Every finding on record at Parkview Home

Based on interview and document review, the facility failed to revise the care plan for 2 of 12 sampled resident (R15 and R18) reviewed.Findings include: R15R15's 4/6/26, accepted quarterly Minimum Date Set (MDS) assessment identified R15's cognition was severely impaired. R15 was independent with her dressing, toileting and ambulation using a walker. R15 had occasional pain and took an antidepressant, diuretic, antiplatelet, and opioid medication. R15's current Diagnosis Report identified Alzheimer's disease, dementia, muscle weakness, long term use of pain medication, hallucinations, anxiety disorder, and high blood pressure. Observation and interview on 5/4/26 at 1:09 p.m., with R15 identified the facility took her scissors away from her and she cannot use her scissors anymore. She reported she was not endangering anyone, she had her knitting stuff but no scissors to cut the string. Observed was a bag next to her recliner with a large ball of yarn on the floor next to the bag with string from the ball of yarn draped into the bag. The bag was open at the top and other balls of yarn were inside the bag. She was unsure when the facility took her scissors. R15's 4/15/26, progress note identified housekeeping staff reported R15 had been cutting her clothes and R15 had cut her hair. Social service spoke to R15 about safety concern with scissors of cutting hair and cutting her clothing while on her. Plan will be to implement supervised scissor use and offer a hair appointment. The facility will provide time for staff and activity staff to utilize scissors when needed with yarn or other material items that are appropriate to cut. R15's undated, care plan identified self-directed leisure profile centered on her pastimes. Activities included that R15 enjoyed interactions with others and would continue with one-to-one interactions. R15 enjoyed music, being outside, going for walks, and putting together jigsaw puzzles. The facility staff were to respect R15's right to decline one-to-one interaction or other activities. There was no mention in the care plan that R15 would be offered supervised assistance with use of scissors for safety reasons. Interview on 5/5/26 at 9:34 a.m., with activity director (AD)-A identified she was unaware of any residents who needed supervision using some scissors. She reported that if a resident was identified to be unsafe using scissors the facility would ask the family to take the scissors home and set up a one-to-one with the resident to use the scissors in the activity room. Interview on 5/5/26 at 9:41 a.m., with interim director of nursing (IDON)-A identified she determined if someone was safe to use a scissors by looking at the residents cognitive level and any actions they may have taken. She would visit with the resident's family and try to allow the resident opportunities to continue to use a scissors with supervision if needed. She confirmed that R15 had been cutting her clothing and her hair with her scissors and was determined not to be safe with the scissors. R15 just needed to ask staff for her scissors and staff will assist or supervise her using her scissors. She confirmed that R15's care plan should reflect that she was unsafe to use her scissors unsupervised. R18R18's 5/6/26, accepted quarterly MDS assessment identified to have a Brief Interview for Mental Status (BIMS) score of 13, as cognitively intact. R18 was independent with dressing, toileting, and ambulation using his walker. R18 was noted to wander 1-3 days during the 7-day assessment period. R18 used oxygen, took antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet medication. R18's current Diagnosis Report identified stroke, one sided weakness, emphysema, chronic obstructive pulmonary disease (COPD), high blood pressure, muscle weakness, insomnia, major depression disorder, and a history of falling. Interview on 5/4/26 at 2:00 p.m., with R18 identified he had an alarm on, and he wanted to go outside but could not. He reported this was illegal and he was calling the police and telling the state people and was waiting to see what they did (the facility). He said this must be against the law to have this thing on so he could not go outside. R18 then reported staff told him he needed someone to go outside with him but remarked there was never anyone that had time. When asked about going out into the enclosed courtyard, he reported he could go out there, but he did not want to. He wanted to sit out front and look around. R18's current, care plan identified R18 had cognition focus related to diagnosis of dementia and cognitive deficits as evidenced by BIMS. Staff were to communicate with R18 and address his needs and support his capabilities. Staff were to cue, reorient and supervise as needed, monitor cognitive function and report changes. Staff were to provide information and allow R18 to make decisions independently. R18 had a wander guard based on elopement assessment. The care plan lacked identification that R18 was at risk for elopement and what the goal was. There were no interventions of what staff were to do if R18 attempted to leave, or interventions to help meet R18 needs when he wanted to go outside and sit or take a walk. R18's 3/24/26 elopement evaluation identified he wanted to return home and was one time progress notes at 6:41 p.m., identified R18 had gone outside, staff observed R18 and went outside with him. R18 had said he was leaving and wanted to go home. Staff had walked with R18 to the assisted living apartment entrance. R18 entered the assisted living and began visiting with the staff at the assisted living. The assisted living staff assisted R18 later to the long-term care side of the building. A wander guard will be started. R18's 4/16/26, Elopement Evaluation identified R18 did not have a history of elopement or an attempted elopement while at home. R18 did not express the desire to go home and/or pack his belongings to go home or stay by an exit door. R18 did not wander and had not been admitted recently within the last 30 days. The risk for wandering and/or elopement was left blank with no care plan focus, goal, or interventions identified. The assessment did not identify the prior history of elopement or attempts to leave the facility without informing staff or R18's desire to go home. Interview on 5/5/26 at 1:14 p.m., with activity director (AD)-A identified she assessed residents' likes and dislikes and reviewed things they enjoyed prior to coming to the facility. For residents who have a wander guard on, and they want to go outside she would attempt to take them out depending on the weather and staff availability. Interview on 5/5/26 at 1:24 p.m., with nursing assistant (NA)-A identified R18 liked to go outside and sit in front of the building. The activity staff did take him outside when they can. R18 did go to the doors and attempt to go out on his own, but he has a wander guard on, so the door alarmed when he did that. R18 did make comments about not being able to go outside by himself. If someone cannot take him out front, we remind R18 he can go out in the courtyard by himself if he wants too. Interview on 5/5/26 at 2:58 p.m., with registered nurse consultant (RNC)-A identified R18 went out of the building but did not leave the premises so according to the facility policy that was not considered an elopement. She confirmed an elopement assessment had been completed on 3/24/26 and a wander guard had been applied to R18. When NC-A was asked if the care plan should have been revised to identify R18 was at risk for elopement with interventions of what staff were to do when he attempted to go outside, she stated I will not answer that. She then reported that the floor nurses do not update care plans as they have not been educated on updating care plans and at this time only NC-B and the interim director of nursing (IDON) updated care plans. Interview on 5/5/26 at 3:10 p.m., with RNC-B identified R18's care plan met the minimum requirements as RNC-B had put on R18's care plan that he had a wander guard per his elopement assessment. RNC-B agreed that the care plan could be more detailed and have identified interventions of what staff were to do if R18 was wanting to leave. Interview on 5/6/26 at 8:38 a.m., with licensed practical nurse (LPN)-B identified R18 asked to go outside all the time. R18 had moved from the attached assisted living to the nursing home a couple months ago. At that time while he was living in assisted living, he was free to walk around outside but he had declined, and it was just not safe for him to do that anymore. The ground was uneven, and she was not sure if he walked away from the facility, he would be able to find his way back. R18's cognition varies day by day, so it is hard for R18 to wait for someone to go outside with him. The staff try to take him outside when they can. Review of undated, Care Plan Revisions Upon Status Change policy identified when a resident experiences a change the facility will discuss the change and collaborate on intervention options. The team meeting would be documented in the resident medical record, and the care plan would be updated to reflect the change and new interventions. The nurse manager or designated staff member would communicate the changes to all staff involved with the resident's care.

Based on interview and document review the facility failed to obtain a bed hold for 1 of 4 sampled residents (R24) reviewed for hospitalization Findings include: R24's 4/16/26, accepted discharge with return anticipated Minnimum Data Set (MDS) assessment identified R24 had an unplanned short-term general hospital stay beginning on 4/2/26. Additionally, the 4/6/26, accepted quarterly MDS assessment identified R24's cognition was intact. He was independent with set-up assistance from staff for Activities of Daily Living (ADLS), except dressing of lower body, which required some assistance from staff. He was able to ambulate independently and used no assistive devices. R24 had diagnoses including emphysema, heart disease with high blood pressure, congestive heart failure, diabetes, difficulty swallowing, and chronic kidney disease. R24's progress notes identified on 4/2/26 at 10:30 a.m. R24 was increasingly fatigued this morning and continued to be weak and was taken to the clinic by his family. At 3:06 p.m. facility received a phone call that R24 had been admitted to acute care for Pneumonia. On 4/3/26 a 3:29 p.m., R24 remained hospitalized and was discharged from the facility with a return anticipated. Interview on 5/5/26 at 12:51 p.m. with nursing consultant (NC)-A and the interim director of nursing (IDON) confirmed a bed hold should have been completed when the facility was notified R24 had been admitted to the hospital and there was no indication a bed hold had been completed either verbally or in writing. Review of the February 2024 Bed Hold Responsibilities policy identified all residents leaving the facility due to hospitalization or a therapeutic leave and chose to return were to complete a Bed Hold. The policy identified charges that would be incurred with a Bed Hold but failed to identify the process for completion of a bed hold.

