Every finding on record at Sacred Heart Care Center

Based on observation, interview and document review, the facility failed to ensure staff were appropriately trained and educated on how to identify and report mechanical lift maintenance concerns to prevent accidents and hazards. This practice had the potential to affect 11 of 11 residents who were assessed to use the mechanical lifts and stands.Findings include:Review of July 2025 mandatory training skills fair attendance sheet identified 27 of 88 nursing staff had completed the competency checklist.During an observation and interview on 7/21/25 at 1:42 p.m., nursing assistant (NA)-B identified 2 mechanical lifts labeled 31, 32 and 30 a sit to stand lift was missing rubber sling stoppers on the 4-point sling support hook. NA-B identified only a few of the mechanical lifts in the facility had rubber sling stoppers in place and nursing staff was directed to use the mechanical lifts for resident transfers. NA-B acknowledge the rubber sling stopper was to prevent the slings from sliding out of the sling support bar during transfers and to prevent resident falls from the lift, if not properly secured.Further observation on 7/22/25 at 9:22 a.m., identified on wing 3 had 2 mechanical lifts labeled 26, 27 and 28 a sit to stand lift was missing rubber sling stoppers.During an interview on 7/22/25 at 5:30 p.m., licensed practical nurse (LPN)-A confirmed the mechanical lifts did not have rubber sling stoppers in place and verified unawareness the reason for the rubber sling stoppers. Interview on 07/22/25 at 5:34 p.m., with NA-E identified the mechanical lifts was to have rubber stoppers in place and had not seen them on all of the lifts. NA-E identified when he uses a mechanical lift with no rubber stopper in place he would double loop the strap to prevent the sling from sliding off. Interview on 07/23/2025 at 6:54 a.m., with registered nurse (RN)-A and NA-G identified the mechanical lift required 2 nursing staff to assist residents with transfers. Both RN-A and NA-G was unsure of the reason for the rubber sling stoppers. However, NA-G identified the rubber sling stoppers was not important and the lift could still be used to transfer residents.Interview on 07/23/2025 at 7:04 a.m., with RN-B was unsure of the reason for rubber sling stoppers on the mechanical lift. Interview on 7/23/25 at 10:37 a.m., with director of nursing (DON) identified the facility implemented a performance improvement project (PIP) to identify current training processes and improve onboarding practices and staff knowledge to safely provide quality care to residents.Review of April 2025 facility assessment identified the facility utilized corporate resources to train and hire employees, based on experience and competency to ensure continuity of care across all departments, when needed. The facility was to provide information and training that was consistent with standards of practice and facility management was to meet to consider standards of care to ensure nursing staff was knowledgeable to safely care for residents. Education for nursing staff was vital in providing the highest level of care to residents and was to include Client Mobility: Exercise and Ambulation, Lifting and Safe Transfers, Positioning and Range of motion and Minnesota Safe Patient Handling, upon hire. Ongoing annual training of nursing staff was to include Accident prevention and safety measures by Occupational Safety and Health Administration (OSHA). In addition, the medical director was responsible of resident care policies and procedures and was an active participant of all staff education meetings.Interview on 7/23/2025 4:40 p.m., the administrator was hired March 2025 and was unsure if the facility had reached out to the mechanical lift manufacturer to provide a mechanical service part evaluation on the lifts. She was aware the facility had a monthly checklist for routine maintenance to be completed on all lifts implemented by the maintenance director. However, she had no knowledge the facility had an older lift, not routinely checked for maintenance and was in service on the units. The facility held a mandatory skills training in July 2025 for nursing staff to be educated on the mechanical lifts, however, she identified nursing staff could return to work and continue to transfer residents with the mechanical lifts, even though the mandatory training was not completed for all employees. She acknowledged, it would be difficult for nursing staff to identify and voice maintenance concerns when they have not received appropriate training on equipment use. Review of revised July 2025 Lifting Machine, Using a Mechanical policy identified the nursing staff was to demonstrate competency to ensure safe lifting practices when using the mechanical device in the facility.Review of revised July 2025 General Orientation Policy for Staff identified nursing staff was to receive a comprehensive orientation to promote regulatory compliance and enhance resident safety. All employees, regardless of their role or classification was to participate in a structured orientation program before assuming independent responsibilities when caring for residents.

Based on observation, interview and document review, the facility failed to ensure a process was in place to maintain 4 of 4 MedCare mechanical lifts and 2 of 4 MedCare sit to stands. This practice had the potential for unsafe transfers of 11 of 11 residents (R6, R16, R19, R23, R27, R35, R38, R42 R4, R20, R33) when it was identified the equipment used was missing safety parts used to help prevent accidents and hazards and equipment was not routinely maintained per manufacturer's recommendation.Finding includes:R6, R16, R19, R23, R27, R35, R38, R42, R4, R20 and R33, care plans included nursing staff to provide 2-person assistance for transfers and mobility either with a mechanical lift or a sit to stand lift.During an observation and interview on [DATE] at 1:42 p.m., nursing assistant (NA)-B identified 2 mechanical lifts labeled 31, 32 and a sit to stand lift numbered 30 missing rubber sling stoppers on the 4-point sling support hook. NA-B indicated a few of the mechanical lifts in the facility had rubber sling stoppers in place and nursing staff are directed to use the mechanical lifts for resident transfers. NA-B acknowledged the rubber sling stopper were to prevent the slings from sliding out of the sling support bar during transfers and to prevent resident falls from the lift, if not properly secured.During an interview on [DATE] at 8:32 a.m., maintenance technician identified the facility administration informed him the rubber sling stoppers were to be ordered and placed on the mechanical lifts. Several of the lifts had received rubber sling stoppers, however, the facility was awaiting delivery of additional rubber sling stoppers to be applied to the remainder of the lifts. He was aware the nursing staff were to use the mechanical lifts and identified routine maintenance checks and cleaning was needed for all lifts on a routine basis.Further observation on [DATE] at 9:22 a.m., wing three (3) had two (2) mechanical lifts with number 26, 27, and a sit to stand numbered 28, all included serial numbers on the labels, and all missing rubber sling stoppers.During an observation on [DATE] at 9:48 a.m., NA-C and NA-Z went in to assist R27. NA-B and NA-Z applied a yellow sling sheet under R27's back. The mechanical lift number 31 was used and was noticed to be missing the rubber sling stoppers. R27 was lifted off the bed and was transferred to R27's wheelchair. Review of a Check off List for Lifts 2025, identified number 26, 27, 31, and 32, had a routine safety check completed in the month of July.Review of Check off list for Stands 2025, identified 28 and 30 had a routine safety check completed in the month of July.Prior months Check off List for January through [DATE] lacked evidence safety checks were completed on the mechanical lifts to determine if the equipment was appropriate for resident use.Interview on [DATE] at 1:03 p.m., maintenance director who had been employed for two months had no formal training of lift maintenance, upon hire. The mechanical lifts safety check was completed once after he started and was for the month of [DATE]. In addition, the facility records lacked documentation of a lift maintenance program. He identified the facility had no process in place to ensure the mechanical lift devices were checked monthly for resident use.Interview on [DATE] at 2:34 p.m., MedCare sales representative identified the facility's mechanical lift with serial number 0203LF0412 labeled #32, was manufactured in 2002 and was [AGE] years old. She identified mechanical lifts was designed to last 20 years, however, after 10 years they recommend the lift to be replaced. Although after 10 years, the mechanical lift may continue to be used, provided routine maintenance was performed to ensure the integrity of the structure and function of the lift. If, routine maintenance was not performed on a routine basis, the mechanical lift was to be pulled out of service. In addition, the company stopped providing routine maintenance checks on mechanical lifts in 2018, however, the company would need to make arrangements for an authorized dealer in the local area to provide checks upon request from the facility.Follow up interview on [DATE] at 4:32 p.m., with maintenance director identified he was not aware one of the mechanical lifts was expired and had no knowledge of how to verify when a lift was expired. He previously, sent an email to the manufacture to verify information of the lifts used at the facility and had not received a reply, however the lift remained on the unit for use. When asked about the expired mechanical lift that had not received routine safety checks, was it safe for resident use, he had no response. He acknowledged he recently created a checklist based on the MedCare Manufacturer's preventative checklist for lift maintenance and safety check. However, his checklist did not include the manufacturer's recommendation to contact a safe patient handling consultant for lifts beyond the life expectancy of 10 years. Interview on [DATE] 5:32 p.m., with LPN-B and NA-D both identified the rubber sling stoppers was not placed on all the mechanical lifts.Interview on [DATE] at 10:37 a.m., with director of nursing (DON) identified, several months prior, the facility lacked a thorough training plan for new hires that was to include components of nursing care, including use of facility equipment that was used for residents. The facility implemented a performance improvement project (PIP) to identify current training processes and improve onboarding practices and staff knowledge to safely provide quality care to residents. During a follow up interview on [DATE] at 10:49 a.m., MedCare sales representative identified the rubber sling stoppers was an added safety precaution that was implemented for all mechanical lifts to prevent the slings from sliding off. In addition, she identified residents who use the full body mechanical lift was at a higher risk of falling out of the lift when the rubber sling stoppers was missing from the mechanical lift. Notification regarding discontinuation of lifts, services, and parts availability was sent in a mass email to all facilities on record.Interview on [DATE] 4:40 p.m., the administrator was unsure if the facility had reached out to the mechanical lift manufacturer to provide a mechanical service part evaluation on the lifts prior to their employment. She was aware the facility had a monthly checklist for routine maintenance to be completed on all lifts that was implemented by the maintenance director. However, she had no knowledge the facility had an older lift, not routinely checked for maintenance and remained in service on the units. The facility held a mandatory skills training in [DATE] for nursing staff to be educated on the mechanical lifts, however, she identified nursing staff could return to work and continue to transfer residents with the mechanical lifts, even though the mandatory training was not completed for all employees. She acknowledged, it would be difficult for nursing staff to identify and voice maintenance concerns when they have not received appropriate training on equipment use. Review of 2014 MedCare Operational Manual identified under Routine Maintenance Overview that periodic maintenance was a vital component in keeping mechanical lift in safe operating condition and a manufactured checklist was attached in the manual. Equipment that was not properly maintained would create potentially hazardous situations for nursing staff and residents. If, the equipment did not pass the maintenance test, it was to be removed from service. Periodic testing included general visual inspection of the external parts and functions to ensure no adverse damage has occurred. Recommended service of lifts identified lifts had an expected life of 10 years. In addition, the serial number was posted on the lift had identified the month and date when the product was manufactured. The medical director was contacted during survey visit; however, a call was not received back.

