleach option. During interview on [DATE], at 1:58 p.m. NA-I stated she floated between units, and while sorting soiled laundry, she would open the washing machine door, using it to hold laundry while she sorted from the laundry basket. NA-I stated she only wore gloves while sorting, unless she was instructed to wear more by the nurses. NA-I stated she normally just pressed the start button on the washing machine, and used the settings from the previous resident unless she was instructed to change them from the previous shift. NA-I reported she would only use the detergent with bleach for white loads, further reporting, I'm told temperature is normally set so I don't touch it, stating she never washed personals on hot, only cold or warm settings so nothing shrunk. NA-I thought the drier was set to a hot heat in order to kill bacteria, like[DIAGNOSES REDACTED]. Further stating, with[DIAGNOSES REDACTED], they would probably want some type of sanitizer run through. Review of the facility detergents indicated the following: - Product labeling for Ecolab Tri-Star-Duo identified its recommended use as a laundry detergent with active ingredients of boric acid, alcohols, and potassium [MEDICATION NAME]. The label did not indicate it was effective against[DIAGNOSES REDACTED] infection. - Product information for industrial laundering was requested but not received. During interview on [DATE], at 2:59 p.m. NA-K stated R19 had[DIAGNOSES REDACTED] for the last couple of weeks, and staff help her with cleaning up and wiping and everything. NA-K reported R19 was having incontinent stools, did come out of her room for meals, and had come to supper last evening and sat with R25 and R71. NA-K confirmed no other residents on the unit were having loose stools. During interview on [DATE], at 3:05 p.m. TMA-D stated R19 had been on precautions for[DIAGNOSES REDACTED] going to say less than a week, but wasn't sure. TMA-D stated R19 came out of her room for supper and always sat with the same residents, R25 and R71, stating she consistently saw R19 with them. TMA-D confirmed neither R25 or R71 were having loose stools. INFECTION CONTROL PR(NAME)ESS During interview on [DATE], at 3:08 p.m. the infection control coordinator (ICC)-H indicated she had been the ICC nurse for ,[DATE] years. They handed out an informational sheet to staff by each unit's RNCs when residents are on precautions. The sheets tell staff what the necessary precautions were for isolation rooms. Staff are encouraged to ask questions but are not given any other instruction or education. When entering a room, contact precautions are based on staff's judgement and if they do cares. If staff are handing out medications, her expectation is staff are to wash their hands when they go in and then wash their hands prior to leaving. The purple top Super Sani-Cloth wipes were used at least every 24 hours and on multi-use resident items. Since she has never had cross contamination using the Super Sani-Cloth wipes and thought the products used were appropriate and worked effectively for[DIAGNOSES REDACTED]. ICC-H added, Its never spread before. ICC-H did not direct the cleaning of the rooms or what chemicals were to be used. That is managed through housekeeping. Environmental staff were to use the same wipes and detergents for everyone, regardless of the infection. Whatever we are using, its working. ICC-H did not provide any education to staff regarding infection control or transmission-based precautions. The corporate ICC is responsible for the education of facility staff. ICC-H stated[DIAGNOSES REDACTED] is usually caused by antibiotics, loose stools, and was easily spread. ICC-H did not refer to CDC guidance on[DIAGNOSES REDACTED] and was unaware what chemicals were effective at killing the[DIAGNOSES REDACTED] spores. ICC-H has completed random audits on units by observing staff for handwashing. She also performs audits on call lights, room order, and checked to see if staff had supplies for isolation, but that's it. ICC-H had no documentation to show a record of the audits she performed. The last IC audit was completed in June (2017). She watched 3

Based on observation, interview and document review, the facility failed to ensure expiration dates for pharmaceuticals were monitored for 2 or 4 resident units (Hillside Bend and Agate Units) that potentially affected 30 residents on these units. Finding include: During observation on 9/13/17, at 10:27 a.m. of the Hillside Bend and Agate unit medication cart, storage room, and the medication cupboard with trained medication assistant (TMA)-A identified the following: The medication cart/room in the Hillside Bend Unit identified the following: (1) 2 bottles of hydrogen peroxide. Those bottles were opened, actively in use, and had both expired. One bottle expired in 2010 and the other in 2014. (2) 1 box of Aquacel (silver impregnated dressing used for wound care) with manufacturers expiration date of September of 2012. (3) 2 boxes of skin prep (barrier protectant); with a manufacturer expiration date of June 2016 and September 2015. Both boxes were currently used for residents. During review of the Agate unit medication room identified an opened, in-use bottle of hydrogen peroxide with an expiration date of 2010. During interview of the medication unit, TMA-A stated someone checked the medication cart, room, and resident's rooms about every four months for expired medications. She thought the night shift staff were responsible for checking expiration dates. Review of the Harmony River Resident List Report, printed 9/11/17, identified 30 residents lived on the Hillside and Agate units.

