Every finding on record at St Anthony Park Home Inc

Based on interview and document review the facility failed to ensure 1 of 8 staff nursing assistant (NA)-M had completed the required Alzheimer's and dementia care training program. This had the potential to affect all residents in the facility who had an Alzheimer's or dementia diagnosis.Findings include: On 8/13/26 at 8:48 a.m., a request was made to the administrator and the director of nursing (DON) for Alzheimer's and/or dementia care training for eight employees. During an interview on 8/13/26 at 12:05 p.m., the administrator stated they were unable to find Alzheimer's or dementia care training for NA-M who had a start date of 9/9/25. It is the expectation all staff were to receive Alzheimer's and/or dementia care training before working with residents and should also have documentation of the training being completed. A policy related to Alzheimer's and dementia care training was requested, but none was received.

Based on observation, interview, and document review, the facility failed to provide the ordered services for the behavioral health needs for 1 of 1 resident (R22) reviewed for mood and behavior.Findings Include:R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was cognitively intact, and had no hallucinations or delusions. The MDS indicated R22 was depressed, had trouble falling asleep, had poor appetite, and had diagnoses of heart failure, Parkinson's disease, anxiety and depression disorder. R22's Medical orders dated 7/13/26, indicated an order for escitalopram oxalate 10 milligrams daily for depression. This order was dated 7/30/24. R22's care plan dated 7/13/26, indicated resident had potential for alteration in mood related to depression, and anxiety. The interventions directed staff to arrange for a psychology and follow-up consult as indicated. It also directed staff to discuss with the resident any concerns, fears, and issues regarding health, or other subjects routinely. Furthermore, the care plan indicated R22 needed time to talk and encouragement to express her feelings.R22's medical record indicated she had a care conference on 7/6/26. The Social Services note indicated R22 was cognitively intact, had mild signs and symptoms for depression, and had no behaviors. The note also indicated R22 saw psychology on a regular basis. R22's electronic medical record (EMR) identified an order for psychology to evaluate and treat. The order was dated 4/13/26. The EMR lacked documentation of psychology visits in the last 12 months, which contradicts 7/6/26 social services documentation that R22 saw psychology on a regular basis. During observation and interview on 8/10/26 at 1:17 p.m., R22 stated she got sad very often, especially when her son visited her. R22 said, I just start crying and I can't stop crying. I am sad, am thinking about dying. I am old, I know I am going to die. R22 said she would like to talk to somebody. She said she used to talk to somebody, and it helped her. R22 said she would like to talk to a counselor. During interview on 8/12/26 at 2:26 p.m., DON stated social services oversaw the processing of psychology orders. During interview on 8/13/26 at 8:56 a.m., the social services director (SSD) stated R22 used to receive psychology services but was discharged in December 2024. SSD stated she received R22's order dated 4/13/26, but did not send the referral to psychology. During a follow-up interview on 8/13/26 at 9:40 a.m., SSD stated she needed to obtain a new consent and send the referral to psychology. SSD added, when she started in March, she had not received very much training, and she was unaware the facility had in-house visits from psychology. The SSD stated if she knew about this service, she would have made a list of all the residents who did or were supposed to see psychology to ensure this was occurring.During interview on 8/13/26 at 9:44 a.m., DON stated she expected the social workers would fax the referral orders to psychology as soon as possible and have residents seen as ordered. Requested the facility's policy about referral to psychosocial services but none was received.

Based on observation, interview, and document review, the facility failed to honor a request for different room lighting for 1 of 1 resident (R5), reviewed for self-determination. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated a diagnosis of moderate unspecified dementia. Behaviors related to disorganized thinking, altered level of consciousness, or difficulty focusing attention were not present. R5's care plan dated 6/23/26 included a primary diagnosis of Sjogren syndrome (an autoimmune disorder where the immune system attacks the body's moisture producing glands) with keratoconjunctivitis (inflammation of the cornea), which can cause pain, impaired eyesight, and light sensitivity. During observation and interview on 8/11/26 at 12:49 p.m., R5 was noted to be cognitively alert and able to answer questions appropriately. R5 stated she really hated the lights in her room. She described the lighting as too white, bright, and harsh. The two lights which bothered her the most were the circular overhead light located between the two resident spaces in the room and the rectangular wall light above her bed. Nursing assistant (NA)-A was in the room during the interview. R5 mentioned the bright lights to NA-A and he responded by shutting the lights off. The resident stated, That is what they always do whenever I complain about the lights. They just shut them off. The resident stated she would prefer different bulbs, with a softer, more yellow light.During an interview on 8/12/26 at 8:49 a.m., registered nurse (RN)-B stated if a resident complained about the lighting in their room, she would complete a work order form and forward it to maintenance. She said R5 had occasionally complained the light in her room was too bright and RN-B said she usually responded by turning off the lights. She had not completed a work order for R5. RN-B mentioned she once had a request from another resident to remove the light bulb completely from a fixture in the room but was told by maintenance that they could not do that. During an interview on 8/12/26 at 9:04 a.m., the Director of Maintenance (DOM) stated the normal process for replacing lighting in a resident room was for nursing staff to send him a maintenance request. He said he had not received any requests recently for different lighting or light bulbs in any of the rooms, but he could change out the bulbs if lights were too bright. The DOM stated he had a variety of bulbs available, including a good stock of the older halogen and incandescent light bulbs.During an interview on 8/12/26 at 1:59 p.m., RN-A stated if a resident mentioned the lights were too bright in their room, staff were expected to offer to turn them off. If a resident expressed concerns regarding the type of light in their room, RN-A stated staff were expected to submit a work order request to maintenance. She was not aware of R5's request and had not submitted a work order.During an interview on 8/13/26 at 11:23 a.m., the Director of Nursing (DON) stated nursing staff were expected to contact maintenance if a resident complained about the lighting or requested a different type of lighting in their room.A policy regarding resident choices was requested but not received.

Based on interview and record review, the facility failed to ensure a PRN (as-needed) antipsychotic medication was limited to 14 days and that the continued use of the PRN antipsychotic medication was evaluated by the attending physician or prescribing practitioner for 1 of 1 residents (R12) reviewed for unnecessary medications.Findings include:R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 had a severe cognitive impairment and diagnoses that included Alzheimer's disease and dementia. R12 received hospice services and used antipsychotic, antianxiety and opioid medications.R12's care plan revised 7/16/26, The resident has a behavioral problem of refusing cares and wandering related to Alzheimer's disease, peripheral vascular disease and dementia with agitation. Staff were directed to: Administer medications as ordered. Monitor/document for side effects. Explain all cares to the resident before starting and allow time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.R12's Order Summary Report dated 8/11/26, identified the following orders:7/4/26 - 7/8/26 haloperidol 2 milligram (mg)/milliliter (ml) solution Give 0.5 ml by mouth every 4 hours as needed (PRN) for agitation and delirium. 7/8/26 - 7/10/26 haloperidol 2mg/ml solution Give 0.5 ml by mouth every 4 hours as needed for agitation and delirium for 10 Days. 7/10/26 - open ended haloperidol 2mg/ml solution Give 0.5 ml by mouth every 4 hours as needed for agitation and delirium. The 7/10/26 order was written as open-ended, rather than being limited to 14 days as required for a PRN antipsychotic medication.R12's Electronic Medication Administration Record (EMAR) dated 7/2026, identified R12 received a PRN dose of haloperidol 6 times.R12's EMAR dated 8/11/26, identified R12 had received a PRN dose of haloperidol 1 time. R12's physician progress note dated 7/7/26, indicated R12 had Alzheimer's disease with late onset: advanced dementia with behavioral disturbance. R12 exhibited advanced cognitive impairment and was disoriented, unable to make needs known. R12 had a history of agitation, nonsensical speech and required assistance with all activities of daily living (ADLs). R12 had no reported hallucinations and had intermittent agitation. Continue haloperidol 1 mg every 4 hours PRN agitation. Maintain structured environment and safety precautions.R12's physician progress note dated 7/28/26 identified R12 had advanced dementia and was unable to reliably communicate needs. R12 had a history of agitation which was currently controlled, no reported hallucinations, and required full assistance with ADLs. The physician directed continuation of haloperidol 1 mg (0.5 mL) every 4 hours PRN for agitation and continued non-pharmacological behavioral interventions. However, the note did not identify an evaluation addressing the appropriateness and continued need for the PRN antipsychotic medication or provide an adequate rationale for renewal of the PRN order.R12's nursing progress note dated 7/10/26 at 6:20 a.m., identified a monthly regimen review (MRR) - see report for recommendation.R12's MRR dated 7/10/26 was requested but not received.R12's nursing progress note dated 7/19/26 at 2:07 p.m., identified R12 was an [AGE] years old male and was alert and oriented with confusion. R12 needed two assist for transferring and ADLs. R12 became restless that morning, and PRN haloperidol 0.5 ml was administered at 9:17 a.m. and was effective. However, the note failed to identify what non-pharmacological interventions were attempted prior to administration of haloperidol. During an interview on 8/12/26 at 1:58 p.m., licensed practical nurse (LPN)-C stated R12 did have a lot of agitation when he was first admitted to the facility R12 would stand up, try to walk and fall. It was really bad there for a while. R12 had settled down and became used to living at the facility. Staff sat with R12, tried to calm him down and then if nothing worked, R12 had a PRN medication as well. During an interview on 8/13/26 at 9:01 a.m., the director of nursing (DON) stated R12 should have had a 14-day face-to-face evaluation to ensure the ongoing need for PRN antipsychotropic medication to prevent unnecessary medications or unnecessary sedation. During a telephone interview on 8/13/26 at 8:01 a.m., the pharmacist stated she had reviewed R12's medications on 7/10/26 and again on 8/12/26. On 7/10/26, the pharmacist stated she informed the facility R12's haloperidol did not have an appropriate rationale for use and that PRN antipsychotropic medications required a face-to-face medical provider evaluation every 14 days to ensure the PRN order needed to be continued. On 8/12/26, R12's haloperidol order was discontinued, and the pharmacist had no further recommendations. The pharmacist stated agitation and delusions were an inappropriate indication for use and PRN medications needed to be evaluated every 14 days to prevent misuse such as staff convenience.The facility policy Use of Psychotropic Medication undated, identified psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted:PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on interview and document review, the facility failed to ensure written transfer notices were provided as soon as practicable for 1 of 1 resident (R79) reviewed for hospitalization.Findings include:R79's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R79 had severe cognitive impairment. R79's progress note dated 2/7/26 at 12:12 a.m., indicated R79 slept most of the time, had a decreased level of consciousness, and was nonverbal. R79's daughter was designated as her legal representative.R79's progress noted dated 7/4/26 at 11:28 p.m., indicated R79 was transferred to the emergency department by ambulance for labored respirations and a change in level of consciousness. The note indicated verbal consent was obtained via phone from R79's daughter for a bed hold.A review of R79's medical record lacked evidence that written transfer and bed-hold notices were sent with R79 to the hospital and/or provided to the resident representative. During an interview on 8/12/26 at 8:06 a.m., licensed practical nurse (LPN)-A stated she sent documents such as a medication list, the most recent vital signs, and Physician's Orders for Life-Saving Treatment (POLST) with any resident who transferred to the hospital. LPN-A stated she was not familiar with a written transfer notice. She said standard practice was to contact family to see if they wanted to place a bed hold. If they did, she filled out a paper bed-hold form. This form was kept at the facility and was not sent with the patient or given to the resident representative.During an interview on 8/12/26 at 9:06 a.m., LPN-B stated the paperwork sent with residents transferring to the hospital included the resident's face sheet, diagnoses, POLST, medications, immunizations, and most recent progress note. Bed holds were documented on a paper form which was then scanned to the resident's medical record. LPN-B stated she completed a progress note when a resident transferred to the hospital which typically said, 911 called. Paperwork sent. Bed hold placed. She stated written transfer notices or bed-hold forms were not sent with the resident or provided to the resident's representative. She said a copy of the bed-hold notice was faxed to the ombudsman and the Minnesota Department of Human Services (DHS) by the medical records department. During a subsequent interview on 8/12/26 at 10:15 a.m., LPN-A confirmed she was unable to find either a written transfer notice or a written bed hold notice associated with R79's transfer to the hospital on 7/4/26 in R79's medical record.During an interview on 8/13/26 at 1:47 p.m., the Director of Nursing (DON) stated when a patient transferred to the hospital, the resident or family was asked whether they would like to hold the bed. Nursing staff filled out a paper bed-hold form and then gave this to medical records to be scanned into the resident's chart. The DON stated she did not know if a written transfer notice and/or a written bed hold notice was required to be sent with the resident or provided to the resident's representative.An undated policy titled Transfer and Discharge (including AMA) provided by the facility on 8/13/26, indicated that in the event of a transfer or discharge, the facility's transfer/discharge notice will be provided to the resident and/or the resident representative in a language and manner in which they can understand. The notice was to include the details of the transfer and information on how to appeal the transfer. The Transfer and Discharge policy also specified the information that was to be given to the receiving provider in the event of a transfer.An undated policy titled Bed Hold Notice provided by the facility on 8/13/26, indicated that in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The written bed-hold notice was to specify the duration of the State bed-hold policy, the reserve bed payment policy, the facility policies regarding bed-hold periods, and the conditions upon which the resident would return to the facility.

Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 of 1 residents (R77) reviewed for MDS accuracy.Findings include:R77's quarterly Minimum Data Set (MDS) dated [DATE], identified R77 had a severe cognitive impairment and diagnoses that included Type I Diabetes and Alzheimer's disease. The MDS also identified R77 had 2 deep tissue injuries (DTI) and used a pressure reducing device for her bed and chair. However, R77's electronic medical record (EMR) identified R77's DTI were healed 6/9/26. R77'S Weekly Wound Documentation dated 6/9/26, identified R77's DTI on each heel had healed.R77's physician order dated 6/9/26 to 7/7/26, identified Wound Care - Left Heel Unstageable DTI Using Clean / Aseptic Technique 1. Apply Skin Prep to area and let dry daily and as needed.During an interview on 8/12/26 at 2:02 p.m., registered nurse (RN)-E stated R77 did have a deep tissue area to each of her heels, but the areas had healed and R77's weekly wound notes reflected that. During an interview on 8/12/26 at 2:07 p.m., RN-G stated she was responsible for completing R77's MDS. RN-F reviewed all assessments and R77's medical record to gather the required information. RN-F stated she was unsure why she had entered R77 had two DTI. RN-F stated she would do further review, but to find out if it was entered in error. RN-F stated MDS accuracy was very important because it affected billing and proper resident care because it determined what would be care planned for R77. At 2:45 p.m., RN-F stated she had entered two DTI for R77 because R77 had been receiving wound care until 7/7/26. At 2:57 p.m., RN-E stated R77's wounds were healed on 6/9/26 and the following wound care until 7/7/26 was a preventative measure. RN-F stated the DTI should not have been identified on R77's MDS and the DTI was entered in error.During an interview on 8/13/26 at 9:12 a.m., the director of during (DON) stated MDS accuracy affected everything: level of care, the resident care plan, just everything and should reflect the resident's current needs.A MDS accuracy facility policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care, shaving) was provided for 2 of 2 residents (R58, R5) reviewed for activities of daily living (ADLs) and were dependent on staff for their care. Findings include: R58 R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58 was cognitively impaired, had no behaviors, did not refuse personal cares, needed maximal assistance with personal hygiene, and was dependent on toileting hygiene and bathing. R58's Clinical Diagnosis report dated 8/12/26, indicated diagnoses of unspecified dementia with mood disturbance, macular degeneration, major depressive disorder, hypertension, and vascular dementia. R58's Activities of Daily Living (ADLs) Care Plan dated 8/12/26, indicated R58 had a self-care deficit related to moderate cognitive impairment and diagnosis of dementia. R58's care plan indicated she was dependent on staff with bathing and personal hygiene. During observation on 8/10/26 at 12:32 p.m., R58 was awake in bed, but did not answer any questions. R58's nails were uneven in length and shape. The nails length ranged between 1 centimeter (cm) to 1.5 cm in length. During interview on 8/11/26 at 11:46 a.m., nursing assistant (NA)-C stated the NAs checked the residents' fingernails and toenails on shower days and cut them as needed. NA-C added the nurses cut the nails of residents with diabetes. During observation and interview on 8/12/26 at 8:21 a.m., R58 was in the dining room sitting up in her wheelchair. R58's clothes were clean, but her nails were still long, uneven and had black matter underneath. During interview on 8/12/26 at 8:36 a.m., licensed practical nurse (LPN)-B verified R58's fingernails were long, uneven, and had black matter underneath. LPN-B stated she would try to cut them, but most likely, R58 would refuse. During interview on 8/13/26 at 9:51 a.m., director of nursing (DON) stated the residents' nails needed to be cut on their shower day. DON stated NAs were supposed to attempt cutting residents nails, and if they failed, NAs needed to report this failure to the nurses. The nurses also needed to reapproach to try and cut the residents' nails. DON stated the facility had ordered different nail care supplies and would try to file F58's fingernails. DON stated long nails get dirty and they were an infection control issue. Requested a facility's policy about Nail Care but none was provided. R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated a diagnosis of moderate unspecified dementia. Behaviors related to disorganized thinking, altered level of consciousness, or difficulty focusing attention were listed as not present. R5's MDS indicated she was dependent on staff for personal hygiene and toileting and required maximal assistance with showering/bathing. A review of R5's care plan dated 6/23/26, did not specify the need to assess and shave facial hair. During an interview on 8/10/26 at 3:27 p.m., R5 was noted to be cognitively alert and able to answer questions appropriately. She stated that the whiskers on her chin really bothered her and she wished she could do something about them. Light grey hairs approximately 1/4 inch in length were observed to extend across the bottom of R5's chin. R5 mentioned this facial hair on three different occasions throughout the interview, and she vigorously rubbed the whiskers back and forth with her hand several times. R5 stated she has mentioned the whiskers to staff multiple times but had never received any response or any offers to shave them. During observation on 8/11/26 at 12:47 p.m., facial whiskers were still visible on R5's chin. During an interview on 8/11/26 at 3:35 p.m., nursing assistant (NA)-A stated shaving depended on resident preferences. Most residents preferred to be shaved every day. Orders were not typically placed for shaving as it was considered a thing we just do. NA-A said many residents had their own razors but otherwise, the facility provided them. He stated female residents were not typically asked about shaving facial hair. He said he only knew of one woman who shaved her facial hair regularly and she did this herself. NA-A said he had not received a request from R5 to shave her facial hair, and he has never offered to do it for her. During an interview on 8/11/26 at 3:48 p.m., NA-B stated that her residents varied in terms of shaving requests. She said that she shaved her residents every day unless they told her not to. NA-B stated if a female resident requested to be shaved, she would just do it. She has never asked a female resident if they wanted their facial hair to be shaved. During observation on 8/12/26 at 11:35 a.m., facial whiskers were still evident on R5's chin. During an interview on 8/12/26 at 1:55 p.m., registered nurse (RN)-A stated shaving was not typically included in the care plan. She said NAs were expected to shave or offer shaving to every resident each morning. Shaving was considered a standard of care, like brushing teeth, washing faces, applying deodorant, etc. NAs were also expected to offer shaving to female residents, especially if they noticed unexpected facial hair. During an interview on 8/13/26 at 11:20 a.m., the Director of Nursing (DON) stated daily shaving was a standard of care for both males and females. She stated that NAs were expected to offer this service to every resident and if a resident refused, the NA should inform the RN so the refusal could be documented in the chart and the care plan updated. A policy titled Activities of Daily Living (ADLs) dated 4/15/26, indicated care and services were provided by the facility for bathing, dressing, grooming, and oral care and that a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming and personal hygiene. An undated policy titled Grooming a Resident's Facial Hair received on 8/13/26, specified that it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure a sleeve protector was provided in accordance with the comprehensive care plan for 1 of 1 residents (R12) reviewed for pressure ulcers.Findings include:R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and peripheral vascular disease. R12 required partial/moderate assistance with upper body dressing and footwear. R12 was at risk for pressure ulcer/injury but had no pressure ulcers.R12's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 7/8/26, identified R12 was at risk for pressure ulcers and required a pressure relieving device for his bed and chair.R12's care plan revised 7/28/26, identified R12 had a skin tear/potential for skin tear of the left anterior shin and left posterior calf related to falling and hitting self on wheelchair. Staff were directed R12 needed protective sleeves to his left elbow at all times.During an observation on 8/10/26 at 11:50 a.m., R12 was seated in his tilt-in-space wheelchair in the dining room eating his meal. R12 was not wearing a protective sleeve to his left elbow.During an observation on 8/11/26 at 11:00 a.m., R12 was seated in his tilt-in-space wheelchair in the dining room. R12 was reclined back and was audibly snoring with his mouth hanging open. R12 was not wearing a protective sleeve to his left elbow.During an observation on 8/11/26 at 1:30 p.m., R12 was sitting in his tilt-in-space wheelchair at the table in the dining room. R12 was awake and tapping on the table to the beat of the music playing on the radio. R12 was not wearing a protective sleeve to his left elbow. During an observation on 8/12/26 at 7:10 a.m., R12 was sitting in his tilt-in-space wheelchair in the dining room. R12 was not wearing a protective sleeve to his left elbow. During an observation on 8/13/26 at 8:37 a.m., R12 was seated in his tilt-in-space wheelchair in the dining room. R12 was not wearing a protective sleeve to his left elbow. During an interview on 8/13/26 at 8:42 a.m., nursing assistant (NA)-D stated she had been the nursing assistant assigned to R12 all week. NA-D did not put the protective sleeve on R12 because if she did R12 would take it off and chew on it. During an interview on 8/13/26 at 8:51 a.m., registered nurse (RN)-D stated he was unaware R12 was not wearing the protective sleeve but R12 should wear a protective sleeve if it was a care planned intervention for R12. During an interview on 8/13/26 at 8:57 a.m., the director of nursing (DON) stated R12's sleeve protector should be assessed and removed from his care plan if inappropriate. However, staff were expected to follow the resident care plan to ensure the resident received the care needed for the resident.The facility policy Pressure Injury Prevention Guidelines revised 6/1/26, identified Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include:Development of a new pressure injury.Lack of progression towards healing or changes in wound characteristics.Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 1 resident (R10) reviewed for catheter and 1 of 1 resident (R2) reviewed for pressure ulcers.Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had a moderate cognitive impairment and diagnoses that included Type 2 Diabetes and obstructive reflux uropathy (a blockage that stops urine from flowing normally through the urinary tract). R10 required an indwelling catheter and was dependent on staff for assistance with toileting. R10's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 1/4/26, identified R10 had an indwelling catheter. Interventions included were to ensure tubing was not kinked, bag was covered, monitoring for urinary tract infection (UTI) symptoms, etc. The CAA directed to review R10's care plan. R10's care plan revised 6/14/26, identified R10 required Enhanced Barrier Precautions (EBP) due to have an indwelling catheter. Staff were directed: Alcohol based hand rub in room Educate resident/ family on EBP and answer any questions or concerns EBP per CDC guidelines EBP signs on doors Garbage in room by exit for personal protective equipment (PPE) removal Gown/gloves prior to high care contact (face mask plus goggles must be worn in activity at risk for high splash or spray) Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices Use PPE during high contact dressing, bathing/showing, transferring, hygiene, changing linen, changing briefs, toileting device care or wound care. During an observation on 8/11/26 at 3:26 p.m., there was an isolation door caddy with disposable gowns and gloves hanging on R10 with a sign that stated R10 required EBP. Registered nurse (RN)-D and nursing assistant (NA)-E assisted R10 to his room and encouraged R10 to lie down for a while. RN-D put on a disposable gown and gloves but NA-E did not. NA-E cleared R10's personal items from the top of R10's bed and then assisted R10 to stand up from his wheelchair. At 3:28 p.m., NA-E pulled R10's wheelchair away from R10 while R10 stood holding his front-wheeled walker. NA-E assisted R10 to turn and sit on his bed, then removed R10's shoes. At 3:29 p.m., NA-E assisted R10 to stand again and pulled down R10's pants. R10 sat down on the bed again so NA-E could remove his pants paying attention to wear his indwelling catheter bag was, NA-E stated R10 was ok'ed to stand up on his own as well before asking R10 to stand back up. NA-E removed R10's soiled brief and cleaned feces from R10's skin using a disposable wipe. At 3:34 p.m., NA-E removed her gloves, washed her hands in the bathroom sink and left the room. RN-D assisted R10 to lie down on his bed. During an interview on 8/12/26 at 2:22 p.m., NA-E stated 5 weeks ago there was a meeting and staff were told it was facility policy to wear a gown and gloves with any resident that had a catheter. NA-E again stated it was facility policy and wasn't a state reg. NA-E then stated that she was going to be honest and staff didn't wear the gown or gloves when they were busy. During an interview with RN-E and RN-G on 8/12/26 at 2:57 p.m., RN-E and RN-G stated staff were expected to follow EBP per CDC guidelines. During an interview on 8/13/26 at 9:07 a.m., the director of nursing (DON) stated EBP was an important intervention to stop the spread of infection for residents without indwelling catheters and staff were expected to follow EBP according to CDC guidelines. R2 R2's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. Diagnoses included multiple sclerosis, obesity, diabetes mellitus, and a right below-the-knee amputation (BKA). R2's MDS also indicated diagnoses of neurogenic bladder and obstructive uropathy for which R2 had an indwelling suprapubic urinary catheter. R2's MDS specified he was always incontinent of bowel. R2 was dependent on staff for toileting, showering, and dressing, and required moderate assistance with personal hygiene. He used a wheelchair for mobility and was dependent on staff for repositioning in bed and all transfers. R2's wound/skin care progress note dated 8/4/26, indicated R2 had a stage 4 pressure ulcer on his left buttock with a wound vacuum in place. He also had a stage 3 sacral pressure ulcer and a chronic diabetic left foot ulcer. R2's care plan revised on 5/12/26, identified Enhanced Barrier Precautions (EBP) were initiated on 1/18/26, related to his urinary catheter and pressure ulcers. Staff were directed to: Alcohol-based hand rub in room Educate resident/ family on EHBP and answer any questions or concerns EBP per CDC guidelines EBP signs on doors Garbage in room by exit for PPE removal Gown/gloves prior to high care contact including dressing, bathing/showering, transferring, hygiene, changing linen, changing briefs or toileting, device care, or wound care During an observation on 8/12/26 at 7:16 a.m., there was an isolation caddy with disposable gowns and gloves hanging on R2's door with a sign that indicated R2 required EBP. The hand sanitizer dispenser outside R2's door was empty. A hand sanitizer dispenser inside R2's room near the door was full. R2 was observed eating breakfast in bed. At 7:33 p.m., NA-G arrived at R2's room with a Hoyer lift accompanied by NA-H. Both NA-G and NA-H put on gloves and a disposable gown. NA-G was observed to be wearing her gown open to the front, like a jacket or housecoat. NA-G and NA-H entered R2's room and closed the door. At 7:40 a.m., NA-H opened the door while wearing her gown and gloves, removed her gown and gloves in R2's room, and placed them into the wastebasket in R2's room. She exited the room without performing hand hygiene and returned the Hoyer lift to the storage room across the hall. NA-H stated they had changed R2's brief, emptied his catheter bag, dressed him, and transferred him to the wheelchair with the Hoyer lift. At 7:42 a.m., R2 was observed to be dressed and seated in his wheelchair. NA-G picked up the trash in the room, placed it in R2's wastebasket, and cleaned R2's tray table. NA-G stripped R2's bed and placed the dirty linens in a plastic bag and knotted the top while wearing the same gown which was still open to the front. At 7:48 a.m., NA-G removed her gown and gloves and placed them in R2's wastebasket. She did not perform hand hygiene and did not don another pair of gloves. She removed the liner from the wastebasket, knotted the top of the bag and carried it to the storage room across the hall. NA-G returned to R2's room without performing hand hygiene and gave R2 a washcloth for his face. She put on gloves and carried the sealed bag of dirty linen out of R2's room and placed it in the storage room. She returned to R2's room, removed her gloves, and performed hand hygiene. During an observation on 8/12/26 at 11:14 a.m., NA-G entered R2's room with the Hoyer lift accompanied by NA-F. Both NAs put on a gown and gloves and made up the bed with clean linens. At 11:20 a.m., R2 was transferred to the bed using the Hoyer lift. NA-G told NA-F they needed to check and change R2. At 11:23 a.m., NA-F emptied R2's urinary catheter bag into a plastic bedside urinal and cleaned the tip of the catheter bag with an alcohol wipe. NA-F did not perform hand hygiene or change gloves after emptying the catheter bag or cleaning the tip. At 11:26 a.m., NA-F and NA-G removed R2's soiled brief, cleaned R2's skin with disposable wipes, and placed a clean brief on R2. NA-G removed her gloves, performed hand hygiene, and donned new gloves. NA-F kept her gloves on and did not perform hand hygiene. NA-G placed a pillow behind R2's back and another pillow between his legs. NA-F assisted in adjusting the pillows while wearing the same gloves. At 11:29 a.m., NA-F removed her gown and gloves and left R2's room with the Hoyer lift. She did not perform hand hygiene. NA-F placed the Hoyer lift in the storage room and proceeded down the hall. During an interview on 8/13/26 at 9:51 a.m., NA-D stated she put on a gown and gloves before entering the rooms of any residents on EBP for whom she would be providing direct cares. She removed the gown and gloves prior to exiting the room and either washed her hands or used hand sanitizer. NA-D stated she changed her gloves and performed hand hygiene in the room whenever her gloves became soiled or when she had performed a more high-risk task such as emptying a catheter bag. She stated the purpose of the gown and gloves was to prevent germs from spreading to other residents on her clothes. She said gowns should be worn with the opening in the back and the ties wrapped around to the front. NA-D stated the facility provided annual training on EBP both online and in-person. During an interview on 8/13/26 at 10:31 a.m., NA-G stated she put on a gown and gloves before entering the room of a resident on EBP if she knew she was going to be providing hands-on care to the resident. NA-G said the purpose of the gown was to protect herself and other residents. NA-G stated gowns should be worn with the opening in the back and the strings wrapped around and tied in the front. When asked if she was wearing her gown open to the front on 8/12/26 when providing cares to R2, NA-G stated, Oh, maybe I did. I'm so sorry. NA-G confirmed she would change gloves and perform hand hygiene after emptying a urinary catheter or cleaning the tip of the urinary catheter bag. NA-G stated nursing staff had online EBP training every year and the Director of Nursing (DON) had done an in-person training session a couple months ago. During an interview on 8/13/26 at 11:29 a.m., the DON stated in-service training on EBP was conducted for all nursing staff in May and June. Staff were expected to follow EBP according to the CDC guidelines. The DON stated all nursing staff were expected to don a gown and gloves when a resident was on EBP and they were performing high-contact activities including changing linens, bathing, dressing, transferring, changing briefs, performing catheter care, etc. The DON said gowns are to be worn with the opening to the back. The DON stated she expected gloves to be changed and hand hygiene to be performed if gloves become soiled or after providing any high-contact cares, including transferring a resident, changing linens, performing pericare, and emptying a urinary catheter bag. An undated policy titled Enhanced Barrier Precautions received from the facility on 8/13/26, stated it was the facility's policy to implement EBP for the prevention of transmission of multi-drug resistant organisms (MDROs). The policy outlined specific steps related to staff training, EBP initiation, implementation measures, and examples of MDROs of particular concern. An undated policy titled Hand Hygiene received from the facility on 8/13/26, indicated all staff would perform proper hand hygiene procedures to prevent the spread of infection. The policy outlined when hand hygiene was to be performed and which techniques were to be used in specific circumstances.

