Every finding on record at Parkview Manor Nursing Home

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate time allowed to dedicate to oversight of the infection control program. This had the potential to affect all 28 residents. Findings include: Review of the January 2026 Employee Illness Log identified the following columns:Report dateEmployee nameVomitingDiarrheaJaundiceFeverRespiratory (cough, sore throat, runny nose)Comments or additional symptomsDate returned to workDiagnosed with a pathogen?If diagnosed, was local health agency contacted?None of the monthly employee illness logs were filled out completely and the date returned to work was left blank each time. There was also no indication staff had been tested for COVID after becoming symptomatic during a COVID outbreak. Review of January 2026, Monthly Employee Illness log identified on:1/3/26, NA-E reported a sore throat, headache and congestion.1/3/26, NA-I called in with a headache.1/5/26, NA-F reported dizziness, lightheadedness, and a sore throat.1/7/26, NA-I called in again and reported a headache.1/21/26, NA-G called in with diarrhea.1/22/26, NA-C reported vomiting.1/22/26, NA-H reported diarrhea.1/28/16, NA-B called in with sinus congestion and cough.1/29/26, NA-B called in with vomiting and diarrhea.1/30/26, NA-C called in with vomiting and a fever. There was no indication on the forms, the above-mentioned staff had been tested for COVID, nor if they had been vetted before potentially returning to work according to CDC guidance. Interview on 5/11/26 at 8:30 a.m., with the infection preventionist (IP) identified that she had been in that position for less than a year. Her hours working in the IP role depended on current staffing levels and if she had to work on the floor as a charge nurse, however; she typically worked on infection control only 4-5 hours a week. She tracked staff call-ins on an absence report form that went to the business office first. If staff were sick, she would get a copy of the form from the business office and then transferred that information to the employee illness logs. Staff were to be off work for a minimum of 24 hours after symptoms were resolved for vomiting, fever, or diarrhea. She attempted to review the infection control information at least weekly, but that was dependent on staffing and if she had to work as a charge nurse on the floor. She confirmed the surveillance logs were not thoroughly completed and she had not really looked for trends or patterns since starting the infection preventionist role. The IP made no mention if she felt the 4-5 hours she was able to dedicate to her role was enough to provide appropriate oversight and vetting for employee RTW. Interview on 5/11/26 at 11:04 a.m., with the director of nursing (DON) identified she provided oversight of the infection control program by reviewing the IP's monthly data prior to the QAPI meeting. She had not been reviewing any of the surveillance logs since the new IP started. Review of the undated, Infection Control policy identified the program was to minimize the risk of infection between residents, staff, volunteers, and visitors. The facility would monitor, assess, identify, and manage infections through education and record keeping. Review of the undated, Surveillance for Infection policy identified surveillance of infections would be monitored for trends to guide appropriate interventions to slow or stop the spread of infections. Review of the undated, current Return to Work Policy for Infectious Illness identified it included guidance on RTW for suspected or confirmed cases of COVID. Staff were able to RTW at least 3 days after symptom onset, must be fever free for at least 24 hours, symptoms improving, and use source control upon RTW. There was no indication, this return to work followed the CDC guidance above. Review of the 9/21/20, undated Infection Control Policy identified the facility was to ensure effective implementation of infection control. Records of IC activities were to be maintained. There was no mention in the policy how the IP was to perform her duties and have appropriate oversight. Review of the 6/10/25, Facility Assessment identified the assessment was to describe how the facility would evaluate if the IC program included effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff that followed accepted national standards and referred to the Centers for Disease Control (CDC).

Based on interview and document review, the facility failed to ensure employees were documented as having been tested and illnesses monitored and tracked to identify potential or actual correlation between residents with known COVID and staff exposure and/or subsequent illness, or indicate when an employee would be able to return to work (RTW) after illness, according to the Centers for Disease Control, for 7 of 9 staff (Nursing assistant (NA)-B, NA-C, NA-E, NA-F, NA-G, NA-H, and NA-I) with symptoms of COVID during an outbreak. This had the potential to affect 11 remaining residents who showed no documented signs and/or symptoms of COVID, but who may have been exposed to staff.Findings include: Review of the March 2025, Centers for Disease Control (CDC), Symptoms of COVID-19 article, located at https://www.cdc.gov/covid/signs-symptoms/index.html, identified the following list does not include all possible symptoms. Symptoms may change with new COVID-19 variants and can vary depending on vaccination status. Possible symptoms include:Fever or chillsCoughShortness of breath or difficulty breathingSore throatCongestion or runny noseNew loss of taste or smellFatigueMuscle or body achesHeadacheNausea or vomitingDiarrhea Review of the 3/18/24, CDC article, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, located at https://www.cdc.gov/covid/hcp/infection-control/guidance-risk-assesment-hcp.html, identified:Health care personnel (HCP) with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected.If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT.If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test.For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), andAt least 24 hours have passed since last fever without the use of fever-reducing medications, andSymptoms (e.g., cough, shortness of breath) have improved.*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later Review of the January 2026, Resident Infection Surveillance log identified 12 residents (R27, R11, R14, R4, R19, R6, R25, R33, R3, R34, R9, and R2) had been diagnosed with COVID during an outbreak and showed signs and symptoms of cough, runny nose, congestion and wheezing. 5 additional residents (R20, R1, R29, R26 and R4) also showed signs of potential COVID (loose stools and vomiting) however; it was unknown if those residents had been tested or had been found to be positive for COVID. Review of the January 2026 Employee Illness Log identified the following columns:Report dateEmployee nameVomitingDiarrheaJaundiceFeverRespiratory (cough, sore throat, runny nose)Comments or additional symptomsDate returned to workDiagnosed with a pathogen?If diagnosed, was local health agency contacted?None of the monthly employee illness logs were filled out completely and the date returned to work was left blank each time. There was also no indication staff had been tested for COVID after becoming symptomatic during a COVID outbreak. Review of January 2026, Monthly Employee Illness log identified on:1/3/26, NA-E reported a sore throat, headache and congestion.1/3/26, NA-I called in with a headache.1/5/26, NA-F reported dizziness, lightheadedness, and a sore throat.1/7/26, NA-I called in again and reported a headache.1/21/26, NA-G called in with diarrhea.1/22/26, NA-C reported vomiting.1/22/26, NA-H reported diarrhea.1/28/16, NA-B called in with sinus congestion and cough.1/29/26, NA-B called in with vomiting and diarrhea.1/30/26, NA-C called in with vomiting and a fever. There was no indication on the forms, the above-mentioned staff had been tested for COVID, nor if they had been vetted before potentially returning to work according to CDC guidance. Interview on 5/11/26 at 8:30 a.m., with the infection preventionist (IP) identified that she had been in that position for less than a year. Her hours working in the IP role depended on current staffing levels and if she had to work on the floor as a charge nurse, however; she typically worked on infection control only 4-5 hours a week. She tracked staff call-ins on an absence report form that went to the business office first. If staff were sick, she would get a copy of the form from the business office and then transferred that information to the employee illness logs. Staff were to be off work for a minimum of 24 hours after symptoms were resolved for vomiting, fever, or diarrhea. She attempted to review the infection control information at least weekly, but that was dependent on staffing and if she had to work as a charge nurse on the floor. She confirmed the surveillance logs were not thoroughly completed and she had not really looked for trends or patterns since starting the infection preventionist role. The IP made no mention if she felt the 4-5 hours she was able to dedicate to her role was enough to provide appropriate oversight and vetting for employee RTW. Interview on 5/11/26 at 11:04 a.m., with the director of nursing (DON) identified she provided oversight of the infection control program by reviewing the IP's monthly data prior to the QAPI meeting. She had not been reviewing any of the surveillance logs since the new IP started. Review of the undated, Infection Control policy identified the program was to minimize the risk of infection between residents, staff, volunteers, and visitors. The facility would monitor, assess, identify, and manage infections through education and record keeping. Review of the undated, Surveillance for Infection policy identified surveillance of infections would be monitored for trends to guide appropriate interventions to slow or stop the spread of infections. Review of the undated, current Return to Work Policy for Infectious Illness identified it included guidance on RTW for suspected or confirmed cases of COVID. Staff were able to RTW at least 3 days after symptom onset, must be fever free for at least 24 hours, symptoms improving, and use source control upon RTW. There was no indication, this return to work followed the CDC guidance above.

Based on observation and interview, the facility failed to ensure food was not outdated, foods were thawed in a safe and sanitary manner, and the walk-in freezer and the floors of the walk-in cooler were kept in a sanitary manner in 1 of 1 kitchen. This has the potential to affect all 30 residents.Findings include: Observation and interview on 5/10/26 at 11:02 a.m., with dietary cook (C)-A on initial tour of the kitchen identified in the refrigerator next to the prep area in the kitchen had a 1/2 gallon milk container with the lid off, and what looked like pancake batter on the outside of the container and inside. C-A stated oh, I am throwing this and reported it was butter milk, and the best used-by date was 4/6/26. Also, in the same refrigerator there were 5 bowls of undated pre-made salad, covered with plastic wrap with lettuce starting to turn brown. C-A confirmed the butter milk was expired and the salads should have been dated and proceeded to remove all items and dispose of them. As we entered the walk-in cooler there were 2 sheet pans on the bottom shelf of a wire rack the first one had a bag of turkey thawing with juice noted on the tray. The second tray had 2 items wrapped in tin foil and a 10-pound sleeve of ground beef sitting on the tray. All items were sitting in blood juice from one of the items. C-A moved the tray and one item wrapped in tin foil had label on it that identified prepared date 4/29/26, she thought that was turkey, but it did not say on the label, the other item wrapped in tin foil had label on it that identified it was ground beef, and dated 5/3/26. The 10-pound sleeve of ground beef had a hole in the plastic with a dark, hard looking, exposed ground beef. Continued observation on 5/10/26 beginning at 11:02 a.m., identified C-A then opened the walk-in freezer that was inside of the walk-in cooler. Once the door to the freezer was opened it was observed to be full of multiple boxes stacked on top of each other in the walk-through space. Some of the boxes were tipped over, some directly on the floor, and some on top of a plastic crate. The shelves within the walk-in freezer were full. One box tipped over directly on the floor was labeled sea food. The outside of the box identified 15 pieces of fish were left and dated it had been opened on 3/27/26. The box was not closed and the bag inside the box was not closed or secured. There was a plastic tote cover tipped upside down with 5 bags of thawed chicken sitting in the cover directly onto the floor. C-A stated she had just placed the remaining chicken in the freezer that she had not used for the noon meal. There was no room to place the chicken on the shelf, so she placed it on the plastic cover and just put it in the freezer on the floor. C-A confirmed there was no way to step into the walk-in freezer due to all the boxes in the walk-through space. Back inside the walk-in cooler it was observed to have a large amount of blood or brown juices spilled on the floor under both wire racks in the cooler. There were also a couple of butter packets mixed in with the dried meat juices and/or debris under one rack and a dirty plastic cup in the spilled juices under the other rack. C-A confirmed that the observed blood or brown dried areas was probably juices from thawing meat spilled. She identified there was no schedule for cleaning and no specific person oversaw cleaning; staff were just to clean as they needed. Interview and observation on 5/10/26 at 11:50 a.m., for follow up tour of kitchen with C-B identified inside the walk-in cooler remained the tray of 2 items wrapped in tin foil and the 10-pound sleeve of ground beef sitting in blood juices on the tray. Also noted was a large item wrapped in tin foil sitting on top of a box back towards the back on the bottom shelf. C-B pulled that out and it was labelled ham and dated 5/5/26. C-B stated, the meat should each be on their own tray to thaw. He then stated, they should not be together (the ground beef and the turkey). He confirmed that all items were sitting in blood juices on the one tray. He removed the tray from the walk-in cooler, and he opened both items in tin foil. One was sliced turkey, and the other one was 10 pounds of ground beef. He confirmed there was a hole in the plastic of the 10-pound sleeve of ground beef and that the exposed area appeared dried and crusty. C-B then entered the walk-in freezer, and stated, oh no! that should not be there and pointed to the chicken sitting on the floor inside the plastic cover. He confirmed that you could not step into the walk-in freezer as it was full of boxes in the walk-through space, and confirmed the boxes were tipped over, some on the floor, and some on top of a plastic crate. Interview on 5/11/26 at 9:48 a.m., with the administrator identified, he has had multiple conversations in the past with the dietary manager and staff about keeping the kitchen neat, clean, and organized not only for infection control purposes, but also for ordering supplies. He revealed there had been some ongoing concerns with expired items and cleaning in the kitchen with newer staff. He had even done some spot checks in the kitchen related to the concern and had asked the dietary manager to make sure she was checking for expired items as well. He further revealed he had completed a check one time and found a 10-pound sleeve of ground beef sitting on the wire rack with no tray under it dripping onto the floor. He talked with the dietary manager and staff about thawing items in the walk-in cooler and making sure the item was on a tray. Items thawing in the walk-in refrigerator should be on a tray by itself and not with other food. He was unaware that the walk-in freezer had so many items on the floor that you could not step into the walk-in freezer or that the walk-in cooler had spilled drippings from thawing items on the floor. If the kitchen staff could not reach under the wire rack to clean that up, they should have asked for maintenance to assist. His expectation was that the kitchen monitored for expired items and removed those items, thawed foods appropriately, did not place items on the floor, and maintain a clean and sanitary kitchen. Interview on 5/11/26 at 5:09 p.m., with dietician identified she had been at the facility the week prior and discussed all the identified area's of concern with the dietary manager. She would expect the meat to be thawed on individual trays on the bottom shelf in the refrigerator, and any spills would be cleaned up, and the kitchen would be maintained in a sanitary manor. She revealed that having more than one type of meat thawing on the same tray was a concern for cross contamination. Nothing should be stored on the floor and the walkways inside the freezer and refrigerator should remain clean and items should be kept on the shelves. The facility should be monitoring for expired items on a regular basis. She revealed that the facility needed to have a better protocol for monitoring and cleaning of the kitchen with audits to ensure things were getting done. A policy on infection control in the kitchen was requested but not provided. A policy on safe food storage was requested but not provided.