Based on observation, interview, and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 2 resident (R3) reviewed for PASARR R3's Minimum Data Set (MDS) assessment dated , 4/23/25, indicated R3 had intact cognition, adequate hearing, clear speech, can understand others, and able to make needs known.R3 was admitted on [DATE] with diagnoses of Personality Disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), Suicidal Ideation ((SI) thinking about or planning to harm yourself), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Generalized Anxiety Disorder (mental health condition characterized by persistent and excessive worry about a variety of events or activities), and Post-traumatic Stress Disorder (mental health condition that can develop after experiencing or witnessing a traumatic event).R'3 current medications include hydroxyzine for general anxiety disorder and imipramine for major depressive disorder.Facility document titled, Senior 'LinkAge Line dated 1/30/2023, indicated R3 had a primary diagnosis of severe major depressive disorder. Yes for R3 having a current diagnosis of a mental illness. Yes for R3 having a mental illness as the primary diagnosis for hospitalization. Yes for R3 having a mental illness that has significantly interfered with functioning. Yes for R3 needing supportive services or interventions due to a mental illness. The document indicated R3's provided information met criteria for Mental Illness (MI) and needed to be referred to lead agency for further evaluation (level 2 PASARR).During interview on 7/24/25 at 9:19 a.m., assistant director of nursing (ADON) confirmed R3's level 1 PASARR was completed on 1/30/23; indicating R3 met criteria for a level 2 PASARR. ADON confirmed R3's level 2 PASARR had not been completed.During interview on 7/24/25 at 9:29 a.m., director of nursing (DON) and regional consulting registered nurse (RC-RN) confirmed R3's admission diagnosis and R3 met the criteria for completing a level 1 PASARR. DON and RC-RN confirmed R3 had a completed level 1 PASARR dated 1/30/23. DON and RC-RN confirmed the level 1 PASARR indicated R3 should have a level 2 PASARR. DON and RC-RN confirmed the level 2 PASARR had not been completed.An undated facility policy titled Mood and Behavior Policy, the facility will complete a level 1 PASARR for all new admissions, completing a level 2 PASARR as indicated before admission to the facility.

Based on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 2 residents (R3) reviewed who had post-traumatic stress disorder (PTSD) symptoms.Findings include:R3's Minimum Data Set (MDS) assessment dated [DATE] indicated R3 had intact cognition, adequate hearing, clear speech, can understand others, adequate hearing, and able to make needs known.R3 was admitted on [DATE] with diagnoses of Personality Disorder ((PD) a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), Suicidal Ideation ((SI) thinking about or planning to harm yourself), Major Depressive Disorder ((MDD) mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Generalized Anxiety Disorder ((GAD) mental health condition characterized by persistent and excessive worry about a variety of events or activities), and Post-traumatic Stress Disorder ((PTSD) mental health condition that can develop after experiencing or witnessing a traumatic event).R'3 current medications include hydroxyzine for general anxiety disorder and imipramine for major depressive disorder.R3's care plan dated 2/7/23, identified a potential for altered mood related to PTSD, MDD, GAD, SI, and PD. R3's interventions for altered mood included opportunity to express self, contact family, contact provider, encourage activity participation, medicate as ordered, monitor side effects, monitor changes/declines in mood, and redirect/reorient/reassure as needed.R3's care plan dated 2/7/23, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization.During interview on 7/24/5 at 8:59 a.m., R3 stated the sign on her door was because she does not like loud noises; they scare her. She prefers visitors and staff knock softly so she does not get scared. R3 stated she believes this was due to her past trauma; she just doesn't like loud startling noises. R3 stated facility staff have not asked her about her past trauma, so she is unsure if they know anything.During interview on 7/24/25 at 9:14 a.m., infection preventionist (IP) who was immediately outside resident room, stated she did not believe R3 had a diagnosis of PTSD. IP stated she does not think R3 had any other mental health diagnosis.During interview on 7/24/25 at 9:16 a.m., nursing assistant (NA)-A stated, to her knowledge, the resident does not have a PTSD diagnosis. NA-A stated R3 does not have any PTSD-related triggers.During interview on 7/24/25 at 9:19 a.m., assistant director of nursing (ADON) stated resident does have a diagnosis of PTSD, anxiety, and depression. ADON confirmed R3 does not have a PTSD-specific care plan with related interventions to prevent re-traumatization. ADON confirmed R3 should have a PTSD-specific care plan.During interview on 7/24/25 at 9:29 a.m., director of nursing (DON) and regional consulting registered nurse (RC-RN) confirmed R3's admission diagnosis of PTSD. DON and RC-RN confirmed R3 does not have a PTSD-specific care plan with related interventions to prevent re-traumatization. ADON confirmed R3 should have a PTSD-specific care plan.A facility policy titled Trauma Informed Care and Culturally Competent Care dated August 2022, the facility will address the needs of trauma survivors by minimizing triggers and/or re-traumatization by developing individualized trauma-based care plans that address past trauma.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness, dependent upon their symptoms for 2 of 3 sampled staff (certified nursing assistant (NA)-Y and dietary aide (DA)-A). This had the potential to affect all 50 residents, staff and visitors. Findings include: Review of Employee Illness logs from May through July 2025 identified the following areas of documentation: department, employee name, job title, symptom onset, illness reported, last shift worked, resolution date, return to work, specimen source, and treatment results. However, the facility did not accurately complete the logs to ensure all necessary information was monitored or identified how staff were cleared to return to work. Review of Centers for Disease Control (CDC) article, Norovirus, located at https://www.cdc.gov/norovirus/about/index.html, identified Norovirus is a contagious virus that spreads through direct contact with another person. Symptoms develop 12 to 48 hours after being exposed to norovirus. Prevention was to wash your hands, often, clean and disinfect contaminated surfaces and stay home when sick for 2 days after symptoms stop. Symptoms improve after 1 to 3 days, however, there is no treatment to alleviate norovirus symptoms. Review of the Centers for Disease Control (CDC) article, Clinical Guidance for Group A Streptococcal Pharyngitis, located at https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html, identified Strep is spread through close contact with another person. Crowded settings can increase the risk for spreading the bacteria. Treatment with an appropriate antibiotic for 12 hours or longer limits the person's ability to transmit Strep. Persons infected should stay home from work until both conditions are met: 1) They are without fever. 2) At least 12-24 hours after starting an appropriate antibiotic. Review of June 2025, employee illness log identified DA-A was noted to have called in to work with symptoms of nausea and an upset stomach related to an unknown gastro-intestinal (GI) illness on 6/13/25. Review of DA-A timesheet identified DA-A had worked on 6/13/25 from 7:02 a.m. to 7:12 a.m., for a total of 15 minutes. The log further identified DA-A worked in the kitchen and rarely had exposure to residents. Review of June 2025, employee illness log identified NA-Y was noted to have called in to work with symptoms of sore throat on 6/20/25. Review of NA-Y timesheet identified NA-Y had worked on 6/20/25 from 8:00 a.m. to 10:45 a.m., for a total of 2.75 hours. The log identified NA-Y was found positive with strep throat. NA-Y returned to work on 6/25/25. Review of June 2025, resident infection log identified no residents with outbreak of strep or GI illnesses. Review of July 2025, employee illness log identified NA-Y was noted to have called in to work with symptoms of diarrhea on 7/07/25. Review of NA-Y timesheet identified NA-Y had worked on 7/07/25 from 4:06 p.m. to 10:51 p.m. The log further identified NA-Y was on break for one hour with symptoms of diarrhea and returned back to work the same day to finish her shift.Overall, there was no mention when DA-A and NA-Y symptoms resolved prior to returning to work. Review of July 2025, resident infection log identified no resident with GI illnesses. Interview on 7/25/25 at 08:54 a.m., with registered nurse (RN)-C identified her process to track employee illnesses was to receive a copy of each departments staff call-ins, review and identify staff who reported sick and to and discuss at the facility's morning meetings. RN-C was to call those employees who was sick, identify the illnesses reported and determine if further evaluation was needed, depending on the employee's symptoms and risk of transmission. RN-C identified both DA-A and NA-Y lacked appropriate tracking and surveillance of DA-A and NA-Y illnesses to determine if DA-A and NA-Y was appropriate to return back to work. Interview on 7/25/25 at 0:29 a.m., with director of nursing (DON) expectations was for the infection preventionist (IP) or designee, to track, monitor and identify when employee's symptoms resolved and when it was appropriate for employees to return to work. Review of December 2024, Communicable/Contagious Disease, Employee policy identified facility staff who was active with communicable infections, was not to be in contact with residents, resident environment, residents care items and equipment until they were no longer contagious. The IP was to oversee employee health practices, including work restrictions and return to work criteria. In addition, employees was responsible to report suspected or confirmed infections with communicable or infectious disease to their supervisor upon onset and/or prior to reporting to their scheduled shifts. Review of April 2025, Facility assessment identified the facility's infection prevention department was to implement protocols to execute and ensure accurate tracking and mapping of the spread of infections and complete screenings to identify when staff was a potential transmitter of infections and/or communicable diseases.

Based on interview and document review the facility failed to implement their abuse prohibition policy when there was an allegation of misappropriation of resident property for 1 of 1 resident (R1) reviewed for drug diversion. Findings include: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and lorazepam (medication used for anxiety). Licensed practical nurse (LPN)-E sent an email on 4/11/25 at 10:57 p.m.,to registered nurses (RN)-B, RN-C, RN-D, and interim director of nursing (IDON) identifying R1's liquid morphine bottle was way off. There were 16.5 milliliters (ml) in the bottle and at the end of her shift there was 12 ml left in the morphine bottle. LPN-E requested the nurse managers to look into the situation and identifed the narcotic page number. Follow up email dated 4/11/25 at 10:59 p.m., identified RN-B replied to LPN-E asking if that's what it was at when you did narcotic checks coming on shift. There was no evidence of an email follow up on RN-B's question to LPN-E. LPN-E sent another email to RN-B on 4/12/25 to report that R1's lorazepam count was off as well and was at 10 ml and was supposed to be at 12 ml. LPN-E responded to RN-B question about the liquid morphine stating, I can't remember what the bottle was at the start of the shift, but I did not spill, when I left last Friday, everything was on track. During an interview on 4/29/25 at 12:31 p.m., registered nurse (RN)-B stated she received an email on 4/11/25 at around 11:00 p.m. to inform her of R1's narcotic count not being correct. RN-B stated she did not complete a facility narcotic count to ensure if other narcotics were missing. She called the facility the next day and the nurse that was working believed the loss of narcotic was due to spillage or evaporation and RN-B did not think anything of it. after talking to the nurse. RN-B did not report R1's narcotic count being incorrect until 4/14/25 or start an investigation as a result of the missing medication. During an interview on 4/29/25 at 2:31 p.m., the Administrator stated she had not received a report about R1's narcotic count being off until the afternoon on 4/14/25. However, she did not initiate an investigation at that time attributing the discrepancies to spillage or evaporation. The Administrator further noted that an investigation into R1's missing narcotics was only initiated after she received an anonymous note under her door on April 17, 2025, alleging narcotic diversion involving R1. The note specifically suggested investigating the destruction of R1's narcotics on April 15, 2025, as the counts had been inaccurate at the time of destruction. After she received the anonymous note on 4/17/25 she had the nurse managers perform a count of all the liquid narcotics in the facility on 4/17/25. Administrator stated, they were unable to pinpoint missing narcotics to just one nurse, since it had been multiple nurses recording R1's amounts incorrectly. The facility was unable to provide an investigation into the incident but provided documentation of training for the nurses on performing narcotic counts. However, this training did not include guidance on reconciling narcotics. Review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of resident property policy dated 3/14/24, identified the following: Investigation regarding misappropriation -Complete an active search for missing item(s) including documentation of investigation. -The investigation will consist of at least the following: A review of the completed complaint report An interview with the person or persons reporting the incident. Interviews with any witnesses to the incident A review of the resident medical record if indicated. A search of resident room (with resident permission) An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. Interviews with the resident's roommate, family members, and visitors A root-cause analysis of all circumstances surrounding the incident.