Based on interview and record review, the facility failed to ensure adequate monitoring was in place for 1 of 1 resident (R9) on a high-risk medication (i.e., a diuretic), reviewed for unnecessary medications. Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], included diagnoses of coronary artery disease with angina pectoris (chest pain), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). R9's diagnoses also included moderate cognitive deficit and unspecified dementia with impaired decision making and poor short-term memory. A review of R9's order set located in the facility's electronic medical record (EMR) dated 6/5/26, listed the following provider orders:9/8/21: Knee high compression bandages placed in the morning and removed at bedtime3/4/25: Orthostatic blood pressure assessment completed weekly7/7/25: 2-gram sodium diet8/7/25: 40 milligrams (mg) of furosemide (Lasix), a diuretic, to be given to be given by mouth once per day4/7/26: Shortness of breath to be assessed three times per dayR9's medical record lacked evidence of orders for weights or edema monitoring.R9s care plan dated 7/12/26, indicated R9 was on diuretic therapy related to excess fluid. Interventions listed included: administer diuretic medications as ordered by physician, monitor for side effects and effectiveness every shift, and report pertinent labs results to the provider. R9's care plan also indicated staff were to monitor/document/report any changes in edema and weight. However, the record lacked evidence of specific parameters for provider notification of changes in edema and/or weight. A nutrition/dietary progress note dated 1/8/26 at 5:08 p.m., indicated R9's furosemide was increased on 8/27/25, and R9 had the potential for weight fluctuations related to edema and the diuretic. A review of R9's weight summary dated 8/12/26, indicated weights were done monthly with the following results: 6/6/26: 227 pounds 7/13/26: 235 pounds8/6/26: 227 pounds R9's medical record lacked evidence of provider notification of the eight-pound weight fluctuations. During an interview on 8/13/26 at 1:15 p.m., registered nurse (RN)-C stated she monitored for edema, shortness of breath, blood pressure changes, and congestion in any resident taking a diuretic. She expected weights to be ordered and completed weekly.During an interview on 8/13/26 at 1:37 p.m., RN-D stated he cared for R9 frequently. He stated since R9 was on furosemide, he monitored for shortness of breath and swelling. If he noticed an increase in edema, he obtained a weight and notified the provider. RN-D stated R9 wore compression bandages on his legs for edema, and these were put on by nursing staff in the morning and removed at night. RN-D stated he believed R9 was on weekly weights. However, after reviewing R9's record, he stated R9 did not have an order for weekly weights, and he confirmed there were no orders for edema monitoring and no specific parameters for provider notification.During an interview on 8/13/26 at 1:52 p.m., Nurse Practitioner (NP)-A. stated since R9 was on furosemide, nursing staff should check for worsening edema regularly. She was not sure if the facility had edema monitoring in place, but she expected staff to take weights at least weekly and update her with a weight gain of greater than five pounds in a week.During an interview on 8/13/26 at 2:23 PM, the Director of Nursing (DON) stated for residents on furosemide, nursing staff were expected to regularly monitor for edema and obtain weights weekly. The DON confirmed weights were being done monthly for R9 and that there were no orders in place for edema monitoring. The DON also confirmed there were no parameters listed for provider notification when changes in weight and/or edema were noted. The DON stated that two weeks ago, she changed weights from monthly to weekly for all residents based on their diagnoses and/or medications, including diuretics. She stated R9 must have been missed.A review of the policy titled High Risk Medications dated 4/12/26, stated the resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications and include interventions to minimize the risk of adverse consequences.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn by staff according to the Center for Disease Control and Prevention (CDC) guidelines for a facility in outbreak status. This had the potential to affect all 73 residents in the building. Findings include:CDC Infection control guidance: SARS-CoV-2 (Covid-19) dated 6/24/2024 advised source control is recommended for those residing or working on a unit of the facility experiencing a Covid-19 or other outbreak of respiratory infection. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. On 1/14/2026 at 8:30 a.m., a sign was observed on the front door and in the elevator which directed Masks required for staff.On 1/14/2026 at 9:04 a.m., licensed practical nurse (LPN)-A was observed not wearing a mask while standing at the nurse's desk in close proximity to other staff members. LPN-A stated he did not know if he should be wearing a mask, but was going to put one on until he could find the answer.On 1/14/2026 at 9:12 a.m., laundry assistant (LA)-A was observed not wearing a mask while talking with a resident in the resident's room. Nursing assistant (NA) was observed at the nurse's desk not wearing a mask. At 9:19 a.m., NA-A was observed wearing a mask.During an interview on 1/14/2026 at 9:19 AM LA-A stated she delivers laundry to all resident rooms in the facility. She did not have a mask on because it made her face break out. At 9:26 a.m. LA-A was observed wearing a mask. LA-A stated she was informed she needed to wear a mask whenever she was around the residents.On 1/14/2026 at 10:13 a.m., NA-B was observed wearing her mask under her chin while in a common area with residents. NA-B stated masks should be worn covering the nose and mouth whenever she is around residents.On 1/14/2026 at 11:50 a.m., LPN-B was observed wearing her mask under her chin while at the nurse's desk with other staff members. LPN-B stated she should have had her mask covering her nose and mouth when she was around other people. All staff members were required to wear a mask.On 1/14/2026 at 1:45 p.m., NA-A was observed wearing a mask under her chin in a common area with residents. NA-A stated all staff are required to wear a mask and acknowledged she was not wearing a mask this morning until she was reminded to put one on. NA-A stated a mask should be worn covering her nose and mouth when around residents.During an interview on 1/14/2026 at 2:29 p.m., the infection preventionist nurse (IP) stated all staff members are required to wear a mask when in resident care areas and at the nurse's desk. A mask is worn properly when covering the nose and mouth.The undated Covid-19 policy and procedure instructed signage will be posted regarding an outbreak, personal protective equipment, and source control.

Based on observation, interview, and document review, the facility failed to ensure a low-temperature sanitization commercial dishwasher used in 1 of 1 main production kitchen was adequately monitored (i.e., every shift) to ensure effective chemical concentration and dishware sanitization to reduce the risk of foodborne illness. This had potential to affect all 72 residents, staff and visitors who consumed food from the kitchen. Findings include: On 5/27/25 at 8:13 a.m., an initial kitchen tour was completed of the main production kitchen located in the basement-level of the care center. The kitchen had a single CMA low-temperature commercial dishwasher placed along the wall with various chemicals positioned below in bottles and connected to the machine via clear tubing. These chemicals included rinsing aid(s) and sodium hypochlorite (used as a chemical sanitizer). Later, at 8:22 a.m., dietary aide (DA)-A was present at the machine and rinsing soiled dishware before placing it onto hard-plastic racks and into the machine causing the machine to activate upon the entry door closure. DA-A stated the care center had just gotten this new dishwasher installed a few months prior and verified it was a low-temperature sanitization machine. DA-A pointed to a single gauge positioned below the machine which displayed the water temperature during each cycle. This gauge displayed a washing temperature of 126 degrees Fahrenheit (F) and a rinse temperature of 140 F. DA-A stated they checked the machine for chemical concentration using a Hydrion strip and showed this process to the surveyor. DA-A removed a strip from the packaging and placed one-half of it into pool water in the base of the machine after the dishwasher stopped. The strip turned a purple-color which DA-A compared to the packaging showing a concentration of 50 parts-per-million (PPM). DA-A stated the concentration should be like 50 to 100 [PPM] to ensure sanitization adding the machine was checked every day in the morning before cooking and food service started. DA-A provided a flow sheet labeled, St [NAME] Park Home, which was dated, May 2025, and had columns to record the date, wash temperature, chlorine concentration (i.e., PPM), rinse temperature and staff initials. This identified only a single recording for each date (5/12 to 2/27) and only listed a PPM reading being completed/documented since 5/21 (i.e., six times) with each days' reading being recorded, 50 [ppm]. There were no other recorded ppm checks on the flow sheet. DA-A verified the flow sheet lacked any additional readings and expressed, Maybe they [staff] forgot. DA-A reiterated the machine was only checked once a day to their knowledge for a PPM reading, and they verified the strips were the only testing mechanism used to check the PPM. Later, on 5/27/25 at 2:02 p.m., dietary aide (DA)-B was interviewed. DA-B verified they worked the evening (i.e., second) shift and helped with washing dishes using the CMA commercial dishwasher in the main kitchen from the supper meal. DA-B stated the machine was just installed a few months prior and the morning shift was responsible to check the machine for PPM concentration. DA-B verified they do not complete any checks of the PPM using the Hydrion strips or any other mechanical indicators adding aloud, I don't do that, no. On 5/28/25 at 11:26 a.m., the dietary manager (DM) was interviewed, and they verified the dishwasher was only checked once-a-day for ppm concentration of the sanitizing solution. DM acknowledged the flow sheets used to record this process only started having a documented PPM check on 5/21/25, and expressed it took awhile for staff to get used to running the machine and checking it for function and sanitization. DM stated they would adjust the flow sheet to ensure a twice-a-day check (i.e., every shift) was completed and recorded. DM stated it was important to ensure the machine was checked adequately for sanitization so as to make sure the chemicals are at equal levels to make sure the dishes are getting sanitized. A facility provided Cleaning Dishes/Dish Machine policy, undated, outlined all flatware, dishes and cookware would be cleaned, rinsed, and sanitized after each use adding, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy outlined a process to ensure sanitization for both a high-temperature sanitization machine and a low-temperature machine. This directed a 50 PPM hypochlorite reading should be obtained, however, the policy lacked a frequency for how often to test this PPM reading.