Based on observation, interview, and document review, the facility failed to ensure staff had appropriately followed medication administration through to completion for 1 of 1 sampled resident (R4) with a nebulized (inhaled) medication by providing appropriate supervision and follow policy and procedure for the cleaning of the medication cup after administration was completed. Findings include: R4's quarterly Minimum Data Set (MDS) assessment accepted on 4/6/26, identified her cognition was intact and had diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure with hypoxia (low oxygen levels), and was dependent on supplemental oxygen, sleep apnea. R4 required moderate assistance of 1 staff for transfers, dressing, and hygiene. Observation on 5/4/26 at 5:30 p.m., in R4's room identified a handheld nebulizer was lying on her end table still connected to the nebulizer machine. The cup that holds the liquid medication still contained approximately half of the liquid medication. R4 was not in the room. Observation and interview on 5/4/26 at 5:45 p.m., with registered nurse (RN)-A identified she observed the nebulizer cup on the end table. She agreed there was a moderate amount of medication remaining in the cup. She identified nursing should have followed up with R4 to ensure the medication had been fully administered. In addition, she said the handheld nebulizer should have been disassembled and rinsed following the completion of the administration to prevent potential infection. She further identified the nebulizer treatment was scheduled to be administered at 2:00 p.m., confirming this treatment had occurred 3 hours and 45 minutes prior to this observation. R4's May 2026 medication administration record (MAR) identified on 5/4/26 documentation that R4 had received a nebulizer treatment of ipratropium/albuterol inhalation solution 0.5-2.5 milligrams (MG) per milliliter (ML) for acute respiratory failure with hypoxia at 2:00 p.m The documentation identified RN-B had signed off the completion of the nebulizer treatment. The MAR further identified R4 was able to self-administer oral medications and nebulizers after set- up. Observation on 5/5/26 at 8:34 a.m., of R4's room identified her hand-held nebulizer was again laying on her end table assembled with approximately 1/4th of the liquid medication remaining in the cup. R4 was lying in bed asleep. Interview on 5/5/26 at 8:37 a.m., with licensed practical nurse (LPN)-A identified R4 had not been administered any medication for morning medication pass. She confirmed the nebulizer was still lying on the end table and had a small amount of medication still in the cup. She reviewed the medication record and identified the last nebulizer treatment had been during the night at 1:20 a.m. R4's 4/13/26, self-administration of medication assessment, completed by RN Consultant (RNC-B), identified R4 was not capable of self-administering inhalants or use inhalers without supervision. The summary identified R4 was not safe to self-administer at that time. Interview on 5/5/26 at 12:35 p.m., with RNC-B identified he had completed the assessment when R4 returned following a hospital stay on 4/13/26. He identified the assessment was accurate and agreed he did not update R4's administration record to show she was no longer safe to self-administer nebulizer treatments. He agreed he should have updated the MAR immediately to ensure nursing staff were aware they would need to supervise R4 while she completed her nebulizer treatments. Interview on 5/5/26, at 1:00 p.m., with the interim director of nursing (IDON) identified it was her expectation that staff follow the facility policy for nebulizer treatments. She further identified they have noted in the orders if a resident is safe to self-administer and that all areas of the electronic medical record should have been updated immediately following the change with re-assessment. Review of the undated facility Nebulizer Therapy Policy identified staff were to verify the order, assemble the tubing and nebulizer cup, place the ordered medication solution into the nebulizer cup, remain with the resident during the procedure and monitor for any change in condition. When the medication is complete, staff were to disassemble, rinse the nebulizer with warm water and allow to air-dry.

Based on observation, interview and document review, the facility failed to ensure documentation of 1 of 1 sampled resident's (R4) ability to self-administer medication was consistent and accurate throughout the medical record.Findings include: R4's quarterly Minimum Data Set (MDS) assessment accepted on 4/6/26, identified her cognition was intact, she had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. R4 requires moderate assistance of 1 staff for transfers, dressing, and hygiene. Observation on 5/4/26 at 5:30 p.m., in R4's room identified a handheld nebulizer was lying on her end table still connected to the nebulizer machine. The cup that holds the liquid medication still contained approximately half of the medication. R4 was not in the room. R4's May 2026 medication administration record (MAR) identified on 5/4/26 staff documented that R4 had received a nebulizer treatment of ipratropium/albuterol inhalation solution 0.5-2.5 milligrams (MG) per milliliter (ML) for acute respiratory failure with hypoxia at 2:00 p.m., the documentation identified RN-B had signed off the completion of the nebulizer treatment. The MAR further identified R4 was able to self-administer oral medications and nebulizers after set- up. R4's 4/13/26, self-administration of medication assessment, completed by RN Consultant (RNC-B), identified R4 was not capable of self-administering inhalants or use inhalers without supervision. The summary identified R4 was not safe to self-administer at that time. Interview on 5/5/26 at 12:35 p.m., with RNC-B identified he had completed the assessment when R4 returned following a hospital stay on 4/13/26. He identified the assessment was accurate and agreed he did not update R4's administration record to show she was no longer safe to self-administer nebulizer treatments. He agreed he should have updated the MAR immediately to ensure nursing staff were aware they would need to supervise R4 while she completed her nebulizer treatments. Interview on 5/5/26, at 1:00 p.m., with the interim director of nursing (IDON) identified it was her expectation that staff follow the facility policy for nebulizer treatments. She further identified they have it noted in the orders on the MAR if a resident is safe to self-administer and that should have been updated immediately following the change with re-assessment. Review of the undated facility Resident Self-Administration of Medication policy identified the interdisciplinary team (IDT) would complete the assessment to determine if the resident was clinically appropriate to self-administer medications. The results of the IDT assessment were to be recorded on the Medication Self-Administration Assessment form and added to the resident's medical record. The policy made no mention that staff were to update/revise the MAR to reflect the results of the assessment.

Based on observation, interview, and document review the facility failed to ensure 1 of 1 observed nebulizer (inhaled medication) medication cup was rinsed and left to air dry after each medication administration for 1 of 1 resident (R4) to prevent potential complication of infection. Findings include: R4's quarterly Minimum Data Set (MDS) assessment accepted on 4/6/26, identified her cognition was intact, she had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. R4 requires moderate assistance of 1 staff for transfers, dressing, and hygiene. Observation on 5/4/26 at 5:30 p.m., in R4's room identified a handheld nebulizer was lying on her end table still connected to the nebulizer machine. The cup that holds the liquid medication still contained a approximately half of the medication. R4 was not in the room. Observation and interview on 5/4/26 at 5:45 p.m., with registered nurse (RN)-A observed the nebulizer cup on the end table. She agreed there was a moderate amount of medication remaining in the cup. She identified nursing should have followed up with R4 to ensure the medication had been fully administered, in addition she said the handheld nebulizer should have been disassembled and rinsed following the completion of the administration. She further identified the nebulizer treatment was scheduled to be administered at 2:00 p.m., confirming this treatment had occurred 3 hours and 45 minutes prior to this observation. R4's May 2026 medication administration record (MAR) identified on 5/4/26 staff documented that R4 had received a nebulizer treatment of ipratropium/albuterol inhalation solution 0.5-2.5 milligrams (MG) per milliliter (ML) for acute respiratory failure with hypoxia at 2:00 p.m. The documentation identified RN-B had signed off the completion of the nebulizer treatment. The MAR further identified R4 was able to self-administer oral medications and nebulizers after set- up. Observation on 5/5/26 at 8:34 a.m., of R4's room identified her hand-held nebulizer was again laying on her end table assembled with approximately 1/4th of the liquid medication remaining in the cup. R4 was lying in bed asleep. Interview on 5/5/26 at 8:37 a.m., with licensed practical nurse (LPN)-A identified R4 had not been administered any medication yet that morning. She confirmed the nebulizer was still lying on the end table and had a small amount of medication still in the cup. She reviewed the medication record and identified the last nebulizer treatment had been during the night at 1:20 a.m. R4's 4/13/26, self-administration of medication assessment, completed by RN Consultant (RNC-B), identified R4 was not capable of self-administering inhalants or use inhalers without supervision. The summary identified R4 was not safe to self-administer at that time. Interview on 5/5/26, at 1:00 p.m., with the interim director of nursing (IDON) identified it was her expectation that staff follow the facility policy for nebulizer treatments. She further identified she would expect staff to remain with the resident to ensure the entire dose of the medication was administered. She would expect it to be noted in the orders if a resident is safe to self-administer and that should have been updated immediately following the change with re-assessment. Review of the undated facility Nebulizer Therapy Policy identified staff were to verify the order, assemble the tubing and nebulizer cup, place the ordered medication solution into the nebulizer cup, remain with the resident during the procedure and monitor for any change in condition. When the medication is complete, staff were to disassemble, rinse the nebulizer with warm water and allow to air-dry.

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 18 residents. Findings include: Review of the monthly QAPI meeting minutes from November 2024 identified department heads were bringing data forth to QAPI on various topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, adverse event monitoring however, only falls and pressure ulcers had a benchmark goal identified with data but no analysis of the data or identified actions the facility was going to take to achieve their goals and monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. The other areas identified had no documented benchmarks for goals the facility was trying to achieve, nor analysis of the data brought forth, or identified actions the facility was going to take to achieve a goal. Review of the monthly QAPI meeting minutes from January 2025 identified department heads were bringing data forth to QAPI on various topics such as medications, nutritional risk, staffing, admissions and discharges, activities, infection control, falls and adverse event monitoring. There were no documented benchmarks for goals the facility was trying to achieve, nor analysis of data brought forth, identified actions the facility was going to take to achieve their goals, and monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Review of the monthly QAPI meeting minutes from April 2025 identified department heads were bringing data forth to QAPI on various topics such as falls, quality indicator data, activities, pharmacy report, weight summary report, maintenance report, admissions and discharges however, there was no documented benchmarks for goals the facility was trying to achieve, nor analysis of data brought forth, identified actions the facility was going to take to achieve their goals, and monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Interview on 4/22/25 at 3:53 p.m., with regional administrator identified the facility had not identified goals, action plans, or analyzed data brought forth in the QAPI meetings and the facility would be working on that. Review of the undated, Quality Assurance and Performance Improvement (QAPI) policy identified the QAPI committee would oversee areas for improvement, develop an action plan, and analyze the results of the plan. The facility would maintain evidence of the ongoing QAPI program with documentation of data, analysis, and implementation and evaluation of actions for improvement activities.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 18 residents. Findings include: Review of QAPI minutes from 11/8/24 through 4/11/25 identified No PIP projects were noted. Interview on 4/22/25 with regional administrator (RA) identified the facility had identified a PIP project however, they had not developed a goal, there was no action plan, it had not been discussed at the QAPI meeting, and no staff had been trained. The RA agreed the facility failed to have the identified PIP follow through. Review of the undated, Quality Assurance and Performance Improvement (QAPI) policy identified the QAPI committee would oversee areas for improvement, develop an action plan, and analyze the results of the plan. The facility would maintain evidence of the ongoing QAPI program with documentation of data, analysis, and implementation and evaluation of actions for improvement activities.The policy identified that the facility would conduct at least one distinct PIP project annually that focused on high risk or problem areas.

Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure they received reports from the infection preventionist on the infection control program for 1 of 3 quarters reviewed. Findings include: Review of monthly QAPI meeting minutes of November 2024, January 2025 and April 2025 identified that April had no data brought forth or report on the infection control program for review by the QAPI committee. The April QAPI meeting sign in sheet identified attendance by the director of nursing (DON) as the infection preventions/DON. Interview on 4/22/25 at 4:46 p.m., with the administrator identified he was unaware that the infection preventionist had not provided data or a report on the infection control program however, he confirmed he was at the meeting. He revealed he had received his administrator license 4 weeks ago and the facility had a lot of turnovers recently as the social service designee had resigned and the director of nursing was an interim, so he did not realize the infection control information had been missed. No policy obtained related infection preventionist presenting at QAPI meeting related to infection trends or other pertinent data.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness dependent upon their symptoms. In addition, the facility failed to ensure 2 of 5 (certified nursing assistant and dietary aide) had completed tuberculosis testing (TST) upon hire. This had the potential to affect all 18 residents in the facility Findings include: EMPLOYEE SURVEILLANCE Review of Employee Absence Report sheets from April 2025 identified the following areas of documentation: employee name, date, time, called in, scheduled shift, reason for absence, illness and symptoms, physician visit and date of visit. However, the facility did not accurately complete the logs to ensure all necessary information was monitored. On: 1) 4/2/25, nurse aide (NA)-D was noted to have called in sick from work with symptoms of not feeling well and unable to sleep and stomach issues. U-A was not seen by a physician. There was no mention when or if NA-D's symptoms resolved prior to returning to work. 2) 4/2/25, the activity director (AD) was noted absent from work. It is unknown if they reported to work that day, developed symptoms and then left, or had called in. Symptoms noted were a cough, stuffy nose, sore throat, and a tight chest. There was no mention if they had tested for potential COVID or if/when symptoms resolved, and if they were cleared to return to work. 3) 4/07/25, the AD was then was identified as having had pneumonia. The form indicated the AD had seen the physician. There was no mention of what symptoms the AD had, if they had tested for potential COVID, if the pneumonia was potentially contagious, or if/when the AD's symptoms resolved. 4) 4/17/25, NA-C called in for work. No symptoms were noted. The form lacked any other details. 5) 4/17/25, the administrator was noted to be absent. It is unknown if the administrator called in to work or became ill after reporting to work. Symptoms reported were cough and loss of voice. The form identified the administrator had tested for COVID and influenza and was found to be negative. 6) 4/18/25, licensed practical nurse (LPN)-A was sick and reported to have had a fever. There was no mention if staff had tested for potential COVID, or if/when LPN-A's symptoms resolved. There was no mention on the forms of dates when staff returned to work or if they met any criteria to return to work. Interview on 4/22/25 at 10:48 a.m., the interim director of nursing (DON) identified the facility had not completed employee illness surveillance. The DON identified there were areas of concern that was deficient and would need to implement a process to manage effective tracking of employee illnesses. Review of Employee Illness policy identified the facility staff who were direct or indirect care staff, who had symptoms of an illness, would report the to charge nurse or the infection preventionist (IP) to determine when an employee was to return to work. The policy identified examples of illnesses, work restrictions, and duration of the restriction for facility staff and was directed contact the state department for guidance. Lastly, the policy indicated facility staff was to contact the IP or supervisor before returning to work. TB Review of the July 2013, Tuberculosis Control in Minnesota Health Care Settings identified all employees should have TB screening and an employee may begin working with patients after a negative TB symptom screen (i.e., no symptoms of active TB disease) and a negative IGRA or TST (i.e., first step) dated within 12 months before hire. The second TST may be performed after the health care worker (HCW) starts working with patients. Review of employee health file for certified nursing assistant (NA)-B identified NA-B was hired on 2/11/25. NA-B had a baseline TB symptom screening and a first step TST completed on 3/19/25. The form lacked evidence of a second TST. Review of employee health file of dietary aide (DA)-A was hired 3/11/25. DA-A had a baseline TB symptom screening and a first step TST on 3/11/25. The form lacked evidence of a second TST. Interview on 4/22/25 at 10:56 a.m. with registered nurse (RN)-B consultant and the interim director of nursing (DON) had voiced agreement that new hires should have TB screening and testing completed upon hire. Review of current, undated Tuberculosis (TB) Screening--Employees policy identified the facility should screen all health care personnel upon hire and was to follow the centers of disease control and prevention (CDC) recommendations. In addition, the TB screening was to include a baseline individual TB risk assessment, TB symptom evaluation, and TB testing.

Based on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's director of nursing (DON)) had completed specialized training in infection prevention and control. This had the potential to affect all 18 residents residing in the facility. Findings include: Interview on 4/22/25 at 10:23 a.m., with the interim director of nursing (DON) identified she oversees the infection control program but had not completed her IP training and certification course. Interview on 4/22/25 at 10:24 a.m., with registered nurse (RN)-B, who is the facility consultant, identified the facility used advertisements through online job boards to recruit a permanent DON, as well, as an assistant director of nursing (ADON) to oversee the infection control program. Interview on 4/22/25 at 10:46 a.m., with the regional administrator identified the facility did not have a certified IP who worked at least part time nor onsite at the facility. An Indeed (online job search website) post identified the facility had listed for an IP under the ADON position. The qualification was for the ADON to have education, training, experience or certification related to infection control and prevention. Review of 4/22/25 at 5:25 p.m., email correspondence identified the interim DON was hired January 2025. Review of the current, undated facility's Infection Surveillance-Overview policy identified the IP would lead, document and monitor surveillance findings to the quality assessment and assurance committee (QAA), and local health authorities, as needed. The IP was to properly identify active communicable disease or infections, provide staff training, data collection of infected residents, observation and audits, and to track employees, volunteer and agency staff of flu and gastrointestinal outbreaks, as needed.

Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility's specific Quality Assurance Performance Improvement (QAPI) Program to all staff to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how staff was to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the potential to affect all 18 residents. Findings include: Interview on 4/22/25 at 11:03 a.m., with nursing assistant (NA)-C identified that the facility had QAPI meetings, but she was unsure when they last had one. She was unaware of anything the facility was working on and had no training on what the facility was working on for QAPI but did complete QAPI training on Health Academy the facilities online training. Interview on 4/22/25 at 3:53 p.m., with regional administrator identified that there had been no staff training specific to the facility's own QAPI program. Interview on 4/22/25 at 4:28 p.m. with dietary aide (DA)-B identified she completed QAPI training on the Health Academy but had no other training. She reported she would not know anything about what the facility was working on as she worked in the kitchen. Interview on 4/22/25 at 4:30 p.m., with activity aide (AA)-A identified she had no training on QAPI and was not aware of anything the facility had worked on or was working on. No policy related to facility staff training on their QAPI program provided by end of survey.

Based on interview and document review the facility failed to follow facility policies and ensure reports to the State Agency (SA) were submitted not later than 2 hours for an incident of potential abuse or neglect for 1 of 1 resident (R15) after the facility became aware of the incident. Findings include: Review of 2/14/25 at 11:03 a.m. Incident Huddle progress note identified R15 had an unwitnessed fall from his Broda chair ( wheelchair that provides comfort, support, and mobility) on 2/13/25 at 4:00 p.m., when he was unattended in the day room. R15 was not able to verbalize what he had been attempting to do related to his dementia. The note identified no injury from this fall, but identified his right hand remained swollen from a previous middle finger fracture. R15's 3/19/25 quarterly Minimum Data Set (MDS) assessment identified he had severe cognitive impairment, and moderate to severe depression according to his PHQ-9 score of 15/27. R15 required extensive to total assistance with activities of daily living (ADLS) from 1-2 staff persons. R15's diagnoses included non-traumatic brain dysfunction, dementia, depression, and other fracture. He received pain medications as needed, and scheduled antidepressant and anti-platelet medications. R15's current undated care plan identified he required total assistance with ADLs and had the potential for physical aggression toward staff during cares related to his dementia. Triggers were identified as not liking to be woken up, with de-escalation techniques of allowing time to wake up, explain tasks prior to initiating, move slowly, and leave in a safe position and return later. The care plan identified he had a fall without injury and a history of frequent falls. He had a fall alert system on both his bed and wheelchair, a floor mat with the bed in low position, and following the 2/13/25 fall the intervention to tip the Broda chair back slightly when left unattended in his chair. Nursing staff were to be notified if he was left in his Broda chair unattended, and out of his room. Interview on 4/22/25 at 1:26 p.m., with nursing assistant (NA)-A reported R15 had dementia and was not able to consistently communicate his needs. She reported he required 1-2 staff assistance with ADLS and that he also was combative at times when staff were attempting to provide cares. She reported she was not aware of R15 having any recent falls, and she was not aware of how he had injured his right hand. NA-A reported she had received annual education on Vulnerable adult and reporting of bruising or injury to the charge nurse. Interview on 4/22/25 at 1:45 p.m., with the DON reported R15 had fallen from his Broda chair on 2/13/25 p.m. at 4:00 p.m. when he had been positioned upright in his Broda chair and left unattended in the day room. There was no injury noted on the incident report of the unwitnessed fall, but the progress note identified swelling in his right hand from a previous finger fracture. The DON reported it was felt R15 had injured the middle finger on his right hand when he had struck out at staff, but she was not able to provide any report of the unwitnessed injury, or that a report had been made to the SA. She reported she would need to investigate the matter further, for documentation of the incident. A subsequent interview on 4/22/25 at 1:50 p.m. with the DON identified she had reviewed R15's EMR, and the Risk Management record, and there was no documentation of an injury prior to the 1/23/25 note, nor was she able to locate an incident report or evidence the incident on 1/23/25 had been reported to the SA. She stated her expectation for any resident bruise or injury to be reported and documented, and if there was no evidence of the cause it should have been reported to the SA. Interview on 4/22/25 at 3:50 p.m. with the facility administrator reported his expectation for an injury of unknown origin to be investigated, and incident report completed and reported to the SA according to the facility policy and regulations. Interview on 4/22/25 at 3:53 p.m., with the consulting administrator reported she recalled having been notified of R15's injury and had contacted the interim Social Services Designee (SSD) to investigate the incident. She reported she thought the injury had occurred due to R15 being combative, and she would look for the investigation report. She questioned if the injury was reportable to the SA, but agreed the injury was unwitnessed and there was no documentation in the record of a cause of injury. On 4/22/25 at 4:25 p.m., the administrative consultant returned and identified there was not adequate investigation or reporting of the injury of unknown cause which she would have expected to be documented on an incident report and reported the SA according to the facility policy on Abuse. Review of the undated posting Suspected Abuse/Reportable Incidents Guide identified suspected abuse and/or reportable incidents were reportable to the SA within 2 hours of discovery. The instructions directed staff to report and then investigate. Staff were to locate the Vulnerable Adult Reporting packet which provided step by step instructions on the process to be followed. Examples of reportable incidents to the SA included injuries of unknown origin, such as a fracture with no fall, bruises, or injury without a known cause. Review of the February 2024 Policy Abuse Prevention Program identified the facility was to develop and ensure implementation of policies to train staff in abuse prevention and identify and report incidents in addition to handling verbal or physical aggressive resident behavior. Review of the undated facility policy Conducting Internal Investigations identified investigations could include review and preservation of any documents, interview of appropriate staff and/or residents; review of policies and procedures; collaboration with facility administration' and engagement of an outside consultant, authority, or law enforcement to assist in the investigation.