Based on observation, interview and document review, the facility failed to comprehensively assess and provide individualized activity programming for 1 of 1 dependent residents (R145) reviewed for activities. Findings include: R145 was admitted to the facility 9/2015, the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment was dated 7/18/17 identified R145 had severe cognitive impairment, and as totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and locomotion on/off the unit (ADLs). R145's Life Enrichment Summary note dated 7/17/17, listed R145 as dependent on family and/or staff for social interaction/cognitive stimulation to meet leisure needs. When awake, spends much leisure time in living area of neighborhood, watches TV/movies, observes people, listens to music, socials. Participates as able (eye contact, occasional word, smiles) and passively in 1:1's and groups. Regular contact with family, clergy and volunteers. R145's care plan with a revision date of 10/28/16, indicated she had problem area of ADL Self Performance and was totally dependent on staff for all areas and had impaired ability to communicate and was on comfort care. R145 was dependent on staff for activities, cognitive stimulation, and social interaction related to dementia and listed interventions which included: Escort to/from Catholic communion and in house church services; engage in simple structured activities, requires escort to/from activities; prefers to spend majority of day in the common areas of the neighborhood: watching TV, listening to music, pet visits, 1:1 visits, and etc. Review of the activity attendance record for R145 indicated attendance during the dates of 8/17/17 - 9/12/17: Religious (church service)-7 times (is available 2/week); Music-3 times; reading-5 times; beauty shop-1 time. There were no 1:1 activities documented. R145 was not included on the activity 1:1 schedule nor was R145 included in the Memory and Music program (an individualized program for residents with dementia and who enjoyed music). R145 was observed on 9/11/17, at 5:07 p.m. seated in her Broda chair in a reclined position in front of the TV with her eyes closed. There was a news program playing and R145 did not demonstrate any interest in the program and continued sitting with her eyes closed until transported to the dining room at 5:45 p.m. R145 was assisted to eat her evening meal, afterwards having an unidentified staff person transported her and place her in front of the TV. R145 continued to sit in her chair with her eyes closed and did not indicate any interest in TV program. R145 was continuously observed on 9/12/17, from 8:19 a.m. - 9:45 a.m. At 8:19 a.m. R145 was transported from her room in her Broda chair by nursing assistant (NA)-D and placed in front of the TV, reclined the back of the Broda chair and walked away. R145's eyes were closed, mouth open, and breathing softly. Various unidentified staff persons walked by the resident, and no one stopped to speak or interact in any way with her. At 8:29 a.m. social worker director (SWD) walk past R145 twice as he went to and from the nursing station and then returned and wheeled R145 to the breakfast meal and walked away. After R145 completed breakfast at 9:15 a.m. she was transported and placed in front of the TV, that had a talk show playing. the back of R145's chair was reclined and had her eyes closed. R145 continued to sleep as various unidentified staff passed by R145's chair. No one attempted to speak to or converse with the resident as she sat in her chair. At 9:45 a.m. various persons came to area along with LED who indicated Mass was being held at 10:00 a.m. The LED instructed an unidentified person to transport R145 to Mass. The indicated person walked over to R145's chair and without speaking to her, pushed her from the room At 10:55 a.m. R145 was returned to the neighborhood and placed back in front of the TV, still appearing to be sleeping. At 12:00 p.m. R145 was transported to the dining room and positioned at the table for the noon meal and assisted with dining. At 1:15 p.m. R145 was in bed, the room was quiet. Family (F)-A was interviewed on 9/12/17, at 10:57 a.m. and indicated the TV programing is not always appropriate for the population and day time programs which included talk shows, etc. were not of interest to most of the elderly population. F-A indicated her mother enjoyed listening to music programs