Based on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic including prophylactic antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure an ongoing review of prophylactic antibiotic use for 1 of 1 residents (R51) reviewed for oral antibiotic use. R51 R51's admission Minimum Data Set (MDS) dated [DATE], indicated R51 had intact cognition and had been admitted to the facility on [DATE]. R51's provider note dated 5/20/25, indicated R51 was diagnosed with anemia and wounds of the left and right ankle. The note did not indicate that R51 had a history of urinary tract infections or an indication of review for the continued use of cephalexin. R51's Order Summary Report dated 5/27/25, indicated R51 had an order for cephalexin (an antibiotic) 250 milligrams (mg) daily for urinary tract infection (UTI) prophylaxis. R51's medical record was reviewed and did not indicate that R51' s order for prophylactic cephalexin had been reviewed with indication for its continued use. During an interview on 5/27/25 at 8:46 a.m., R51 stated she had seen a urologist sometime in 2023 after she had fallen and broken her pelvis, and he had started the cephalexin because she had multiple UTIs. R51 stated thought the urologist had told her to keep taking the cephalexin until the body heals but did not recall being told an exact duration of use. During an interview on 5/28/25 at 1:27 p.m., the assistant director of nursing (ADON), also in the role of infection preventionist, confirmed she had reviewed R51' s medical record and was unable to find documentation that the Cephalexin had been reviewed by the provider for the appropriateness of continued use. The ADON stated she would prefer to get rid of prophylactic antibiotics when a resident was admitted to the facility but had been struggling with getting provider participation in reviewing these medications for residents. During an interview on 5/29/25 at 2:27 p.m., nurse practitioner (NP)-A stated R51 had been admitted with the cephalexin, and she had thought R51 had been taking the medication for years and she tend[s] to leave it[those medications] alone. NP-A stated that R51 was currently on a transitional care unit status, so she was not going to review if the continued use of the cephalexin was appropriate for R51, until she transitioned to long-term care as was her practice. NO PROPHYLACTIC ANTIBIOTIC MONITORING The Antibiotic Surveillance and Symptom Tracker report, printed 5/28/25, was reviewed. The log included the following information: resident names, date of birth , unit, room numbers, onset date, diagnostic order and results, current prescription, infection, isolation, organism, signs and symptoms and status. The report lacked prophylactic antibiotic tracking. During an interview on 5/28/25 at 1:57 p.m., assistant director of nursing (ADON) stated she was the facilities infection preventionist (IP). ADON stated she has been in the IP role for over a year. ADON stated she was not tracking any prophylactic antibiotics in the facility and verified they were not included on the antibiotic tracking sheet which was reviewed in QAPI (Quality Assurance and Performance). ADON stated she was currently not reviewing prophylactic antibiotics and was not able to state the number of residents on prophylactic antibiotics. ADON stated she had not determined where or how she was going to track them. ADON stated she relied on the pharmacy to review the prophylactic antibiotics but was unsure how this was completed. ADON stated it was important to monitor prophylactic antibiotics as according to a lot of people they are not effective. During an interview on 5/29/25 at 1:56 p.m., consulting pharmacist (CP)-A stated that during her monthly audits of resident charts, she reviewed antibiotics to ensure they were the appropriate dose for the resident. CP-A stated she did not review for the duration of the antibiotic and stated, I would leave it up to the provider to determine how long the resident should be on a prophylactic antibiotic. During an interview on 5/29/25 at 12:51 p.m., director of nursing (DON) stated it was important to track prophylactic antibiotics to make sure they were appropriate for why they were prescribed. A facility policy titled Antibiotic Stewardship Policy, dated 10/4/21, indicated The Infection Control Nurse will complete monthly chart reviews of all ordered and administered antimicrobials for the residents. The data will be recorded and presented at the Quarterly Quality Assurance Committee Meeting. A review of possible trends will be discussed at this time. The Consulting Pharmacist will complete a monthly review for indications and justification of use to verify that antibiotics are used in accordance with CDC recommended guidelines.

HAND HYGIENE AND GLOVE USE R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 had intact cognition and no hallucinations, delusions, behaviors, or rejection of cares. R62 had impairment to both lower extremities, required partial and/or moderate assistance for upper body dressing and to roll left and right, and was dependent on toileting hygiene and lower body dressing. R62's diagnoses included heart failure, hypertension, malnutrition, anxiety, depression, post traumatic stress disorder, respiratory failure, and chronic obstructive pulmonary disease. During observation on 5/28/25 at 11:10 a.m., nursing assistant (NA)-G wore gloves, unhooked R62's incontinent product, and completed peri-cares. NA-G disposed of R62's incontinent product soiled with urine and used the same gloves to apply a clean brief and clean bed pad. NA-G removed their gloves, did not perform hand hygiene, exited the room, and grabbed a clean gown from the floor's clean linen area. NA-G returned to R62's room with the gown, applied new gloves, and assisted R62 to apply the gown. NA-G bagged soiled linen and garbage, removed gloves, and washed their hands. During interview on 5/28/25 at 11:22 a.m., NA-G stated they changed their gloves after changing R62's incontinent product. NA-G acknowledged they did not complete hand hygiene with glove change or when they exited room to get clean gown. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E expected staff to change gloves and complete hand hygiene after a dirty process and before touching clean products. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON), who was the facility's infection preventionist, stated hand washing was the best form of infection prevention. The facility Handwashing/Hand Hygiene policy dated 1/18/22, directed staff to complete hand hygiene after removing gloves, before and after direct contact with resident, before moving from a contaminated body site to a clean body site during resident care, and after contact with blood or bodily fluids. BLOOD GLUCOSE MACHINE The Medline Evencare G2 Blood Glucose Monitoring System dated 2017, included the following cleaning instructions: Wash hands with soap and water, inspect the machine for blood debris, etc., clean the machine with a validated disinfecting wipe, allow it to air dry, and if cracking of the plastic housing is noted, stop using the device. R40's annual Minimum Data Set (MDS) dated [DATE], indicated R40 had moderately impaired cognition and was diagnosed with kidney disease and diabetes. The MDS indicated R40 received insulin (an injection used to lower blood sugar) during the look-back period (LBP). R40's order summary dated 5/29/25, indicated R40 had orders for: -Insulin Lispro (fast-acting insulin) three times a day per sliding scale based on blood glucose level (70 - 149, zero units; 150 - 199, 2 units; 200 - 249, 4 units; 250 -299, 6 units; 300 - 349, 8 units; 350 - 399, 10 units; 400 or greater, 12 units and notify provider) -Humulin 70/30 insulin (combination of insulin isophane and regular, both short and intermediate-acting insulin), 52 units in the morning and 44 units in the evening. During an interview and observation on 5/28/25 at 8:13 a.m., registered nurse (RN)-F stated R40 had insulin due this morning, so he was going to check his blood sugar. RN-F was observed to take a Medline Evencare G2 blood glucose machine which had about an inch-long crack in the plastic housing on the left side of the machine, sporadic white building up on the machine, and was missing a back battery cover which was instead covered with clear medical tape. RN-F was observed to complete hand hygiene, apply gloves, and use the machine to take R40's blood glucose reading. RN-F confirmed this machine was used for the floor and not solely for R40. RN-F stated he was unsure how long the machine had been cracked. During an interview on 5/28/25 at 12:45 p.m., RN-E, the unit nurse manager, stated she was unsure if the blood glucose machine was still a cleanable surface but was going to take the machine out of service and see if they had a different blood glucose machine to use instead. During an interview on 5/29/25 at 12:38 p.m., the director of nursing (DON) stated if a blood glucose machine was cracked, she would expect nursing staff to take it out of service as it was no longer a cleanable surface and could affect the accuracy of the measurements. The facility's Obtaining a Fingerstick Glucose Level policy dated 9/30/21, indicated that blood glucose monitoring equipment was to be cleaned and disinfected according to manufacturer's instructions and current infection control standards of practice. Based on record review and interview, the facility failed to report a suspected Norovirus outbreak to the State Agency (SA) as required. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure a blood glucose machine was kept in good repair to ensure the surface could be adequately disinfected and for 1 of 4 residents (R40) reviewed for medication administration. The facility also failed to ensure proper hand hygiene and glove use was utilized for 1 of 2 residents (R62) observed during personal cares. Findings include: NOT REPORTING SUSPECTED NOROVIRUS OUTBREAK TO STATE AGENCY According to 2024-2025 Norovirus Information for long-term care facilities from www.health.state.mn.us, By Minnesota state law ([NAME]. Rules part 4605.7050), any pattern of cases, suspected cases, or increased incidence of any illness beyond the expected number of cases in a given period shall be reported immediately to MDH. This includes suspected outbreaks, increases in GI illnesses, or unusual disease activity at your facility. The Antibiotic Surveillance and Symptom Tracker report, printed 5/28/24, was reviewed. The log included the following information: resident names, date of birth , unit, room numbers, onset date of symptoms, diagnostic order and results, current prescription, infections, isolation, organism, status and signs and symptoms. The report identified between 1/31/25 -2/16/25, 14 residents were suspected of Norovirus. One resident was also identified on 2/26/25 and another on 4/18/25. Recorded signs and symptoms included vomiting, diarrhea, nausea, abnormal bowel movement and GI complaints. Isolation precautions were listed as contact for all residents listed for Norovirus. During an interview on 5/28/25 at 1:57 p.m., assistant director of nursing (ADON) stated she was the facilities infection preventionist (IP) and had been in the IP role for over a year. ADON stated she did all the required reporting for any suspected outbreaks in the facility. ADON stated the facility had a Norovirus outbreak in February, however she did not have any documentation that the outbreak was reported to the state agency as she did not report the outbreak and was unsure if it was required to report a Norovirus outbreak. ADON stated she thought one resident was tested for Norovirus but any residents with symptoms were treated as though they had Norovirus. During an interview on 5/29/25 at 12:52 p.m., director of nursing (DON) stated it was the facilities responsibility to report any suspected outbreak to the state agency. DON stated there was a Norovirus outbreak in February and it should have been reported. A facility policy titled Reporting Communicable Diseases, undated, indicated the infection preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases.