Based on interview and document review, the facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R5) who was reported to be receiving insulin.Findings include: R5's, quarterly MDS assessment, accepted on 2/3/26 and 4/15/26. identified R5 received an INSULIN injection (1) time during the last 7 days. R5 had a diagnosis of diabetes, but her current physician orders identified no orders for insulin. R5'S current physician orders included an order dated 12/17/25, for Semaglutide (0.25 or 0.5 milligrams (mg/dose,) subcutaneous (SQ) 2 mg/3 milliliter (ml). staff were to inject R5 with 0.25 mg subcutaneously (SQ) in the morning, every Wednesday for diabetes with hyperglycemia for 4 Weeks, and then 0.5 mg sq every Wednesday morning. Interview on 5/10/26 at 2:30 p.m. with R5 identified she was diabetic and received an oral medication daily for her diabetes. She reported she did not receive insulin, but received a weekly injection of a GLP1 medication that was administered on Wednesdays. Interview on 5/11/26 at 8:14 a.m. with registered nurse (RN)-B confirmed she had incorrectly coded both the 1/16/26 and 4/10/26 quarterly MDS assessments as R5 received no insulin. She identified she would need to complete and submit a modification of the assessment. Interview on 5/12/26 at 11:28 a.m., with director of nursing (DON) identified she would expect the MDS to be accurate and reflect the status of each resident. There was no policy related to accuracy of the MDS provided by the end of survey.

Based on observation, interview, and document review, the facility failed to timely notify the physician for 1 of 1 sampled resident (R15) when she experienced worsening cough with no relief. Findings include: R15's quarterly Minimum Data Set (MDS) assessment, accepted on 3/20/26, identified her cognition was intact, and she had diagnosis of edema (swelling), heart failure, high blood pressure, premature contractions of the heart ventricles, and tricuspid regurgitation (a heart condition that can cause extreme tiredness, shortness of breath and swelling in the belly, legs, or neck veins). R15 required moderate assistance of one staff for transfers, dressing, and hygiene. Intermittent observations on 5/10/26 from 11:30 a.m., to 7:00 p.m., and again on 5/11/26 from 7:33 a.m., to 4:30 p.m., identified R15 remained in her room was seated in her recliner. She could be heard coughing continuously and the cough was worsening. Review of R15's nursing progress notes identified on 5/6/26, at 4:30 p.m., R15 returned from AN appointment with new orders to provide comfort cares only. Staff were advised to not hospitalize R15, stop metolazone, increase Lasix to 80 milligrams (MG) twice daily, and discontinue any labs per family request. R15's physician progress notes identified that she was seen at the clinic by MD-B on 5/6/26, for concerns of fluid retention in her legs. The physicians' progress note identified R15 had a history of heart failure and chronic fluid retention and was experiencing weight gain, generalized edema, and decreased strength. Although R15's diuretic medications had been increased previously, they were not seeing an improvement. R15's weight gain over the past month was significant despite the medication changes. R15's respiratory symptoms included occasional shortness of breath and persistent cough, though she generally reports her breathing as pretty good. MD-B identified after discussion of prognosis and limited benefit of further hospitalization; the family opted for comfort care. The plan was to include no further lab draws, do not hospitalize R15, continue morphine (pain medication) as needed for comfort at the facility and the family did not want hospice at this time. R15's undated, current care plan identified R15 was on diuretic therapy (medication is given to alleviate excess fluid buildup in the tissues) related to edema (swelling from excess fluid) and high blood pressure with a focus for R15 to be free of discomfort. Staff were to administer diuretic medication as ordered and monitor for their side effects and report pertinent lab results to the physician. The care plan made no mention that R15 was to be provided comfort care at the facility, should not be hospitalized , or that staff were to discontinue all lab draws. In addition, the care plan did not identify how the facility should maintain comfort if R15's overall condition were to change. Further review of R15's Nursing progress notes identified on:5/7/26 at 1:52 p.m., R15's family member requested the nurse to arrange for R15 to receive the catholic last rights. A call was place to the Catholic church. 5/8/26 at 4:45 a.m., staff noted R15 was not resting well that night and had been coughing chronically since 10:45 p.m They administered as needed morphine 0.25 milliliters (ML) in attempts to alleviate her discomfort from chronic cough related to fluid overload. 5/8/26 at 5:28 a.m., staff noted the morphine was ineffective and R15 reported her pain scale was 8 of 10 which is considered severe. R15 did not appear to have any relief from her cough and discomfort. The nurse will continue to monitor. Interview on 5/11/26 at approximately 2:00 p.m., with registered nurse (RN)-A identified she was aware of R15's coughing. She presumed it was caused by fluid retention. She identified they had received an order from the physician to not send R15 to the hospital. Interview on 5/11/26, at 2:34 p.m., with the director of nursing (DON) identified she was aware of R15's cough. She had been seen at the clinic on 5/6/26 and had new orders for comfort care and was not to be transported to the hospital. She agreed comfort measures should have been added to the care plan. Additional review of R15's progress notes identified on 5/11/26 at 2:47 p.m., a nursing assistant reported R15 was coughing. Staff documented a nurse assessment identified R15 was not feeling well, was short of breath, and continued to cough. Nurse administered cough syrup and 0.25 milliliters (ML) of morphine and brought her some warm coffee. R15 experienced very little relief from these measures. Follow up interview on 5/11/26 at 3:32 p.m., with the director of nursing identified they had sent a fax to the physician earlier but had not received a response. She further identified they could not call the doctor during clinic hours and had been advised to fax. They could call the nurse triage line but were told calling that line would be no faster than sending a fax. She agreed R15's care plan should have been revised to identify what staff were to do to provide comfort for R15 if her condition worsened. Additional review of R15's progress notes identified on 5/11/26 at 2:47 p.m., a nursing assistant reported R15 was coughing. Staff documented a nurse assessment identified R15 was not feeling well, was short of breath, and continued to cough. Nurse administered cough syrup and 0.25 milliliters (ML) of morphine and brought her some warm coffee. R15 experienced very little relief from these measures. Follow up interview on 5/11/26 at 3:32 p.m., with the director of nursing identified they had sent a fax to the physician earlier that day on 5/11/26 but had not received a response. She further identified they could not call the doctor during clinic hours and had been advised to fax. They could call the nurse triage line but were told calling that line would be no faster than sending a fax. R15'S progress note review identified on:5/11/26 at 5:00 p.m., the nurse noted communication with the family to ask if they would be in agreement with increasing R15's morphine dose to help with her frequent coughing and to discuss a hospice referral. The family agreed. 5/11/26 at 6:43 p.m., a call was placed to the on-call physician (MD-C), who ordered staff to increase the frequency of as needed morphine to every 2 hours as needed for pain, shortness of breath, or cough and monitor if it was more effective for the cough.5/11/26 at 8:05 p.m., staff documented following the morphine administration, they felt the cough was better this evening.5/11/26 at 10:39 p.m., a fax was sent to the clinic to request an order for a hospice referral per the family's request. Review of the facilities May 2017, Change in a Resident's Condition or Status policy identified the nurse would notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical/emotional/mental condition, there is a need to transfer the resident to the hospital. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The policy made no mention of how the facility staff should contact the physician for guidance if a residents change of condition was not emergent but needed to be reviewed in a timelier manner.

Based on interview and document review the facility failed to develop a care plan for 1 of 13 residents (R15) who was identified as being at risk for falls upon admission.Findings include: R15's quarterly Minimum Data Set (MDS) assessment, accepted on 3/20/26, identified her cognition was intact, her vision was severely impaired (no vision or sees only light, colors or shapes). R15 required moderate assistance of one staff for transfers, dressing, and hygiene. R15's comprehensive MDS assessment accepted on 12/22/25, identified the Care Area Assessment (CAA) portion of the MDS identified falls would be addressed on the care plan. Staff were to monitor for fall risks related to medication, new surroundings and adjustment due to vision and hearing deficits. They were to ensure the call light was within reach, ensure R15 knew where it was located, and attach the call light so it would not slide away due to her vision impairment. Interview on 5/10/26 at 1:38 p.m., with R15's family member (FM)-A identified R15 recently had a fall. She had been sitting in her wheelchair in her room. She fell asleep and fell face forward out of her chair hitting her face on the nightstand sustaining facial bruising. R15's 5/1/26 at 2:43 p.m., nursing progress note identified R15 had a fall on 5/1/26 at 10:01 a.m., that was not witnessed. The fall occurred in R15's room. She forgot to lock her brakes on her wheelchair, fell asleep, and leaned too far forward and tipped out of the chair. R15 sustained a facial bump and bruise and a skin tear on her right ring finger. Review of R15's current undated care plan made no mention that R15 was at risk for falls. There was nothing to identify what staff were to do to minimize R15's risk of falls. Interview on 5/12/26 at 10:18 a.m., with the MDS nurse identified R15 had no history of falls prior to admission to the facility. If a resident was identified as being at risk for falls upon admission but has no history of falls she does not always add that to the care plan regardless of the Care Area Assessment findings. Interview on 5/12/26 at 12:42 p.m., with the director of nursing (DON) identified it was her expectation that any resident who was assessed to be at risk for falls would have a section on the care plan to alert staff of those risks and how they were to provide care and minimize risk for injury. Review of the facilities 2/20/20, Care Plan policy identified staff were to develop a care plan within 7 days after completion of the comprehensive assessment. The care plan was to address the resident's needs, strengths, and preferences as identified in the comprehensive assessment with measurable objectives and timetable to meet the residents long and short-term goals for medical, nursing, and psycho-social needs that are identified in the assessment. The care plan was to list services that will be furnished to attain or maintain the resident's highest and practicable physical, mental, and psycho-social well-being. The care plan was to be reviewed and revised by the interdisciplinary team, the resident, and/or the legal guardian at least quarterly and updated at any time to account for day-to-day changes in care.