and that the family did want her out of the room when she was not in bed. On 9/12/17, at 1:45 p.m. nursing assistant (NA)-B was interviewed and indicated R145 is total care for all ADLs and attendance to any activities. R145's usual routine is to be washed up, dressed and then to remain in bed until time for breakfast. If R145 is awake following her AM cares, then she is transferred into her Broda chair and positioned in front of the TV until time for breakfast. NA-B further indicated R145 usually sleeping in front of the TV. Following breakfast R145 is then transferred back into bed, checked and changed and allowed to rest until time for the noon meal. NA-B indicated when R145 is taken to Catholic Mass it usually lasts about 45 minutes and upon return to the unit she is positioned in front of the TV until noon meal and is laid down following meal and remains in bed until gotten up by PM shift around 2:45 p.m.- 3:15 p.m. The social work designee (SWD) was interviewed on 9/12/17, at 2:31 p.m. and indicated R145 was previously more independent and able to assist with cares and attend activities of choice. Now she is dependent upon staff, and there are some 1:1 activity is provided at times and she attends some large group activities where she is a passive participant. On 9/12/17, at 3:13 p.m. NA-E and NA-D were interviewed and indicated R145 is totally dependent for all cares and is gotten out of bed for the afternoon/evening between 2:45 p.m. - 3:15 p.m. R145 is placed in her Broda chair and positioned in front of the TV. R145 then remains up in chair until 7:00 p.m. when she is put to bed for the night. Both NA-D and NA-E indicated R145 doesn't seem to be interested in TV programs, but the family doesn't want her to remain in her room when she is not in bed. The Life Enrichment director (Activity-LED) was interviewed on 9/13/17, at 12:31 p.m. and indicated R145 sits out in the common area observing persons coming and going, staff passing by stop and visit with her and resident is able to respond by blinks or smiles and at times will speak a few words. The LED indicated R145 does attend a few small group activities in the neighborhood such as devotions, short stories, chat circles that are held monthly and that she is care planed to receive 1:1 visits which consist of casual visits as staff are passing by and stop to visit with her. The LED further indicated R145 is not on a scheduled 1:1 visit program and other than church which is held twice weekly is not on a list. LED listed programs available for persons with dementia and indicated R145 enjoyed music and would probably enjoy the Music and Memory program which included individualized music loaded on an individualized IPOD and played with headphones. During a subsequent interview at 1:32 p.m. the LED confirmed R145 was not receiving a 1:1 program and had not been reassessed, (to her knowledge) related to appropriate interventions or likes/dislikes related to activities. The LED thought R145 would benefit from an individualized plan with music and/or activity which occurred more frequently than weekly or monthly. On 9/14/17, at 10:09 a.m. the SWD indicated R145 is usually sleeping when she is up in her Broda chair, positioned in front of the TV especially if the chair is in a reclined position. The SWD stated he has seen R145 open her eyes, look toward the TV and then close her eyes and appear to go back to sleep. This was especially true if there was a talk type program on the TV and saw R145 had some interest in old time programing which was turned on more in the PMs. The Therapeutic Recreation and Activities and Psychosocial Assessment Policy with a review date of 5/2016 included: Policy: To be completed on all Care Center residents on admission, annually and with any significant change This will be reviewed quarterly and updated as needed. Purpose: The purpose of this policy is to ensure the gathering of accurate, timely information that reflects the resident's lifestyle, preferences and choices. Update the Care Plan and My Best Day or Nursing Assistant Care Plan to correspond with the information on the assessment to facilitate staff honoring of preferences. Music & Memory Program Policy and Procedures included: Or policy is to provide opportunities for enjoyment and wellness to residents in our care by providing them with music of their choice utilizing iPod devices and iTunes computer software.