ROOM KNOCK During observation and interview on 5/27/25 at 2:34 p.m., R62 was in their bed in a shared room near the window and furthest from the door. Nursing assistant (NA)-I peeked into the room without knocking, made an unheard comment, and then brought in linens and set them on a chair close to the door before exit. R62 confirmed they did not hear a knock on the door. Surveyor exited the door after interview with R62, and NA-I entered R62's shared room without knocking and went into the bathroom. During interview on 5/27/25 at 2:55 p.m., NA-I acknowledged not knocking on R62's door. During interview on 5/28/25 at 2:13 p.m., R62 stated he was bothered by staff entering the room when not knocking and stated the action made him feel vulnerable. During interview on 5/29/25 at 8:17 a.m., NA-F stated staff should knock on residents' doors before entering, introduce themselves with their name, and explain why they are there. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E expected staff to knock and announce themselves when entering a room. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON) stated they would not want anyone barging in their home and could be scary if staff did not have permission to enter. The facility Quality of Life - Dignity policy dated 4/17/24, indicated residents' private space and property shall be respected at all times. The policy directed staff to knock and request permission before entering residents' rooms. Based on observation, interview and document review, the facility failed to provide a dignified dining experience by serving meals on hard plastic trays which had the potential to affect all residents who ate in the dining room. Additionally, the facility failed to ensure all staff knocked on individual resident bedroom doors and introduced themselves prior to entry for 1 of 1 residents (R62) reviewed with concerns with staff entering their room. Findings include: DIGNIFIED DINING: R47's quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated R47 was severely cognitively impaired with no hallucinations or delusions. Further indicated R47 was set up assistance for eating. During an observation on 2nd floor dining room on 5/27/25 at 8:41 a.m., residents were observed to be eating breakfast. On the table in front of each resident was a breakfast meal that sat on a hard plastic tray. During an observation on 3rd floor dining room on 5/27/25 at 8:44 a.m., residents were observed to be in the dining room eating breakfast. In front of all residents, were a hard plastic tray that contained breakfast items. R40 was observed to be seated in his wheelchair with his head down on his plate which sat on a hard plastic tray. Unidentified staff prompted him to sit up and eat. R40's hard plastic tray, which contained breakfast items, was moved from directly in from on him and R40 put his head back on the table. On 5/27/25 at 12:03 p.m., the lunch meal service on the first floor was observed in the main dining room. The room had multiple tables present with residents seated at each and, in the middle of the room, was a large metallic mobile cart which had meal trays inside them. The staff members removed the trays from the mobile cart, brought them to another table and set them down while they prepared drinks, and then took the drinks and place them back onto the hard-plastic meal tray. The entire hard-plastic tray was then delivered to the seated resident at their table. However, the hard-plastic service trays were then left on the table with plates, cutlery and drinks on top of them. During this time, no staff serving trays were observe to ask or offer to remove the items from the tray and place them onto the table. At 12:07 p.m., R13 was observed eating from the hard-plastic meal tray despite sitting at the table. When asked about using a tray despite being at the table, R13 shrugged his shoulders and responded aloud, I don't mind it. R13 added, Given the clientele here, on the plate [removed from tray] would be too messy. At 12:09 p.m., a single table positioned by the hallways was observed which had three residents present along with nursing assistant (NA)-A and NA-B whom were seated at the same table. The three residents each had a hard-plastic meal tray placed in front of them on the table and were being assisted with eating by NA-A and NA-B. NA-A and NA-B were asked about the trays being used and both responded meals were always served on them, adding items weren't removed from the trays and placed on the tables as everything comes together on the tray from the kitchen. Further, NA-A and NA-B expressed nobody from management had ever told them to offer to remove items from the trays for residents when served. During an observation on 3rd floor dining room on 5/27/25 12:08 p.m., residents were observed coming to the dining area for lunch. Lunch carts were brought to 3rd floor and delivered to the 2nd floor dining room by unknown dietary staff. Each lunch cart was an enclosed metal cart on wheels with slots which held hard plastic trays that contained resident meals. Each slot could hold two hard plastic trays which could be slid from the front or back of the approximately 6-foot metal cart. The hard plastic trays each contained a paper slip that identified who the meal was intended for, and a plate of food that was sitting on a plate warmer covered with a hard plastic dome shaped lid. The tray contained a set of silverware along with a napkin. Staff grabbed the trays from the lunch cart, added the drinks that were requested from a different cart, and delivered the entire tray to residents sitting at the table. Staff left the food and drinks on the hard plastic tray that contained the entire meal including the drinks and silverware. At 12:23 p.m., R47 was served lunch on the hard plastic tray, just as all residents were. R47 was non-interviewable. During an observation on 5/27/25 at 12:28 p.m., all residents (approximately 15) seated in the second-floor dining room were observed at dining tables with filled cups and plates placed on top of hard gray plastic trays. During interview on 5/27/25 at 12:41 p.m., registered nurse (RN)-B stated resident food and drinks came on trays so they were served in the same manner. RN-B stated residents usually seemed to eat okay with their food and drinks on the trays and was not aware of any concerns with food or dining. During an interview on 5/27/25 at 12:51 p.m., nursing assistant (NA)-F stated it was the nursing assistant's responsibility to serve the residents the meals during mealtimes, make sure they get what they need, and give them their preferences. NA-F stated all meals were served on hard plastic trays as that is how we are supposed to do it. NA-F stated the meals came up from the kitchen that way and it was expected to serve it that way. NA-F stated it was more dignified to serve meals on hard plastic trays but was not able to explain this. On 5/28/25 at 11:29 a.m., the dietary manager (DM) was interviewed, and they verified each floor's meal service was done on hard-plastic serving trays. DM stated they had, prior, attempted to remove the trays and leave items on the table but then some residents got upset. As a result, they just served all meals on the trays to everyone, however, DM expressed removing the items and placing them on the table was more dining etiquette. DM stated the management had a discussion about this, however, it was not recorded or documented adding they had discussed potentially care-planning which residents wanted or didn't want the trays kept on the table. Further, DM stated they had not ever brought the issue to the resident council for review or input, either, adding aloud, I never thought about that. During an interview on 5/29/25 at 12:58 p.m., the administrator and director of nursing (DON) verified residents had not been individually assessed for preferences on meals served on hard plastic trays. Furthermore, they stated it has not been discussed during resident council meetings. DON stated after the last annual survey they discussed dining with residents but did not recall if the conversations were related to serving meals on the hard plastic trays and how that related to a dignified dining experience, nor did they have documentation of any such conversations. DON stated no resident care plans had been updated to reflect preferences regarding a resident's preference to keep their meals on a hard plastic tray. DON and administrator verified it was important to have a dignified, home-like dining experience for residents as this was their home. A policy regarding dignified dining was requested and not received.

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 4 of 4 residents (R56, R10, R40, R47) reviewed for use of psychotropic medications. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment, demonstrated hallucinations during the review period, and had episodes of rejection of care behaviors. The MDS recorded R56 as consuming multiple psychotropic medications and being on hospice care while a resident. R56's Order Summary Report, signed 5/2/25, identified R56's current provider-ordered medications and treatments. These included lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times a day scheduled and every 4 hours as needed (PRN), haloperidol (anti-psychotic medication) 0.5 mg every 4 hours PRN, and Dilaudid (narcotic medication) 1 mg every hour as needed for pain/shortness of breath. In addition, R56's Medication Administration Record (MAR), dated 5/2025, identified R56's medications and treatments along with spacing to record their administration or refusals. The MAR recorded multiple administrations of the PRN medication(s) including: On 5/5/25 at 10:23 a.m., R56 was given a PRN dose of haloperidol which had a response recorded as, U [unknown]. A corresponding progress note, dated 5/5/25, identified the medication was given with symptoms recorded, agitated yelling help help. On 5/19/25 at 4:31 a.m., R56 was given a PRN dose or lorazepam which was recorded as effective. However, R56's medical record was reviewed and lacked evidence a signed consent for use of the medication was obtained prior to them being provided. Further, the record lacked evidence the risks of expected benefits of the medication regimen had been reviewed or discussed with R56 or his responsible family member prior to initiation of the medications. On 5/29/25 at 8:34 a.m., a telephone call was placed to R56's family member (FM). However, they were unable to be reached. When interviewed on 5/29/25 at 9:30 a.m., licensed practical nurse (LPN)-A explained the medical provider who ordered the medication was responsible to review the medication risks and benefits with the resident adding the direct care nurses rarely, if ever, do it. LPN-A added, Usually we don't [do that]. LPN-A reiterated, Usually the nurse practitioner does. LPN-A stated any conversation on the medications, including consent or risks and benefits, would be charted in the progress notes. R10 R10's quarterly Minimum Data Set (MDS), dated [DATE], indicated R10 was cognitively intact, had no hallucinations, delusions, behaviors and did not refused cares. MDS indicated R10 was independent with activities of daily living and mobility. MDS indicated diagnoses of Alzheimer's disease, hypertension, anemia and arthritis. R10's Clinical Orders, printed 5/28/25, indicated orders for quetiapine fumarate (antipsychotic medication used to treat schizophrenia, bipolar disorder and depression) 125 milligram (mg) tablets via gastric tube for anxiety, paranoia related to bipolar disorder currently in remission. R10's electronic medical record lacked a consent including risk and benefits related to the anti-psychotic medication. During interview on 05/28/25 at 1:48 p.m., LPN-A stated she was not sure if R10 had a consent to take a psychotropic medication. R40 R40's annual MDS assessment, dated 3/21/25, indicated R40 was moderately cognitively impaired with no hallucinations or delusions, no behaviors, wandering or rejection of care. MDS indicated R40 was on an antidepressant. Relevant diagnoses included: depression. R40's Order Summary Report, printed 5/27/25, included the following orders: -duloxetine HCL (antidepressant medication) give 60 milligrams (mg) by mouth one time a day for depression R40's May's Medication Administration Record (MAR), printed 5/28/25, included the following orders: -DULoxetine HCl Oral Capsule Delayed Release Particles (Duloxetine HCl) Give 60 mg by mouth one time a day for depression -Start Date- 10/10/2024. Documentation indicated administered as ordered. A review of R40's progress notes in the electronic medical record (EMR), dated 11/27/24 to 5/28/25, lacked documentation of education being provided regarding duloxetine. Review of R40's entire EMR lacked evidence of a signed consent for antidepressant medication which would include risks, benefits and alternatives. R47 R47's quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated R47 was severely cognitively impaired with no hallucinations or delusions, no behaviors or rejection of care. MDS did note R47 wandered daily. Further, identified R47 was on an antidepressant. R47's relevant diagnoses included: Parkinson's disease without dyskinesia and without fluctuations (a disorder of the central nervous system that affects movement, often including tremors), orthostatic hypotension (condition when blood pressure decreases when rising from sitting or lying down causing dizziness, lightheadedness or fainting), dementia (a group of thinking and social symptoms that interferes with daily functions), depression, psychotic disorder, hypopituitarism (condition where the pituitary gland doesn't produce enough hormones), benign neoplasm of pituitary gland, and tremor. R47's Order Summary Report, printed 5/29/25, included the following orders: -Celexa (antidepressant medication) give 10 mg by mouth one time a day for major depressive disorder with a start day of 5/13/25. R47's May Medication Administration Record (MAR), printed 5/29/25, included the following: - CeleXA Oral Tablet 10 MG (Citalopram Hydrobromide) Give 10 mg by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42). Start celexa after zoloft is d/c [discontinued]-Start Date- 05/13/2025. Documentation indicated administered as ordered. - Sertraline (antidepressant medication) HCl Tablet 25 MG Give 25 mg by mouth one time a day for Major Depression Disorder related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42) for 7 Days -Start Date- 05/06/2025. Documentation indicated it was administered all scheduled days except 5/11/25 and 5/12/25 when it was coded as 6 indicating R47 was hospitalized . -Sertraline HCl Tablet 25 MG Give 50 mg by mouth one time a day for Major Depression Disorder related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42) -Start Date- 11/21/2023 0900 -D/C Date- 05/05/2025. Documentation indicated administered as ordered. During an observation on 5/27/25 at 12:30 p.m., R47 was observed sitting at the dining room table for lunch. During an observation on 5/28/25 at 9:04 a.m., R47 was observed sitting in the dining room in his wheelchair with his eyes closed. R47 does not respond to questions when asked. A voicemail was left for resident representative (RR)-B on 5/29/25 at 9:35 a.m. requesting a call back. No return call was received. A review of R47's progress notes in the EMR, dated 4/1/25 to 5/29/25, lacked documentation of notification of starting new antidepressant (Celexa), decreased doses of sertraline, or notification to the RR-B. Furthermore, lacked documentation of risks vs benefits of medications or alternatives. Review of R47's EMR lacked evidence of a signed consent for antidepressant medication which would include risks, benefits and alternatives. During an interview on 5/29/25 at 10:23 a.m., registered nurse (RN)-A stated that floor nurses did not obtain consents for any psychotropic medications. RN-A stated she was unaware of who did that and added I know we (floor nurses) don't do that. On 5/29/25 at 12:50 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed the medical records for R56, R10, R40, and R47. ADON acknowledged the lack of a clear signed, informed consent for several of the residents' psychotropic medications and explained the standard practice was to notify family when a medication was started and to document that. ADON verified the records lacked evidence of this, and explained they were currently trying to develop a consent form to record this moving forward. ADON stated consent was important as residents and families have the right to choose if they want to take that medication or not. During interview on 05/29/25 at 1:34 p.m., director of nursing (DON) stated their QAPI (Quality Assurance and Performance Improvement) team had been talking about psychotropic medications. DON stated the facility needed to get consents and educate the residents and families about psychotropic medications to ensure residents were aware of the risks and benefits, and it was documented. A facility policy on residents rights regarding medications was requested and not received.