Based on interviews and document review the facility failed to report to state agency (SA) potential misappropriation of resident property (missing narcotics) no later than twenty-four after an allegation was made for 1 of 3 resident (R1) reviewed for narcotic diversion. Findings included: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), chronic kidney, and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and lorazepam (medication used for anxiety). During an interview on 4/29/25 at 12:31 p.m., registered nurse (RN)-B stated she received an email on 4/11/25 at around 11:00 p.m., from one of the nurses stating that one of R1's narcotic count was not correct in the narcotic record. RN-B stated she responded via email on 4/11/25, however, did not call the facility until the next day to begin determination of the missing narcotics. RN-B stated she did not report R1's missing medication to the Administrator until the afternoon on 4/14/15, because she did not think it was a concern. During a follow up interview at 4:54 p.m., registered nurse (RN)-B stated she was unsure of the timeframe for reporting a possible drug diversion to the SA but believes it would be within 24 hours and she should have notified the administrator on 4/11/25. During an interview on 4/29/25 at 2:31 p.m., the Administrator stated she had not received a report about R1's narcotic count being off on 4/11/25 until the afternoon on 4/14/25, however did not report this to the state agency at that time, because the investigation determined it was not a drug diversion, however the investigation was not completed until 4/18/25. During an interview on 4/29/25 at 11:56 a.m., RN-A stated if a medication is missing, she would notify the administration immediately and it would need to be reported within 24 hours to the SA. Review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 3/13/24, identified that all alleged violations of misappropriation of resident property are reported no later than 24 hours, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on observation, interview, and document review the facility failed to implement policies and procedures to ensure accurate reconciliation of controlled substances to ensure rapid detection of potential narcotic diversion for 2 of 3 residents (R1, R3) reviewed for medication pass who received narcotic medications. Findings include: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and Lorazepam (medication used for anxiety). Review of R1's Individual Narcotic Record for morphine sulfate concentrate (RX#233843) identified the following: -Page 69 of the narcotic record identified on 3/18/25 (RX# 2333843) 30 milliliters (ml) was received from pharmacy. On 4/1/25 remaining amount was 22.50 ml and was transferred to page 79. -Page 79 of the narcotic record identified on 4/1/25 (RX# 2333843) 22.50 ml moved from page 69. On 4/13/25 remaining amount of 14.75 ml was transferred to page 97. -Page 97 of the narcotic record identified on 4/13/25 (RX# 2333843) 14.75 ml transferred from page 79. On 4/15/25 at 1:35 p.m., the narcotic record identified that remaining amount was 13 ml. On 4/15/25, the narcotic record identified that 13 ml was wasted, with two nurses signatures on page. However, there was a correction note on 4/15/25 that identified 9 ml were destroyed with three initials, one was the director of nursing (DON). However, there was no indication for the change. Review of R1's Individual Narcotic Record for Lorazepam identified the following: -Page 86 of narcotic record identified on 4/14/15 remaining amount was 10.5 ml. On 4/15/25 the amount destroyed was 8.5 ml, signed by two nurses. However there was no indication why 8 ml were wasted instead of 10.5 ml as identified in the narcotic record. During an interview on 4/29/25 at 10:40 a.m., licensed practical nurse (LPN)-B stated narcotics are counted at the beginning and end of each shift by two nurses. LPN-B stated R1's morphine and Lorazepam counts had been off for a while; however, could not identify how long. She and other nurses continued to document what the count was supposed to be with the doses given and not what was present in the bottle. LPN-B further stated she had been told by the nurse managers the counts could be off due to spillage or evaporation. LPN-B stated LPN-E had send an email to the nurse managers on 4/11/25 to notify that R1's counts were not correct, but was unsure what occurred. LPN-B reviewed R1's narcotic record on April 15, 2025, and noted the recorded amount was 13 ml of morphine. However, when she physically checked the bottle at 1:35 p.m. that same day, she found only 9 ml left. To align with the narcotic log, she documented an incorrect remaining amount. LPN-B did not notify the nurse managers about the discrepancy since another nurse had already done so. During an interview on 4/29/25 at 12:31 p.m., registered nurse (RN)-B stated that nurses had not been recording the correct amount in R1's narcotic record during shift-to-shift narcotic count because they may be off due to spillage or evaporation. The liquid Lorazepam was kept in a locked refrigerator in the front of the wings and was unsure if the nurses were performing the counts on these bottles at shift change. R3's face sheet dated 4/29/25, identified diagnoses of dementia, chronic kidney disease, diabetes (disease where the body use sugar as fuel). Review of R3's individual narcotic record for morphine sulfate concentrate identified the following: -Page 19 of the narcotic record identified on 4/6/25 that 26.50 ml of morphine sulfate 20 mg/ml was transferred from old book. On 4/29/25 R1's morphine count was recorded at 26.50 ml at shift change. During an observation and interview on 4/29/25 at 11:49 a.m., LPN-C removed R3's morphine sulfate (20 mg/ml) bottle out of locked medication cart and held R3's morphine bottle in the air stating R3's morphine bottle had around 25 ml in the bottle. LPN-C then placed R3's bottle on the top of the medication cart and leaned over to read the side of the bottle on the cart and stated R3's morphine bottle was closer to 24 ml mark. Observation of R3's morphine sulfate 20 mg/ml bottle had a blue liquid substance in it with lines on one side with measurements and the blue liquid substance was at the 24 ml mark. LPN-C stated R3's bottle had been off for quite some time and the previous director of nursing had talked to the consulting pharmacist and stated the liquid bottles can appear to have less in the due to spillage or evaporation. LPN-C stated R3's narcotic record had not been corrected to the correct amount and nurses have been recording in the log what the amount is supposed to be not what was in the bottle. LPN-C further stated when she performs narcotic counts at the beginning or end of her shift and the count would not be correct then she would contact the nurse managers immediately, however had not informed the nurse managers about the R3's count being off. During an interview on April 29, 2025, at 1:02 p.m., the interim director of nursing (IDON) stated that she assisted in the destruction of R1 ' s morphine and Ativan alongside a second nurse on April 15, 2025. Initially, both nurses documented the expected amount in the narcotic log, but later corrected the wasted amount upon discovering discrepancies in the medication count. IDON reported that she contacted the consulting pharmacist about the discrepancy. She had been told about possible spillage or evaporation but could not recall the exact date of the discussion. IDON stated her expectation would be for nurses to do narcotic counts at the beginning or end of their shifts and if the counts are not correct they should notify the director of nursing or administrator immediately and not sign the narcotic record until the medication can be accounted for. During a phone interview on 4/30/25 at 8:17 a.m., consulting pharmacist (Pharm) stated she was not aware of R1's narcotic counts being incorrect until the medications were destroyed on 4/15/25. She had received a call from the IDON to discuss R1's counts being off and suggestions of how this could have occurred. Pharm further stated when a resident's narcotic count are not correct during count, then administration and pharmacist should be notified immediately to account for the medication loss and ensure a diversion had not occurred. Pharm further stated she does not perform routine reconciliation of the narcotics and the facilities will do this. She stated liquid narcotics can show slight discrepancies in volume due to various factors, including the type of syringe used, errors in dosage measurement, and loss from spillage or evaporation as staff frequently access the medication bottles. When the facility noticed the liquid narcotics being incorrect then they should have provided education to the nurses on proper reconciliation of narcotics and what to do when the counts are incorrect. Review of the facility's Medications-Controlled Policy and Procedure dated 1/13/25 and unsigned by DON or Medical Director, identified the following: - narcotics are to be counted at the change of each shift by the off-going and the on-coming nurse and both sign the change of shift count record. -if the count is incorrect, and you cannot resolve the count, notify the supervisor. -Both nurses must stay until the supervisor tells them that they may leave. -Do not adjust the count of leave spaces in the book. -Only those nurses who do the actual count should sign that the count is correct.

Based on interview and record review the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day on 10/7/23 and 10/21/23. Findings include: A review of the facility schedule was completed for the dates of 10/1/23 through 12/31/23. Upon this review, it was identified there was a lack of RN coverage for eight consecutive hours on 10/7/23 and 10/21/23. During interview on 5/2/23, at 3:20 p.m. the director of nursing (DON) stated she had been unaware of any days where there was not an RN on the schedule for a minimum of eight consecutive hours. DON stated she had reviewed the schedules for those dates identified, and verified there was not RN coverage for eight consecutive hours on the dates listed. During interview on 5/2/23, at 4:00 p.m. the administrator stated she had been unaware of the any days where the facility lacked eight consecutive hours with RN coverage. The administrator stated she had reviewed the schedules as outlined above, and verified both with the schedules and time card entries there was not eight consecutive hours of RN coverage on those dates. A policy was requested for staff scheduling but was not received.