Based on interview and document review the facility failed to throughly investigate an injury of unknown origin for 1 of 1 resident (R15). Findings include: Review of 2/14/25 at 11:03 a.m. Incident Huddle progress note identified R15 had an unwitnessed fall from his Broda chair ( wheelchair that provides comfort, support, and mobility) on 2/13/25 at 4:00 p.m., when he was unattended in the day room. R15 was not able to verbalize what he had been attempting to do related to his dementia. The note identified no injury from this fall, but identified his right hand remained swollen from a previous middle finger fracture. R15's 3/19/25 quarterly Minimum Data Set (MDS) assessment identified he had severe cognitive impairment, and moderate to severe depression according to his PHQ-9 score of 15/27. R15 required extensive to total assistance with activities of daily living (ADLS) from 1-2 staff persons. R15's diagnoses included non-traumatic brain dysfunction, dementia, depression, and other fracture. He received pain medications as needed, and scheduled antidepressant and antiplatelet medications. R15's current undated care plan identified he required total assistance with ADLs and had the potential for physical aggression toward staff during cares related to his dementia. Triggers were identified as not liking to be woken up, with de-escalation techniques of allowing time to wake up, explain tasks prior to initiating, move slowly, and leave in a safe position and return later. The care plan identified he had a fall without injury and a history of frequent falls. He had a fall alert system on both his bed and wheelchair, a floor mat with the bed in low position, and following the 2/13/25 fall the intervention to tip the Broda chair back slightly when left unattended in his chair. Nursing staff were to be notified if he was left in his Broda chair unattended, and out of his room. Review of Risk Management in Point Click Care (PCC) for R15 failed to identify the injury on his right middle finger that was documented on 1/23/25 at 3:38 p.m. in the Progress notes by an unidentified Restorative NA. The progress note on 1/24/25 at 2:53 p.m., identified swelling in R15's right hand, and no evidence of injury. On 1/24/25 at 7:17 p.m., the progress note identified greenish/purplish discoloration between R15's second, third and fourth fingers and he became, teary eyed when his hand was touched. The note identified R15 was administered Tylenol for discomfort, and a family member was contacted and gave authorization for R15 to be further evaluated in the Emergency Department. R15 returned on 1/24/25 at 9:30 p.m. with a diagnosis of a closed, displaced fracture of his proximal phalanx of his right middle finger. Both the family member and the DON were notified of R15's return and diagnosis. There was no documentation of investigation into R15's right hand fracture. Interview on 4/22/25 at 1:26 p.m., with nursing assistant (NA)-A reported R15 had dementia and was not able to consistently communicate his needs. She reported he required 1-2 staff assistance with ADLS and that he also was combative at times when staff were attempting to provide cares. She reported she was not aware of R15 having any recent falls, and she was not aware of how he had injured his right hand. NA-A reported she had received annual education on Vulnerable adult and reporting of bruising or injury to the charge nurse. Interview on 4/22/25 at 1:45 p.m., with the DON reported R15 had fallen from his Broda chair on 2/13/25 p.m. at 4:00 p.m. when he had been positioned upright in his Broda chair and left unattended in the day room. An incident report was available in PCC and identified he had no injury from the unwitnessed fall, but the progress note Incident/Huddle on 2/14/25 at 11:03 a.m. identified swelling in his right hand from a previous finger fracture. The DON reported it was felt R15 had injured the middle finger on his right hand when he had struck out at staff, but she was not able to provide any documentation to indicate the finger fracture had been investigated, nor that a report had been made to the SA. A subsequent interview on 4/22/25 at 1:50 p.m. with the DON identified she had reviewed R15's EMR, and the Risk Management record, and confirmed there was no documentation of an injury prior to the 1/23/25 note, nor was she able to locate an incident report or evidence the incident on 1/23/25 had been reported to the SA. She stated her expectation for any resident bruise or injury to be reported and documented, and if there was no evidence of the cause it should have been reported to the SA. Interview on 4/22/25 at 3:50 p.m. with the facility administrator reported his expectation for an injury of unknown origin to be investigated, and incident report completed and reported to the SA according to the facility policy and regulations. Interview on 4/22/25 at 3:53 p.m., with the consulting administrator reported she recalled having been notified of R15's injury and had contacted the interim Social Services Designee (SSD) to investigate the incident. She reported she thought the injury had occurred due to R15 being combative, but returned at 4:25 p.m. and confirmed R15's finger fracture had not been investigated appropriately and an incident report should have been completed according to her expectation. She also voiced agreement that there should have been a report to the SA and further investigation following R15's ED evaluation with diagnosis of a fracture to his right middle finger and she would look for the investigation report. She questioned if the injury was reportable to the SA, but agreed the injury was unwitnessed and there was no documentation in the record of a cause of injury. Review of the undated, facility policy Conducting Internal Investigations identified investigations could include review and preservation of any documents, interview of appropriate staff and/or residents; review of policies and procedures; collaboration with facility administration' and engagement of an outside consultant, authority, or law enforcement to assist in the investigation.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 21 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/6/23, 7/10/23, 7/12/23, 7/13/23, 7/14/23, 7/15/23, 7/16/23, 7/17/23, 7/18/22, 7/19/23, 7/20/23, 7/24/23, 7/25/23, 7/28/23, 7/29/23, 7/30/23, 7/31/23, 8/3/23, 8/5/23, 8/6/23, 8/8/23, 8/9/23, 8/10/23, 8/11/23, 8/12/23, 8/13/23, 8/14/23, 8/15/23,/8/16/23, 8/17/23, 8/18/23, 8/20/23, 8/21/23, 8/22/23, 8/23/23, 8/24/23, 8/25/23, 8/26/23, 8/27/23, 8/28/23, 8/29/23, 8/30/23, 8/31/23, 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/6/23, 9/7/23, 9/8/23, 9/9/23, 9/10/23, 9/11/23, 9/12/23, 9/13/23, 9/14/23, 9/15/23, 9/16/23, 9/18/23, 9/19/23, 9/20/23, 9/22/23, 9/23/23, 9/24/23, 9/27/23, 9/28/23, 9/29/23 for failure to have licensed nurse coverage 24 hours per day. In addition, excessively low weekend staffing triggered for review. Review of staffing schedules from 7/1/23 thorough 9/30/23, identified the facility had eight staff identified to have worked: registered nurse (RN)-A, RN-B, Licensed Practical Nurse (LPN)-B , LPN-C, LPN-D, LPN-E, LPN-F, and director of nursing (DON) on each of the above dates listed. In addition, review of staff's time cards from 7/1/23 through 9/30/23, on the above-mentioned dates identified licensed nursing staff had worked. Review of facility schedules and staff's time cards from 7/1/23 through 9/30/23 identified sufficient staff coverage for weekends. Review of the facility's staffing schedules and time cards identified discrepancies with the PBJ report. During an interview on 2/28/24 at 10:04 a.m., director of nursing (DON) and executive administration (EA) confirmed the above findings and stated licensed staff had worked on the dates mentioned above. In addition, the DON confirmed sufficient weekend staffing had taken place between the use of current, contracted employees and herself. DON stated when she punched in her hours were not accurately being pulled to the PBJ report. EA indicated the PBJ report was inaccurate and was aware of the issues. Review of facility policy titled Payroll Based Journal undated, identified it was the policy of the facility to electronically submit timely to Centers for Medicare & Medicaid (CMS) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. This deficient practice had the potential to affect all 21 residents who received food and beverages from the refrigerators. Findings include: On [DATE] at 1:15 p.m., during the final tour of the kitchen area with the dietary manager(DM), the following concerns were identified.: Kitchen refrigerator: -large plastic container ,d+[DATE] full of V8 vegetable juice with black crusty substance around the lid without any notation of the date it was opened. Resident freezer: - two ice packs with eight containers of ice cream and six ice cream bars. Resident Refrigerator: - ,d+[DATE] bottle of Soda stream mix opened [DATE]. - ,d+[DATE] container of Italian coffee creamer opened [DATE], with a manufacturer's expiration date of [DATE]. - ,d+[DATE] container of Gatorade opened with no date or resident name. - ,d+[DATE] bottle of cranberry juice with no date or resident name with a manufacturer's expiration date of ,d+[DATE]. - eight pieces of lefse in a Ziploc bag with no date or resident name. - ,d+[DATE] bottle of pickled herring with a white crusty substance on the lid with no date or resident name. - ,d+[DATE] piece of chocolate cake with no date or resident name. During an interview on [DATE] at 3:18 p.m., DM confirmed the above findings and indicated the residents had recently been served the above items. DM stated all the above items should have been discarded. DM stated the resident fridge was a shared responsibility of nursing and dietary and was unsure that last time it had been checked for dated or expired items. DM stated his expectation was all items would have been dated and discarded per facility policy. During an interview on [DATE] at 3:33 p.m., director of nursing (DON) stated she was unaware of the undated and outdated food in the refrigerators. DON stated she was unsure of who's responsibility the resident refrigerator was however her expectation was that all food would have been dated and thrown out per facility policy. Review of a facility policy titled Refrigerator Cleaning Instruction Policy & Procedure undated, indicated all foods should be covered, labeled, dated, and routinely monitored to assure that foods (including leftovers) would be consumed by their safe use by dated, or frozen (where applicable), or discarded. Review of a facility policy titled Use & Storage of Food and Beverage Brought in for Residents by Family and Visitors dated [DATE], indicated staff would label with resident name and date food and beverage items were brought in for residents. Indicated staff would monitor food and beverage items for use -by dates and notify resident when items needed disposal.