Based on observation, interview, and document review, the facility failed to coordinate care with an outside hospice agency to ensure ongoing, consistent care delivery and promote comfort for 1 of 1 resident (R56) reviewed for hospice services. In addition, the facility failed to assess and appropriately monitor developing bruising to ensure healing for 1 of 1 resident (R46) reviewed who had visible bruising on their skin. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment and demonstrated hallucinations and rejection of care behaviors. Further, the MDS outlined R56 received hospice services while a resident. On 5/28/25 at 7:19 a.m., R56 was observed lying in bed while in his room. R56 could be heard from the hallway speaking aloud and had mostly non-sensical speech, however, at times would have statements which could be understood such as, Thank you very much, goodbye, and, What's the subject matter? R56 would also, at times, shout loudly with, Help me! A female staff member did enter R56's room and expressed staff would be down shortly to help get him up and ready for the day. R56's facility care plan, dated 4/16/25, identified R56 was at the end stage(s) of life and using hospice or palliative care services. The plan listed a goal which read, The resident will be comfortable, along with interventions including calling hospice when new physician orders were received, coordinating with hospice and other end-of-life services, and multiple others including, Hospice pastoral care visits are scheduled for: See hospice binder at nursing station, and, Medications will be ordered through: See hospice binder at nursing station. However, the facility' care plan lacked any further specifics on these services nor how often they'd be provided for R56 while at the care center. A white-colored binder was located at the nursing station which was labeled, Our Lady of Peace Hospice & Home Care, along with a telephone number to contact them. This binder was inspected and R56's name was recorded inside. The binder contained various medical paperwork along with a yellow-colored copy of the Service Agreement and Election of Hospice Benefit, dated 4/3/25, which identified a hospice registered nurse (RN), social worker (SW), and chaplain would visit along with anticipated frequencies (i.e., 1-2 times/month); however, lacked information on what services these disciplines would be doing or performing while onsite. SEE F656 FOR ADDITIONAL INFORMATION. The binder contained a single, white-colored calendar page labeled, 2025 [space] April [space] 2025, along with hospice' staff names handwritten on 4/3, 4/4, 4/9, and 4/14, respectively. This calendar showed a total of three nurse visits and two social worker visits were completed. On the reverse side of the calendar, a handwritten label was made reading, May, along with, Mon May 5 - [staff name] SW. The entire binder lacked any further calendar(s) or direction on when hospice staff would be visiting the campus. On 5/28/25 at 9:07 a.m., licensed practical nurse (LPN)-B was interviewed, and explained they were waiting for a call back from hospice as some of R56's as-needed medications had expired and needed to be renewed. LPN-B stated R56 had been on hospice a couple months now and they were unsure when hospice would visit most of the time prior to them arriving adding they'd see the hospice nurse once a week, if I'm lucky. LPN-B explained R56's as-needed lorazepam (anxiety medication) needed to be renewed before it could be given adding if staff were not Johnny on the spot with watching it then this would happen where the timeframe to give it would lapse. LPN-B reiterated the hospice staff would never tell care center staff prior to coming, rather, just show up which had been the practice since they came onboard. LPN-B stated the calendar used in the binder was for staff to write their names on when they visited, not beforehand, and expressed the hospice staff never seemed to stay very long when they did visit. LPN-B stated they rarely, if ever, even looked in the hospice binder at the calendar or notes adding they only had it with them now to get the number to call about the expired medication. During the interview, at 9:12 a.m., hospice registered nurse (HRN) then entered into the building. LPN-B and HRN then discussed the expired medications before HRN left the desk to see R56. When interviewed on 5/28/25 at 10:02 a.m., HRN stated they visited R56 one to two times per week, and the hospice social worker would visit one or two times per month. HRN stated they couldn't recall another time when R56's medication prescriptions lapsed like had just happened, and expressed they tried to always ask staff when they visit if they needed anything, like prescriptions renewed, at their visits. However, HRN stated it was ultimately care center staff whom were responsible to ensure they don't lapse the medication availability. HRN stated they felt there was collaboration between hospice and the care center adding it was good for what it is here. HRN stated R56 was their only patient at the campus and things were still being worked out adding, It still feels like new, adding there was always opportunity to communicate better. HRN stated they were going to adjust R56's Seroquel order today, and acknowledged the lack of a hospice care plan being readily available for the care center staff. HRN then reviewed the provided calendars in their hospice binder which was left for the care center. HRN acknowledged it lacked a May 2025 calendar (despite being almost June) and it did not outline upcoming visits for care center staff to be aware of adding, I'm not very good at this part. HRN stated having a more routine, set schedule in writing for staff to see would be an area of opportunity, too. On 5/28/25 at 1:30 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed R56's medical record. ADON explained they didn't typically work with R56's hospice agency and verified the hospice care plan had not been provided to the campus prior to survey. ADON stated one should have been adding it was important to ensure the care plans were available and meshing together so staff were all on the the same page. ADON verified a calendar had also just been placed into the binder to help show when hospice would be visiting more easily adding, prior, it had been a struggle to know exactly what day they're coming. ADON stated the hospice staff should be reviewing R56's medication supplies and prescriptions when onsite to ensure they don't lapse with availability adding, The hospice nurse would catch this [assumed]. ADON verified the importance of coordinating care with a hospice provider adding they should be working together to take care of this resident. A facility provided Hospice Program policy, dated 7/2017, identified the care center would have written agreements with hospice providers and those providers would be held to the same professional standards of service as other contracted agencies or individuals. The policy outlined responsibilities of both the hospice and the care center, however, the spacing to record a person designated to coordinate with the hospice was left blank and not filled out with text reading, 12. Our facility has designated __________ (Name) __________ (title) to coordinate care provided to the resident by our facility staff and the hospice staff. R46 R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had moderately impaired cognition and no hallucinations, delusions, or rejection of cares. R46 required partial and/or moderate assistance to roll left and right, required substantial/maximal assistance with upper body dressing and transfers, and was dependent with lower body dressing and toileting hygiene. R46's diagnoses included peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. R46's anticoagulant care plan, revised 4/23/25, indicated R46 was on anticoagulant therapy related to atrial fibrillation. Interventions directed staff to complete labs as ordered and report abnormal lab results to the provider and administer anticoagulant medications as ordered by physician and observe for side effects and effectiveness every shift. R46's skin integrity care plan, revised 4/23/25, indicated R46 had an impairment to skin integrity related to new colostomy and surgical wound on abdomen and surgical incision on right hip. R46 had the potential for further skin integrity concerns related to redness on coccyx and groin. Interventions directed staff to use barrier cream after each incontinent episode, keep skin clean and dry, use lotion but not to open areas, use pressure relieving/reducing cushion to protect the skin while in wheelchair and mattress to protect the skin while in bed. R46's care plan lacked resident specific interventions to prevent bruising. R46's Order Summary Report printed 5/28/25, indicated: -11/18/24, apixaban (an anticoagulant medication used to treat and prevent blood clots) oral tablet 2.5 mg by mouth two times a day. -11/18/24, weekly skin check and complete the weekly skin review assessment in the electronic health record every Saturday day shift. -5/28/25, anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/ See Nurses Notes and progress note findings three times a day related to long term (current) use of anticoagulants. R46's progress notes indicated: -1/1/25 at 2:07 p.m., R46 had multiple bruises on bilateral upper extremity. -3/22/25 at 12:35 p.m., R46 had a bruise on back of left hand, and staff would continue to monitor. R46's assessments and other documents viewable in the electronic health record lacked information on bruising assessment and monitoring. During observation on 5/27/25 at 9:28 a.m., R46 was in bed and had bruising on both hands. During observation on 5/29/25 at 8:08 a.m., R46 sat at a dining room table. R46 had general discoloration and a bruise approximately less than one inch by one inch to his left hand and general discoloration and a bruise approximately greater than one inch by one inch to his right hand. R46's right hand had a dark bluish-black scab with reddish drainage between his first and middle finger. During interview on 5/29/25 at 8:23 a.m., nursing assistant (NA)-F stated they notified a nurse when they saw a bruise on a resident. NA-F stated they worked with R46 once in a while and was not aware of bruising to R46. When asked about the new area on R46's right hand, NA-F stated they thought R46 bumped their hand this morning and notified the nurse right away. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E stated staff followed-up on bruises to residents' hands on a case-by-case basis. RN-E stated R46 was on a blood thinner, and staff should evaluate bruises for a potential cause. RN-E stated staff documented new skin concerns in risk management. RN-E stated R46 came out of their room a lot and sat in their wheelchair, and RN-E would have to review R46's progress notes and risk management documents to comment further on R46's skin or bruising. During follow-up interview on 5/29/25 at 2:31 p.m., RN-E stated they looked at RN-E's hands and offered skin protectors or gloves, and R46 declined. RN-E stated R46's hands lined up with the dining table when he sat in his wheelchair and stated R46 was able to move in their wheelchair. RN-E stated they reviewed R46's progress notes and did not see follow-up on R46's bruising. RN-E reviewed R46's risk management documents and stated on 3/5/25, R46 had a scratch from a call light clip, and on 3/28/25, a skin tear was identified on R46's left forearm. RN-E did not see a risk management entry related to bruising. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON) expected bruises to be documented in risk management and staff to assess the root cause to prevent future bruises and monitor until healed to ensure the skin does not worsen. R46's skin assessments were requested from the facility. The facility provided Integrated Wound Care progress notes, which lacked documentation of bruising, and did not send any documentation related to the weekly skin assessments. The facility Prevention of Skin Breakdown policy dated 7/2/18, indicated the care plan was to be evaluated and revised based on response, outcomes, and needs of the resident. The facility policy Anticoagulation - Clinical Protocol undated, directed the staff and physician to monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

Based on observation, interview, and document review, the facility failed to ensure symptoms of potential psychiatric distress were recorded; and non-pharmacological interventions were attempted then documented prior to the use of as-needed (i.e., PRN) psychotropic medication to improve continuity of care for 1 of 5 residents (R56) reviewed for unnecessary medication use. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment, demonstrated hallucinations during the review period, and had episodes of rejection of care behaviors. The MDS recorded R56 as consuming multiple psychotropic medications and being on hospice care while a resident. On 5/28/25 at 7:36 a.m., R56's morning cares were observed with nursing assistant (NA)-A and NA-B involved. R56 was lying in bed which had an air-pressure mattress in place; along with staff helping to wash him up. R56 would converse with staff as they provided care, however, it was not always sensical to the situation including, A bridge of bread, that's perfect for ya. NA-A and NA-B completed R56's morning cares without R56 having any visible, physical behaviors towards them. R56's care plan, dated 9/2024, identified R56 had behaviors including yelling, cursing, accusations and physical aggression. The care plan listed multiple non-pharmacological interventions which could be attempted including redirection, distraction, and providing a calm environment. The care plan continued and identified R56 consumed psychotropic medications due to sleep issues and behavioral needs. The care plan directed to administer the medications as ordered, monitor for their effectiveness, and monitor/record occurrences of R56's target behaviors and interventions. R56's Order Summary Report, signed 5/2/25, identified R56's current provider-ordered medications and treatments. These included lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times a day scheduled and every 4 hours PRN, haloperidol (anti-psychotic medication) 0.5 mg every 4 hours PRN, and Dilaudid (narcotic medication) 1 mg every hour as needed for pain/shortness of breath. R56's Medication Administration Record (MAR), dated 5/2025, identified R56's medications and treatments along with spacing to record their administration or refusals. The MAR recorded multiple administrations of the PRN medication(s) including: On 5/5/25 at 10:23 a.m., R56 was given a PRN dose of haloperidol which was recorded as, U [unknown]. A corresponding progress note, dated 5/5/25, identified the medication was given with symptoms recorded, agitated yelling help help. However, again, the note lacked what, if any, non-pharmacological interventions were attempted or offered prior to the medication. On 5/19/25 at 4:31 a.m., R56 was given a PRN dose or lorazepam which was recorded as effective. A corresponding progress note, dated 5/19/25, identified the medication was given, however, lacked any symptoms R56 displayed to warrant the medication nor what, if any, non-pharmacological interventions were attempted prior to help calm or settle R56 down. Further, the MAR recorded on 5/19/25 at 4:30 a.m. (same time), R56 was provided Dilaudid for a pain rating of six (6) and was recorded as effective. However, again, the record lacked information or evidence on what symptoms R56 displayed, rationale why both medications were provided at nearly the same time nor what, if any, non-pharmacological interventions were attempted prior to multiple PRN(s) being given. R56's POC (Point of Care) Response History, printed 5/29/25, identified spacing for staff to record behaviors and interventions attempted to reduce them. This identified: On 5/5/25, R56 was recorded as having no behaviors present by the nursing assistant (NA) staff members. The corresponding response of interventions attempted recorded, Response Not Required. On 5/19/25, R56 was recorded as having no behaviors present by the NA staff members. However, the corresponding response of interventions recorded staff attempted providing a calm environment but the behavior was unchanged. This entry of the intervention attempted was recorded at 6:43 p.m. (over 12 hours after the PRN medication was given). When interviewed on 5/29/25 at 9:30 a.m., licensed practical nurse (LPN)-A stated R56 demonstrated behaviors like calling out and would, at times, become immediately aggressive with staff adding, It can be challenging [to care for him]. LPN-A stated R56 was hard of hearing which they felt contributed to his behaviors, and expressed staff often had to leave him alone and then reproach him to get cares done. LPN-A stated giving R56 snacks seemed to help with his behaviors. LPN-A explained if a PRN medication needed to be given, staff should attempt non-pharmacological interventions prior and those should be documented in the progress notes. LPN-A stated PRN medications should only be given one at a time and rarely, if ever, should multiple ones be given at the same time. LPN-A stated it was important document symptoms and the non-pharmacological interventions attempted so as to see if that will help and stuff before you give the medication. LPN-A added, Maybe he just needs someone to talk to, or maybe he's hungry. On 5/29/25 at 12:50 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed R56's medical record. ADON stated, I saw what you saw, and verified the lack of consistent symptom or non-pharmacological charting with the PRN medication use. ADON stated the charting was a PIP (performance improvement project) they were addressing and verified staff should be attempting and charting symptoms and non-pharmacological interventions with PRN psychotropic medication use. ADON stated this was important to help the IDT see what's working and not working for the resident. ADON added medication may not always be needed if non-pharmacological interventions were attempted prior.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive care plan for hospice care and services was developed and/or readily available to promote continuity of care for 1 of 1 resident (R56) reviewed for hospice services. Findings include: R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment and demonstrated hallucinations and rejection of care behaviors. Further, the MDS outlined R56 received hospice services while a resident. On [DATE] at 7:19 a.m., R56 was observed lying in bed while in his room. R56 could be heard from the hallway speaking aloud and had mostly non-sensical speech, however, at times would have statements which could be understood such as, Thank you very much, goodbye, and, What's the subject matter? R56 would also, at times, shout loudly with, Help me! A female staff member did enter R56's room and expressed staff would be down shortly to help get him up and ready for the day. R56's facility care plan, dated [DATE], identified R56 was at the end stage(s) of life and using hospice or palliative care services. The plan listed a goal which read, The resident will be comfortable, along with interventions including calling hospice when new physician orders were received, coordinating with hospice and other end-of-life services, and others which read: Hospice pastoral care visits are scheduled for: See hospice binder at nursing station, Hospice social service visits are scheduled for: See hospice binder at nursing station, The Hospice [sic] staff will provide bathing services on: See hospice binder at nursing station, Medications will be ordered through: See hospice binder at nursing station, and, Supplies will be ordered through: See hospice binder at nursing station. The facility' care plan lacked any further specifics on these services nor how often they'd be provided for R56 while at the care center. A white-colored binder was located at the nursing station which was labeled, Our Lady of Peace Hospice & Home Care, along with a telephone number to contact them. This binder was inspected and R56's name was recorded inside. The binder contained various medical paperwork including a POLST (Provider's Orders for Life Sustaining Treatment), hospice emergency contact information, and multiple 'summary' notes completed by hospice staff when they visited. The binder included a yellow-colored copy of the Service Agreement and Election of Hospice Benefit, dated [DATE], which identified a hospice registered nurse (RN), social worker (SW), and chaplain would visit along with anticipated frequencies (i.e., 1-2 times/month); however, lacked information on what services these disciplines would be doing or performing while onsite with R56. R56's medical record and hospice binder both lacked a complete, comprehensive care plan detailing what services the outside hospice agency would provide. SEE F684 FOR ADDITIONAL INFORMATION. On [DATE] at 9:07 a.m., licensed practical nurse (LPN)-B was interviewed, and explained they were waiting for a call back from hospice as some of R56's as-needed medication supply had expired. LPN-B stated there was no hospice aide coming in to see R56 to their recall and the hospice nurse (HRN) they'd see about once a week, if I'm lucky. LPN-B stated the HRN typically visited with R56 for a bit and then left again adding such was what a majority of them do. LPN-B stated they couldn't recall ever seeing a hospice care plan in R56's binder of information but then added, I can't say I've looked, either. When interviewed on [DATE] at 10:02 a.m., HRN stated they visited the campus once or twice a week, and the hospice SW would visit once or twice a month. HRN stated they typically obtained R56's vital signs and reviewed him for pain control when they visited. HRN stated they'd also, at times or if needed, visit with R56's family members on his condition. HRN stated the hospice care plan was usually housed in their own electronic record which was just for us with no care center staff having access to it. HRN stated a copy should have likely been printed and placed into R56's binder of information. On [DATE] at 1:30 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had looked into R56's hospice binder and medical record. ADON stated the care center had hospice outlined on their own care plan, however, the interventions were somewhat generic and mostly directed to the hospice binder for information. ADON verified the hospice care plan was not provided prior to survey and expressed it was important to have both the care center and hospice plans together and available so staff were on the same page. A provided Care Plans - Comprehensive policy, dated 6/2022, identified an individualized, comprehensive care plan with measurable objectives and timetables would be developed for each resident. This care plan was to be developed within seven (7) days after the completion of the comprehensive MDS.