Based on interview and document review the facility failed to provide policies and procedures for their quality assurance and quality improvement committee (QAPI). This had the potential to effect all 49 residents currently residing in the facility. Findings include: During entrance conference on 4/29/24, at 1:44 p.m. a copy of the facilities QAPI plan was requested from the director of nursing (DON). The facility provided a Quality Assurance and Performance Improvement (QAPI) Plan Sacred Heart Care Center, Inc. document, reviewed and updated on 9/10/21. This document included the following: Vision Statement, Mission Statement, QAPI statement, QAPI Guiding Principles, and the Scope of QAPI. The document identified the QAPI program; assessed quality in all areas, aimed for safety and high quality with all clinical interventions, used the best available evidence to determine appropriate care, and defined measures and goals. The document indicated the QAPI program provided guidelines for supervisors and the nursing home board. The document also listed the resources available for QAPI, the outline of the QAPI leadership process, reporting of QAPI activities to the Board of Directors, also the resources for feedback, data systems, and monitoring. The document lacked policies and procedure on; the QAPI committee's responsibilities and the process' on how the committee would conduct activities necessary to identify and correct quality deficiencies; including how they would track and measure performance, establish goals and thresholds, identify and prioritize quality deficiencies, systemically analyze underlying causes, develop and implement corrective action or performance improvement activities, and monitor and evaluate the effectiveness and revise as needed. During interview on 5/2/24, at 3:55 p.m. the administrator stated that QAPI meetings were held monthly, and QA (Quality Assurance) meetings were held quarterly. Those in attendance at the quarterly meetings included the medical director, environmental services, social workers, infection control preventionist (ICP), the clinical dietary manager, activities director, clinical managers, staff development coordinator, director of nursing, and the administrator. Upon request for the meeting minutes of those meetings held, a hand written copy of a meeting titled Orientation Meeting Agenda, dated 5/2/24 was provided. Upon review of recurrent citations, the administrator stated they did track and trend the information for infection control, and this information was provided by the Infection Control Preventionist (ICP). The administrator stated this process was not included in the meeting minutes, but was managed by ICP. The administrator stated previous performance improvement plans (PIP) included the admission process, which was now complete. The administrator stated their newest identified PIP was for the staff orientation process. A request was made for additional documentation to reflect meeting minutes, information regarding performance improvement processes, attendance rosters, and notification process of the information for those not in attendance, including the information provided. This information was not provided.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) were put into place for 4 of 4 residents (R10, R16, R22, and R45) In addition, the facility failed to complete contact source tracing during two outbreaks (norovirus and COVID-19). This deficient practice had the potential to affect all 49 residents who resided in the facility. Further, the facility failed to perform hand hygiene and PPE audits to ensure proper technique. Findings include: ENHANCED BARRIER PRECAUTIONS, (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), PPE USE AND HAND HYGIENE Review of CDC guidance, dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) indicated examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R10's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R10 had severe cognitive impairment and was dependent with all activities of daily living (ADL's) and had an indwelling catheter. R10's diagnoses included: heart failure, peripheral vascular disease (condition that affects the blood vessels outside of the brain and heart), renal failure (condition in which the kidneys can no longer adequately filter waste products from the blood), and Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior). R10's care plan dated 3/13/24, indicated R10 required staff assistance with all ADL's and had an indwelling catheter. During observation on 4/30/24 at 1:27 p.m., R10 did not have cart with PPE or hand hygiene in or outside of room, nor did they have signage posted indicating that R10 was on enhanced barrier precautions. R16's significant change MDS assessment dated [DATE], identified R16 had moderate cognitive impairment, required assistance with all activities of daily living (ADL)'s and had an indwelling catheter. R16's diagnoses included hereditary ataxia (group of rare, complex diseases that affect the cerebellum, spinal cord, and peripheral nerves), atrial fibrillation, hypertension, renal failure, neurogenic bladder (urinary tract condition that causes a person to lack bladder control due to nerve, spinal cord, or brain damage), thyroid disorder and depression. R16's care plan dated 3/19/24, indicated R16 required staff assistance with all ADL's and had an indwelling catheter. During observation on 4/30/24 at 11:39 a.m., R16 did not have cart with PPE or hand hygiene in or outside of room, nor did they have signage posted indicating that R16 was on enhanced barrier precautions. R22's admission MDS assessment dated [DATE], identified R22 had intact cognition, required assistance with all activities of daily living (ADL)'s and had an indwelling catheter. R22's diagnoses included heart failure, hypertension, renal failure, benign prostatic hyperplasia, pneumonia, chronic obstructive pulmonary disorder and respiratory failure. R22's care plan dated 4/11/24, indicated R22 required staff assistance with all ADL's and had an indwelling catheter. During observation on 4/29/24 at 3:24 p.m , R22 did not have cart with PPE or hand hygiene in or outside of room, nor did they have signage posted indicating that R22 was on enhanced barrier precautions. R45's quarterly MDS dated [DATE], identified R45 had moderately impaired cognition, required assistance with all activities of daily living (ADL)'s and had an indwelling catheter. R45's diagnoses included hypertension, peripheral vascular disorder, renal failure, Alzheimer's disease, stroke and depression. R45's care plan dated 5/1/24, indicated R45 required staff assistance with all ADL's and had an indwelling catheter. During observation on 4/30/24 at 1:16 p.m , R45 did not have cart with PPE or hand hygiene in or outside of room, nor did they have signage posted indicating that R45 was on enhanced barrier precautions. During review of infection control, it was identified the facility had an outbreak of COVID in January and February 2024 and an outbreak of Norovirus in March of 2024. Documentation lacked evidence that infection control audits (hand hygiene and PPE) had been completed. Documentation lacked evidence that source contact tracing had been completed with both outbreaks. During interview on 5/2/24 at 1:33 p.m., infection preventionist (IP) stated enhanced barrier precautions (EBP) had not been implemented and confirmed R10, R16, R22 and R45 should be on EBP due to each of them having a catheter. IP stated hand hygiene and PPE audits had not been completed and confirmed that they should have been done during the norovirus outbreak and COVID outbreak to ensure staff were using proper technique to prevent the spread of infection. IP stated she did not go in depth with contact tracing and could not provide documentation of conversations with staff. During interview on 5/2/24 at 3:48 p.m., director of nursing (DON) confirmed that EBP precautions had not been implemented. DON stated she was aware that the facility could have done a better job with this. DON stated EBP precautions were important for both resident and staff safety. DON stated source tracing should have been started with the resident identified with the infection and continued with every staff that assisted positive resident. The tracing should have been done with other residents those staff had cared for. DON stated she had expected IP to document all conversations that occurred regarding the infection control process, including plans for and implementation of tracking and tracing. DON stated it was important to document tracing so that facility had all the information in the event another resident or staff tested positive. DON stated if conversations were not documented, it wasn't completed. DON stated it was her expectation infection control audits had been completed, and potentially increased during the outbreaks to ensure proper infection control practices. Facility Enhanced Barrier Precautions policy and procedures, infection control audits and source contact tracing policies were requested but were not received.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R32) observed with medications at bedside. Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 had intact cognition and required assistance with all activities of daily living (ADL)'s. R32's diagnoses included Parkinson's disease with dyskinesia (uncontrollable and involuntary movements of the body), heart failure, hypertension (high blood pressure), renal failure (condition in which the kidneys can no longer adequately filter waste products from the blood), Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior) and depression. R32's care plan dated 3/20/24, indicated R32 did not want to self-administer or was not currently self-administering medications. During observation and interview on 4/30/24 at 7:17 p.m., R32 was in his room without staff present sitting in his recliner. There was a bottle of nasal spray on the bedside table and a medicine cup with four unidentified pills. During observation and interview on 4/30/24 at 7:17 p.m., licensed practical nurse (LPN)-A confirmed the presence of the nasal spray and oral medications at R32's bedside. LPN-A identified the oral medications as Quetiapine, Senna, Sinemet (Carbidopa-Levodopa). LPN-A stated there was no residents on wing one who could self-administered medications and medications are never supposed to be left in resident's rooms. LPN-A stated R32 asked her to leave the medications on his bedside table as he was in the bathroom. LPN-A stated R32 is alert but she did not know him that well yet and assumed he would not touch them. LPN-A verified R32 did not have a current order for SAM. R32's order dated 5/2/23, indicated saline nasal spray solution 0.65%, 1 spray in both nostrils two times a day for dry and stuffy nose. R32's order dated 4/29/24, indicated quetiapine fumarate 25 mg, 0.25 tablet by mouth one time a day for anxiety/restlessness, give at 6pm. R32's order dated 2/6/24, indicated Senna-S 8.6-50mg, two tablets by mouth at bedtime for constipation. R32's order dated 8/16/23, indicated Carbidopa-Levodopa 25-100 mg, two tables by mouth four times a day related to Parkinson's disease. R32's medical record lacked a self-administration of medications (SAM), a physician's order for SAM or a SAM assessment. During interview on at 5/2/24 at 12:42 p.m., registered nurse (RN)-B stated residents must have an order and assessment for SAM and it should also be care planned. RN-B verified R32 did not have a current order or assessment for SAM. RN-B stated medications should not be left at the bedside without the appropriate order and assessment in place. During interview on 5/2/24 at 3:48 p.m., director of nursing (DON) stated expectation was a resident would have an order and an assessment for SAM and it would be care planned to ensure a resident could safely self-administer medications. DON stated it was not appropriate for medications to be left in R32's room at bedside. The facility Self-Administration of Medications policy, dated 5/2/24, indicated if the resident chooses that the resident should self-administer medications, the clinical manager or designee conducts an initial assessment before the initial care conference, or sooner if the resident requests, or if nursing staff feels it is needed. The team will assess the resident's cognitive, physical, and visual ability to carry out this responsibility. The licensed nursing staff will obtain a physician's order for self-administration, and the name and dose of medications to self-administer. Nursing staff will update the care plan. The resident's ability to self-administer medications should be reviewed at the quarterly care conference.

Based on observation, interview, and document review the facility failed to provide opportunities for participation in the activities of choice (walking outside) for 1 of 1 residents (R44), reviewed for choices. Findings include: R44's initial Minimum Data Set (MDS) assessment, completed on 8/3/23, indicated her medical diagnoses included coronary artery disease, hypertension, and anxiety and was cognitively impaired. MDS also identified R44 was able to express herself and be understood, and was able to understand others. R44's responses regarding her preferences for customary and routine activities identified R44 consistently responded it was very important for her to be around animals and to go outside to get fresh air when the weather was good. R44's care plan, last reviewed on 3/20/24, identified the following diagnoses; impaired mobility due to lower back pain; anxiety; frailty; age related physical debility; and cognitive deficit due to dementia. The care plan identified a strength of R44 was her ability to walk independently with a four wheeled walker. Although it was identified walking was a strength, the care plan lacked direction, and identification, that it was very important for R44 to walk outside when the weather was good. The care plan also identified a potential for alteration in mood stated related to admission and directed staff to encourage activity participation for social/mental stimulation. R44's care plan goal was to participate in activities of choice one to three times a week, yet lacked direction as to what her interests were. During interview on 4/30/24, at 12:49 p.m. R44 stated she has always enjoyed being outside, and expressed frustration about not being outside and stated she wished to be outside on more walks. R44 stated she feels she is getting weaker and weaker. On 5/1/24, at 1:32 p.m. activity aide (AA)-B was observed interacting with R44. R44 was observed sitting with her sunglasses on during their visit. Once the visit was completed, AA-B was interviewed and asked if she had been outside with R44. AA-B stated she had not, and identified they had just been visiting. AA-B stated last week she had gone outside with R44 in the gated courtyard and walked around. AA-B stated she had not walked with R44 outside of the gated courtyard. While speaking with AA-B, R44 was observed to stop by and visit with unidentified staff at the front desk in the day room area. R44 could be heard expressing frustration about not being allowed to go for walks outside. The conversation between R44 and the staff member was observed in it's entirety and lasted approximately ten minutes. R44 progress notes identified, R44 expressing the desire to be outside: On 2/16/24, a call was received from R44's family member (FM)-A to inform the facility that R44 had told her that she planned to leave the facility unattended at times. The note indicated R44 had not expressed this to staff, and had not made any attempts. FM-A requested R44 be directed to stay within the nursing home area and not walk to the reception desk, as that was near the exit door. A discussion was held regarding the potential for R44 to leave the facility unattended, as well as the potential use of a wander guard (an electronic alarm worn by the resident to alert staff of attempts to leave unattended) but family member chose not to use the wander guard at that time. On 3/7/24, the progress notes identified Resident talked about how she loves to go outside and how she was a big walker back in the days. On 3/12/24, the progress notes identified resident had again expressed desire to go outside. Resident told nurse that she feels like she is in a prison because she can't go outside on her own. Comfort and reassurance given. SW notified and activity director brought resident outside with her. On her way outside, she thanked nurse with a smile on her face. Will monitor. On 4/4/24, the record reflected SW stopped in to do a weekly visit with resident. She talked about how she use to walk around town with her dog. On 4/14/24, the progress notes indicated: Very emotional this shift. A lot of crying noted. Resident states she is going to break a window to get out of here, and go for a long walk. States she is going nuts never being able to leave. On 4/17/24, the note read: Resident said that she is sick of being inside all the time. SW let her know that when it is nice out that one of the aides is going to be walking with her otherwise Activities will be walking with her outside. Resident replied, good because I love to walk. Resident talk about the things she use to due back in the days when she was littler. SW asked if she had any issues. She said no just the walking outside would be nice. On 4/18/24, the notes indicated She has not talked about wanting to go outside or how she feels she's in a prison. On 4/19/24, notes indicated: She stated she felt like she was in a prison. She brought up how everyone yelled at her when she was trying to walk up front where it is quiet. She stated she didn't know how much longer she could take this. She also mentioned a resident who recently passed which was her best friend and was 'with the program' unlike others here. On 4/20/24, (R44) expressed concerns about declining mentally and physically d/t being confined in a place like this. Comfort and reassurance given. On 4/24/24, narrative notes reflected: Nurse told her she would see her later and she said, Well I'm not going anywhere! Nurse said she wasn't either, and resident said to nurse, You're lucky you have freedom! and how that's a big word with big meaning. During interview on 5/1/24, at 3:44 p.m. , registered nurse (RN)-B stated R44 was able to walk around the facility, and added staff will walk outside if it is nice. (RN)-B stated R44 also walked in the assisted living area with staff. The assisted living area is beyond the reception area. The (RN)-B was asked about family concerns identified in February regarding R44 going to the reception area. (RN)-B stated this area was not always staffed so request was made for her not to walk there. (RN)-B responded R44 would most probably return if she was taken for a walk outside of the gated areas with staff. (RN)-B stated R44 also went out on day leaves with family with no concerns regarding a return to the facility. On 5/2/24, at 9:42 a.m. the activity director (AD) stated the staff were aware of R44's desire to go outside on walks, as had been informed by staff and family members. AD stated R44 had gone outside with the activity aides and walked in the gated courtyards. AD stated she was aware family had requested R44 not go beyond nursing home doors. A review of care plan was completed at this time and AD identified R44's request to walk outside was not indicated in the care plan. AD stated this was reflected in the MDS. A review of the R44's activity attendance identified R44 had walked outdoors with activity staff four days out of 30 days in April on 4/15/24, 4/18/24, 4/23/24, and 4/25/24. It was noted none of these dates corresponded with the above indicated times R44 expressed extreme frustration and desire to be outside. A review of the Complete Activity Assessment, completed 8/3/23, indicated in a handwritten notation enjoys sitting outdoors. A request was made for the policies for assessment and care plan development. A policy, reviewed 1/5/16, titled Assessment and Care Plan System-Care Plan and Conference-Interdisciplinary was provided. The policy directed staff to complete a written assessment and evaluation of the resident prior to the care conference. The policy directed staff to work with members of the team to initiate, develop, review, and update each individual's plan of care.

Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold policy at the time of hospital transfer for 1 of 3 residents (R21) who was reviewed for hospitalization . Findings include: R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R21 had intact cognition and required assistance with all activities of daily living (ADL)'s. R21's diagnoses included schizoaffective disorder (mental disorder characterized by abnormal though processes and an unstable mood), heart failure, hypertension, peripheral vascular disease (vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain), renal failure, schizophrenia (mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misperception of reality), and chronic obstructive pulmonary disease (progressive lung disease). R21's progress notes indicated R21 was hospitalized on [DATE] and returned to the facility on [DATE]. R21's medical record lacked evidence of a bed hold was provided at the time of transfer for hospitalization . During interview on 5/2/24 at 11:23 a.m., director of nursing (DON) stated she expected when a resident was transferred out of the facility that a bed hold was initiated by the nurse. DON stated she expected the case manager/social worker to follow up to determine if the resident wanted to continue holding the bed. DON confirmed she had not found communication with the resident in regard to a bed hold for R21 hospitalization . DON stated it was important for the bed hold to be obtained as the facility needs to know from the resident/representative if they wished to hold the bed and/or return to the facility. The facility Bed Hold Notice at the Time of Transfer policy, dated 3/21/24, indicated each resident and the responsible party were to be fully informed about our bed-hold policies and associated costs whenever the resident is hospitalized or on a therapeutic leave from Sacred Heart Care Center. Any time a resident was transferred to the hospital, a copy of our Bed-Hold Policy was to be sent to the hospital with the hospital transfer form. The reason for transfer was to be written on the Bed-Hold Policy form. If it was unknown at the time of the transfer whether the resident was to be admitted , a copy of the Bed-Hold Policy was to be sent with the resident or responsible party. A copy of the Bed-Hold Policy was also be provided to a family member or responsible party at the time the resident was transferred to the hospital. If the appropriate person was at the facility at the time of transfer, the Bed-Hold Policy might be handed to them. If they were not at the facility, the Bed-Hold Policy and accompanying letter was to be placed in a stamped envelope, address, and mailed to them. The nurse who arranged the hospital transfer was to document in the progress note that the Bed-Hold Policy was sent with the resident to the hospital and/or was given/mailed to a family member, including the name of the person to whom it was given or sent. A Bed-Hold Policy was also to be provided to the resident and a responsible party whenever the resident goes on a therapeutic leave exceeding 24 hours. In most cases, a family member would have been transporting the resident, and a Bed-Hold Policy was to be given to them at the time. If this was not the situation, a copy was to be mailed to the appropriate person. The nurse who had released the resident's medications was responsible for providing these notices and for documenting on the Nurses Notes that they were given, as well as to whom they were given. During extended hospitalization s, the Director of Nursing or Social Worker was to make personal contact with the resident or responsible part to ascertain their wishes regarding a bed hold.

Based on observation, interview, and record review, the facility failed to consistently follow orders for application of splints for 1 of 2 residents (R15) reviewed for limited range of motion. Findings include: R15's quarterly minimum data set (MDS) assessment dated [DATE] indicated R15 was moderately cognitively impaired, had no history of rejection of care/behaviors, was dependent on staff for all activities of daily living (ADL's), and had limited range of motion on both upper extremities. R15's Careplan dated 3/14/2024 indicated staff were to put on white hand splints in the morning and remove them at 3 pm. R15's care plan further indicates resident was dependent for showering/bathing, upper and lower body cares. R15's skin integrity care plan indicated R15 had bilateral hand contractures (tightening of muscles and ligaments causing joint deformity). R15's provider orders, active as of 5/1/2024, indicated please place hand rolls (bilateral) from morning AM till 3 pm daily. Watch for redness. R15's occupational therapy note, dated 8/11/2023, indicated please put on new white hand splints in the morning and take off around 3 pm, instead of blue hand rolls During observation and interview on 4/30/2024, at 11:47 a.m., R15 was noted to have both hands clenched tight. R15 was able to straighten thumb and index finger on right hand. R15 made no attempt to straighten remaining fingers on right hand or fingers on left hand. An impression was noted in R15's left hand from left thumbnail. [NAME] powder was noted in thumb/hand crease. R15 denied discomfort. R15's fingernails on both hands were 1/4 to 1/2 inch long. R15's Record review , indicated R15 participated in rehab exercises including shoulder, elbow, forearm, wrist, and finger exercises as resident tolerated. There were no documented refusals. R15's medication/treatment administration record lacked indication of refusal of splints. During observation on 5/01/2024, at 8:00 a.m., R15 was observed seated in broda chair (specialized wheelchair to assist with positioning) and was dressed for the day. R15 did not have hand splints on. During interview on 5/1/2024 at 10:00 a.m., licensed practical nurse (LPN-A) stated R15 wore hand braces to both hands. Braces were put on in the morning and taken off by 3 pm. LPN-A stated staff washed R15's hands and applied powder to prevent skin issues. R15 received pain cream and oral pain relievers for discomfort. LPN-A stated R15 never refused her hand splints. LPN-A indicated the splints were important for comfort prevention of skin issues. LPN-A stated she would look into R15's long nails and hand splints. During observation on 5/1/2024, at 10:30 a.m., R15 was noted to be wearing hand splints to both hands and fingernails were cut. R15 denied discomfort. During interview on 5/1/2024, at 3:35 p.m., registered nurse (RN-C) stated R15 wore hands splints from the morning until 3 p.m. RN-C stated staff checked R15's hands for redness. RN-C stated she had noted R15's nails had dug into her hands at times. RN-C stated she had never had an issue with R15 refusing cares or treatments. During interview on 5/2/2024, at 8:40 a.m., nursing assistant (NA-A) stated splints were put on in the morning and taken off at 3pm. NA-A stated she had not experienced R15 refusing to wear splints. During interview on 5/2/2024 at 9:54 a.m., clinical manager (CM-A) stated R15 had been enrolled in hospice, however family decided to disenroll R15. R15 was started on therapies to assist with ROM upon disenrollment from hospice. CM-A stated R15 wore splints to both hands in the morning, which were removed at 3 pm. CM-A stated R15 never refused to wear them, however, R15's husband (another resident) did remove them at times. CM-A stated when R15's husband removed them, staff offered to put them back on if R15 is agreeable. During an interview on 5/2/2024 at 1:48 p.m., the director of nursing stated she did not know why R15 did not have her hand braces on and confirmed R15 should have been wearing them if agreeable. A policy titled Physical Device and Restraint Policy dated 4/10/2024, made no mention of assisting with application of hand splints. A policy titled Activities of Daily living (Daily Life Functions) reviewed 4/3/2024, made no mention of assisting with applying hand splints.