Based on observation, interview and document review, the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) Level II screening after a significant change in condition and approved length of stay had expired and was not reassessed for an extension of these services for 1 of 1 residents (R130) reviewed for PASRR services. Findings include: R130's most recent quarterly Minimum Data Set ((MDS) dated [DATE], identified R130 had intact cognitive impairment, required extensive assistance with dressing and toileting, and did not have a prognosis of life expectancy being less than six months. Further, a significant change MDS had been completed on [DATE]. R130's printed census listing dated [DATE], identified R130's payer source to be, Medicaid MN. R130's [DIAGNOSES REDACTED]. Further, R130's Order Summary Report signed [DATE], identified R130 consumed [MEDICATION NAME] (an antipsychotic medication) on a daily basis for a listed [DIAGNOSES REDACTED]. During observation on [DATE], at 9:24 a.m. R130 was seated in a chair in the dining room eating a danish. R130 appeared clean and well groomed with her hair pulled back into a ponytail. R130's Evaluative Report Level II Preadmission Screening (PAS) for Persons with Mental Illness dated [DATE], identified R130 had [MEDICAL CONDITION] and was being screened for, SNF (skilled nursing facility) placement, due to her medical needs being unable to be managed in the community. A section labeled, Findings and Recommendations, identified R130, .may have a serious mental illness and may need specialized services, but meets one of the categorical determinations for admission, and had a handwritten checkmark placed next to, Terminal Illness. Further, the screening identified R130's admission to the SNF had been approved for 180 days (effective [DATE]) with bolded print instructions of, Follow-up will be required if extension is needed beyond the specific time limit. R130's progress note dated [DATE], identified R130 had been admitted to the SNF on hospice care, however, has come off hospice on [DATE]. R130's medical record was reviewed and lacked any evidence additional or further Level II PASARR screenings had been completed since R130's significant change MDS was completed on [DATE], since she was removed from hospice care, or since the 180 days identified on her original PASARR ran out. During interview on [DATE], at 1:31 p.m. nursing assistant (NA)-A stated R130 needed assistance to complete dressing, toileting and bathing. NA-A stated R130 had a, very quiet, and, to herself, demeanor most of the time and, absolutely loves to color. Further, NA-A stated she was not aware of any specific interventions for R130 regarding her mental health, but added staff locked up R130's snacks as she, won't stop herself from eating otherwise. When interviewed on [DATE], at 12:58 p.m. licensed social worker (LSW)-A stated R130 admitted to the SNF on hospice care, however, was removed from hospice on [DATE], and was, absolutely great, now. LSW-A stated she was unaware R130's original Level II PAS had a 180 day limit, nor was an additional Level II screening completed when R130 had a significant change assessment as she, wasn't really aware I needed to be doing that. Further, LSW-A stated it was important to ensure Level II PAS(s) were completed, to make sure we're meeting their (residents) mental health needs. A facility Admission Prescreening for MR/MI (Mental [MEDICAL CONDITION] / Mental Illness) Individuals (PASARR) Policy dated ,[DATE], identified a standard to, ensure that individuals with mental illness and mental [MEDICAL CONDITION] receive care and services they need, and directed the staff to, coordinate assessments, which included, Referring all level II residents . for a level II resident review upon a significant change in status assessment.