Based on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 (R19 and R22) sampled residents reviewed for antibiotic stewardship.Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the residents' current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out [ATO]. Review of Monthly Antibiotic surveillance reports from January 2026 through April 2026 identified columns for; resident's name, infection from previous month, infection type, symptoms, onset date, device, infection risk factors, diagnostic performed, date performed, test type, specimen source, results, antibiotic resistant organism, antibiotic name, dose, route, frequency, provider, antibiotic start date, antibiotic end date, total days of therapy, antibiotic reassessment time out, transmission based precautions required, date symptoms resolved, and comments. Review of January 2026 surveillance identified R19 had symptoms of nasal congestion with no onset date. R19 had been started on doxycycline 100 milligrams (mg) orally, twice a day, beginning 1/15/26 with an end date of 1/22/26, and an ATO was documented as completed. The diagnoses listed was a sinus infection. There was no information in the column labeled date symptoms resolved to identify if R19's treatment had been successful or there was a need to change or continue treatment. R19's progress notes identified on:1/15/26, R19 had been seen by doctor at the facility and was started on doxycycline 100 mg for 7 days.1/18/26, (identified as an antibiotic time out) staff documented R19 continued to have symptoms of a sinus infection with thick mucus. R19 reported feeling better. Staff noted R19 would continue taking the antibiotic. The note lacked any identification that the doctor was notified or reviewed the information to make an informed decision if the antibiotic should be continued, changed, or discontinued. Review of March 2026 surveillance identified R22, had symptoms of red, warm to touch with onset date of 2/12/26. R22 had been started on doxycycline 100 mg orally, twice a day, beginning on 3/12/26 with an end date of 3/19/26, and an ATO was documented as completed. The diagnoses listed was cellulitis. There was no information in the column labeled date symptoms resolved to identify if R22's treatment had been successful or there was a need to change or continue treatment. R22's progress notes identified on:3/12/26, R22 had been seen by the doctor at the facility and started on doxycycline 100 mg twice a day for 7 days and refer to vascular surgery if family desires.3/15/26, (identified as an antibiotic time out) staff documented R22 continued Doxycycline for cellulitis to right lower extremity. R22's lower right extremity continued to appear red and slightly swollen and warm to touch. R22 was also noted to have increased confusion, staff were unsure if this was related to antibiotic use or worsening dementia. Staff noted minimal, if any improvement was observed from the antibiotic use. The note lacked any identification that the doctor was notified or reviewed the information to make an informed decision if the antibiotic should be continued, changed, or discontinued. Interview on 5/10/26 at 3:12 p.m., with the director of nursing (DON) identified the antibiotic time-out would be documented in the residents' progress notes. The nurse would complete an assessment of the resident after starting an antibiotic and would documented that in the residents progress notes. That assessment information was not communicated to the prescribing provider. The DON stated, I have talked with the medical director, but she said that she did not think her colleges would want to be bothered with that information. She revealed that the facility determined that the antibiotic was working if the resident was getting better or not. Interview on 5/11/26 at 8:30 a.m., with the infection preventionist (IP) identified that she had been in the IP position for less than a year. Her hours working in the IP role depended on staffing and if she had to work in another role. She typically worked on infection control 4-5 hours a week. She identified that if an antibiotic time-out was not completed she had just missed doing it. The providers have told the facility they do not want to see the information or the time-out form. The only way the facility determined if the antibiotic was working was if the residents' symptoms improved. She identified that the nurse made a progress note in the resident record on how the resident was doing on the antibiotic. She revealed the facility did not communicate that information with the prescribing provider that ordered the antibiotic as they did not want that information. Interview on 5/11/26 at 9:48 a.m., with the administrator identified he was unaware that there was an issue with antibiotic time-out and that the ordering physician should be updated on the resident's status after starting an antibiotic. He was unaware that the medical director had reported to the director of nursing that the providers did not want to review the antibiotic assessment information. Review of facility Antibiotic Flow Sheet that facility staff were supposed to be using identified columns for:Resident nameXray yes or noPrescribing Physician and FacilityDate Treatment StartedSpecimen yes or noIndication for AntibioticCulture yes or noAntibiotic Ordered with dosage/durationRoute of AdministrationSpecimen identified from cultureAntibiotic time-out yes or noA place to document vital signsLast date of antibiotic givenNurses signatureHas a different antibiotic been ordered for this same infection?The form lacked a column for the facility to make notes of how the resident was doing and for the provider to respond if the antibiotic should be continued, changed, or discontinued. Review of undated, Antibiotic Stewardship policy, identified the program goal was to reduce adverse events associated with antibiotic use and promote appropriate use of antibiotics to treat infection. The facility will implement policies and practices to improve antibiotic use, will monitor antibiotic use and outcomes, and provide feedback to the prescribing provider on antibiotic use and resistance. Antibiotic time-out at 72 hours after an antibiotic started will be completed to assess antibiotic need, duration, selection, and de-escalation potential and would be recorded in the resident's record.

Based on the facility failed to revise the care plans for 2 of 12 sampled residents (one who was to be receiving comfort cares (R15), and one (R2) who developed a pressure ulcer). Findings include: R15R15's quarterly Minimum Data Set assessment, accepted on 3/20/26, identified her cognition was intact, she had diagnosis of edema, heart failure, high blood pressure, premature contractions of the heart ventricles, and tricuspid regurgitation (a heart condition that can cause extreme tiredness, shortness of breath and swelling in the belly, legs, or neck veins). R15 required moderate assistance of one staff for transfers, dressing, and hygiene. Intermittent observations on 5/10/26 from 11:30 a.m., to 7:00 p.m., and again on 5/11/26 from 7:33 a.m., to 4:30 p.m., identified R15 remained in her room was seated in her recliner. She could be heard coughing continuously and the cough was worsening. Review of R15's nursing progress notes identified on 5/6/26, at 4:30 p.m., R15 returned from AN appointment with new orders to provide comfort cares only. Staff were advised to not hospitalize R15, stop metolazone, increase Lasix to 80 milligrams (MG) twice daily, and discontinue any labs per family request. R15's 5/6/26, physicians (MD-B) progress note identified that she was seen at the clinic for concerns of fluid retention in her legs. The corresponding physicians' progress note identified R15 had a history of heart failure and chronic fluid retention and was experiencing weight gain, generalized swelling, and decreased strength. Although R15's diuretic medications had increased previously they were not seeing an improvement. R15 had weight gain over the past month that had been significant despite the medication changes. R15's respiratory symptoms included occasional shortness of breath and persistent cough, though she generally reported her breathing as pretty good. MD-B identified after discussion of R15's prognosis and limited benefit of further hospitalization; the family opted for comfort care. His plan was to do no further lab draws, not hospitalize her, and continue morphine as needed for comfort at the facility. The family did not want hospice at this time. R15's undated, current care plan identified R15 was on diuretic therapy (medication is given to alleviate excess fluid buildup in the tissues) related to edema (swelling from excess fluid) and high blood pressure with a focus for R15 to be free of discomfort. Staff were to administer diuretic medication as ordered and monitor for their side effects and report pertinent lab results to the physician. The care plan made no mention that R15 was to be provided comfort care at the facility, should not be hospitalized , or that staff were to discontinue all lab draws. In addition, the care plan did not identify how the facility should maintain comfort if R15's overall condition were to change. Further review of R15's Nursing progress notes identified on:5/7/26 at 1:52 p.m., R15's family member requested the nurse to arrange for R15 to receive the catholic last rights. A call was place to the Catholic church.5/8/26 at 4:45 a.m., staff noted R15 was not resting well that night and had been coughing chronically since 10:45 p.m They administered as needed morphine 0.25 milliliters (ML) in attempts to alleviate her discomfort from chronic cough related to fluid overload.5/8/26 at 5:28 a.m., staff noted the morphine was ineffective and R15 reported her pain scale was 8 of 10 which is considered severe. R15 did not appear to have any relief from her cough and discomfort. The nurse will continue to monitor. Interview on 5/11/26 at approximately 2:00 p.m., with registered nurse (RN)-A identified she was aware of the coughing. She presumed it was caused by fluid retention. She identified they had received an order from the physician to not send R15 to the hospital. Interview on 5/11/26, at 2:34 p.m., with director of nursing reported she was aware of R15's cough. She had been seen at the clinic on 5/6/26 and had new orders for comfort care and was not to be transported to the hospital. R15's 5/11/26 at 2:47 p.m., nursing progress note identified a nursing assistant reported R15 was coughing. R15 was not feeling well, was short of breath, and continued to cough. Staff documented they administered cough syrup and 0.25 milliliters (ML) of morphine and brought her some warm coffee. Staff noted R15 experienced very little relief from those measures. Follow up interview on 5/11/26 at 3:32 p.m., with the director of nursing identified they had sent a fax to the physician earlier but had not received a response. She further identified they could not call the doctor during clinic hours and had been advised to fax. They could call the nurse triage line but were told calling that line would be no faster than sending a fax. She agreed R15's care plan should have been revised to identify what staff were to do to provide comfort for R15 if her condition worsened. Review of the facilities March 2018, Palliative/End of Life Care-Clinical Protocol policy identified the interdisciplinary team would complete an assessment of the resident and family for the basis of the individualized palliative care plan. The assessment would include at least:1. Documentation of disease status, including diagnosis and prognosis2. Documentation of co-morbid medical and/or psychiatric conditions3. Functional status4. Strengths5. Concerns, goals and values of the resident and family6. Preferences and documentation for end-of-life decisions and care7. Appropriateness of a hospice referralThe comprehensive assessment was to recur on a regular basis and in response to significant changes of condition or change in resident and family goals or wishes. The physician was to help identify or verify underlying causes of A resident's decline or end stage/terminal status. Palliative (comfort) care was to focus on physical, psychological, social and spiritual quality of life for the resident and family. The physician was to order appropriate interventions for symptom relief, and advise the resident/patient, family, and facility staff about the prognosis and overall medical plan periodically, including any impact of significant changes of condition. The physician and staff were to monitor and assess the resident's course of treatment, identify complications or additional decline, and adjust their approaches accordingly. R2R2's comprehensive MDS, accepted on 3/20/26, identified his cognition was severely impaired, and he required partial to moderate assistance of 1 staff for transfers, dressing, and hygiene. R2 had four Stage II pressure ulcers (top layer of skin has broken down, exposing the pinkish layer underneath the dermis). The Care Area Assessment (CAA) portion of the MDS identified staff were to address the pressure wounds on the care plan to identify that staff were to provide pressure ulcer treatment daily, monitor weekly and as needed, and update the physician of if there was a decline or signs of infection. The care plan goals would be to slow or minimize decline, minimize risks, and provide symptom relief or palliative measures. R2's current treatment administration record (TAR) identified a physician order to apply Calmoseptine (topical barrier cream) and a foam patch to the areas on buttocks daily. Review of R2's current, undated care plan identified he was at risk for skin integrity impairment and staff were to encourage good nutrition, avoid moisture, keep skin clean and dry, apply moisture barrier cream after toileting, and monitor for medication side effects such as rash. R2's care plan did not identify he had an actual pressure ulcer and made no mention what staff were to do to promote healing or reduce/minimize risk for infection or discomfort. Interview on 5/11/26 at 3:18 p.m., with nursing assistant (NA)-A identified she was aware R2 has a rashy area on his bottom. She reported staff ensure the open area on his bottom is clean then the nurse comes in and does his dressing. Staff check him once in the morning and once in the afternoon. She had never been told that he is supposed to be repositioned. He is supposed to have assistance with standing and transferring. Interview on 5/11/26 at 2:04 p.m., with the MDS nurse identified she did not revise the care plan to include R2's pressure ulcers. Normally, she would have added this with interventions and goals for healing but she missed it. She agreed it should have been added so staff were aware of the interventions that should be implemented to promote healing and minimize risks. Interview on 5/11/26 at 2:19 p.m., with the DON identified it was her expectation that a pressure ulcer should be identified on the care plan with appropriate goals and interventions. Review of the facilities 2/20/20, Care Plan policy identified staff were to develop a care plan within 7 days after completion of the comprehensive assessment. The care plan was to address the resident's needs, strengths, and preferences as identified in the comprehensive assessment with measurable objectives and timetable to meet the residents long and short-term goals for medical, nursing, and psycho-social needs that are identified in the assessment. The care plan was to list services that will be furnished to attain or maintain the resident's highest and practicable physical, mental, and psycho-social well-being. The care plan was to be reviewed and revised by the interdisciplinary team, the resident, and/or the legal guardian at least quarterly and updated at any time to account for day-to-day changes in care.