Based on observation, interview, and document review, the facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for 1 of 1 resident (R29) reviewed for respiratory care. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had intact cognition and was independent with all activities of daily living (ADL)'s. R29's diagnoses included dyspnea (feeling that you can't get enough air into your lungs), anxiety disorder, depression, Post Traumatic Stress Disorder (PTSD) and slow transit constipation. R29's care plan dated 4/3/24, indicated R29 had potential for altered airway clearance related to sleep apnea and dyspnea. Interventions indicated SPO2 (pulse oximeter reading which indicates what percentage of your blood is saturated) as ordered and prn. The care plan lacked interventions related to oxygen tubing, bubbler, or humidified oxygen. R29's orders dated 2/8/24, indicated R29 received humidified oxygen two liters per minute via nasal cannula continuously during sleep. The orders lacked indication for changing R29's oxygen tubing, bubbler or humified oxygen. During observation and interview on 4/29/24 at 5:04 p.m., R29 was sitting in recliner with two liter per minute (lpm) of oxygen being delivered by nasal cannula. The oxygen tubing lacked a label to indicate when it was last changed. The nasal cannula was connected to a bubbler and the canister lacked a date to indicate when it was last changed. Nasal cannula tubing was a brown-tinged color and was stretched out by the prongs that insert into nares causing tubing to hang on R29's face. R29 stated she wore the oxygen at all times and stated she did not know when the tubing or humidifier was changed last, verified there was no date on tubing or humidifier, and indicated she had to ask staff to have tubing changed when it got too loose. During observation on 4/30/24 at 5:24 p.m., R29 was sitting in a recliner in her room with nasal cannula oxygen tubing. The tubing lacked a date to indicate when it was last changed. During observation on 5/1/24 at 10:00 a.m., R29 was sitting in a recliner in her room with nasal cannula oxygen tubing. The tubing lacked a date to indicate when it was last changed. During interview on 5/2/24 at 8:43 a.m. registered nurse (RN)-A verified R29's electronic medical record (EMR) lacked an order to change R29's oxygen tubing and humidifier bi-weekly and therefore, could not verify when they had last been changed. During interview on 5/2/24 at 12:46 p.m., registered nurse clinical manager (CM)-B stated oxygen tubing should be changed every 2 weeks and as needed. CM-B stated when tubing is changed, staff document it on the treatment administration record (TAR) and write date of change on the tubing and/or humidifier. CM-B verified R29's EMR lacked an order to change R29's oxygen tubing and humidifier bi-weekly and therefore, could not verify when they had last been changed. During interview on 5/2/24 at 3;48 p.m., director of nursing (DON) stated there should have been an order for the licensed nursing staff to complete the change of the oxygen tubing and humidifier on a scheduled basis. DON stated it was important to ensure that the tubing and humidifier was changed for infection prevention. A facility Oxygen tubing and humidifier policy was requested but was not received.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 1 of 1 resident (R27) who was prescribed antibiotics prophylactically. Findings include: R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R27 had intact cognition and required supervision/assistance with all activities of daily living (ADL)'s. R27's diagnoses included type 1 diabetes mellitus, cancer, hypertension, renal failure, anxiety disorder, Waldenstrom macroglobulinemia (rare, slow-growing type of cancer that affects white blood cells called plasma cells and lymphoplasmacytoid cells), encephalitis (inflammation of the active tissues of the brain caused by an infection or an autoimmune response), auditory and visual hallucinations. The MDS also indicated that R29 received an antibiotic. R27's physician orders, printed 5/2/24, indicated R27 received Bactrim 400-80 mg tablet once daily at bedtime for infection prevention related to kidney transplant status. This order was implemented on 6/21/2021, and lacked an end date for antibiotic use. During interview on 5/2/24 at 1:33 p.m., infection preventionist (IP) stated R27 was admitted to facility with orders for prophylactic antibiotics for chronic conditions. IP confirmed the physician orders did not have an end date. IP stated residents on prophylactic antibiotics were not monitored with infection monitoring charting or tracking, and confirmed she had not followed up on R27's prophylactic antibiotic use with the provider. IP stated that prophylactic use of antibiotics was not reviewed or discussed at the facility's quality assurance and performance improvement (QAPI) team meetings. The facility Antibiotic Stewardship Program policy, revised 3/20/24, indicated the facility aimed to monitor antibiotic (ATB) use amongst residents and ensure ATB were prescribed and used appropriately throughout the facility to decrease the changes of MDRO development amongst residents. It also identified the facility aimed to ensure proper education was provided to employees and physicians regarding meeting criteria for antibiotic use ATB were requested and prescribed. The policy also indicated the facility aimed to monitor residents throughout their treatment and assess for any development of MDROs and/or adverse effects from ATB use. The Centers for Disease Control and Prevention's (CDC) undated, The Core Elements of Antibiotic Stewardship for Nursing Homes state antibiotic prescribing and use policies must, Specify dosing (including route), duration (i.e., start date, end date, and planned days of therapy), and indication, which includes both rationale (i.e., prophylaxis vs. therapeutic) and treatment site (i.e., urinary tract, respiratory tract), for every course of antibiotics.

Based on observation, interview and document review, the facility failed to ensure the required and complete nurse staffing information was posted and readily available for viewing by the residents and visitors. Additionally, the facility failed to maintain the staffing logs for 18 months, as required, in the event this information was needed for review. This had the potential to affect all 49 residents and visitors who wanted to review the information. Findings include: On 4/29/24, the nurse staff posting was observed to be in place in main entrance area. On 4/30/24, at 12:04 p.m. the nurse staff posting was noted to remain in place for staffing of 4/29/24, and had not been updated to reflect staffing for 4/30/24. Upon follow up observation on 4/30/24, at 2:00 p.m. it was noted to have been updated and reflected information for 4/30/24. At this time, the nurse staff posting information was present for 4/29/24, 4/30/24, and 5/1/24. On 5/1/24, at 8:34 a.m. the nurse staffing information posted was dated as 4/29/24. Additional nurse staffing information was present for 5/1/24, however the nurse staff posting for 4/30/24 was no longer posted. An attempt was made to interview the staff scheduler in follow up, however, she was not in the facility at this time. On 5/1/24, at 10:41 a.m. registered nurse (RN)-B was interviewed in follow up, as RN-B stated she was responsible to oversee scheduling. RN-B stated the current nurse staffing information posted was reflective of 4/29/24, and not the current date. Upon review of the information, RN-B identified there also had not been any changes in the nurse staff posting information from 4/29/24 to reflect changes related to staff call ins or staff updates of 4/29/24. A request was made at this time for additional staff posting information to complete the Payroll-Based Journal (PBJ) staffing review. On 5/1/24, at 11:18 a.m. RN-B stated she was unable to provided the staff postings from prior to 12/8/23 as they were unavailable. RN-B stated the staff posting information prior to 12/8/24 had not been retained as the facility was unaware of the need to retain this information for an extended period. On 5/2/24, at 3:20 p.m. the director of nursing (DON) stated she was unaware the nurse staff posting information was to be maintained for a period of 18 months. A policy was requested for retention of staff schedules and nurse staff posting information but was not provided.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information during 1 of 1 quarters (Quarter 1) reviewed for payroll based journal (PBJ). Findings include: A review of the PBJ Staffing Data Report from fiscal year (FY) Quarter 1 2024 (October 1-December 31, 2023) identified there were no registered nurse (RN) hours for the time period from 10/1/23 through 12/31/23. In addition, the facility was also triggered for a lack of licensed nursing coverage 24 hours/day for the time period from 10/1/23 through 12/31/23. On 4/29/24, at 1:44 p.m., a request was made for the staff schedules for the time frame of 10/1/23 through 12/31/23. A review of the licensed staffing schedules for these dates was completed. A comparison of the staff schedules in correlation to the nursing staff postings from 12/8/23-12/31/23 was also completed. A comparison was unable to be completed prior to 12/8/23 as the postings had not been retained by the facility. The following discrepancies were noted. RN coverage was noted to be in place for all of the above dates with the following exceptions initially identified: 10/7/23, 10/21/23, 11/4/23,11/5/23, 11/18/23, 11/19/23, 11/23/23, 12/24/23, 12/26/23, and 12/27/23. On 5/1/24, at approximately 4:00 p.m., copies of the licensed staff time card logs for the above listed dates were provided for review in correlation to the staff schedules/nursing staff posting. The records were reviewed in correlation with the dates reported on the PBJ report, staff schedules, and time card logs. Upon completion of review, it was noted the facility lacked RN coverage for eight consecutive hours on 10/7/23 and 10/21/23. Upon review of the hours identified on the PBJ report as having a deficit for licensed nursing coverage 24 hours/day during the period of 10/1/23 through 12/31/23, it was noted this was found to be an error in submission. The review of the nursing staff schedules for this period lacked identification of insufficient licensed nursing staff for the 24 hour per day. During interview on 5/2/23, at 3:20 p.m. the director of nursing (DON) stated the PBJ submission is currently completed by the administrator. The DON stated they were aware the PBJ reports were not submitted in a timely process, and the person who had been completing this task was no longer on staff. The DON stated she was unaware of any days where there was not an RN on the schedule for a minimum of eight consecutive hours. During interview on 5/2/23, at 4:00 p.m. the administrator stated she was currently responsible for submission of the information for the PBJ reports. The administrator was unaware of the any days where the facility lacked eight consecutive hours with RN coverage. Additionally, the administrator stated she was unaware of any time where there was not licensed nursing coverage for the entire 24 hour period per day. The administrator stated she was unaware of any areas triggered in the PBJ report, with the exception of timely submission. The administrator stated she was now responsible for submission of all PBJ reports. The administrator stated there was not an officially a facility policy for completion of the PBJ submission, however, the process is completed as outlined on the CMS (Centers for Medicaid and Medicare Services) website.

Based on interview and document review the facility failed to ensure infection control data and performance improvement plans were incorporated into the facility-wide Quality Assurance and Performance Improvement (QAPI) Plan. In addition, the facility failed to provide documentation to reflect systems management, tracking and trending of infection control program, and performance improvement plan process and progress. This had the potential to effect all 49 residents currently residing in the facility. Findings include: During entrance conference on 4/29/24, at 1:44 p.m. a copy of the facilities QAPI plan was requested from the director of nursing (DON). The facility provided a Quality Assurance and Performance Improvement (QAPI) Plan Sacred Heart Care Center, Inc. document, reviewed and updated on 9/10/21. This document included the following: Vision Statement, Mission Statement, QAPI statement, QAPI Guiding Principles, and the Scope of QAPI. The document identified the QAPI program; assessed quality in all areas, aimed for safety and high quality with all clinical interventions, used the best available evidence to determine appropriate care, and defined measures and goals. The document identified the QAPI program provided guidelines for supervisors and the nursing home board. The document also indicated the resources available for QAPI, the outline of the QAPI leadership process, reporting of QAPI activities to the Board of Directors, and feedback, data systems, and monitoring. The Facility Assessment provided for review was last reviewed and updated on 9/19/22. A review of the information in the Facility Assessment related to infection prevention and control was completed. The overview identified the process of preadmission screening for infections and communicable diseases, as well as review of immunization status. The assessment indicated in the event of more than one case of an infection or communicable disease, a line listing was created to ensure accurate tracking and mapping of the spread of infections and/or disease. The assessment indicated protocols were executed to ensure the outbreak was contained to a section or unit within the building to the extent possible. During interview on 5/2/24, at 3:55 p.m. the administrator stated that QAPI meetings were held monthly, and QA (Quality Assurance) meetings were held quarterly. Upon request for the meeting minutes, a hand written copy of a meeting titled Orientation Meeting Agenda, dated 5/2/24 was provided. Upon review of recurrent citations for infection control, the administrator stated they did track and trend information for infection control within the QA/QAPI documentation, and this information was provided by the Infection Control Preventionist (ICP) during the meetings. The The administrator stated she was unaware the tracking, trending, and contact tracing for infections/illness was not tracked in consistent formatting. A request was made for additional documentation to reflect meeting minutes, information regarding performance improvement processes, attendance rosters, and notification process of the information for those not in attendance, including the information provided. This information was not provided for review.