Based on observation, interview and document review, the facility failed to ensure dental concerns were addressed for 1 of 3 residents (R205) reviewed for dental hygiene. Findings include: R205's BIMS (brief interview for mental status) and [MEDICAL CONDITION] assessment dated [DATE], identified R205 had moderate cognitive impairment, but displayed no disorganized thinking. Further, R205's Admin Census/Rate listing dated 9/13/17, identified R205's current payer source as, Medicare A. During interview on 9/12/17, at 9:40 a.m. R205 stated he had dental concerns which he did not feel had been adequately addressed by staff. R205 showed the surveyor a missing tooth on his lower palate, however, then added he had a tooth on his upper palate, which bothers my tongue, and he would like to see a dentist to have it fixed. Further, R205 stated nobody from the facility had visited with him about his teeth or his dental concerns. R205's Communication, Hearing, Vision, and Oral - V 4 assessment dated [DATE], identified R205 had a oral examination completed with identified, Mouth or facial pain, discomfort or difficulty with chewing, being checked as present. Further, staff identified, (R205) does c/o (complain of) his right front tooth feels sharp. It appears a filling has fallen out and edge is sharp with touch by finger. Writer will have family called in AM to make a dental appointment for resident(.) R205's medical record was reviewed and lacked any identified follow-up for R205's dental concern. When interviewed on 9/12/17, at 2:58 p.m. family member (FM)-A stated she was not aware of (R205's dental concern), adding staff had not reported it to her. Further, FM-A stated R205 should see the dentist if he wanted to, in order to have his tooth checked and fixed. During interview on 9/12/17, at 3:15 p.m. registered nurse (RN)-B stated she wrote directions to call R205's family on a facility 24 hour report form on 9/5/17, with instructions of, Right Front Tooth Filling fell out Call Family for Dental Appt (appointment). RN-B stated the nurse working on the medication cart or the clinical coordinator should have notified the family. Further, RN-B reviewed R205's medical record and stated there was no documentation to demonstrate the dental concern had been addressed as, It wasn't followed up. When interviewed on 9/12/17, at 3:28 p.m. RN-C stated she was unaware R205 was having any dental concerns. If they were having concerns it would typically be reported through the shift and staff, and they would follow up on the next day, however, R205's medical record lacked any evidence it had been addressed. Further, RN-C stated dental concerns should be addressed timely because they can follow into larger and greater health concerns including nutritional compromise and infections. A facility Oral Assessment Policy dated 2/2016, identified the facility would provide routine dental services on an annual basis or, as needed unless otherwise indicated by resident or responsible party. Further, the policy directed to, keep a record of all the resident's dental visits in the resident's medical record.

Based on observation, interview, and document review, the facility failed to post notice of availability of the last three years of State agency survey results. This had the potential to affect all 116 current residents, visitors, and staff who wished to review this information. Findings include: During initial tour on 9/11/17, at 1:58 p.m. a black laminated folder labeled, State Survey was observed in a plastic wall shelf attached to the front entrance receptionist desk. The folder only contained the most recent survey results, dated 8/25/16, from the federal re-certification survey and the most recent survey results, dated 8/23/16, from the life safety code survey. There was no posting to inform the public more surveys, up to three years, were available. During observation on 9/12/17, at 2:34 p.m. the survey results were again observed to contain only one year, and no additional availability posting information was found. During interview on 9/12/17, at 2:39 p.m. heath unit coordinator (HUC)-A stated more surveys were available to look at, but was not aware of any posting information to the public. During interview on 9/12/17, at 2:42 p.m. the director of nursing (DON) stated she was not aware they needed a posting that informed the public that additional years of survey results were available upon request. During interview on 9/13/17, 6:59 a.m. the administrator stated she was responsible for posting the survey results and was not aware of the regulation requiring a public posting of the survey results available. A policy was requested but not provided.