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R4, R15, R8, R1, R2) were offered or received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations dated 3/15/2023, revealed The Center for Disease Control and Prevention (CDC) identified adults [AGE] years of age or older who had not previously received any pneumococcal vaccinations or one dose of Pneumococcal 13-valent Conjugate Vaccine (PCV13) should receive one dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20) or one dose of Pneumococcal Polysaccharide Vaccine 23 (PPSV23). Adults [AGE] years of age or older who received one or more does of PCV13 and one dose of PPSV23 should receive a dose of PVC20. Shared clinical decision-making for those who already completed the series PCV13 and PPSV23 should occur. Together, with the patient, vaccine provider may choose to administer PCV20 to adults greater than [AGE] years who already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. Review of R4's immunization report, R2, age 87, was admitted to the facility on [DATE]. Review of R4's Minnesota Immunization Information Connection (MIIC) undated, identified R4 had not received a pneumococcal vaccination. R4's medical record lacked documentation R4 had been offered or received the PCV20 or PPSV23 vaccines. Review of R15's immunization report, R15, age 100, was admitted to the facility on [DATE]. Review of R15's MIIC undated, identified R15 had received the PCV-13 vaccination on 9/14/16. R15's medical record lacked documentation R15 had been offered or received the PCV20 or PPSV23 vaccines. Review of R8's immunization report, R8, age 89, was admitted to the facility on [DATE]. Review of R8's MIIC undated, identified R8 had received the PCV-13 vaccinations on 7/29/15 and 8/24/18. In addition, R8 received the PPSV23 vaccination on 10/31/16. R8's medical record lacked documentation R8 had been offered or received the PCV20 vaccine based on shared clinical decision-making with the provider. Review of R1's immunization report, R1, age 82, was admitted to the facility on [DATE]. Review of R1's MIIC undated, identified R1 had received the PCV-13 vaccination on 12/5/17, and received the PPSV23 vaccination on 8/23/12. R1's medical record lacked documentation R1 had been offered or received the PCV20 vaccine based on shared clinical decision-making with the provider. Review of R2's immunization report, R2, age 88, was admitted to the facility on [DATE]. Review of R1's MIIC undated, identified R2 had received the PCV-13 vaccination on 5/6/16, and received the PPSV23 vaccination on 9/19/18. R2's medical record lacked documentation R2 had been offered or received the PCV20 vaccine based on shared clinical decision-making with the provider. During an interview on 2/28/24 at 9:54 a.m., director of nursing (DON) confirmed the above findings and indicated she and the assistant director of nursing (ADON) needed to go through each resident's chart to ensure immunizations were completed as required. DON stated the facility did not have a process to ensure residents were offered or received immunizations per CDC recommendations. A Pneumococcal vaccination policy was requested, however one was not provided.

Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R19) who was observed to self administer a nebulizer and had been assessed as not safe to self administer medications. Findings include: R19's admission Minimum Data Set (MDS) dated [DATE], indicated R19 was cognitively intact. Identified R14 had diagnoses which included heart failure, chronic obstructive pulmonary disease (COPD), and hypertension (high blood pressure). Indicated R19 required moderate assistance of one for personal hygiene and maximum assistance of one with toileting. Review of R19's electronic health record (EHR) revealed a SAM assessment had been completed on 1/8/24, which identified R19 was not capable of administering inhalants or inhalers and lacked physician's orders for self administration. R19's signed Physician's Telephone Orders signed 2/9/24, directed staff to administer DuoNeb Inhalation Solution 0.5-2.5 (3) milligrams (mg) per 3 milliliters (mL) (medication used to relax the muscles in the airways and increase air flow to the lungs) 1 vial inhale orally two times a day related to COPD. R19's care plan dated 2/12/24, indicated R19 was at risk for alterations in respiratory status, able to self administer medications after set-up (oral/inhalants or both), had an activities daily living (ADL) self-care performance deficit, and was legally blind. During an observation on 2/28/24 at 7:01 a.m., licensed practical nurse (LPN)-A applied gloves, reviewed R19's medications, gave R19 oral medications, checked oxygen saturations (O2), poured the neb solution into nebulizer container, turned on the nebulizer machine, handed R19 the nebulizer container and informed R19 she would be back. LPN-A then exited R19's room. During an observation on 2/28/24 at 7:21 a.m., LPN-A returned to R19's room, turned off the nebulizer machine, rinsed the nebulizer container, placed it on the counter to dry and exited R19's room. During an interview on 2/28/24 at 8:22 a.m., director of nursing (DON) verified the above information and confirmed R19 did not have an up-to-date SAM. DON indicated R19 had a SAM upon admission however a reassessment had not completed. DON stated R19 was able to self administer the nebulizer and a reassessment was needed. DON verified with the current SAM and lack of an order R19 should not have self administered the nebulizer. DON stated staff should have remained with R19 during the entire administration. DON stated her expectations were for staff to follow the self administration policy. Facility policy titled Self Administration of Medications revised 5/24/18, indicated it was the policy of the facility to assess the resident and determine if it was clinically appropriate for the resident to self administer. Facility policy titled Medication Administration revised 12/10/21, indicated it was the policy of the facility to ensure that residents had their medications administered in a safe manner. Trained staff would verify the medication order and specific instructions for administration.

Based on observation, interview, and document review, the facility failed to obtain and implement oxygen orders for 1 of 2 residents (R20) and reviewed for respiratory care. Findings include: R20's significant change Minimum Data Set (MDS) dated [DATE], indicated R20 was severely cognitively impaired and had diagnoses with included heart failure, cerebrovascular accident (CVA), and depression. R20's signed Provider Orders dated 2/9/24, lacked orders for oxygen use. R20's care plan dated 1/25/24, lacked a plan for oxygen use. R20's electronic medical record (EMR) dated 1/1/24 to 2/29/24, lacked orders to assess oxygen use. R20's Shortness of Breath assessment dated [DATE], indicated R20 was on one and a half liters (L) of oxygen per nasal cannula. During an observation on 2/27/24 at 9:44 a.m., R20 requested assistance, R20 stated her head was feeling funny. R20's oxygen tubing was hanging down from her left ear and the nasal cannula was not present in her nose. During an observation on 2/27/24 at 9:47 a.m., director of nursing (DON) entered R20's room to obtain vitals. The oxygen concentrator was running at two L via nasal cannula and DON placed the oxygen back on R20. DON completed an assessment on R20. R20's oxygen saturations (O2) were 94%. DON indicated she planned to contact hospice for additional assistance. During an observation on 2/27/24 at 10:01 a.m., R20 was seated in her recliner, oxygen was back in her nose via nasal cannula at 2L. During an observation on 2/27/24 at 10:33 a.m., R20 was seated in the commons area listening the the news/history being read. R20 did not have oxygen on at that time. During an observation on 2/27/24 at 12:00 p.m., R20 was seated at the dining table with three other residents waiting to receive her lunch meal. R20 did not have oxygen on at that time. During an observation at 2/27/24 at 4:28 p.m., R20 was seated in her recliner with her eyes closed and television was playing. Oxygen tubing was laying across the foot of her bed running at 2L. During an interview on 2/27/24 at 1:58 PM nursing assistant (NA)-A indicated R20 was receiving hospice services and required extensive assistance with cares. NA-A stated R20 was supposed to have oxygen on at two L of via nasal cannula while in her room. NA-A indicated nursing staff were responsible for setting the amount of liters of oxygen R20 was to be receiving. During an interview on 2/28/24 at 7:44 a.m., NA-B stated NA's can turn the oxygen machine on however nurses were responsible for setting the amount of liters the resident was using. During an interview on 2/28/24 at 8:53 a.m., hospice registered nurse (HRN) indicated R20 was admitted to hospice on 1/19/24, and oxygen orders were started at that time per hospice standing orders. HRN stated she was unaware if signed orders had been received and updated in R20's EHR. HRN stated she would call back to verify however, a call back was never received. During an interview on 2/28/24 at 9:06 a.m., assistant director or nursing (ADON) confirmed the above findings and indicated there were no signed oxygen orders present in R20's EHR. ADON indicated nursing staff would need to look at orders to confirm the oxygen settings and since there were no orders for oxygen present in R20's chart, nursing staff would not be able to implement the correct oxygen administration. During an interview on 2/28/24 at 9:52 a.m., DON confirmed the above findings and indicated no orders had been placed in R20's EHR. DON stated her expectations were that nursing staff would obtain a signed order from the provider and the order would be placed into the residents EHR. Review of facility policy titled Oxygen Administration revised 12/27/17, it was the policy of the facility to ensure that residents requiring oxygen administration received the correct concentration of oxygen via the appropriate equipment in a safe manner according to the physicians orders.