Based on observation and interview, the facility failed to ensure 1 of 1 exhaust vent located above the gas stove was free from accumulation of dirt and grease that had the potential to contaminate food being prepared and served. This had the potential to affect all 28 residents who received food prepared in the facility kitchen. Findings include: Observation and interview on 3/24/25 at 10:45 a.m., during the initial kitchen tour with the certified dietary manager (CDM). identified a large rectangular vent positioned in the wall above the stove. The vent was covered with a black, thick grease-like substance. The CDM reported the vent had been cleaned by maintenance a couple of months previously and she thought the black substance was likely rust and dust. She also reported she had not noticed how it appeared, but stated it needed to be cleaned. Interview on 3/24/25 at 11:30 a.m., with the Maintenance Supervisor (MS) reported he had replaced the vent a couple of months ago due to rust and paint chipping, but he did not realize how much more dirt and grease had accumulated. He reported he was not able to wipe off the black buildup but had to utilize a heavy degreaser to remove it and would need to put it on his maintenance schedule for regular cleaning. A policy on cleaning of vents and equipment in the kitchen was requested but not provided.

Based on observation and interview the facility failed to avoid the potential risk of burns from 1 of 1 unattended Bunn brand coffee warmer used in the dining room. Findings include: Observation on 3/26/25 at 11:30 a.m., as an unknown dietary staff member entered the dining room and switched on the heating elements on a Bunn double element coffee warmer. The warmer was used to place glass coffee pots on during meals to keep the coffee hot. The coffee warmer with glass pots was positioned on a counter within easy reach of a resident walking or in a wheelchair. The warmer was observed to be very hot when a hand was held an inch above the surface, in addition to the glass coffee pots which held hot coffee. Neither dietary or nursing staff were consistently in the dining room, and no one was observed monitoring the coffee to ensure a resident did not attempt to serve themselves. Interview on 3/26/25 at 11:33 a.m. with the certified dietary manager (CDM), reported the Bunn coffee warmer was turned on prior to meals to allow it to become hot before the glass coffee pots were placed on it for service during the meal. She acknowledged the potential for burns if a resident attempted to self-serve coffee or touched the hot plate surface. The CDM reported she would make a change to utilize a pump type coffee server to eliminate the risk of a resident being burned. Interview on 3/26/25 at 11:55 a.m., with the administrator acknowledged the potential hazard the coffee warmer and glass coffee pots presented. He reported this was the system that had been utilized, but he had not identified the potential hazard. The administrator reported the facility would need to utilize a different method for serving coffee in the dining room and acknowledged the CDM had replaced the warmer and glass pots with a pump type pot for safety following the observation. A policy for safety in the dining room was requested, but not provided prior to survey exit.

R7's annual Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment without hallucinations or delusions. R7 had diagnoses of neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, bipolar disorder, mild dementia, major depressive disorder, and anxiety disorder. R7's physicians orders indicated the following psychotropic medication orders: quetiapine dated 1/9/25 (an antipsychotic). Informed consents regarding risks versus benefits of these medications were not found in the resident record. During interview on 3/25/25 at 4:54 p.m., Director of Nursing (DON) stated she was unaware of the requirement, and this had not been completed. DON stated understanding of the importance of residents and their representatives being aware of the risks verses benefits of the psychotropic medications being prescribed. There was no policy provided related to medication by the end of the survey. R8's 2/21/25, Significant Change Minimum Data Set (MDS) assessment identified her cognition was intact, she had diagnosis of bi-polar disorder, post-traumatic stress disorder, anxiety, and hallucinations. R8 was dependent on staff for transfers, dressing, and hygiene, she used a wheelchair for mobility. R8 took an antipsychotic and an antidepressant on a routine basis. R8's current, undated medication administration record (MAR) identified she was administered Abilify (anti-psychotic) 15mg oral tablet at bedtime and duloxetine HCI (antidepressant) 60 mg oral tablet daily in the morning. R8's medical record identified no documentation that a gradual dose reduction had been attempted since March of 2024. The medical record did not include any documentation that the resident or the resident representative had been educated on the risks and benefits of using psychotropic medications. R28's 2/27/25 admission Minimum Data Set (MDS) assessment identified his cognition was moderately impaired and he required extensive assistance from staff to complete activities of daily living (ADL)'s. R8 had diagnosis of atrial fibrillation, hypertension, and arthritis, but did not have any psychiatric mood disorders. R8 was being administered an antipsychotic on a routine basis. Review of R28's March 2025, medication administration record identified he was being administered quetiapine (antipsychotic) 25 milligrams orally twice daily for disorientation. R28's medical record lacked any documentation of an appropriate diagnosis for the use of an antipsychotic. Interview on 3/26/25 at 1:11 p.m., with the director of nursing identified she does not monitor or review medication for the need of a gradual dose reduction, she also has not completed any informed consents including an explanation of the risks and benefits of using psychotropic medication. she reports that the gradual dose reductions are done by the contracted pharmacist consultant. Interview on 3/27/25 at 11:16 a.m., with the pharmacist consultant identified that she reviewed R8 and R28's medications monthly, she agreed that R8 would be appropriate for a recommendation to have a gradual dose reduction.She also agreed that R28 does not have an appropriate diagnosis documented for the use of an antipsychotic and reports that she must have missed it. She identified she would expect the facility to provide education on risks and benefits to the resident and have that documented in the medical record. Interview with the administrator on 3/27/25, at 3:00 p.m., with the administrator agreed with the above findings and identified he would expect the facility to notify the primary physician when a gradual dose reduction is appropriate. He would also expect the nursing department to ensure residents and/or their representatives were informed of the risks and benefits and alternative treatments available to taking a antipsychotic medication and to ensure residents have an appropriate diagnosis for the use of psychotropic medications. Based on interview and record review the facility failed to obtain informed consents for the use of psychotropic medications for 6 of 6 residents, (R7, R8, R10, R18, R22 and R28). The facility also failed to act upon pharmacy reviews and provide justification for not attempting a gradual dose reduction (GDR) for 2 of 5 residents (R8 and R10) reviewed for unnecessary medications. Findings include: R10's 1/10/25 quarterly Minimum Data Set (MDS) assessment identified her cognition was intact, she was able to make choices to attend activities but required extensive assistance of 1 staff person for activities of daily living (ADLs). R10 had diagnosis of heart failure, high blood pressure, and major depressive disorder. R10's current physician orders identified an order for Venlafaxine (anti-depressant medication) extended release (ER) tablet 150 milligrams (mg) by mouth (PO) daily for major depressive disorder with a start date of 2/20/24. The 2/13/25 physician 60-day routine visit documented a pharmacy concern regarding her Venlafaxine (Effexor) dose, but the family had requested it not be changed. No GDR had been attempted, nor rational documented as clinically contraindicated. R10's paper and electronic medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. R18's 2/7/25 quarterly MDS assessment identified her cognition was intact, and she required extensive assistance of 2 staff persons for her ADLs. R18 had pressure reducing devices for both her bed and chair and mobility was via wheelchair due to limited mobility on one side. R18 had diagnosis of congestive heart failure, high blood pressure, arthritis, and anxiety disorder. R18's current physician orders identified an order for Cymbalta DR 30 mg PO every (Q) morning for neuropathy (a condition that affects the nerves, causing damage or dysfunction), depression and anxiety. 12/6/24 was identified as the start date for this medication and the medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. R22's 2/7/25 quarterly MDS identified his cognition was intact, he required moderate to extensive assistance with ADLS, and used a walker or wheelchair for mobility. R22 had an indwelling catheter, and received scheduled pain, insulin, antidepressant, anticoagulant, and diuretic medications. He had diagnosis of Type I diabetes, chronic pain, depression, polyneuropathy, urine retention, blood clots of his right lower extremity, swelling, malaise, and a fracture of the leg. R22's current physician orders identified an order for Cymbalta (anti-depressant) 30 mg PO QD started on 3/15/24 for depression/chronic pain syndrome. The medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. Interview on 3/26/25 at 2:47 p.m., with the director of nursing (DON), identified there were no consents obtained for residents who received psychotropic medications, and she was not aware this was required. She further reported the facility did not have a policy regarding consents for psychotropic medications.