Based on observation, interview and document review, the facility failed to implement all necessary infection control practices to prevent and/or minimize a facility wide outbreak of COVID-19 for 21 of 46 residents (R1, R2, R3, R4, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22) resulting in an immediate jeopardy (IJ). This deficient practice had the potential to affect all residents residing in the facility and staff who were at risk for contracting COVID-19. The immediate jeopardy began on [DATE], when the facility's failure to implement appropriate infection control practices to mitigate or reduce the spread of COVID-19 in the facility, the IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 5:10 p.m. on [DATE]. Additional IJ findings were identified on [DATE], when it was identified the facility failed to separate a symptomatic resident from a healthy resident roommate, and failed to initiate risk assessments to determine potential causal factors of transmission and identify high risk resident exposures. The administrator and director of nursing were notified of this additional information at 3:00 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], when the facility had developed and implemented an acceptable plan. However, non compliance remained at the lower scope and severity level of G, isolated scope and severity level, which indicated harm that is not immediate jeopardy. Findings include CMS memo COVID-19 Long Term Care Facility Guidance, dated [DATE], directed nursing homes to immediately ensure they were complying with all CMS and CDC guidance related to infection control which included the use of standard, contact and droplet precautions. In addition, the memo directed long-term care facilities to separate patients and residents who have COVID-19 from patients and residents who did not, or whose status was unknown. Upon entrance to the facility, on [DATE] at 8:30 a.m. the receptionist, who was responsible for screening staff and contracted staff, was not wearing a mask or eye protection. The receptionist stated because she was not a direct care provider, and was not working on the nursing floor, she didn't have to wear a mask or eye protection. During the entrance conference on [DATE], at 8:46 a.m. the DON stated the facility had a COVID isolation unit that had six beds which had been filled after they'd conducted testing earlier in the month. The DON stated because there was not enough available staff to have another separate unit, the facility had designated their 200 wing to be the new quarantine area and was in the process of moving another four residents into that area. The DON and IP (infection preventionist) verified wing 200 currently had both COVID positive and negative residents. The DON further stated the 100 and 300 wings did not have symptomatic or COVID positive residents. The IP stated the facility had identified their first COVID positive resident on [DATE], and then other residents started demonstrating symptoms around the same time. The IP stated 13 residents and 7 staff tested positive after testing was conducted [DATE]. The IP also stated she was unaware which residents currently displayed signs and symptoms of illness, and stated the information would be in the resident infection tracking notes in the electronic health record. The IP stated she had not completed the infection control surveillance log and/or performed any related activities such as track/trending, risk assessments, or audits since around the end of [DATE]. During a facility tour with the DON on [DATE], at 10:10 a.m. the DON again stated not all residents on the 200 wing were positive for COVID, and confirmed the wing was not divided into sections for COVID-19 positive and negative. During the tour R1 and R2 were observed to reside in the same room. The DON stated R1 and R2 continued to share a room even though R1 had tested COVID-19 positive and had symptoms. The DON stated staff were using transmission based precautions (TBP) when they entered the room. The DON stated R8 was the first resident to test positive for COVID-19 and was immediately transferred to the COVID unit. The DON stated after the unit was at capacity, residents who tested positive remained in their rooms, and residents with shared rooms who became positive, or who had symptoms, remained in the same room as the roommate even if the roommate was not positive or had symptoms. During the tour, dietary assistant (DA)-A was observed in the kitchen area with a cloth mask on. DA-A stated said she was wearing a cloth mask per the facility policy. DA-B stated dietary staff could use either a cloth mask or a medical grade mask because they didn't have direct contact with residents. DA-B stated up until a couple of weeks ago dietary staff were not wearing any type of mask. R8's census line indicated R8 resided on wing 200. A progress note dated [DATE], indicated R8 was tested for COVID-19. Progress noted dated [DATE], indicated R8 tested positive for COVID-19. A subsequent progress note at 11:40 a.m. indicated R8 was tested again, and swab was sent to local clinic for processing. At 11:59 p.m., a physician notification note was sent to the physician to inform the physician of R8's positive test results, another swab was collected and sent to local clinic, and R8 was in an isolation room, and staff were wearing N95's masks when in her room. A progress note dated [DATE] included, Tolerated move to quarantine area well. The facility lacked evidence of completed risk analysis of potential exposures and/or transmission to other residents, investigation of the illness, and identification of potential causal factors of disease transmission. According to the facility's census report R11 and R12 resided in the same room on 200 wing. R11's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R11's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R11 had severe cognitive impairment. R11's progress note dated [DATE] at 3:42 a.m., indicated R11 had low blood oxygen saturation of 88% and required an increase of supplemental oxygen from 2 LPM (liters per minute) to 4 LPM. An Illness Tracking Note (ITN) from [DATE] at 2:46 p.m., indicated R11 had reported to nursing she didn't feel good. The ITN included, Type of illness: Possible Respiratory. States doesn't feel good and face flush. Despite the ITN dated [DATE], indicating a possible respiratory illness, the facility lacked evidence transmission based precautions (TBP) were implemented immediately and R11 was separated from her roommate. According to an ITN note dated [DATE], R11 tested positive for COVID with use of the [MEDICATION NAME] testing machine; R11 was then moved to the COVID isolation unit. R12's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R12's progress notes for [DATE], indicated R12 had testing conducted with the facility's [MEDICATION NAME] machine with negative results, and was moved to the COVID isolation unit. A subsequent progress note dated [DATE], indicated R12 tested positive for COVID-19 with the [MEDICATION NAME] machine. According to the facility's census report R9 and R10 resided in the same room on 200 wing. R10's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R10's annual Minimum Data Set ((MDS) dated [DATE], indicated R10 had moderate cognitive impairment. R10's progress note dated [DATE] included, Resident had a small emesis this A.M. Yellow in color. Resident has a temp (temperature) of 99.6. Will continue to monitor. R10's record lacked evidence TBP were immediately implemented and R10 was separated from her roommate. An ITN's dated [DATE], indicated R10 had loose stools. ITN note dated [DATE], indicated R10's blood oxygen saturations were ,[DATE]% on room air. On [DATE], the ITN indicated R10 had a fever of 100.0. On [DATE], at 2:51 a.m. indicated R10 had fever of 99.7 and had a dry harsh cough. R10's [DATE] progress note from 9:25 a.m., indicated R10 tested positive for COVID-19 from the [MEDICATION NAME] machine. Progress note on [DATE], at 11:44 a.m. indicated R10 was transferred to the COVID isolation unit. R10's progress notes dated [DATE], indicated R10 was transferred to the hospital for further evaluation related to worsening respiratory status and was subsequently admitted to the hospital. A physician notification note dated [DATE], indicated R10 had passed away in the hospital today at 5:10 p.m. R9's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R9's quarterly MDS dated [DATE], indicated R9 had moderate cognitive impairment. R9's progress note dated [DATE], at 5:36 a.m. indicated R2's oxygen saturations were ,[DATE]% on room air so the nurse started oxygen at 2.5 lpm (liters per minute). R9's physician [DATE], at 11:41 a.m. notification included, (R9) seems more and more confused from her baseline, getting times of day mixed up. Had a fever today of 99.8. wheezing noted in upper lobes of lung sounds. The note also indicated R9 had low blood sugar, declined to each lunch. A response from the physician at 5:47 p.m. included, I recommend checking a COVID-19 test ASAP. R9's record lacked evidence TBP were implemented or whether R9 was separated from her roommate immediately. The record identified TBP were implemented more than 24 hours later on [DATE]. R9's progress note dated [DATE], at 9:20 a.m. included Results for COVID came back Positive with [MEDICATION NAME] machine testing. A subsequent note on [DATE], indicated R8 moved to the COVID isolation unit. According to the facility's census report R1 and R2 resided in the same room on 200 wing. R1's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 did not have cognitive impairment. R1's Illness Tracking Note (ITN) dated [DATE], at 11:19 a.m. included R1 had dry non-productive cough, potential Covid exposure. R1's ITN dated [DATE] at 11:49 a.m,. included: Dry non-productive harsh cough, Covid [MEDICATION NAME] test was negative. A Subsequent note at 8:58 p.m. indicated R1 had a cough, and rubs were noted in both lungs. Despite R1's symptoms, R1's record lacked evidence of initiation of transmission based precautions (TBP) or whether R1 was separated from her roommate (R2) to prevent and/or mitigate the risk of disease transmission. R1's ITN dated [DATE] at 10:29 a.m., indicated R1 had a cough and lungs were clear. A subsequent note at 12:37 p.m. included, Resident swabbed for COVID and tested with the [MEDICATION NAME] Machine. Results = POSITIVE (+). R1's physician visit note dated [DATE], included: [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] test was positive on [DATE]. Due to the COVID-19 isolation unit being at full capacity, she has remained on isolation in her semi-private room. Nursing staff indicates that she has had a fever and occasional cough. R1's ITN notes from ,[DATE] to [DATE], identified R1 continued to have symptoms associated with COVID-19 which included: elevated temperatures up to 101.6, non-productive cough, wheezing lung sounds, and congestion. A progress note dated [DATE], indicated R1 needed to be reminded to try to keep a mask on and a progress note dated [DATE], indicated R1 was reminded to cover her mouth when she coughs. Despite R1's COVID symptoms, R1's record did not identify when TBP were initiated and R1 was not separated from her roommate to prevent and/or mitigate the risk of disease transmission. R2's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R2's significant change MDS dated [DATE], indicated R2 did not have cognitive impairment. R2's ITN note dated [DATE], indicated R2 had an elevated temperature of 100.2. The ITN for [DATE], indicated R2 had a temperature of 99.0. A subsequent note on [DATE], indicated R2 was tested via [MEDICATION NAME] machine with negative results. R2's record lacked evidence that TBP were initiated when she initially developed the fever [DATE]. ITN note dated [DATE], indicated droplet precautions were in place. R2's record indicated R2 was moved to a private room on the 200 wing on [DATE], after the facility was notified of the immediate jeopardy. R2's progress note dated [DATE], indicated the registered nurse assessed R2's mobility and included, Transferred her with AO1 (assist of one), belt, and 4 w/w (wheeled/walker) from her recliner and walked her to just outside her room and then back in again. R2's progress note dated [DATE], indicated R2 was tested for COVID-19. R2's progress note dated [DATE], indicated R2 tested positive for COVID-19. According to the facility's census report R13 and R14 resided in the same room on 300 wing. R13's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R13's quarterly MDS dated [DATE], indicated R13's cognitive skills for daily decision making were severely impaired. R13's ITN dated [DATE], indicated R13 had a fever of 99XXX,[DATE].2 and had an emesis. A progress note dated [DATE], indicated R13 was tested with the [MEDICATION NAME] machine with negative results. R13's record lacked evidence TBP were immediately implemented or whether R13 was separated from her roommate. R13's progress note dated [DATE], indicated R13 had some coughing with large amounts of phlegm while eating On [DATE], the ITN indicated R13 had experienced temps of 102.3, 100.8, and 101.4, and had exhibited a cough and sinus congestion. Subsequent progress notes on [DATE], indicated R13 tested positive for COVID-19 with the [MEDICATION NAME] machine and was moved to the COVID isolation unit . R13's progress note dated [DATE], indicated R13 died . R14's ITN note dated [DATE], indicated R14 had exhibited an increase in temperature of 99.5 degrees. R14's record lacked evidence TBP were implemented, and failed to identify illness tracking was immediately initiated. R14's record indicated R14 was tested for COVID on [DATE], results were not documented in the record. A progress note dated [DATE], indicated R14 had undergone