Based on observation, interview, and document review the facility failed to ensure insulin was administered according to manufacturer's guidelines for 1 of 1 resident (R1) resulting in the potential for serious harm or death when R1 had to be sent to emergency department (ED) for hypoglycemia (low blood sugar (BS)) when staff administered R1's insulin without ensuring he ate within the required time frame of 5-10 minutes. The IJ began on 2/5/24, when licensed practical nurse (LPN)-A failed to follow manufacturer guidelines when administering Novolog (a rapid acting insulin) to R1. R1 was administered insulin at 11:14 a.m. without being fed any type of meal or sustenance within 5-10 minutes of administration and was subsequently sent to the ED with severe hypoglycemia for medical treatment. The facility administrator and director of nursing (DON) were notified of the IJ on 2/21/24 at 2:22 p.m., which was identified at the scope and severity of J-ISOLATED. The IJ was removed on 2/22/24 at 11:37 a.m., but non-compliance remained at the lower scope and severity of D: No actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: Review of current, Novolog manufacturer guidelines for Novolog, located at https://www.mynovoinsulin.com/insulin-products/novolog/home.html, identified it was a rapid acting insulin and patients using Novolog should eat a meal within 5 to 10 minutes after taking it. Review of the 2/7/24, report to the State Agency (SA) identified LPN-A had checked R1's blood sugar at 11:14 a.m., then immediately administered 10 units of rapid acting Novolog insulin. R1 was found in his room unresponsive approximately 1 hour and 20 minutes later. It was discovered he had not eaten any of his dinner (normal was to consume 100% of his meals). R1's blood sugar was checked and found to be 39 (severe hypoglycemia requiring medical attention). He was given a tube of glucose gel. The DON and LPN-A suspected possible seizure activity and called for ambulance transport to the hospital's ED for evaluation and treatment. The DON identified in the report R1 was a brittle diabetic and should not have been administered his rapid acting insulin that long prior to receiving his meal or some form of sustenance. R1's 12/14/23, Minimum Data Set (MDS) identified R1 had a diagnosis of diabetes mellitus type II (DM) and he required staff assistance with meal tray set up or clean up. R1's 2/20/24, diagnosis list identified he had a developmental disorder and other signs and symptoms involving cognitive functioning. R1's Novolog physician orders identified the following on: 1) 6/20/23, R1 was to be given Novolog 10 units 2 x a day. No other instructions were noted on the order. 2) 2/9/24, R1 was to be given Novolog 10 units 2 x a day, however staff were to hold his insulin if his BS was less than 100 milligrams per deciliter (mg/dL). 3) 2/21/24, R1 was to be given Novolog per sliding scale. If R1's BS was 0-100 mg/dL, staff were to hold his insulin. It was also noted staff were to administer R1's insulin within 5-10 minutes before a meal. Meal times were listed as 12:00 noon and 4:50 p.m Staff were to ensure the resident received a meal within 10 minutes of administration. There was no mention staff should call the provider if the insulin was held to determine when they would potentially give it. R1's 2/5/24, Medication Administration Audit Report related to the above incident identified LPN-A checked R1's blood sugar which was 85 mg/dL and administered 10 units of Novolog at 11:14 a.m. at the time his insulin was administered. Observation on 2/20/24 at 11:45, with LPN-A identified she checked R1's blood sugar and documented it as being 86 mg/dL. She administered 4 ounces of orange juice and left the room. LPN-A was unable to be interviewed at this time. Interview on 2/20/24 at 12:30 p.m., with LPN-B identified staff were to check R1's blood sugar (BS) prior to dinner. If it was below 100 milligrams mg/dL, facility management advised staff they were to give him orange juice and give him dinner to artificially raise his BS to 100 mg/dL or above, and then go back and recheck his blood sugar so they could then administer his insulin, even though that was not according to the physician order noted above. She identified staff have no access to manufacturer's guidelines, nor had they any professional references to follow. Interview on 2/20/24 at 2:30 p.m., with the medical director (MD)-A identified while at the facility doing rounds on 2/9/24, he had been notified of the incident that occurred on 2/5/24 with R1. His understanding was R1's BS was at the lower end of normal when R1 was administered 10 units of Novolog. When made aware of how low R1's BS had gotten after the administration at the time of the 2/5/24 incident, MD-A stated R1 should not have been administered his insulin without getting food within 10-15 minutes of administration at the latest, and agreed that was what caused R1's acute hypoglycemic episode. After the incident, MD-A reviewed R1's medications on 2/9/24, and placed a new order for staff to hold his insulin if his BS was less than 100 mg/dL. He was unaware nursing staff were currently giving R1 orange juice in an attempt to elevate his BS so they could administer insulin (as seen in the above observation on 2/20/24 at 11:45 a.m.). MD-A identified this was not in accordance with his physician order. He would not expect staff to give orange juice unless R1's BS was below 70 mg/dL, as intentionally raising his BS prior to insulin would be counter-productive and not according to his MD order or manufacturer's guidelines. Interview on 2/20/24, at 2:40 p.m., with the DON identified she was unaware staff were not following the physician's current order for R1's insulin by holding his insulin if it dropped less than 100 mg. She was unaware there was no physician order to give R1 orange juice to artificially raise his blood sugar prior to administer insulin. She agreed she had directed staff to give orange juice to elevate his BS. She placed a re-education document in each nurse's mailbox for them to review after the incident occurred which included R1's insulin order. She identified all the staff signed and returned the printed information except for LPN-A who incorrectly administered R1's insulin at the time of the incident. She did not follow up with LPN-A to see if she had received the re-education document, and confirmed LPN-A had worked several more shifts following the incident. She did not complete any face-to-face training with any of the nursing staff and did not complete any competencies to confirm the training was successful. She identified LPN-B was contracted from an agency, and she does not do any re-education or competencies with contracted nurses. Review of the 2/7/24, Reportable Incident Re-education, identified signs and symptoms of hypoglycemia, which was also noted to be identified by a BS below 70 mg/dL regardless of the presence of symptoms. The document advised staff to not give fast acting insulin unless the resident will be eating in 20-30 minutes, if blood sugar is low you should wait to administer insulin until closer to meal-time or give an oral equivalent to increase their blood glucose level prior to administering the insulin. The document included a signature line for staff to sign indicating they read and understand the education and directions to return the form to the DON. The training document did not provide the correct administration guidelines for Novolog rapid acting insulin that was administered to R1 on 2/5/24. R1's current care plan printed 2/20/24, identified he had a diagnosis of DM and was at risk for alteration in glucose levels. Staff were to ensure R1 received his diet and medications as ordered, staff should be aware, observe, and report signs and symptoms of hypoglycemia (low blood sugar). Interview on 2/21/24 at 9:07 a.m., with dietary aid (DA)-A who delivered and picked up R1's meal tray the date of the incident identified that day staff were running behind in the kitchen. The dietary manager (DM) had gone to the assisted living area of the facility and did not return until 12:00 noon. Staff finished serving the residents in the dining room and then served the room trays. I delivered R1 his meal tray around 12:15, and I noticed he was 'loopy'. DA noted she had not reported R1's abnormal mental function to the nurse she observed when she delivered his room tray. DA-A reported she continued delivering room trays and returned to R1's room later around 12:45 to collect his tray and noticed he had not consumed any food and found R1 to be incoherent. DA-A left the room and reported to the nurse that something was wrong. Interview on 2/21/24 at 8:11 a.m., with LPN-A identified she had checked R1's blood sugar and administered Novolog on 2/5/24, at 11:15 a.m. She was not certain when he received his meal tray, and she did not alert the kitchen R1 had received his insulin or that he needed a meal tray right away. When she was told R1 was in his room and unresponsive, she went to assess R1 and found him to have a blood sugar of 39 mg/dL. She was able to arouse him enough to give him sips of orange juice and call the DON to bring the emergency kit to the room. He was diaphoretic (sweating) and swaying back and forth, and his speech was slurred. Glucose gel (sugar gel used in diabetic emergencies for low BS) from the emergency kit was administered. R1 started to display seizure like activity. LPN-A used her personal cell phone to call emergency services (EMS) for an emergency transport to the ED for evaluation and treatment. R1's 2/5/24, ED provider notes identified R1 presented to the ED at 1:45 p.m., after being found to be hypoglycemic and having a blood sugar of 39 mg/dL. R1 was diagnosed as having had an episode of acute hypoglycemia due to insulin administration. He had received glucose prior to arrival and was served a plate of food while at the ED. R1 returned to baseline, laboratory tests were completed and R1 was discharged from the ED back to the facility at 4:45 p.m. Interview on 2/21/24, at 9:36 a.m., with administrator identified he would have expected the DON to provide face to face training and competencies with all licensed nurses following the incident and prior to their next shift to avoid an incident like this from happening again. Review of the current, undated Insulin Pen and Storage Policy identified how staff were to administer insulin. Staff were to always review the physician order prior to administering any medication. Next, the procedure was described, however, monitoring for signs or symptoms of hypoglycemia was not present, nor was there any indication staff should contact the physician and hold the insulin if it fell below acceptable parameters. Review of the 3/17/17 Notification of Changes in Resident Condition policy identified a significant change in status was noted to be a deterioration in health that could lead to a life-threatening condition or clinical complications. The objective of the policy was to ensure staff made the appropriate notification to a physician where there was a change in a residents condition that may require physician intervention. There was no mention on any specifics related to insulin administration or hypoglycemia noted to identify when those situations would require an immediate call to EMS or the physician. The IJ was removed on 2/22/24 at 11:37, when it could be verified through observation, staff interviews, and document review, the facility medical director reviewed R1's current physician order and made appropriate changes to follow manufacturers guidelines. Face-to-face education was provided to licensed nurses on how to manage diabetics with respect to low BS or changes of condition, insulin administration, review of the facility's insulin pen policy and manufacturer guidelines for Novolog and was completed prior to licensed staff returning to work on the unit.

Based on interview and document review, the facility failed to ensure an emergency dental agreement had been completed which had the potential to affect all 22 residents residing in the facility reviewed during the extended survey. Findings include: During the extended survey document review on 2/21/24 at 2:20 p.m., a copy of the facility dental agreement was requested. The facility was unable to provide a copy of an agreement. The Administrator confirmed the facility did not have a current dental agreement in place. There was no policy related to ensuring dental services were provided through contract.