Based on observation, interview, and document review the facility failed to ensure the use of appropriate personal protection equipment (PPE) was utilized during blood glucose testing, and subsequent insulin administration for 2 of 2 residents (R7 and R22). In addition, the facility failed to ensure mechanical lifts were regularly cleaned and/or disinfected between resident use. Findings include: Observation on 3/25/25 at 11:30 a.m., as licensed practical nurse (LPN)-A prepared to check R7's BS and administer his lunch time insulin. She retrieved the necessary supplies from the medication cart, retrieved a BS strip from the bottle and placed it into the meter, then went to the dining room and informed R7 she needed to check his BS and administer his insulin. R7 voiced agreement and was transported from the dining room to the tub room for privacy. LPN-A asked which finger he would like to use to test. R7 then held up a finger. With her un-gloved hands, she proceeded to use an alcohol wipe to wipe his finger, then dried it with a cotton ball, picked up the automatic lancet, and lanced R7's finger to obtain a drop of blood. LPN-A then took the meter with the strip in place and touched the drop of blood to the strip, then placed the cotton ball on R7's finger. Still using her un-gloved hands, LPN-A picked up the used lancet, cotton ball, and monitor strip and placed them into the left side pocket of her scrub top. LPN-A continued with her un-gloved hands and picked up the insulin pen, applied the needle, dialed the pen to 2 units, primed the pen, then dialed to the ordered 10 units of insulin and administered the dose in R7's left lower quadrant. LPN-A recapped the pen and placed it into the same scrub top pocket with the used blood glucose items. LPN-A transported R7 back to the dining room, and then returned to the medication cart, applied hand sanitizer, and removed the items from her pocket and disposed of the used lancet, cotton ball, and glucose strip into the sharp's container. She placed the meter on the top of the cart, with un-gloved hands, took the insulin pen from her pocket, removed the needle from the pen and disposed in the sharps container. She then obtained a purple labeled Sani wipe, applied gloves and wiped the surface of the meter for disinfection, wrapped the wipe around the meter and identified it would remain on the meter until dry. LPN-A did sanitize her hands after the conclusion of the deficient practice. Observation on 3/25/25 at 11:39 a.m. with LPN-A identified she reported she also needed to administer insulin to R22. LPN-A transported R22 from the dining room to the tub room for privacy, prepared his insulin pen by wiping the tip with alcohol, attaching the needle, priming with 2 units, then dialing the pen to a total of 14 units. R22 requested the insulin be administered into his right upper arm. With her un-gloved hands, she administered the insulin. LPN-A recapped the insulin pen placed it into her scrub top pocket, transported R22 back to the dining room, and returned to the medication cart. She then she removed the used needle from the insulin pen, disposed in the sharps container and returned the insulin pen to the medication cart drawer. She then cleansed her hands with hand sanitizer. Interview on 3/25/25 at 11:43 a.m., with LPN-A reported she should have been wearing gloves and performed hand hygiene, but stated was nervous at being observed and had forgotten. Interview on 3/25/25 at 11:55 a.m., with the director of nursing (DON) identified her expectation for all staff to follow infection control measures including appropriate use of PPE when administering medications, and especially when the administration involved contact with blood. She agreed putting contaminated supplies and pens in her scrub pockets and placing contaminated insulin pens back into the medication carts would contaminate any item the pens came into contact with. Review of the 2001 MED-PASS, Inc (revised April 2019) Administering Medications policy identified staff were to follow infections control policies and procedures (handwashing, antiseptic technique, gloves, and any precautions identified) for all medications being administered. 47638 LIFTS Observation on 3/25/25 at 9:04 a.m., CNA in training (CNAT) identified CNAT pushed a Hoyer (total mechanical lift) into a resident room. The door was open as CNAT conversed with the resident and placed the residents designated sling beneath him while he waited for another staff member to assist with the transfer. When another staff member arrived, the door was closed to provide privacy during the transfer from wheelchair to recliner. After the transfer was completed, the residents door was opened and CNAT was observed pushing the hoyer lift out of residents room and down the hall, and into another residents room. The door was again closed while assisting the resident. Interview on 3/25/25 at 9:15 a.m., CNAT confirmed the lift was not cleaned between residents. He stated he was trained to complete cleaning of lifts at the end of each shift, and believed this was their policy. CNAT confirmed neither resident was on EBP. Interview on 3/25/25 at 3:59 p.m., with the director of nursing (DON) who was also the Infection Preventionist, identified lifts were to be cleaned and disinfected between residents regardless of their precaution status. DON stated new staff were trained to clean and disinfect them after each resident use. DON also stated CNAT had received a lot of information all at once, and she had clarified this expectation earlier when CNAT asked her about it. Review of the 2001 MED-PASS, Inc (revised October 2018) Cleaning and Disinfection of Resident-Care Items and Equipment policy identified staff were to clean and disinfect or sterilize reusable or durable medical equipment (DME) between residents.

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (R5) had been appropriately assessed for wheelchair size by therapy. Findings include: R5's 1/3/25, annual Minimum Data Set (MDS) assessment identified she had admitted to the facility in January of 2022, with intact cognition. She had no psychosocial behaviors, and required extensive assistance from staff to complete Activities of Daily Living (ADL). R5 had diagnoses of severe morbid obesity, arthritis, and reduced mobility. She had pain that occasionally interfered with her ADL and had a stage II pressure ulcer (characterized by partial-thickness skin loss). R5 was not receiving any therapy. Observation and interview on 3/24/25 at 2:57 p.m., of R5 in her room, identified she was seated in a recliner with her legs elevated. R5 identified she has asked for a new wheelchair. She reported she does not go to any activities or leave her room for anything. She would like to take part in activities but I'm stuck in here because it was so painful to sit in her wheelchair. Interview on 3/26/25 at 2:24 p.m., with the activity aid (AA)-A identified R5 used to come out for activities but then started refusing, she said its painful to sit in her wheelchair so she cant come to activities. AA-A identified she had reported the concern to the director of nursing but did not know if anything had been done. Interview on 3/26/25 at 2:28 p.m., with the nursing assistant (NA)-A identified she was aware R5 does not come out of her room because her wheelchair is uncomfortable. NA-A identified she had reported the refusals and the reason given to the director of nursing. Interview on 3/26/25 at 3:52 p.m., with the registered nurse (RN)-A identified she knew R5 refused to come out of her room but was not aware of the reason. She reports she thought that was her normal, she could not recall anyone telling her that it was because of her wheelchair being uncomfortable. R5's current, undated care plan identified R5: 1) Was at risk for feelings of powerlessness related to (r/t) her inability to regain strength and independence to return to her home as she had hoped on admission and was unable to take care of herself independently. R5 was noted to have preferred to stay in her room; resident expresses that she is fearful of falling; at times resident states/seems fearful of motion/movement in lift and in wheelchair. One of R5's goals was she would spend time out of her room as she feels up to it. 2) Was noted to be at risk for impaired individual coping r/t NH placement, impaired mobility, and at times would appear fearful of motion/movement with EZ-stand and when she was in her wheelchair as resident will scream, yell, and/or cry when staff is assisting her in EZ-stand and in her wheelchair, with an intervention to discuss resident fears with resident and inform the charge nurse when R5 was upset, screaming, yelling and/or crying. 3) Has little or no activity involvement r/t disinterest and immobility and physical limitations. Staff were to establish and record R5's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary and required assistance/escort to activity functions. 4) has ADL self-care performance deficit r/t activity intolerance, morbid obesity, impaired mobility. 5) Chronic Pain r/t osteoarthritis, impaired mobility, and morbid obesity with a goal to not have an interruption in normal activities due to pain. Staff were to monitor/document for probable cause of each pain episode and remove/limit causes where possible and monitor resident's existing conditions which may increase pain and or discomfort. 6) has impairment to skin integrity r/t chronic peripheral edema (swelling of limbs),decreased mobility, obesity and refusals to be repositioned every 2 hours. Staff were to identify/document potential causative factors and eliminate/resolve where possible. R5 required a pressure relieving cushion to protect the skin while up in her chair. Review of R5's progress notes and medical record identified there was no mention if R5 had been assessed per the care plan above as to why she refused to be repositioned, or why she declined to be seated in her wheelchair. There was also no indication therapy had been notified to assess R5 for appropriate wheelchair size. Interview on 3/26/25, at 3:56 p.m., with the licensed practical nurse (LPN)-A reported R5 has the right to refuse. She identified she had never asked her why she refused to come out of her room, but she recalled her being uncomfortable sitting on the commode and states she is almost always uncomfortable. Interview on 3/27/25 at 1:54 p.m., with the administrator identified he agreed the facility had not reached out to R5's physician to request an assessment by therapy for an appropriate wheelchair and had no documentation identifying that they had attempted any interventions to improve R5's comfort while sitting in her wheelchair. The administrator identified he would have expected nursing to update R5's physician and request an order for her to be evaluated by therapy. Therapy was unavailable for interview. Review of the facilities undated Accommodation of Needs policy identified the facility would assist the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. Staff attitudes and behaviors must be directed towards assisting the resident in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes.

Based on interview and document review, the facility failed to notify the resident and/or their responsible party, in writing, of the facility's bed hold policy, including potential costs included with the bed hold, at the time of transfer to the hospital for 4 of 4 residents (R1, R8, R15 and R18). Findings include: R1's 3/5/25, end of PPS stay Minimum Data Set (MDS) assessment identified his cognition was intact and he required assistance of 1-2 staff for activities of daily living (ADLS). R1 utilized a wheelchair for mobility and had a chronic indwelling catheter. He had diagnosis of spinal stenosis, kidney failure, peripheral venous insufficiency, weakness and chronic pain. R1's 1/31/25 at 9:29 a.m., progress noted identified a call had been received from the MD that R1 had an elevated WBC and CRP and she would like him evaluated in the emergency department. R18's 2/7/25, quarterly MDS assessment identified her cognition was intact, and she required extensive assistance of 2 staff members for ADLS. She was non-ambulatory and had pressure reducing devices in her bed and chair. R18 utilized a wheelchair for mobility and had experienced a fall due to attempting to self-transfer from her chair to bed. R18's diagnosis list included heart failure, vitamin B12 deficiency, congestive heart failure (CHF), anxiety disorders, high blood pressure (HTN) and hypokalemia. R18's 11/26/24 at 8:03 a.m., progress notes identified an unidentified nursing assistant (NA) had gone to get R18 up for the day and found her unresponsive. R18's respirations were labored, she opened her eyes when spoken to, but was unable to verbally respond. Appropriate notifications were completed with a plan for transfer via ambulance to the ED for evaluation. R18 was admitted to acute care with a diagnosis of CHF exasperation, until she returned on 11/29/24. Review of R1 and R18's medical record identified there was no documentation of a bed hold provided to either the resident or his family members. Interview on 3/27/25 at 12:00 p.m., with the administrator confirmed the facility had not been providing bed holds to residents who were hospitalized and he was in the process of finding forms to be used for this process. R8's 2/21/25, significant change Minimum Data Set (MDS) assessment identified her cognition was intact, she had diagnosis of bi-polar disorder, post-traumatic stress disorder, anxiety, spinal stenosis, hallucinations, and diabetes mellitus. R8 was dependent on staff for transfers, dressing, and hygiene, and used a wheelchair for mobility. Review of R8's hospital course of stay summary identified she was admitted to the hospital on [DATE], with a diagnosis of a urinary tract infection and was discharged back to the facility on 3/24/25. Review of R8's medical record identified there was no documentation [NAME] support a bed hold notice had been provided. R15's 12/20/24, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she was dependent on staff for all activities of daily living (ADL)'s, and had diagnosis of hemiplegia (one sided paralysis due to a stroke), dementia, and oropharyngeal dysphagia (impairment in the ability to swallow). R15's 12/8/24, nursing progress note identified she had increased rapid respirations, sounded congested and was coughing. Her physician was notified and R15 was transferred to the hospital via ambulance for evaluation and treatment. R15's medical record lacked documentation a bed hold had been offered to the resident representative. Interview on 3/26/25 at 4:19 p.m., with the administrator identified he agreed with the above findings, and he would expect staff to offer a bed hold to either the resident or the resident representative prior to discharge or transfer to the hospital. Review of the facilities 11/20/19, Notice of Bed Hold policy identified they would provide a bed hold notice to the resident or the responsible party upon admission and at the time of leave.