Based on observation, interview and document review the facility failed to ensure a pressure-reducing heel boot was consistently applied to promote healing of a deep tissue injury as directed by the care plan for 1 of 1 resident (R75) reviewed for pressure ulcers. Findings include: R75's current [DIAGNOSES REDACTED]. R75's admission Minimum Data Set (MDS), dated [DATE] indicated severe cognitive impairment, risk for pressure ulcer development with no current pressure ulcers identified and indicated R75 required the extensive assistance of staff for bed mobility, transfers and dressing. R75's care plan, last revised 8/24/16 indicated R75 had a pressure ulcer to the right heel (unstageable suspected deep tissue injury) and was at risk for further impaired skin integrity related to cognitive impairment, diabetes, recent surgery/hospitalization , and immobility. Interventions included a pressure relieving air mattress on the bed, bed cradle on to lift blankets off feet, elevate heels off bed using pillows/heel elevation products while in bed and blue pressure reduction boot on at all times. R75's treatment sheets, dated 8/16 indicated daily skin monitoring for a reddened area on the right great toe and indicated the bandage was to be removed from R75's right heel and checked daily in the morning, bed cradle on each shift when in bed and create a tent for sheet when in bed, 3 inch thick towel or blanket under mattress pad at level of calf. No pressure to heels. During interview on 8/22/16, at 5:56 p.m. registered nurse (RN)-A indicated that R75 had an ulcer on the right heel, and the physician did not feel it required debridement. Staff were elevating the heels and had applied a tent on R75's bed to avoid pressure from the bed sheets. During observation on 8/23/16, at 7:21 a.m. R75 was resting in bed, with a towel rolled up underneath the right calf. A blue boot was in place on the foot, which had a cutout area over the right heel to relieve pressure. R75 had an air mattress with a foot cradle in place. During observation on 8/23/16, at 9:20 a.m. R75 was seated in the hallway on the Agate Trail Unit, with a shoe on the right foot. The right foot was resting directly on the footrests. During observation on 8/23/16, at 11:16 a.m., R75 was noted leaving the therapy department with therapy staff. Her right foot still had the shoe on it, and was directly resting upon the footrest. During interview on 8/23/16, at 11:19 a.m. physical therapist (PT)-A stated R75 wore shoes in therapy for walking, and the shoes she had on now were new and brought in by family due to a wound on the right heel. PT-A placed R75 at the dining room table and walked back to the therapy department, leaving the shoe on R75's foot. During observation and interview on 8/23/16, at 2:08 p.m. the occupational therapy assistant (COTA)-A indicated R75 wore shoes in therapy. R75 had a blue boot on at this time and was assisted out of bed by COTA-A, who removed the boot and applied her shoes. COTA-A indicated the boot was usually worn in bed and seemed to be off when she was up. During observation and interview on 8/24/16, at 7:36 a.m. R75's heel wound was visualized with licensed practical nurse (LPN)-B. The area had rolled skin about the edges and a purple center. R75's blue boot was noted to be lying to the right of her bed, on the other side of her nightstand at the head of the bed. A small purple intact area was noted as well to the medial aspect of the right great toe. LPN-A indicated she had thought R75 wore the boot when up in the wheelchair, but not in bed. RN-A came into the room and also visualized the heel area, and stated R75 should have been wearing the blue pressure reduction boot while in bed and was to wear it at all times in the chair, but could use the shoes for therapy. RN-A stated R75 may have thrown it off. During interview on 8/24/16, at 9:42 a.m. RN-B indicated R75's right heel boot should be on at all times, except when walking with therapy. RN-B indicated she had written R75's care plan and pulled up R75's nursing assistant care guide, which lacked instruction with regard to the right heel boot. RN-B stated she would add this to the care guide now. During interview on 8/25/16, at 10:29 a.m. nursing assistant (NA)-A indicated R75 was usually pretty cooperative with cares, and did not usually remove or throw off her heel boot. During interview on 8/25/16, at 1:34 p.m. the director of nursing (DON) indicated she would have expected the boot to be left on R75 at all times when she was not walking, and for therapy and nursing to communicate with each other when R75 completed her treatments so that the boot could be put back on. The facility policy entitled Pressure Ulcer/Injury Policy and Procedure, last revised 5/16 indicated to avoid positioning the resident on a pressure ulcer/injury. Use protective pressure reducing devices in bed and wheelchair sitting surface as ordered.