Based on interview and document review, the facility failed to identify, intervene and notify the physician for 1 of 1 resident (R22) with a significant medical decline requiring immediate medical assessment. The facility's failure resulted in R22 being sent from the facility via ambulance (EMS) to a local hospital and immediately transfered to a regional hospital for a higher level of care (ICU). R22 succumbed to his illness and later died . The IJ began on [DATE], when R22's decline began to occur and staff failed to identify abnormally low oxygen saturations (SpO2), causing R22 to become hypoxic (lack of oxygen in blood). The facility interim administrator, the administrator in training, and the director of nursing (DON) were notified of the IJ on [DATE] at 1:43 p.m The IJ was removed on [DATE] at 2:10 p.m., but non-compliance remained at the lower scope and severity of D- no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: R22's discharging hospital records, [DATE], identified R22 was admitted for rehabilitation from COVID-19 with additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 required the support of 1 staff with use of a walker for mobility and was admitted to the facility for strengthening. R22 required 2 liters (L) oxygen (O2) at rest and 4L with exertion. R22 was to have SpO2 at 80% or above while resting and no less than 75% with exertion or activity. R22 was a full code. Staff were to call 911 if it was a medical emergency, and notify the physician if they felt he was getting worse or had an increase in problems, if he had a fever over 101 degrees Fahrenheit (F), any sign of infection, coughing, vomiting blood, sever pain, or weight gain of over 3 pounds (lbs) overnight or 5 lbs in a week. R22's progress notes from [DATE] to [DATE] identified the following: 1) [DATE] at 1:30 p.m., call was received from the discharging hospital. Hospital staff advised the facility staff R22's background included he was readmitted to the hospital [DATE] after initial discharge to home on [DATE] related to a fall. R22 was noted to be a full code. R22 was hospitalized for COVID-19. R22 was on 4L of O2 in the hospital and his SpO2 in the hospital while on high flow oxygen, was between 93 to 94%. R22 would arrive that afternoon to the facility. 2) [DATE] at 8:43 p.m., staff administered a neb treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 was given a second nebulizer treatment 2 hours after at 10:29 p.m. that same day. Staff noted the treatment was effective. 3) [DATE] at 11:42 p.m., staff noted R22 was on 3L O2 with an SpO2 of 81%. At that time R22 was able to reposition himself in bed. 4) [DATE] at 5:37 p.m., R22's SpO2 was in the mid 80's. R22 was able to be up in his chair, and had walked 10 feet at that time. 5) [DATE] at 10:55 p.m., R22 was given a neb treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 6) [DATE] at 1:19 a.m., R22's SpO2 was 86% at this time. Staff noted he had exhibited shallow breathing and use of abdominal muscles. At 4:21 a.m., R22's SpO2 was 89% on 3L O2. Even though R22 had shallow breathing, with accessory (abdominal) muscles the physician was not notified of R22's change in condition. 7) [DATE] at midnight, staff documented they had administered a nebulizer treatment which was ineffective so he requested cough medication. Even though the treatment was identified as ineffective, there was no indication R22 was administered his rescue inhaler or the physician was notified that R22 treatment was ineffective. 8) [DATE] at 3:02 a.m., staff documented R22's SpO2 were 77%, but R22 advised them that is what they are. There was no indication staff identified R22 was normally in the mid 80's since his arrival, nor had they called his MD or on-call provider to seek medical evaluation and failed to follow his physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At 6:36 a.m.: R22 had difficulty breathing and c/o feeling SOB. His SpO2 remained below his baseline at 71% with increased oxygen to 4L high flow/min. At 6:46 a.m., staff noted his medication treatment was effective, yet his SpO2 remained low at 74% at the higher rate of 4L high flow/min. There was no documentation staff identified a change of condition and called emergency services (EMS) or the on-call MD. At 9:46 a.m., staff noted they were to call the nursing supervisor and the MD will be updated related to his poor oxygenation levels. There was no further documentation to support the MD was contacted regardng R22's change in condition. At 11:45 a.m., staff administered another neb treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Unable to cough up anything following neb. O2 [level] did go up to 65%. At 12:01 p.m., staff noted they spoke with R22's spouse and informed her of R22's change of condition and would be sending R22 via EMS to the local hospital for emergency medical evaluation. At 12:13 p.m., staff noted R22's SpO2 was low despite raising the head of the bed (HOB) and having him deep breathe through his nose. Staff were not able to get his SpO2 level higher than 65% on 4L/min of high flow oxygen. His lungs were noted to have wheezes throughout his upper airways. The emergency room (ER) was notified as well as R22's spouse. At 11:56 p.m., MD- B called the facility from the regional hospital and informed R22 was transferred and admitted to ICU due to his respiratory status. R22's nursing discharge summary progress note [DATE] at 3:37 p.m., identified R22 was admitted to the facility for rehab purposes. Staff documented R22's chronic health and history of COVID-19 prior to his admit made him weak and compromised his lung function. R22's condition continued to decline. His SpO2 progressively got worse and was unable to be maintained. R22 was sent to theER on [DATE] at the local hospital where he was immediately transferred to the regional hospital for ICU care. R22 passed away on [DATE]. Interview on [DATE] at 8:10 a.m., with licensed practical nurse (LPN)-A identified if a resident showed a change of condition, she would call 911 only if a resident required CPR if they were a full code status. Otherwise she would only call the on-call MD if she had concerns. If she would need to call the on-call MD for residents who were not a full code, she stated she would wait potentially an hour or so to get a call back from the MD to get an order to send the resident to the ER. Interview and progress note review on [DATE] at 9:09 a.m. with the DON identified although she was not the DON at the time of the incident, she agreed staff failed to intervene when R22's SpO2 began to decline on [DATE] as his SpO2 was below baseline orders of 80%. The facility failed to follow discharge orders from the hospital after R22 was admitted to the facility. The facility had not reviewed his medical record or perform a root cause analysis to determine if the facility had failed to intervene. Interview on [DATE] at 9:22 a.m. identified LPN-B stated if a resident had an identified concern, she would ask her charge nurse that day. Interview and document review on [DATE] at 10:59 a.m. with the medical director (MD)-A identified he was able to review R22's medical records offsite. MD-A agreed R22 showed a decline on [DATE], when R22's SpO2 dropped below baseline of hospital discharge orders of 80%. His expectation was staff should have called the on-call MD with any concerns and/or sent R22 on [DATE] when his SpO2 would not go back to a minimum of 80% or higher. Although R22 had co-morbidity of cancer, he died from [CONDITION(S)] COVID pneumonia. R22's cancer was not the cause of his death. MD-A agreed staff needed more training on what to do if a resident had a change of condition. Review of the [DATE], Notification of Changes in Resident Condition policy identified any change of condition was to be immediately reported to the resident's MD or designee. Staff were to document notification of a change of condition in the resident's medical record. There was no specific mention of when staff should call EMS for a potential emergent situation, or what defined an emergent situation. The policy had not been reviewed yearly per federal regulation to ensure accuracy or the need for revision. The IJ was removed on [DATE] at 2:10 p.m. when it could be verified the facility took steps to ensure staff were educated on what to do in an emergent situation or with a change of condition by reviewing policies, educating staff, and providing nursing reference materials.