Based on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 2 of 2 residents (R14 and R131) to delineate services provided between the facility and hospice. Findings include: R14's 2/7/25, significant change Minimum Data Set (MDS) assessment identified her cognition was severely impaired and she was dependent on staff to complete all activities of daily living (ADL)'s. R14 had diagnosis of heart failure, arthritis, Alzheimer's disease, chronic pain, and lymphedema. She had vocal indicators of pain, received scheduled pain medication, and had a life expectancy of less than 6 months. Review of R14's current care plan identified she would receive visits from hospice. The care plan lacked any indication when the visits would occur and did not identify what services the facility was to provide nor services the hospice agency was to provide. R131's 3/12/25, admission Minimum Data Set (MDS) identified he had a diagnosis of cancer and was admitted to the facility on hospice with a life expectancy of less than 6 months. Review of R131's care plan identified he was receiving hospice services and had a focus of comfort. The care plan lacked any delineation of what care the hospice agency was to provide verses what care the facility was to provide. Interview on 3/24/25 at 3:15 p.m., with the hospice registered nurse, identified they typically fax the hospice care plan to the facility within 48 hours. She identified they had some communication concerns with the facility staff recently and had to explain to the aids that the bath hospice provides must be in addition to the bathing provided by the facility staff. She also reported the facility aids are responsible for assisting the hospice aid with positioning and dressing when they are at the facility providing a bath, however, at times there are no staff available to assist. Review of the 2016 Comprehensive Person Centered Care Plan policy identified the facility would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, Incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect the resident's expressed wishes regarding care and treatment goals, and identify the professional services that are responsible for each element of care. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition.

Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. Refer to F726 Findings include: Interview on 6/24/24 at 2:56 p.m., with administrator identified he had spoken to the director of nursing (DON) about the facility assessment just this morning as they were unsure when it had been last updated. She revealed he had just finished working on the facility assessment about a half hour ago and he would provide what they had at this time. He reported he was unable to find the old facility assessment and he started a new one. Interview on 6/25/24 at 4:18 p.m., with nursing assistant (NA)-A identified there was no review of skills or competencies where someone watched them however, they did complete training on-line. Interview on 6/26/24 at 7:46 a.m. with director of nursing (DON) identified department heads had not been completing annual evaluations however, the previous administrator completed evaluations on all the department heads. She identified that was something the facility would be working on. She further revealed she had not completed any skills training or competencies with staff other than the lift company that came in once a year to cover proper use of the mechanical lifts. She also identified she had not completed any competencies with any nursing staff but wished she had more time to do get those types of things. Review of the 6/24/24, facility assessment tool identified staff education and competencies were necessary to support the care needed for the residents, including certifications as applicable. The facility assessment identified a list of training and competencies which was not all inclusive that included communication, resident's rights, abuse, neglect, and exploitation, culture change, and infection control which included procedures for infection control. The infection control competencies included hand hygiene, standard precautions, isolation, use of personal protective equipment, and environmental cleaning.

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 28 residents. Findings include: Review of QAPI minutes from 6/14/24 identified No PIP projects were noted. Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON) identified the facility had not done a PIP project, as their new administrator had opted not to participate in that project. She agreed PIP projects were crucial in identifying high level areas of concern to provide the highest care possible to residents. Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no indication how QAPI would identify PIP projects or how that information would be educated to staff and residents and their families so input could be achieved and PIP measured to see if goals would be accomplished or how compliance would be achieved. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance 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 28 residents. Findings include: Review of QAPI minutes from 6/14/24 identified QAPI was lacking documentation of facility goals and analysis. There was also no response for how facility would meet goals, or that previous goals were evaluated to identify if current measures were met or new processes had been identified. Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON identified she was agreed there was no analysis of the data brought forth to QAPI, measurable goals set, or if goals were not met, or what actions the facility was going to take to meet their goals. There was no formal process for staff or residents and/or their families to provide feedback to improve areas identified in QAPI. Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no mention of measurable goals, or analysis of data to ensure new areas were identified or if older area benchmarks would be achieved or how compliance would be identified. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

Based on observation, interview, and document review, the facility failed to ensure all 25 nurse aides ((NA)-A, NA-B, NA-C, NA-D, NA-E, NA-F, NA-G, NA-H, NA-I, NA-J, NA-K, NA-L, NA-M, NA-N, NA-O, NA-P, NA-Q, NA-R, NA-S, NA-T, NA-U, NA-V, NA-W, NA-X, NA-Y and NA-Z), who bathed or had the potential to bathe residents were appropriately trained and deemed competent to manufacturer's instructions for the cleaning and disinfection of 1 of 1 whirlpool tub. Findings include: Observation and interview on 6/25/24 at 9:04 a.m., with NA-B on the north unit shower room identified she retrieved a spray bottle labeled Clorox Fuzion cleaner/disinfectant. She then sprayed the inside of the whirlpool tub and had reached for a white long handled brush and scrubbed the inside of the tub. NA-B waited 1 minute and pressed the FILL button. When pressed water came out of the jet and was flushed to the floor of the whirlpool tub down to the drain. She pressed and held the DISINFECT button for 30 seconds. When pressed, a small amount of clear water came from the jet to the floor of the whirlpool down to the drain. She grabbed the brush and scrubbed the interior whirlpool with the water from the floor of the whirlpool tub. She pressed the RINSE button and used the water sprayer to rinse the solution inside the whirlpool for 3 minutes. NA-B was unaware how long the disinfecting the whirlpool would take or if there was any disinfecting solution coming out of the jets at all. NA-B was shown to perform the procedure as noted, however, she felt the spray solution was actually disinfecting the tub. NA-B wore no PPE while performing that task. Review of the posted Cascade Aqua-Aire Tube Operation System guidelines identified staff were to: 1) Close and lock the door. 2) Remove any viable tissue, residue, or fluids from the tub by pressing the SHOWER button and rinsing the inside tub surfaces with the shower sprayer. 3) Press the FILL button and turn the TEMPERATURE control knob to the left to its warmest level to heat the disinfectant solution. 4) Press the FILL button again to turn off the water. 5) Place drain plug over the drain. 6) Press and hold the DISINFECT button. While the disinfect button was held down, the cleaning solution would run through the air injection system and out the air jets. 7) Release the button after seeing solution coming out of all the air jets. 8) Solution that remained in the foot well of the tub should be cleaned with long-handled brush to scrub all interior surfaces of the tub. Staff were to scrub around the door seal area and temperature probe area and allow the disinfectant to stay on surface for 10 minutes. 9) Remove plug from the drain. 10) Finish rinsing the interior surfaces of the tub with the shower sprayer. 11) Press the Aqua-Aire button to start the air blower and run it for 30 seconds and then turn off the air blower. Observation and interview on 6/25/24 at 12:37 p.m., with NA-C identified she pressed the FILL button on the whirlpool tub and sprayed the inside of the whirlpool for 30 seconds. She reached for the Triforce (bleach) solution spray bottle and sprayed the inside of the whirlpool walls and seat. NA-C noted the solution was to sit on the interior surface with a wet contact time of 5 minutes. The smell of the solution permeated the shower room and was overpowering. She pressed the FILL button and rinsed the whirlpool with shower sprayer for 30 seconds. She stated she would use the brush to scrub the inside of the door when spraying the interior of the tub. She stated the Triforce had an irritating smell. She pressed the DISINFECT knob for 30 seconds. She then stated she would rinse the whirlpool and use the shower sprayer for another 30 seconds. She stated cleaning the whirlpool took 10 minutes total time after each resident bath. She was unaware if the spray cleaner was an appropriate cleaner and sisinfectant to use with the whirlpool tub. Interview on 6/26/24 on 9:26 a.m., with NA-C stated she received training for cleaning and disinfecting the whirlpool during her orientation from a colleague who no longer works at the facility. She was unsure if the facility had a training checklist or competencies for the whirlpool and had not seen it implemented for new employees at the facility. Interview on 6/26/24 at 9:30 a.m., with NA-D she stated she had attended facility in-services for resident care and infection control procedures. She was unsure of training specified for whirlpool cleaning had been implemented in the facility. Interview 6/26/24 at 9:47 a.m., with NA-E stated she received training on whirlpool tub cleaning and disinfection from a coworker when hired. She received annual education on the Healthcare academy (online continuing education program). She stated one of the online courses had discussed procedures for bathing residents and tub cleaning but they were not specific to the tub the facility used. She stated the course did not explain procedures for the disinfectant and cleaning of whirlpool. During her orientation, she hand hands-on training from a co-worker but had none since. Interview on 6/26/24 at 11:15 a.m., with DON stated the facility had no formal checklist that would include nurse aide staff being trained on whirlpool cleaning and disinfection. She had no copies of employee training accessible on file at the facility to identify training or competencies had been completed. NA'ss and would be trained on the job alongside other colleagues. DON stated she was unaware of in-services held at the facility that was directed at whirlpool use and cleaning. Review of 2020, Training policy identified initial orientation would be given to all employees and the online Healthcare Academy would be provided yearly for employee training. The facility would monitor completion of training and would send the completed training to the administrator. There was no indication training was specific to the facility and not generalized overall training.

Based on observation, interview and document review the facility failed to ensure staff followed the facility protocols to verify controlled medication count to prevent potential diversion. Findings include: Observation and interview on 6/25/24 at 2:01 p.m., with registered nurse (RN)-A of the locked box within the medication cart that contained the controlled medications. There was a bound narcotic book that listed the residents-controlled medications with a count of that medication and all resident medications were reconciled by 2 licensed nurses. The locked box also contained the emergency kit (Ekit) of controlled medication in a small plastic box that had a plastic numbered tag securing the box closed and a list of medications within the box. RN-A was unable to find any documentation that the Ekit controlled medications had been reconciled. She reported that in the past that was documented in the bound narcotic book and 2 licensed nurses would verify the plastic tag number. She confirmed that without reconciling the Ekit controlled medication tag number each shift a person would not know if the Ekit controlled medication had been tampered with. Interview and observation on 6/25/24 at 2:46 p.m., with licensed practical nurse (LPN)-A revealed that the nurses did not reconcile the Ekit controlled medications that were stored in the locked box within the medication cart. If a nurse would take a medication out of the plastic box, they would fill out a form that they documented the plastic tag number removed, what medication was removed, and the new plastic tag number they applied. The form was then faxed to the pharmacy to notify the pharmacy that a medication had been removed from the Ekit. She reported the forms were kept in the locked box on the medication cart. When she opened the medication cart there were only blank forms in the locked box. She was unable to verify that the Ekit controlled medication plastic box had not been tampered with as she was unsure what the tag number was supposed to be on the Ekit controlled medication box. She agreed there would be no way to know if someone had opened the box and taken something out unless she went back through the old forms that had been faxed to the pharmacy. Interview and observation on 6/25/24 at 2:52 p.m., with the director of nursing (DON) identified the Ekit controlled medication tag on the box should be monitored and documented each shift. The documentation should be located in the front of the bound narcotic book. After examination of the bound narcotic book the DON was unable to find any documentation of the Ekit controlled medication. She retrieved the prior bound narcotic book and that book Identified on page 2 a date of 6/11/23, the Ekit tag number had been transferred from the narcotic book to the new non-narcotic book in the medication room with a line across the entire page, and no signature of who made the note or the change. The DON reported she had no idea who made this change and stated it should have never been changed. Her expectation was that staff reconciled the plastic tag number of the Ekit controlled medication box each shift with the narcotic count completed by 2 licensed staff. She agreed that there would have been no way to identify diversion without monitoring the tag number each shift. She verified the contents of the medication in the Ekit controlled medication box. The DON revealed that the tag numbers for the Ekit controlled medication had not been monitored and documented in the non-narcotic book in the medication room either. Review of the Ekit controlled medication list affixed to the Ekit controlled medication plastic box identified the following medications: morphine sulfate oral solution 20 mg/ml quantity of 30 ml, hydroco/APAP 5-325 mg quantity 6,lLorazepam 0.5 mg quantity 6, tramadol 50 mg quantity 6. Review of the Emergency Kit Replacement Slip documents located in the Ekit book in the medication room identified the last time the Ekit controlled medication box had been opened was on 1/2/24, and lorazepam 0.5 mg 1 tablet had been removed at 5:00 p.m. Forms had also been filled out for removal of medications on 12/13/23, 12/7/23 twice, 9/5/23, 94/23, 8/14/23 twice, and 8/7/23 twice. A policy on controlled medications was requested but not provided.