follow up testing for COVID by PCR. A subsequent progress note dated [DATE], indicated R14 had negative results. R14's record did not identify PCR test results. R14 was transferred to 100 wing and on [DATE] and then on [DATE] was transferred to the 200 wing. R14's progress note did not identify reason for room change, but indicated contact TBP's were implemented on [DATE]. According to the facility's census report R15 resided in a private room on 200 wing. R15's Admission record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R15's progress note dated [DATE], indicated R5 got short of breath with activity, had slight wheeze with trying to get out of bed, another progress note dated [DATE], indicated the [MEDICATION NAME] machine was used with negative results. Despite R15's symptoms, R15's record lacked evidence TBP's were immediately implemented. R15's progress notes on [DATE], indicated R15 required an increase in supplemental oxygen related to decreased saturations of 88%, in addition to temperature of 100.8. A note at 12:36 p.m. indicated R15 tested positive for COVID using the [MEDICATION NAME] machine. R15's progress note dated [DATE], indicated R15 was transferred to the hospital for hypoxic respiratory distress. A progress note dated [DATE], indicated R15 died at the hospital at 10:20 a.m. According to the facility's census report R19 resided on the 200 wing in a private room. R19's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R19's ITN note dated [DATE], indicated R19 reported being weak, was short of breath and dizzy during a transfer, face was red and warm, temp of 101.0, and exhibited decreased oxygen saturations at 88% which required supplemental oxygen. A progress note dated [DATE], indicated R19 had a negative COVID test per use of the [MEDICATION NAME] machine. Despite R19's symptoms, the record lacked evidence TBP were implemented. R19's record identified, R19 continued to have symptoms of elevated temperature, diarrhea, and required oxygen. The record further indicated R19 was tested on ,[DATE] and [DATE] with negative results from the [MEDICATION NAME] machine. A progress note dated [DATE], indicated R19 was transferred to the hospital for further evaluation for [MEDICAL CONDITION] and change in condition. A progress note dated [DATE], indicated the facility had been notified R19 was transferred to the intensive care unit. A progress note dated [DATE], indicated R19 had been diagnosed with [REDACTED]. A subsequent progress note dated [DATE], indicated R19 was readmitted to the facility into a private room on the 200 wing. According to the facility's census report R3 and R4 resided in the same room on 200 wing. R3's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R3 had severe cognitive impairment. R3's ITN dated [DATE], indicated R3 had an elevated temperature of 99.4 degrees. A subsequent progress note indicated R3 tested positive for COVID-19 using the [MEDICATION NAME] machine. R3's record did not address implementation of TBP or whether R3 was separated from roommate. R4's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R4's admission MDS dated [DATE], indicated R4 had severe cognitive impairment. R4's progress note dated [DATE], indicated R4's family was notified R3 had tested positive for COVID-19. R4's progress note dated [DATE], indicated R4 tested positive for COVID-19. R4's record did not address implementation of TBP until [DATE]. R4's progress note dated [DATE] included on isolation precautions. According to the facility's census report R18 resided on the 200 wing in a private room. R18's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. of nicotine dependence, and [MEDICAL CONDITION] stage 3. R18's quarterly MDS dated [DATE], indicated R18 had severe cognitive impairment. R18's ITN note dated [DATE], indicated R18 had an elevated temp 99.3, and had vomited three times within 2 minutes. R18's record lacked evidence TBP were immediately initiated. On [DATE], R18's ITN's indicated temp of 99.3 and emesis. From ,[DATE] thru [DATE], R18's record did not include ITN. On [DATE], an ITN note indicated R18 had a cough. Progress notes dated ,[DATE] and [DATE], indicated R18 tested negative with the [MEDICATION NAME] machine. An ITN note dated [DATE], indicated R18, had a fever of 100.0. A progress note dated [DATE], indicated R18 tested positive with the [MEDICATION NAME] machine. Even after R18 tested positive for COVID-19, R18's record identified TBP were not implemented until [DATE]. According to the facility's census report R16 resided on the 200 wing in a private room. R16's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R16's quarterly MDS dated [DATE], indicated R16 had moderate cognitive impairment. R16's ITN dated [DATE], indicated R16 had a change in respiratory status and crackles could be heard in lungs. R16's record lacked evidence of immediate implementation of TBP. An ITN dated [DATE], indicated R16 had crackles in his lungs. An ITN dated [DATE], indicated R16 had a fever of 99.2 and did not eat or drink at supper. An ITN dated [DATE], indicated R16 had a fever of 99.3. A corresponding progress note dated [DATE], indicated R16 was tested with the [MEDICATION NAME] machine with positive COVID-19 results. Even after R16's tested positive, the record lacked evidence TBP were implemented. According to the facility's census report R17 resided on the 200 wing in a private room. R17's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R17's quarterly MDS dated [DATE], indicated R17's cognitive skills for daily decision making was severely impaired. R17's progress note dated [DATE], indicated R17 was diagnosed with [REDACTED]. R17's progress note dated [DATE], indicated R17 was swabbed for PCR COVID testing, R17's record lacked documentation of implementation of TBP. R17's ITN dated [DATE], indicated R17 had a non-productive cough, and on [DATE], a progress note indicated R17 had tested positive for COVID-19 with the [MEDICATION NAME] machine. R17's record lacked evidence TBP's were immediately implemented when R17 demonstrated symptoms, R1's record indicated TBP were not initiated until [DATE]. During an interview on [DATE], at 10:05 a.m. the infection preventionist (IP) was asked to provide a summary of any new onset of symptoms and/or new COVID positive residents or staff. IP stated on [DATE], R5 who resided on the 100 wing with a roommate, had developed a cough worse than usual, was put on droplet precautions, and was tested with the [MEDICATION NAME] machine with negative results. IP stated she also tested her roommate; results were negative. IP verified that while symptomatic, R5 was not separated from R6 because there was not another room available to move her to. IP indicated an unawareness R5 had an elevated temp of 100.0 on ,[DATE], coughing a lot with diminished lung sounds on ,[DATE], IP indicated precautions should have been implemented. IP stated, an exposure risk assessment was not completed for residents or staff. IP stated on [DATE], R7 developed symptoms of audible wheezing and decrease in oxygen saturations. She verified R7 tested positive for COVID with the [MEDICATION NAME] machine. IP stated R7 resided on wing 200 and placed on droplet precautions. IP indicated on [DATE], R20 who also resided on the 100 wing in a private room had developed shortness of breath, elevated fever, with no coughing; R20 was tested with the [MEDICATION NAME] machine with negative results, and placed on droplet precautions. The IP verified exposure risk assessments were not completed for residents or staff. During an interview on [DATE] at 1:30 p.m., the DON and administrator indicated the facility was in the process of moving residents including R5. When asked why R5 had not been separated from her roommate, the administrator stated R5's cough was thought to have been related to worsening asthma, and was not thought to be symptomatic for COVID. In addition, the administrator stated her roommate was already exposed and the facility did not want to move R5 or her roommate because they didn't want to spread the disease. DON and administrator was not aware R5 had displayed additional symptoms of illness on [DATE]. According to the facility's census report R5 resided on the 100 wing in a shared room. R5's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R5's quarterly MDS dated [DATE], indicated R5 had moderate cognitive impairment. R5's ITN dated [DATE], indicated R5 had loose stools, and on [DATE], had a temp of 100.0 as well as dizziness and confusion. The record indicated R5 was tested with the [MEDICATION NAME] machine and was negative. ITNs were not completed from ,[DATE] thru [DATE] however, a progress note dated [DATE], indicated R5 complained of sternum pain and pain all over. On [DATE] progress notes and ITN's indicated R5 exhibited an occasional dry cough, complained of rattle in chest with diminished lung sounds. R5's record lacked evidence TBP were initiated immediately after symptoms presented. The record indicated R5 was placed on TBP on [DATE], however remained in the same room with her roommate even when ITN documentation through [DATE], indicated R5 continued to have symptoms of intermittent fevers and cough. According to the facility's census report R7 resided on the 200 wing in a private room. R7's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R7's admission MDS dated [DATE], indicated R7 did not have cognitive impairment. R7's progress notes dated [DATE], indicated R7 had decreased oxygen saturations at 86% on room air. Progress notes also indicated R7 was tested with the [MEDICATION NAME] machine with positive results and transition based precautions were initiated. According to the facility's census report R20 resided on the 100 wing in a private room R20's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R20's quarterly MDS dated [DATE], indicated R20 had moderate cognitive impairment. R20's ITNs dated [DATE], indicated R20 developed symptoms of elevated temp of 99.3, shortness of breath, chills, and was pale. R20's record indicated R20 tested negative for COVID using the [MEDICATION NAME] machine and was placed on TBP. A progress note dated [DATE], indicated R20 was retested with the [MEDICATION NAME] machine with positive results. R21's Admission Record provided by the facility on [DATE], included [DIAGNOSES REDACTED]. R21's quarterly MDS dated [DATE], indicated R21's cognitive skills for daily decision making were severely impaired. R21's progress notes dated [DATE], indicated R21's COVID PCR test that was collected on [DATE], was positive and TBP were implemented. R21's census line indicated R21 was moved to a different room on wing 200 as a result. R22's Admission Record provided by the facility on [DATE], included [MEDICAL CONDITION] stage 3, [MEDICAL CONDITION], fatigue, [MEDICAL CONDITION], and allegories. R22's significant MDS dated [DATE], indicated R22 did not have cognitive impairment. R22's progress notes dated [DATE], indicated R22 developed symptoms of loss of taste and temperature of 99.7. The notes indicated R22 tested positive for COVID with the [MEDICATION NAME] machine and was put on TBP and had a room change. R22's census line indicated R22 resided on the 100 wing and on [DATE], was moved to wing 200. The facility's policy Care For (Suspected) or Confirmed COVID-19 dated [DATE], was not consistent with CDC guidelines for removing isolation precautions. The policy included, It is the policy of Sacred Heart Care Center to promptly identify potential COVID infected residents, get orders for testing, get resident on isolation promptly and continue to provide care during duration of illness. It is also the policy to cohort residents with suspected or confirmed COVID test results to a designated area away from non-COVID infected residents. DEFINITIONS: Suspected: Will be defined as having symptoms closely related to an infectious disease and waiting for a sample to be obtained for testing or having had a test done and are still waiting for results. PROCEDURE: Once COVID-19 test results come back 1) If negative results, isolation precautions will be discontinued. 2) If positive, isolation precautions will continue. 4) Resident with positive COVID-19 test results will be moved to designated isolation area. The facility's policy Infectious Disease Outbreak dated [DATE], included, It is Sacred Heart's policy to protect residents form infectious diseases. It is our policy to stop or slow the spread of transmission of infectious disease from resident to resident during an outbreak by acting quickly during the first signs of illness. PROCEDURE: 1) When a resident presents with signs and symptoms of infectious disease (i.e. fever, cough sneezing, runny nose, diarrhea, vomiting, etc.) the resident will be asked to remain in their room until symptoms subside or they are deemed no longer to be contagious. During an interview on [DATE], 12:15 p.m., the DON stated since [DATE], three more residents had tested positive for COVID-19 including: R5, R21 and R22. The DON stated the facility had made wing 200 their dedicated COVID unit and residents were moved so they could be appropriately cohorted. She stated the COVID positive residents were either in private rooms or shared rooms, and residents who were presumptive positive related to displayed symptoms were in private rooms for ongoing monitoring. The also DON stated clinical managers had initiated risk assessments in order to ascertain potential causal factors of transmission that could be removed. The immediate jeopardy that began on [DATE], was removed on [DATE], when it could be verified the facility had reviewed their policies, had appropriately implemented cohorting and transmission based precautions strategies, had initiated risk assessments for residents, and had provided staff education.