Based on observation, interview and document review, the facility failed to appropriately implement isolation and transmission-based precautions for 1 of 1 resident (R1) with signs and symptoms of COVID-19. This resulted in an immediate jeopardy (IJ) situation for 17 of 17 other residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19) in the facility that were exposed to R1 who had symptoms of COVID-19 and participated in a group activity and communal dining while having symptoms. The IJ began on 4/4/20, when it was identified the facility failed to immediately implement Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for isolation and use of transmission based precautions, for 1 of 1 (R1) resident who had signs and symptoms of COVID-19. The facility's administrator and director of nursing (DON) were notified of the IJ on 4/6/20 at 5:45 p.m. The immediacy was removed on 4/7/20 at 12:55 p.m. but non-compliance remained at the lower scope and severity of F, widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Additionally, the facility also failed to actively screen employees at the point of entry to minimize potential exposure, failed to conduct active infection control surveillance since December 2019, and failed to have an infection control preventionist (ICP) qualified by education, training, experience, or certification since February 2020. Findings include: During observation on 4/6/20 at 9:37 a.m., two residents were observed to be seated across from each other at a table in the dining room eating their breakfast meals independently. During observation on 4/6/20 at 9:39 a.m., activity aide (ACT)-A entered the building through the employee designated entrance. Upon entry, ACT-A rummaged through a box of cloth masks and choose a mask, filled out a form on clip board next to time clock, and entered the resident living quarters at 9:47 a.m., walking directly to the activity office. ACT-A was not actively screened for symptoms, or temperature, upon entrance to the facility. During observation and interview on 4/6/20 at 10:00 a.m., ACT-A stated upon arrival to work she was to find a nurse to have her temperature checked. ACT-A verified she had arrived at 9:47 a.m., and had been to the activity office and the dining room to the area with the computer. ACT-A identified she just had found the nurse to have her temperature checked. ACT-A had her temperature checked by registered nurse (RN)-A in the activity office and her temperature was deemed within normal limits at 98.1 degrees Fahrenheit (F). During observation on 4/6/20 at 12:05 p.m., 16 of 18 residents were seated in the dining room. There were two residents sitting approximately three feet apart at each square table with the exception of 1 resident who sat alone at a table. During an observation and interview on 4/6/20 at 1:32 p.m., the dietary manager (DM) was observed to walk the full length of the hallway stopping at end of hall and looked into the nurse's office. The DM then walked down another hallway to her office. The DM identified she had just arrived at work and was attempting to locate the nurse on duty. The DM walked back to the end of the hallway in the nurse's office to get her temperature taken. When interviewed on 4/6/20 at 8:45 a.m., housekeeping staff (H)-A identified staff did not have to have their temperature checked upon entry when they arrived for work. H-A said when staff entered the building, they would write on paper if they had any signs or symptoms of respiratory concerns. There was no active testing performed by a staff member for those who came on duty. H-A stated staff would enter through the employee door and have to find the on-duty nurse in the building to take their temperatures. During interview on 4/6/20 at 8:47 a.m., R2 stated she went to the dining room for all her meals and attended group activities regularly. During interview on 4/6/20 at 9:18 a.m., nursing assistant (NA)-A identified staff were to enter through the employee entrance, write down any respiratory symptoms they may be having, wash their hands, get a mask, then locate the nurse who was assisting residents in the facility. That nurse would check their temperature. NA-A said staff were not actively monitored at the point of entry by another staff for temperature or other signs or symptoms of potential COVID-19. During an interview on 4/6/20 at 9:51 a.m., licensed practical nurse (LPN)-A stated she checked staff temperatures as part of the staff screening when staff alerted her they were onsite. LPN-A stated she had no form or procedure to document staff temperatures, nor did she ask them critical screening questions before they entered the building. LPN-A stated if a staff member had a temperature, she would write it down as a note, but verified there was no formal process for employee symptom screening. LPN- A reiterated staff were to find the nurse after they entered the building, to check their temperature when they arrived for their shifts. She verified at times staff may have to walk around the facility to find the nurse in order to have their temperature checked, because the nurse had to be on the floor with the residents and was unable to be at the point of entry. LPN-A also stated each resident was assessed for potential COVID-19 symptoms once daily in the morning. Record review of the resident assessment forms located in each resident's room, identified assessment criteria of temperature, oxygen level, cough, sore throat, or shortness of breath. Upon review, it was verified R1 had been sent to the hospital by his physician due to symptoms of COVID-19 shortly after midnight 4/6/20. R1's 3/12/20, quarterly Minimum Data Set (MDS) assessment, identified R1 had moderately impaired cognition and required extensive assist of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. Further, R1 required only supervision for eating and was able to feed himself. Review of R1's current Medication Administration Record [REDACTED]. Review of the resident assessment form and progress notes, identified the following: 1) 4/4/20 at 7:40 p.m. R1 had a temperature of 100.3 degrees F. R1 had also been shaky, weak, and had a headache. 2) 4/4/20 at 8:05 p.m., R1 had a temperature of 102.7 degrees F. 3) 4/4/20 at 9:00 p.m., R1 had a temperature of 103 degrees F. 4) 4/4/20 at 10:10 p.m., R1 had a temperature of 102.5 5) 4/4/20 at 11:25 p.m., R1 had a temperature of 101.7 degrees F. 6) 4/5/20 at 1:05 a.m., R1 had a temperature of 102.1 degrees F. 7) 4/5/20 at 2:15 a.m., R1 had a temperature of 101.3 degrees F. 8) 4/5/20 at 2:49 a.m., it was documented R1 had been shaky at BINGO earlier that day, had complained of a huge headache, and a cough was noted. 9) 4/5/20 at 3:40 a.m., R1 had a temperature of 100.3 degrees F. 10) 4/5/20 at 9:50 a.m., R1 had a temperature of 98.8 degrees F. 11) 4/5/20 at 8:45 p.m., R1 had a temperature of 100.4 degrees F. 12) 4/5/20 at 11:05 p.m., documentation showed R1 was heard hollering and found on the floor. R1 was not acting himself and vitals were assessed. R1 had a temperature of 101.2 degrees F, oxygen saturation (SpO2) of 85% and a blood pressure (BP) of 97/51 milligrams of mercury (mg/hg). The local emergency room (ER) was contacted. Medical doctor (MD)-B gave orders to send R1 to the ER. 13) 4/6/20 at 1:49 a.m., emergency medical services (EMS) transported R1 at 12:10 a.m to the ER for evaluation. 14) 4/6/20 at 2:31 a.m., identified a nurse from the ER called and reported R1 would be admitted with aspiration pneumonia and tested for COVID-19 as R1 met the criteria. Prior to R1's transfer, at no time when fever and symptoms began were isolation measures initiated. Review of each of the other 17 residents (R2 through R17) residing in the facility, identified comorbidities that placed the residents at increased risk for complications from COVID 19 if exposed. During interview with the DON on 4/6/20 at 10:15 a.m., the DON stated she expected any resident with COVID-19 like symptoms, such as increased temperature, to be isolated in their rooms and monitored. The DON stated if a resident had other additional symptoms, staff were to move the resident to the designated isolation wing and notify the doctor immediately. The DON stated R1 had a fever and was sent to the hospital for possible aspiration pneumonia. She stated the hospital had updated the facility they were testing for COVID-19 because R1 was symptomatic. The DON stated currently, one resident (R3) had returned from a hospital stay and was placed in isolated as a precaution for 14 days to ensure they had no signs or symptoms of COVID-19. The DON identified the facility did not have any tracking or trending for infections after December 2019. The DON identified she had not completed any tracking or trending since taking over the ICP role. The DON identified she did not have time to complete surveillance. Review of the facility's infection control surveillance tracking and trending from 2019, identified resident infections treated with antibiotics were tracked and trended throughout the year of 2019 with nothing documented after December of 2019. Of the documentation previously performed, it was identified the facility had not tracked or surveilled [MEDICAL CONDITION] activity. ACT-A stated during interview on 4/6/20 at 11:40 a.m., the infection control training received included emails, some fact sheets, and review of a communication book for information. She stated that was how the facility kept staff up to date on information. Laundry assistant (L)-B stated during interview on 4/6/20 at 12:30 p.m., staff were to complete a screening form at the time clock when they arrive, she stated they were to answer the questions and sign the form. L-B said checking temperatures could be done at home, or at the nurse's station. L-B also stated there had been no formal COVID-19 training, but the facility had sent staff emails to tell them about the screening and mask use. During interview on 4/6/20 at 12:32 p.m., NA-A identified all residents went to the dining room for meals except one resident (R3) who was on isolation. When interviewed on 4/6/20 at 1:00 p.m., the infection control nurse at the local hospital confirmed R1 had a COVID-19 test collected early that morning. The infection control nurse stated she did not expect the test results to be back until late 4/7/20. In addition, she stated R1 had an x-ray that indicated potential aspiration pneumonia and R1 was started on an antibiotic. However, he was tested in the hospital for COVID-19 and placed on isolation there while awaiting the results as the symptoms were similar for both illnesses. R4 was interviewed on 4/6/20 at 1:17 p.m., and stated residents played BINGO in the big room with other residents. R4 stated group activities had continued to occur. During interview on 4/6/20 at 1:55 p.m., RN-A identified R3 was the only resident they had isolated at the facility as R3 had recently returned to the facility after a hospital stay. RN-A verified having been aware R1 had a fever on Saturday 4/4/20, but stated she was advised the hospital indicated his symptoms may be related to aspiration of food or fluids into his lungs. RN-A stated no aspiration was witnessed, but could possibly have happened when R1 had evening snack. RN-A verified although R1 had a fever and cough on 4/4/20, he had not been isolated to his room or placed under transmission-based precautions (TBP) because there was no sore throat. RN-A stated R1 had been set farther away from the others for the evening meal, but had still eaten in the dining room. RN-A said the DON had instructed staff to put some precautions in place so they'd put his table in the dining room farther away from the other residents, but R1 had still been allowed to attend group activities. RN-A stated R1 had been sent to the hospital ER around midnight on 4/6/20, and the ER had notified them they were testing him for COVID-19 because he had a cough and fever. RN-A stated R1 had also complained of a headache, which was not identified as a symptom on the facility's list of potential signs of COVID-19. ACT-A stated during interview on 4/6/20 at 2:46 p.m., she had been notified by ACT-B a group activity of BINGO had been held on Saturday who worked 4/4/20. ACT-A said R1, R4, R5, R6, and R7 had attended the activity which had been held in the dining room. Review of emails and communication to all staff related to COVID-19 identified on: 1) 3/13/20, the facility was restricting all visitors per direction of the Minnesota Department of Health and CDC to prevent the spread of COVID-19 in the facility. Included was information about the screening process for visitors. The DON was beginning work on several policies for staff to follow. The note further informed staff of the difficulty obtaining some infection control supplies. 2) 3/25/20, all staff members were to be screened for a fever (100 degrees or above). Staff were instructed to try to take their temperature at home before they left for work. Screening included questions of dry cough with new onset or change, new shortness of breath, sore throat, travel to another country in the past 14 days, or exposure to another person with known or suspected COVID-19 with direction to staff of how to proceed if symptomatic. Staff were to notify their supervisor and/or DON immediately if they had any of the identified symptoms and they could not be at work. There were further instructions that staff were to follow if becoming symptomatic while at work. Staff were to don a face mask immediately, remove themselves from their work area, report to their supervisor and leave for home to isolate. Following isolation at home staff were to communicate with their supervisor and the DON for further screening guidance and instructions. The staff were directed to communicate with DON to report a summary of individuals, equipment and locations they have been in contact with , both at work and at home. and lastly they were to contact their physician immediately and follow their recommendations for their next steps. There was an attached form for the staff to document their answers which indicated in all capital letters: SEE THE CHARGE NURSE AFTER SIGNING TO HAVE YOUR TEMPERATURE CHECKED. 3) 3/31/20, included directions for self-screening when staff arrived to work for respiratory symptoms. Staff were to find the charge nurse to have their temperature checked and leaving their cloth mask at end of shift to be washed at the facility. 4) 3/31/20, staff were informed if they did choose to travel out of the area, upon return, they would not be able to work for the CDC recommended 14 days of self-quarantine. The 14 days of quarantine would be unpaid but staff could use there personal time off during their self-quarantine time. 5) Undated, COVID-19 Precautions Update identified beginning 4/1/20, a cloth mask must be used by all staff and therapists the entire time in the facility and would be available by the time clock. There would be a hamper for staff to place their mask in when they leave at end of shift. The facility would launder the cloth masks. The Minnesota Department of Health had approved the use of homemade masks when disposable masks were not available for use. There was no mention cloth masks were to be used as source control only and not during the care for a resident who was symptomatic or diagnosed with [REDACTED]. When interviewed on 4/6/20 at 3:00 p.m., the DON stated she had been aware of the CMS Quality/Safety & Oversite Group (QSO) 20-14 revised memo providing guidance to long term care facilities to cancel communal dining and all group activities. The DON verified this had not been implemented as it was difficult to do and felt canceling dining and group activities would have had a negative impact on the resident's psychological well-being. The DON stated R1 was currently in the hospital with suspected aspiration pneumonia and was being tested for COVID-19. The DON said she had directed staff to isolate R1 and implement TBP after he developed a fever. The DON acknowledged she had not ensured that had occurred, so was unaware R1 had not had TBP or isolation had not been initiated. The DON stated she was unaware R1 had continued to participate with communal dining, or engaged in group activities potentially exposing others. The DON verified she'd directed staff to check their own temperatures prior to coming to work as the facility did not have a supply of probe covers for the facility thermometer. The DON stated she had assumed the IC duties of the former infection control preventionist (ICP), when the ICP left employment in February 2020. The DON agreed no IC surveillance had occurred since December 2019. Further the DON verified neither she nor the administrator had created policies and procedures related to COVID-19 verifying there had been no formal education provided to staff other than emails and paper communication as identified. The medical director (MD)-B was interviewed on 4/7/20 at 10:00 a.m MD-B stated he was R1's primary care physician. MD-B was made aware of R1's symptoms late in the evening of 4/5/20. MD-B advised staff to send R1 to the ER for evaluation. MD-B agreed R1 had signs and symptoms of COVID-19 but was not aware R1 had exhibited symptoms beginning 4/4/20. MD-B was aware of the communal dining and group activities restrictions placed by CMS. MD-B identified the facility had not asked for assistance with their process to prevent potential exposure to COVID-19 in the facility. MD-B was unaware no surveillance had occurred since 2019. MD-B stated the last Quality Assurance Performance Improvement (QAPI) meeting had been conducted in January 2020. Review of the Parkview Home Infection Control Surveillance and Data Collection Policy dated 10/16/19, indicated all residents of Parkview Home were to be continuously monitored for infections. Notifications to physician, and responsible party would be made for any identified infection or change of condition. Staff were to document all collected data. A monthly infection control log for residents and staff was to be maintained and reported at the quarterly QAPI meeting. The IJ that began on 4/6/20, was removed on 4/7/20, when it could be verified the facility had re-assessed all residents for potential COVID-19 signs and symptoms, had developed and implemented staff education on newly formed policies and procedures using CDC and CMS guidelines: for screening, monitoring, assessment, prevention, and reporting for potential COVID-19. In addition it was verified the facility had implemented immediate cancellation of communal dining and group activities and had initiated active infection control surveillance.