Based on observation, interview and document review, the facility failed to comprehensively assess, monitor interventions, and provide adequate supervision for 1 of 1 resident (R32) who eloped from the facility. This resulted in an immediate jeopardy (IJ) situation for R32, and 2 other residents (R17 and R5) who were at risk for elopement. In addition, the facility failed to ensure 1 of 3 residents (R23) had assessment and interventions identified to prevent falls. The IJ began on 1/18/20 when R32 exited the building multiple times, during blizzard conditions. Law enforcement and emergency medical services (EMS) were summoned and R32 was taken to the emergency room overnight. The IJ was identified on 1/23/19, and the facility's administrator and director of nursing (DON) were notified of the IJ on 1/23/19 at 4:00 p.m The IJ was removed on 1/24/19 at 6:24 p.m., but noncompliance remained at the lower scope and severity of D-isolated, with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of a report to the State Agency (SA) dated 1/20/19, identified on 1/18/20, R32 had exited the facility several times into subzero temperatures with wind gusts up to 50 miles per hour (MPH). The report indicated R32 was redirected back inside each time. Ultimately, 911 was called and a law enforcement officer and EMS had responded. R32 was brought to the emergency room (ER) and stayed there overnight due to weather conditions. The report indicated R32 returned to the facility on [DATE] and was safe. R32's 1/6/20, admission Minimum Data Set (MDS) assessment indicated R32 had [DIAGNOSES REDACTED]. R32's Brief Interview for Mental Status (BIMS) was scored as a 99, which identified R32 was unable to complete the assessment. Further, the MDS indicated R32 had impaired cognition with both long and short term memory problems, and made poor decisions and supervision was required. The MDS indicated R32 had problems with inattention and disorganized thinking, exhibited wandering behaviors that occurred less than daily, but did not put resident at significant risk for getting into a dangerous place. R32 used a wheelchair and walker. R32 required extensive assistance with all activities of daily living (ADLs) and mobility. R32's 1/15/20, Care Area Assessments (CAA) identified wandering behaviors, moderate cognitive impairment with short term and long term memory problems, inattention, and disorganized thinking and failed to identify any interventions. R32's 1/22/19, care plan identified the resident as being at risk for elopement with an intervention for Code Alert bracelet to ankle. No other interventions were identified. Review of 12/30/19-1/18/19 behavior symptom monitoring identified R32 as exhibiting wandering behaviors daily. R32's history and physical prior to admission, dated 12/22/19, indicated R32 had presented to an emergency department after he was found outside for an unknown period of time. He was noted to be confused, mildly hypothermic, had cold injuries to feet and thighs, and lab tests confirmed rhabdomyolysis. Other [DIAGNOSES REDACTED]. The history and physical also described R32 as confused, unable to give any history, and unable to carry on any meaningful conversation. R32's 12/23/19, neurologist consultation report recommended placement in a memory care unit, with locked doors. R32's 12/30/19, Discharge Summary from the hospital indicated R32 had been kept in the hospital until a memory care unit was found, then he was discharged to a memory care unit. R32's 12/30/19, Elopement assessment identified the resident had a known history of elopements while at home, and had wandering behaviors. However, no additional interventions were identified. R32's 12/30/19 progress note, indicated RN-C had identified R32 had disorientation, disorganized thinking, required cues, had short term, memory loss and was oriented to self. This was considered to be baseline for R32. In addition, the progress note indicated R32 had a history of [REDACTED]. R32's 1/3/20 progress note, indicated the licensed social worker (LSW) had interviewed R32 to complete a Brief Interview for Mental Status (BIMS) and had documented a score of 99, indicating R32 could not be assessed by the BIMS. Further, the LSW's progress note indicated additional staff had been interviewed to complete R32's assessment of mental status. The BIMS identified R32 had difficulty focusing all throughout interview, had an unclear flow of ideas, and had difficulty keeping track of information. Additionally, the assessment indicated R32 had mood indicators of little interest, feeling down, trouble staying asleep, feeling tired, poor appetite, feeling bad about himself, trouble concentrating, and restlessness. In a progress note from 1/16/20 at 10:35 p.m., RN-C recorded R32 had been confused, and had gone out of the building. The note indicated R32 had tried to open the door of a car that was running in the parking lot, but the doors were locked so he'd gone back into the facility because it was too cold. In a progress note dated 1/19/20 progress note, RN-D identified the following regarding R32 on 1/18/20: 5:45 p.m., R32 left the dining room and walked out to the nurse's station. RN-D asked him to return to the dining room and proceeded into the dining room with her medication cart. RN-D heard the door open but initially did not see anyone, then observed R32 outside. RN-D requested assistance and went outside to find R32 at the end of the sidewalk, going into the parking lot. The progress note identified the temperatures outside as below freezing, with wind gusts up to 50 MPH (miles per hour). After 5 minutes, RN-D and a nursing assistant (NA)-C were able to convince R32 to return to the building. The note indicated R32's Code Alert alarm did not sound when he'd exited the building, but sounded when he re-entered the building. Further, the notes indicated R32 was adamant he need to go find his wife, but ultimately R32 returned to the dining room to wait for supper. 6:00 p.m., R32 left the dining room and stated he was not hungry. 1-2 minutes later, the Code Alert alarm sounded and R32 was again observed to be outside. RN-D and NA-C again went out to redirect R32 back into the building. R32 refused stating he needed to make sure his wife was safe, and not out on the road somewhere. The note indicated RN-D told R32 they could call his wife, and he agreed to return and stay inside if he knew she was safe. According to the progress note, RN-D called R32's wife and allowed R32 to talk to her. However, R32 became more agitated, yelling and swearing at his wife and hung up on her. He then headed to the door to leave again. RN-D and NA-C were able to get to the door and redirect R32 away from the door before he exited. RN-D called RN-A to request assistance and RN-A agreed to come to the facility to assist with R32. She also instructed RN-D to contact 911. As they waited for assistance, R32 continued to try to exit the facility, threatened to harm staff and also stated I don't care if I die out there, I'll just kill myself. RN-A arrived at the facility and talked to R32 which appeared to calm him. However, when RN-A went to answer a phone call, R32 again exited the building and the Code Alert alarm sounded. RN-A and a visitor were able to redirect R32 back into the building. 6:51 p.m., call was placed to 911 again requesting immediate assistance. (Ambulance that was called out initially was on another call and still not available). 7:05 p.m., law enforcement officer arrived and stayed with R34 in his room. 7:12 p.m., family member (FM)-B notified of events and that R32 would be transferred to the hospital. 7:30 p.m., ambulance arrived and law enforcement officer escorted resident out to the ambulance. 9:40 p.m., the hospital emergency room called and notified the facility, R32 was calm and although there was no medical reason to keep him, due to the white out weather conditions, they would keep him in the ER overnight and he would return to the facility in the morning. R32's 1/18/20, ER visit notes identified the resident had been combative and tried to leave the nursing home and had threatened himself and staff because he wanted to see his wife. The notes indicated while in the ER, R32 was calm, without agitation and he had no complaints. He was stable for discharge back to the facility. The notes further included, R32 probably needs a memory care unit or some more specific Dementia care. an order for [REDACTED]. RN-A documented in a progress note 1/19/20 at 12:15 p.m., that R32 returned to the facility with family member (FM)-A and FM-B. R32's mood was angry because he was unhappy about returning to the facility. The notes indicated FM-B had requested R32 receive an as needed [MEDICATION NAME],which had been administered at 1:00 p.m. During observation on 1/21/20 at 4:15 p.m., R32 wandered the halls and stood at the nurses' station. During an interview on 1/21/20 at 4:16 p.m., NA- identified the only intervention for R32's wandering was a Code Alert on his left ankle. During interview on 1/23/20 at 8:15 a.m., RN-A stated R32 had a Code Alert bracelet to his ankle. RN-A stated the nurses check the Code Alert bracelet once a week, and document on the MAR. RN-A stated if NA's have questions about how to care for residents, they look under the care plan section of the chart. The director of nursing (DON) and surveyor checked each door to the facility together on 1/23/20 at 9:00 a.m., to determine function of the Code Alert. The facility had 5 exit doors, the following observations were identified: 1. Front main entrance door - the door exited onto a sidewalk bordering the parking lot with a road beyond. The door was equipped with a Code Alert alarm system and a Sentry Door Alarm. At that time, LPN-A stated the Sentry alarm was consistently shut off at the nurses' station because that door is used so much, it would always be going off. Using a Code Alert bracelet, the surveyor exited the building without the alarm sounding at the time of exit. The alarm sounded on reentry. This was repeated with the same results. The DON stated maybe the bracelet was old and brought out a new one. The surveyor then walked out the door and the alarm sounded on exit. When DON and a surveyor were at the end of the halls, it was observed the alarm was no longer audible. The DON stated if she were in a resident room, or if there was other noise present, she would not hear the alarm. 2. Front of building east exit, midway down east hallway - The door exited to an icy sidewalk bordering the parking lot with a road beyond. The door was equipped with a Sentry Door alarm and a Code Alert alarm system. Surveyor exited building with the first bracelet and the Code Alert alarm activated, then repeated the test with the new bracelet and the Code Alert alarm activated. The Sentry Door alarm sounded at the door. The DON stated when she was at the nurse's station she was able to hear both alarms faintly however, confirmed she could not hear them down the North or West hallways, and would not be able to hear the alarm if she were in a resident room. 3. End of east hallway exit - The door exited to an icy sidewalk, a park, a road and an alley. This door was approximately 50 feet from R32's room. The door did not have a Code Alert alarm and only had a Sentry Door Alarm that sounded at the nurse's station. When the surveyor opened the door, no alarm was heard. The DON stated the alarm should sound at the desk. LPN-A, was at the desk and verified the alarm did not sound. LPN-A then stated the alarm had been shut off, and turned the alarm back on. After LPN-A had turned the alarm back on, upon exiting the East door, still no alarm could be heard. The alarm was only audible at the desk and within 25-50 feet of the desk. The DON confirmed the alarm could not be heard if staff were down a hallway or in a resident room, even if that room was close to the nurse's station. 4. End of west hallway exit - The door exited to an icy sidewalk, a stand of trees, a yard with a large dog chained up, a street, an alley and main street to the left. The door did not have a Code Alert alarm, but had a Sentry Door Alarm that sounded at the nurse's station. Upon exiting the west door, no alarm could be heard. The alarm was only audible at the desk and within 25-50 feet of the desk. Again, the DON confirmed the alarm could not be heard if staff were down a hallway or in a resident room, even if that room was close to the nurse's station. 