Based on observation, interview and document review, the facility failed to ensure a medication was administered safely for 1 of 1 resident (R10) who had been assessed as unable to safely self-administer medications. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact, had no hallucinations, delusions, behaviors and did not refused cares. MDS indicated R10 was independent with activities of daily living and mobility. MDS indicated diagnoses of Alzheimer's disease, hypertension, anemia and arthritis. R10's Clinical Orders printer 5/28/25, indicated orders for levothyroxine sodium 75 micrograms (mcg) by mouth once a day in the evening without a diagnosis for this medication. Levothyroxine is prescribed for hypothyroidism. R10 also had and order for NPO (nothing per mouth) except for pleasure foods in liquid form. All other medications were ordered to be administered via tube feeding (TF). R10's care plan printed 5/28/25, indicated she had impaired cognition/thought processes related to Alzheimer's disease and bipolar disorder and directed staff to administer medications as ordered. Also, the care plan indicated R10 had hypothyroidism and directed staff to give thyroid replacement therapy as ordered. R10's Self Administration of Medications Assessment (SAM) dated 3/16/25, indicated resident did not want to self-administer her medications and was not able to identify the expiration date of each medication. During observation and interview on 5/27/25 at 10:36 a.m., R10 was in her room sitting at the edge of the bed. Two round pills were observed on the floor. R10 stated sometimes the nurses leave my thyroid medication in a small cup, and I take it on my own. Sometimes the pill slips out of my hand, falls on the floor, and I often forget to tell the nurses, and they don't ask if I took it. R10 added, I don't take the medication in front of the nurses, they leave the room. I put the pill in my mouth, take a sip of water and let the pill dissolve and I swallow it. During interview on 5/27/25 at 10:46 a.m., licensed practical nurse (LPN)-B stated R10 can swallow a little bit and takes the pill with water. LPN-10 stated she did not know why R10 took this medication by mouth when all other medications were administered through her TF. During interview on 5/28/25 at 1:48 p.m., LPN-A stated she usually worked in the evenings, and R10 took her levothyroxine by mouth. LPN-A stated the nurses tried to give it, but sometimes R10 couldn't take it or wanted to take it later. I leave the medication with her, I go back to her room and if the medication is no longer in the medication cup, it means she [R10] took the medication. I don't see her taking the medication. LPN-A stated R11 had never reported dropping the medication on the floor. LPN-A verified the SAM indicated R10 was not able to self-administer medications and had no order for self-administration of medications. During interview on 5/28/25 at 2:21 p.m., nurse manager/registered nurse (RN)-E verified R10 did not have a physician's order to self-administer medications. RN-E also verified R10's SAM indicated she was not capable of self-administering medications. During interview on 05/29/25 at 1:25 p.m., director of nursing (DON) stated on admission a SAM was completed for all residents. DON stated if a resident requested to self-administer their own medications, the nursing staff will determine if it's appropriate and call the physician to obtain an order for self-administration of medications. DON stated the expectation was for nurses to administer the medications as ordered and never leave the medications at bed side without an order for self-administration. Facility's policy titled Self-Administration of Medications dated 12/13/21, indicated as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when he eloped from the facility and was found half a block away. The IJ began on 9/27/24 at 4:00 p.m. when therapy director (TD)-A discovered R1 outside of the facility on the sidewalk, approximately half a block from the building. The administrator and director of nursing (DON) were informed of the IJ on 10/3/24 at 4:53 p.m. The IJ was removed on 10/4/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Face Sheet dated 10/4/24 indicated R1 had diagnoses of Alzheimer's disease, traumatic brain injury, and dementia. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment. The MDS also identified R1 used a wander/elopement alarm daily. R1's Elopement Risk assessment dated [DATE] indicated R1 was at risk for elopement. R1's care plan dated 6/3/24 indicated R1 was at risk for elopement and wandering, and utilized a WanderGuard management system (used to trigger alarms to alert staff when a resident wearing a WanderGuard bracelet is near a door). Interventions indicated WanderGuard was on left wrist, and R1 had wandering safety checks every thirty minutes. R1's Treatment Administration Record dated 6/3/24 indicated staff to check WanderGuard placement every shift, check function weekly, and change WanderGuard every 90 days. On 9/27/24 at 6:08 p.m., a progress note written by registered nurse (RN)-D indicated R1 was found ambulating on the sidewalk approximately half a block from the facility, and assisted back to the facility by staff. R1's WanderGuard was checked and replaced. On 10/3/24 at 9:16 a.m., licensed practical nurse (LPN)-A stated she didn't check R1's WanderGuard to ensure it was functioning on 9/24/24, but she charted she had checked it in R1's electronic medical record (EMR) accidentally. She stated she didn't replace R1's WanderGuard on 9/23/24, but she did chart in R1's EMR it was completed. LPN-A did not offer an explanation as to why she charted she had replaced it, when in fact, she had not. On 10/3/24 at 9:24 a.m., R1 stated he left the facility and they found him on the farm. He stated he does not remember where he was going. He stated he plans on leaving the facility again to go to his wife's house. On 10/3/24 at 11:22 a.m., RN-B stated on 9/27/24 around 3:15 p.m., she saw R1 come off the elevator onto the first floor with RN-A. She told RN-A that R1 was on thirty-minute checks, and asked RN-A to take R1 back to his room. She stated RN-A walked outside with R1, and the alarm didn't go off for R1's WanderGuard. RN-A then went back into the facility a few minutes later and told her (RN-B) R1 was at the patio. RN-B thought RN-A had brought R1 back up to his room. At around 4:00 p.m., therapy director (TD)-A brought R1 back to the facility, and said she had found R1 walking on the sidewalk on [NAME] Avenue. R1's WanderGuard bracelet did not alarm when R1 entered the facility. On 10/3/24 at 12:24 p.m., RN-D stated on 9/27/24 at around 4:10 p.m., TD-A notified her R1 was found on the sidewalk on [NAME] Avenue and was brought back to the facility. She stated R1's WanderGuard was not triggering the alarm system to sound, so RN-D changed R1's WanderGuard at that time. On 10/3/24 at 12:59 p.m., TD-A stated on 9/27/24 around 4:03 p.m., she was driving home from work and spotted R1 on [NAME] Avenue walking toward Commonwealth Street. She turned her car around to pick him up after he crossed Commonwealth Street, and she brought him back to the facility. On 10/3/24 at 1:10 p.m., RN-A stated on 9/27/24 around 3:30 p.m., she got on the elevator and R1 was on the elevator. She walked outside with R1, R1 sat down at a chair in the front patio area, and she went back into the facility. She told RN-B she had to go back upstairs, and asked RN-B to keep an eye on R1. RN-A went back to the second floor. Later that shift, RN-A was told that R1 was on thirty minute checks, and had just been found a half a block away. When she walked outside with R1, the WanderGuard alarm did not go off, so RN-A was not aware R1 had a WanderGuard or was at risk for elopement. On 10/3/24 at 3:25 p.m., the Securitas Healthcare (WanderGuard) representative stated the WanderGuard bracelets should be checked daily to ensure each bracelet was working correctly. The WanderGuard manufacture's manual undated, directed staff to test WanderGuard signaling devices daily and record the results in the resident's records. On 10/3/24 at 3:46 p.m., R1's nurse practitioner (NP)-A stated R1 was a vulnerable adult with poor judgement, and could have been hit by a car, fallen, or walked in on coming traffic and gotten hurt. The facility Wander Management System Policy revised 10/2/24, directed that wander management system bracelets are checked weekly for function. The immediate jeopardy began on 9/27/24, was removed on 10/4/24 when the facility reviewed and revised their current policy on WanderGuards. The facility reviewed all residents with WanderGuards to ensure bracelets were working correctly by checking function daily. The facility completed staff education on the WanderGuard policy. This was verified through observation, interview and document review.

Based on observation, interview and document review, the facility failed to ensure documentation of each resident's code status was consistent throughout their medical record to ensure the code status accurately reflected resident's current resuscitation preference. In addition, the facility failed to ensure staff knew where to find a resident's code status. This resulted in an immediate jeopardy (IJ) situation for 3 of 18 residents (R52, R36, R61) who were at risk to receive cardiopulmonary resuscitation (CPR) and sustain serious bodily injury against their wishes in the event of cardiopulmonary arrest. The IJ was identified on [DATE] when R52's code status was discovered as omitted from the resident's banner in the electronic medical record (EMR). R52's provider order indicated R52 was a full code (desired cardiopulmonary resuscitation) while the Provider Order for Life Sustaining Treatment (POLST) indicated R52 was Do Not Attempt Resuscitation (DNR). In addition, R36 and R61's electronic medical record (EMR) banners and provider orders indicated R36 and R61 were DNR. R36 and R61's POLST indicated DNR, however was not signed by the physician making the POLSTs invalid and by facility policy and procedure defaulted to CPR. This IJ situation was identified on [DATE]. The administrator, director of nursing (DON) and assistant administrator were notified of the IJ at 6:30 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 had moderate cognitive impairment. R52's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's clinical resident profile indicated family member (FM)-A was R52's emergency contact #1, responsible party and care conference person. R52's care plan lacked reference to advanced directives or code status. R52's EMR banner lacked reference to code status. R52's provider order dated [DATE], indicated Code Status: Full Code. R52's POLST signed by FM-A on [DATE], and uploaded in to the EMR on [DATE], indicated DNR. R52's progress note dated [DATE], at 1:00 p.m. indicated R52 was sent to the emergency room for evaluation of right upper quadrant abdominal pain. R52's progress note dated [DATE], at 9:58 p.m. indicated R52 underwent gall bladder removal on [DATE]. R52's progress note dated [DATE], at 7:44 p.m. indicated, Res's [sic] has an order Code Status: Full Code but Res's POLST from [DATE] states DNR. The note further indicated a voice mail was left for nurse practitioner (NP)-A for clarification. R52's hospital discharge orders dated [DATE], indicated, Code Status: Full Code. During an interview on [DATE], at 1:27 p.m. license practical nurse (LPN)-A stated she would look at provider orders in the EMR for the resident's code status. LPN-A looked in R52's EMR and found the provider order for full code. LPN-A stated she would start CPR on R52 if found unresponsive. LPN-A then looked at a document hanging on the wall next to the nurse's station that listed all residents in the facility. The top of the document dated [DATE], at 12:17 p.m. indicated, All Residents ar [sic] DNR/DNI unless otherwise specified. The document did not identify R52 as full code. LPN-A stated according to the document on the wall, R52 was DNR/DNI and that there was a problem. LPN-A further stated understanding what the POLST was but would still refer to the provider orders in the EMR first. LPN-A stated when a resident was admitted or readmitted from the hospital, the orders should always be double checked and confirmed by a second nurse. During an interview and observation on [DATE], at 2:15 p.m. LPN-B stated she would look in a resident's hard chart first and locate the POLST to determine code status. LPN-B looked in R52's hard chart and could not locate the POLST. LPN-B then went to the computer and opened R52's EMR. LPN-B stated the code status should be in a resident's EMR header. LPN-B confirmed R52's code status in the banner was blank. LPN-B stated she did not know where else to look for R52's code status and therefore would start CPR. LPN-B continued to look in the EMR and at 2:21 p.m., 6 minutes later, found the order for full code under provider orders in R52's EMR. LPN-B further stated she would not look at the POLST in the EMR since she did not know where it was in the EMR. During an interview on [DATE], at 2:39 p.m. director of nursing (DON) stated the nurses should look in point click care (PCC) in the resident's EMR banner for code status and could then look in provider orders for further details. DON stated the facility was transitioning from storing the POLST in the hard chart to uploading them into the documents or miscellaneous section of the EMR. DON looked in R52's EMR and confirmed the code status in the banner was blank and then looked in the provider orders and confirmed R52 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON further stated the provider orders should be generated from the POLST and thought this discrepancy was a result of R52's last hospitalization . The DON stated the expectation was the resident's orders would be reconciled with the hospital discharge or transfer orders upon admission or readmission to the facility. During an interview on [DATE], at 3:42 p.m. FM-A stated R52 wished not to be resuscitated. FM-A stated he could not recall any recent conversation regarding R52's code status and that two years ago it was decided to make her DNR. FM-A further stated R52 was adamant at that time she did not want CPR because, she did not want to live like a vegetable. During an interview on [DATE], at 12:48 p.m. NP-A stated she did receive the message regarding R52's code status on [DATE] and called the facility. NP-A could not recall who she spoke to at the facility but directed them to call FM-A for clarification of R52's wishes. NP-A further stated it was her understanding R52 wanted to be DNR. R36's Admission Record dated [DATE], indicated R36 was DNR only. R36's admission MDS dated [DATE], indicated R36 had intact cognition. R36's Electronic Medical Record (EMR) banner indicated R36 was DNR. R36's care plan dated [DATE], indicated R36 had a signed do not resuscitate (DNR) order. R36's POLST dated [DATE], indicated R36 was DNR; however, the POLST lacked a provider signature. R61's quarterly MDS dated [DATE], indicated R61 had intact cognition. R61's Admission Record dated [DATE], indicated R61's code status was DNR-See POLST. R61's EMR banner indicated R61 was DNR. R61's POLST dated [DATE], indicated R61 was DNR; however, the POLST lacked a provider signature. R61's provider note dated [DATE], indicated R61 was full code. During an interview on [DATE], at 10:07 a.m. R61 stated he wanted life-saving measures as long as I am not a vegetable. During an interview on [DATE], at 2:26 p.m. RN-E stated if a resident's POLST was not signed he would initiate CPR. During an interview on [DATE], at 10:56 a.m. RN-D stated if a POLST was not signed by either a provider and the resident or their representative, RN-D would assume the resident was full code (initiate CPR). During an interview on [DATE], at 1:24 p.m. LPN-E stated if a POLST wasn't signed the resident would be treated as full code until it was signed. Facility policy Do Not Resuscitate, revised [DATE], indicated the facility would not use CPR and other emergency measures to maintain life on any resident when there was a DNR order in effect. The policy further indicated the DNR order must be completed and signed by the physician and placed in the front of the resident's chart. The DNR orders must be signed by the resident's attending physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy Medication Orders reviewed [DATE], indicated residents admitted or readmitted to the facility from the hospital, would have their hospital discharge orders entered into the residents EMR by the health unit coordinator (HUC) and would remain pending (not be active) until confirmed by a licensed nurse. The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility conducted a facility wide audit of all resident's code status and confirmed all resident EHR banner, provider orders and POLSTs matched and accurately reflected the resident's wishes. The facility also developed and initiated an all staff in-service to educate all staff on reviewing all resident provider orders and progress notes prior to uploading into the resident's EHR. All POLSTs must be filled out completely and signed by the provider and any discrepancies must be clarified with the provider. All resident's code status' will be located in the resident's EHR and the POLST will be filed under the miscellaneous tab of the resident's EHR. The immediacy was removed with the confirmation of the facility's actions verified through interview and document review, but the noncompliance remained at the lower scope and severity level of D.