5. End of North Hallway door - exits to alley, a park, wooded area with a field beyond and deep snow. The door was equipped with both a Code Alert alarm and Sentry Door Alarm however, LPN-A verified the Sentry alarm was consistently shut off at the nurses' station because the door was used so much the alarm would always be going off. The surveyor exited the door with the original alarm bracelet and the alarm did not sound. However, when the surveyor exited with newer Code Alert bracelet, the alarm sounded. The alarm could be heard at the nurse's desk, however, the DON identified when at the end of east or west hallways, she was not able to hear the alarm. During the check of the doors and immediately following, the DON identified she was unaware that the end of east hallway and end of west hallway doors were not equipped with the Code Alert alarm system. The DON also stated she was unaware the alarms could not be heard throughout the building. The DON stated the function of the door alarm systems was definitely concerning as residents could exit the building without anyone being alerted. The DON then used the Code Alert Transmitter Tester to check the bracelets. Both the old and new bracelets beeped and displayed a flashing green light that flashed at least 3 times to indicate they were working. The DON confirmed both bracelets were in working order. The DON stated there were three residents identified at risk for elopement and each had Code Alert bracelets on. The DON stated the bracelets were checked once per week with the Code Alert Transmitter Tester. During an interview on 1/23/20 at 10:19 a.m., the maintenance director stated he did not have a user manual for either system, and verified there were no routine checks performed for either system. The maintenance director stated both systems had been in place for many years and it had never been a problem before this. During a follow interview with the DON on 1/23/20 at 11:19 a.m., the DON stated she was aware R32 was at risk for wandering on admission and had implemented the Code Alert bracelet on his ankle immediately. The DON stated the Code Alert bracelets were to be checked with the tester weekly to assure functioning. However, she confirmed this may not be adequate. The DON also stated she was unaware R32 had exited the building and attempted to get into a running vehicle on 1/16/20, and stated her expectation was that staff should have notified her immediately. The DON then stated the response of nursing staff on 1/18/20, was appropriate for the incident. However, identified that no further interventions beyond the Code Alert system had been put into place for R32 to assure safety on his return from theER on [DATE]. The DON stated she no longer felt they could meet R32's needs, and stated he really needed the care of a secured dementia unit. During interview on 1/23/20 at 11:45 a.m., the administrator also expressed being unaware of the incident from 1/16/20. The administrator stated staff should have notified the administrator, director of nursing, and the medical provider, and stated she would instruct the licensed social worker (LSW) to report it to the S[NAME] Regarding the 1/18/20 incidents, the administrator reported being unaware until the afternoon of 1/20/20, and stated she had instructed the LSW to report the incident to the SA immediately. After surveyor and DON identified the problems with the alarm system, the administrator stated she had contacted the board of directors to request the Code Alert System be immediately replaced because the current system was at least [AGE] years old. The administrator stated they needed to replace the system and start fresh. The administrator also confirmed there were no maintenance records, or evidence any routine maintenance of the systems having been completed. During interview on 1/24/20 at 3:22 p.m., RN-C stated she was the nurse on duty on 1/16/20. She stated R32 was at the desk and there was a car running outside with the lights on. RN-C stated R32 had asked about the car and had said he better check whether it was his wife. RN-C stated R32 then exited the building, the alarm sounded and RN-C followed him out the door. She said he checked the doors of the car found it to be locked, looked inside the car windows and said it must not be her. RN-C said she'd encouraged R32 to return inside the building as it was cold and R32 agreed and went back in. RN-C stated she should have notified the director of nursing and the administrator of the incident. During interview on 1/24/20 at 3:49 p.m., the DON confirmed there had been no assessment completed or new interventions implemented after R32's incident on 1/18/20, or upon return to the facility on [DATE]. The DON confirmed a new assessment should have been completed, an investigation of the doors and why the alarm did not sound should have been conducted, and interventions should have been put into place immediately to assure R32's safety. The DON confirmed R32's care plan did not have interventions in place and was not updated timely. Although a call was placed, and message left for R32's primary care physician, who was also the medical director, no return call was received. R17's 8/22/19 admission MDS identified [DIAGNOSES REDACTED]. R17 had behaviors of wandering daily that put him at risk for unsafe situations such as wandering out of the facility. No Code Alert was in use. R17's 1/24/20, care plan failed to identify risk for elopement or interventions to prevent elopement. During an observation on 1/23/20 at 8:22 a.m., the DON and activity director were testing the front door Code Alert alarm with R17. When R17 exited the door, the Code Alert alarm did not sound. The DON removed the Code Alert alarm and replaced it with a new alarm. When R17 exited, the alarm sounded. During interview on 1/23/20 at 11:19 a.m., the DON identified R17 had a Code Alert bracelet however, verified there were no other interventions in place to keep R17 safe from elopement. R5 was admitted with [DIAGNOSES REDACTED]. R5's 10/22/19, MDS assessment indentified R5 had severe cognitive impairment and required extensive assist with all activities of daily living (ADL)s. Throughout the survey, R5 was observed to ambulate independently and R5 was observed to wander through out the building. R5 was also observed to require staff assistance to find locations such as her room and the dining room. R5's undated care plan, did not include safety measures of having a code alert device on her ankle due to severe cognitive impairment, or her tendency to wander throughout the facility. The care plan failed to include any monitoring/checks of location in facility, nor was there any checking for function of the device other than the weekly check of the battery for the code alert bracelet. During interview on 1/23/20, at 10:19 a.m. NA-A stated R5 is very confused and requires step by step directions to assist with her ADLs. NA-A stated R5 wanders throughout the facility, is not aware of where she is going and requires staff assist to find her room. In addition, NA-A stated R5 has a code alert bracelet on her ankle but NA-A stated she was not aware of when /if the device was tested . During an interview on 1/23/20, at 11:00 a.m. the DON confirmed R5 had a code alert bracelet on her ankle, but confirmed there was no system in place for otherwise monitoring R5's location as she wandered throughout the facility. The DON stated the code alert device was checked for battery function weekly, but verified there was no system in place to insure function unless the resident attempted to leave the building through one of the alarmed doors and the alarm sounded. Review of the (MONTH) 2020 Code Alert Transmitter (bracelet) Testing instructions found online (rft.com), identified to test proper operation of the transmitter, staff should place the transmitter tester directly on the transmitter; Press and hold the button on the left side of the transmitter tester; While holding the button in, the indicator light flashes and a tone sounds once per second; and wait for at least 3 flashes and 3 tones from the tester to verify that the transmitter is functioning properly. Further, the instructions included: It is recommended you test the transmitters on a periodic basis to ensure proper operation. An undated, Wander Management Transmitters User Guide provided by the facility, included a warning for facility's not to rely exclusively on resident generated alarms for resident care and safety. The most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. The guide identified it was the facility's responsibility to establish and facilitate regular inspection schedules for their system. RF Technologies, Inc. recommends quarterly inspection of the system for safety and performance by a qualified representative. Failure to provide regular inspection of the products may result in equipment failure and/or system failure. System maintenance and testing is the responsibility of the facility to establish a regular maintenance schedule. RF Technologies, Inc. recommends monthly maintenance and testing of the system and to keep records of maintenance and test completions. The National Weather Service identified the following weather conditions for Sioux Falls SD (the closest reporting site to the facility 42 miles): 1/16/20 temperature ranged from -13 to 7 degrees Fahrenheit with wind gusts up to 22 MPH. 1/17/20 temperature ranged from 7 to 28 degrees Fahrenheit with 6.6 inches of snow and wind gusts up to 42 MPH. Also noted to have freezing rain, heavy snow, fog with visibility less than or equal to 1/4 mile. 1/18/20 temperature ranged from -3 to 28 degrees Fahrenheit with 1/2 inch of snow and wind gusts up to 55 MPH. Also noted to have snow, fag, haze, blowing snow. 1/19/20 to 1/24/20 temperatures ranged from -11 to 36 degrees Fahrenheit. The facility's (MONTH) (YEAR) Comprehensive Assessment and Care Delivery Process policy included: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Define issues, problems, risk factors, and other concerns. Define the conditions or problems that are causing or could cause other problems and the contributing factors of problems and symptoms. Identify the current interventions and treatments. Identify overall care goals and specific objectives of individual treatments. Evaluate whether or not these treatments are accomplishing the anticipated results. Monitoring results and adjusting interventions includes periodic review of progress and adjusting treatments. The immediate jeopardy that began on 1/18/20, was removed on 1/24/20 at 6:24 p.m., when the facility had taken steps to ensure residents would not leave the facility unsupervised, and had implemented 1:1 monitoring for R32 who made current efforts to elope. R17 and R5 were placed on 15 minute checks by staff to ensure their safety. Each of these residents were reassessed for elopement risk. The Wanderguard protocol was revised to require every shift checks to ensure it was functioning. Arrangements were made for a new Code Alert system to be installed, and in addition, all staff were educated on policies and procedures for Alarm Checks, Missing Resident Procedures and the Code Alert Safety Device policy. FALLS: R23's 12/19/19 admission MDS, identified She had intact cognition, she required extensive assist of 1 with bed mobility, transfers, ambulation, toileting, dressing and grooming. She used a walker and a wheelchair. She had poor balance and weakness to left upper and left lower extremity. She had [DIAGNOSES REDACTED]. R23's 2/27/19 care plan identified impaired physical mobility and risk for falls. Assist with transfers and ambulation, physical therapy as ordered, and notify provider if fall occurs. Extensive assist of 1 with transfers, bed mobility, ambulation, and toileting. Failed to identify individualized interventions to prevent falls. Interview on 1/21/20 at 3:58 p.m., R23 identified she had fallen a few times because her knees would buckle. She denied any injuries resulting from the falls. The only intervention she was aware of was that 2 staff assist her at times. R23's progress notes identified the following: - 12/17/19 at 4:47 a.m., R23 called out and staff responded. She was on the floor and stated she slid off the bed. Her controller had fallen off the bed and she had reached for it. Staff placed a gripping material to the bed rail so the bed controller would not fall off. Moved bedside table next to bed with TV control and phone within reach. - 1/2/20 at 7:40 a.m., NA was ambulating R23 in the hallway with gait belt and walker. R23's left leg gave out and NA was unable to stop R23 from falling, and both fell to the floor. Contributing factor identified as R23 had increased weakness to left leg. R23 had similar falls in the past. no additional needs or new interventions identified. - 1/6/20 at 4:27 p.m., staff had been transfering R23 from recliner to wheelchair, when R23's left knee gave out and R23 was lowered to the floor. Contributing factors identified recent episodes of left knee giving out. History [MEDICAL CONDITION] left sided residual effect. Had similar falls prior. No further interventions identified. Is working with physical therapy and wears brace to left knee for stability. - 1/24/20 at 9:48 p.m., when staff assisted R23 to stand, her knees gave out and she was lowered to the floor by staff. Has had similar falls with knees giving out. No additional needs identified. R23's incident reports for the incidents on 12/17/19, 1/2, 1/6 and 1/24/20, identified no additional information, investigation, or interventions to prevent subsequent falls. Interview on 1/27/20 at 9:59 a.m., the director of nursing (DON) identified if a resident falls, the nurse is to immediately assess the resident and provide any needed first aid. They are to then notify the doctor, the residents family, and the DON. The nurse is to then update the care plan, complete a fall risk assessment, and implement new safety measures. Staff have been trained to update the care plan but it is not being done. If she is notified of the fall, she will review it and if she sees something was not done she will implement something and document it in the progress notes. However staff do not always notify her of falls and she is unable to check daily because there is so much to do. There is no investigation completed. There is no interdisciplinary review of falls on an ongoing basis. The falls are brought to Quality Assurance meetings every 3 months. The care plan should have been updated with level of assistance needed and interventions to prevent further falls.