Based on interview and document review, the facility failed prevent a burn injury for 1 of 5 residents (R67) who required warm/hot packs. The facility's practice resulted in actual harm for R67 whom received a hot pack that was heated in the microwave resulting in second-[MEDICAL CONDITION] a secondary infection. In addition, the facility policy and practices placed 4 of 4 residents (R41, R45, R36, and R55) who had current orders for hot/warm packs, at risk for being burned. Findings include: R67's quarterly Minimum Data Set ((MDS) dated [DATE], identified severe cognitive impairment with [DIAGNOSES REDACTED]. R67 required extensive assistance with activities of daily living (ADLs). R67's care plan dated 3/1/19, included, (R67's name) has the potential for pain r/t (related to) hx (history) of backache, shoulder and arm pain. Staff were directed to observe, record and report to nurse any signs of pain. R67's physician orders [REDACTED]. R67's progress note dated 5/9/19, at 10:30 p.m. included, Nursing assistant called writer and showed writer blisters on the right knee. Resident had 8 small blisters that are still intact. Resident was grimacing when area was touched. Blisters were in varying sizes, 3 cm (centimeters) x 2 cm, 0.3 cm x 0.5 cm, 0.7 cm x 0.4 cm, 0.5 cm x 0.4 cm, 1 cm x 0.3 cm, 0.3 cm x 1 cm, 1 cm x 0.5 cm, 0.5 cm x 1 cm. Will continue to monitor skin area. Voice message left for nursing practitioner . Family will be called tomorrow and updated about the blisters. R67's facility report dated 5/10/19, indicated on 5/9/19, R67 developed eight blisters on the right knee after a warm pack was applied. A nursing assistant discovered the burn after removing the warm pack during incontinence care. The warm pack had been prepared by license practical nurse (LPN)-D who reported heating the warm pack up in the microwave. The report indicated, The care plan was followed however the proper procedure for heating the hot pack was not followed as a microwave was used. The report further indicated, Microwaves are not to be used to heat up a hot pack. The report indicated the nurse involved as well as all licensed nurses were informed of the proper way to heat hot packs. An email to licensed nurses and nursing assistants dated 5/10/19, included, Never use microwave to re-heat a warm pack. Please use a little hot water from the coffee machine on a towel, place in plastic bag, place in pillow case and place on top of a towel placed over the area that needs a warm pack. Never directly expose skin. Hold warm pack against your hand before placing onto an area of a resident. Make sure it is not too hot. R67's progress note dated 5/12/19, included, Blister opened up. Updated the on call, (practioner name) to obtain order for dressing. The on call gave order. 1. Clean wound with wound cleanser. 2. Apply hyrdo gel daily and cover with nonadherent gauze until healed. R67's progress note dated 5/29/19, included, Wound R knee from burn. There is 0.8 cm open blister area on R knee that is clean. There is a 2.3 by 1.4 cm by 0.1 cm in depth open are front of R knee. Inside this opening there is a 0.5 cm area that is yellow and brown colored. Skin around wound appears swollen and is very tender to the touch. Message left. Waiting for response. A follow up note indicated an antibiotic was ordered for an infection in the burned areas or R67's right knee. R67's progress note dated 5/30/19, included, Keflex (an antibiotic) 500 mg. Give 1 capsule by mouth three times a day for infection until 6/5/19. Res (resident) continues on above medication for infection to wound on right knee. (R67's name) winced in pain when writer changed dressing this morning. When interviewed on 1/14/20, at 9:52 a.m. registered nurse (RN)-C stated residents on occasion require warm packs for comfort. RN-C further stated, I am not familiar with the policy or procedure, but I only use warm tap water to make warm packs. When interviewed on 1/14/20, at 1:55 p.m. RN-A stated, I would use a wash cloth with water from the coffee maker or microwave if not hot enough. Then place in a plastic bag and then in a pillow case. When interviewed on 1/14/20, at 2:00 p.m. LPN-A confirmed the facility does not have pre-made hot packs so staff have to make them. LPN-A stated they use hot water from the coffee maker on a wash cloth inside a plastic bag and pillow case whenever someone needed a warm pack. When interviewed on 1/14/20, at 2:06 p.m. RN-E stated would use a wash cloth and hot water from the coffee maker inside a plastic bag and pillow case. They would leave the bag open for a while to let it cool down a bit. On 1/14/20, at 2:21 p.m. the facility maintenance worker tested the water temperature from the first floor coffee machine using a facility thermometer. The temperature was 160.9 degrees Fahrenheit. On 1/14/20, at 2:23 p.m. the Nestle service technician was observed servicing the second floor coffee machine and stated, We don't want them to go below 160 degrees because the product will not mix correctly. On 1/14/20, at 2:25 p.m. the facility maintenance worker tested the water temperature from the third floor coffee machine using a facility thermometer. The temperature was 156 degrees Fahrenheit. When interviewed on 1/14/20, at 3:01 p.m. the director of nursing (DON) stated staff should use wash cloth or towel and hot water out of the coffee machine or hot water faucet. We prefer that over the microwave because that cause uneven heating. DON further stated staff should check the temperature of the hot pack by placing on their own wrist before applying to resident. I don't know the temperature of the hot water from the coffee machine. Hot packs were only to be used only with a physician/nurse practitioner's order. The DON provided the current facility policy on hot packs. The undated facility policy Hot Wet Compress indicated a procedure for creating hot packs. The procedure included, Wet wash cloth with hot water and test by placing on inside of wrist or with thermometer. (MONTH) heat in microwave. The policy had not been updated after R67 was burned from the hot pack which was microwaved. Nor, did the policy give any direction on using the hot water spigot on the coffee maker, which was set at 160 degrees Fahrenheit. When interviewed on 1/14/20, at 3:25 p.m. RN-B stated not using hot packs very often on residents, but when assembled, RN-B would use hot water from the coffee maker or the microwave and place in a plastic bag. RN-B would test the temperature on own skin first. RN-B further stated would leave the hot pack in place for 5-10 minutes and check if still needed. RN-B stated needing an order for [REDACTED]. R41's annual MDS dated [DATE], indicated R41 had severe cognitive impairment and [DIAGNOSES REDACTED]. R41's physician orders [REDACTED]. as needed for pain 2-3 times a day. Left shoulder. R45's annual MDS dated [DATE], indicated R45 had moderate cognitive impairment and [DIAGNOSES REDACTED]. R45's signed physician orders [REDACTED]. The order had a start date of 7/26/19. When interviewed on 1/14/19, at 3:29 p.m. LPN-E indicated she would use hot packs once in a while for R41 and R45. LPN-E would heat a wet cloth in the microwave or with hot water from the coffee maker and would test hot pack by feeling with palm of hands to tell if it was too hot. LPN-E indicated she would apply hot pack, stay with resident, and ask how it felt to make sure they were safe. When interviewed on 1/15/20, a 10:16 a.m. R45 indicated she did use hot packs to help with comfort. R45 indicated she would check if they were too hot by holding them up to get air for about three to four minutes and would remove them if they were too hot. R36's quarterly MDS dated , 11/19/19, identified severe cognitive impairment with [DIAGNOSES REDACTED]. R36 required extensive to total assistance with ADLs. R36's physician orders [REDACTED]. Document in nursing notes re: effectiveness - check with pt (patient) while the warm pack is ON. as needed. R36's (MONTH) 2020 Medication Administration Record [REDACTED]. Document in nursing notes re: effectiveness - check with pt (patient) while the warm pack is ON. as needed. R36's progress note dated, 7/2/19, at 12:19 p.m. included, Resident complaining of back/abdominal pain this AM (morning). Resident describes pain as tightness and squeezing. Resident crying out in pain. Resident unable to put a rating on her pain level. A warm pack was offered and PRN (as needed) [MEDICATION NAME] was administered . R36's progress note dated, 7/2/19, at 1:36 p.m. included, . Writer gave resident a warm pack and checked in with resident about 15 minutes later. Warm pack did not appear to be effective . R36's progress note dated, 7/13/19, at 2:13 p.m. included, No injury noted from last fall. Denied pain from fall but c/o (complain of) pain from hands to should on both arms. Applied hot pack and it was effective . R36's progress note dated, 7/25/19, at 12:22 p.m. included, Resident was complaining of reoccurring back pain this AM (morning). Warm pack was given and PRN (as needed) [MEDICATION NAME]. This appeared to be effective . When interviewed on 1/14/20, at 3:37 p.m. nursing assistant (NA)-A used hot pack as needed when resident requested but had not applied any recently. NA-A indicated that under a nurse's direction a nursing assistant could apply warm packs to residents. The facility practice was to make warm or hot packs using hot water from the hot water spigots on the facility coffee makers. They would soak a towel that was wrapped in a plastic bag and place inside a pillow case then apply to the affected area on the resident. When interviewed on 1/14/20, at 3:45 p.m. NA-B stated, warm packs are made by soaking a towel with hot water from the coffee maker, placing it in a plastic bag and wrapping it in a pillow case. When interviewed on 1/15/20 at 11:27 a.m. LPN-A recalled using warm packs when caring for R36. LPN-A indicated that the procedure was to make warm packs using hot water from the hot water spigots on the facility coffee makers. Using hot water to soak a towel that is wrapped in a plastic bag and put inside a pillow case, then applied to the affected area on the resident. When interviewed on 1/15/20 at 11:40 a.m. R36's family (F)-1 recalled staff have applied warm packs. However, no burn/injuries had been suffered, and this treatment was effective for R36. R55's quarterly MDS dated [DATE], indicated severe cognitive impairment with a [DIAGNOSES REDACTED]. A provider order dated 8/22/19, from nurse practitioner (NP)-A included, warm pack to right lower extremity 3 times daily for 1 week. When interviewed on 1/14/20, at 3:25 p.m. RN-E could not recall R55 having used warm packs for treatment. RN-E stated the practice to use the hot water from the hot water spigot on the coffee makers and apply the warmed compress to the affected area. RN-E would test the warm pack on own wrist for 10 seconds. When interviewed on 1/14/20, at 3:36 p.m. NA-I stated they had used warm packs on R55 in the past. Under a nurse's direction an NA could apply warm packs to residents. The facility practice was to make warm packs using hot water from the hot water spigots on the facility coffee makers. Using hot water to soak a towel that is wrapped in a plastic bag and put inside a pillow case then applied to the affected area on the resident. When interviewed on 1/14/20, at 3:48 p.m. NA-J stated that the facility practice was to make warm packs by using hot water from the hot water spigot on the facility coffee makers. The hot water then was used to soak a towel that was wrapped in a plastic bag, again wrapped in a pillow case and applied to the affected area of the resident. Even though R67 was burned from a warm pack heated in the microwave on 5/10/19, the facility policy continued to direct staff in using the microwave to heat warm/hot packs. The facility practice was also to use the hot water spigot on the coffee machine which was set to 160 degrees Fahrenheit.