Every finding on record at Tuff Memorial Home

Based on interview and document review, the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data, submitted to the QAPI committee to ensure Performance Improvement Projects (PIPS) areas identified had oversight and a documented action plan. This had the potential to affect all 40 residents living in the facility.Findings include: Review of the QAPI meetings identified in: March 13, 2025, QAPI minutes identified the Restorative program was identified as a PIP, but no measurable goals or action plan was discussed or put in place. April 9, 2025, contained a blank table with labels of Action Plan; Person's Responsible, Target Date, Outcome; and Notes. The QAPI meeting minutes listed a summary from the director of nursing (DON) of days of Restorative therapy provided, and list of residents who did not go to the therapy, but there was no Action plan or measurable goals developed to move forward with the project. July 23, 2025, QAPI meeting minutes, again had a blank table for Action items, Person's Responsible, Target Date, Outcome; and Notes to be followed up at the next QAA meeting, and the area for Restorative Program notes was blank. Interview on 8/27/25 at 11:23 a.m., with the administrator and the social services designee (SSD) identified they acknowledged they had failed to develop a measurable goal and associated Action Plan for the identified PIP of the Restorative Program. They reported there had been discussion but no documentation as to a measurable goal with the identified Action Plan included. Review of the February 2024, Quality Assurance and Performance Improvement Policy identified the committee was to meet at least quarterly to evaluate and coordinate activities including PIP projects under the QAPI program. The facility was to act toward performance improvement with actions monitored and documented in subcommittee and committee meetings.

Based on observation, interview, and document review, the facility failed to establish criteria for employee illness and appropriate return to work for 3 of 3 sampled staff (nurse aide (NA)-A and NA-B, and trained medication aide (TMA)-A). In addition, the facility failed to ensure staff performed appropriate hand hygiene while assisting 5 of 5 residents (R2, R11, R16, R21, and R35) with meals in the dining room. The facility also failed to ensure staff were following manufacturer's instructions by rinsing and air-drying nebulizer administration sets following treatment and between use for 1 of 1 (R27) resident observed.Findings include: Employee Illness Review of sampled employee illness forms and timecards from February 2025 through May 2025 identified: TMA-A’s Paid Time Off (PTO) Request/Overtime Approval Form sheet identified TMA-A called in to work with symptoms of diarrhea and nausea on 2/22/25. There was no mention on the log of when TMA-A had returned to work. TMA-A’s timecards revealed TMA-A had worked on 2/22/25 from 6:29 a.m. to 9:10 a.m., for a total of 2.68 hours and returned to work on 2/23/25. NA-A’s PTO Request/Overtime Approval Form identified NA-A called in to work with respiratory symptoms and fever, myalgia (pain in the muscles), body aches and a productive cough on 5/20/25. NA-A timesheet identified NA-A had worked on 5/19/25 from 10:10 p.m. to 05:48 a.m. the next day, for a total of 7.14 hours. C.N.A-A had returned to work on 5/22/25. NA-B’s Request/Overtime Approval Form identified, NA-B called in to work with dizziness, nausea, and a fever on 5/29/25. NA-B had symptoms of diarrhea, nausea and fever. NA-B’s timesheet identified NA-B last worked on 5/29/25 and returned to work on 5/30/25. There was no mention of any criteria used to identify the appropriateness of the above-mentioned staff’s return to work, if their symptoms had resolved, or if they had come into contact with other staff or residents that may put them at risk for transmission of illness and require heightened surveillance. Interview on 8/27/25 at 8:47 a.m., with the infection preventionist (IP) identified employees who called out for work related to an illness would have a call-out sheet filled out on their behalf by nursing staff on the units. The sheet was placed on her desk to review when she arrived to the office. The IP was to determine when the employee would to return to work, dependent upon their symptoms and communicated it to the employee after reviewing the facility policy related to employee illnesses. When she was out of the office, the director of nursing (DON) was to provide oversight of employee illnesses tracking. On several occasions, the IP identified employees who called out sick had returned to work the following day. Management had not ensured employees who had returned to work were either symptom free or free from infection using criteria. The IP agreed the logs lacked adequate surveillance and monitoring of employee illnesses and appropriate return to work. Interview on 8/27/25 at 11:14 a.m., with DON identified the facility recorded all employee illnesses, but did not have a process in place to ensure consistency when determining if employee symptoms had improved or resolved or before returning to work that would potentially cause an increased risk of exposure to residents or other staff in the facility. Review of July 2025 Employee Work Restriction-Infectious Diseases Policy identified the employee or contract staff was to report communicable or infectious disease to his or her supervisor. It was the responsibility of the employee’s supervisor to make determinations regarding work-restrictions. The designated Infection Preventionist (IP) was to be consulted to provide guidance when the employee was to return to work and the employee was to stay away from the facility until the employee was no longer contagious or cleared by a medical provider. In addition, the facility was to follow Centers for Disease Control and Prevention (CDC) guidelines, as well as, state and local regulations, if absent, to determine work restrictions. NEBULIZER R27 was admitted on [DATE] with hospice services in place due to a terminal diagnosis of chronic obstructive pulmonary disease (COPD). R27 had physician orders for budesonide inhalation (bronchodilator used to open airways of the lungs)1 unit, to be inhaled orally 2 times a day for COPD at 8:00 a.m. and again at 5:00 p.m R27 also had an order for ipratropium-albuterol, 1 unit to be inhaled every 4 hours as needed for COPD. Observations, document review, and subsequent interview on: 8/25/25 at 1:00 p.m. and again at 6:30 p.m. with R27, noted a nebulizer was placed on this bedside table, with a face mask and medication container attached that had been connected during the last administration, hanging on the side of the machine by the mask strap. 8/26/25 at 8:30 a.m., noted the face mask with medication container attached was hanging on the nebulizer machine with oxygen tubing attached and not rinsed following administration. Review of the Treatment Administration Record (TAR) identified R27 had received his most recent nebulized medication at 8:00 a.m. 8/26/25 at 11:29 a.m. identified registered nurse (RN)-A prepared to administer R27's albuterol medication. She obtained the medication from the medication cart, went to R27's room, applied gloves, picked up the mask with the medication container attached, removed the medication container from the mask, and placed the liquid medication into the container. She then reattached the medication container to the mask and placed the mask on R27's face as she switched on the machine. 8/26/25 at 11:45 a.m. RN-A returned to R27's room, removed the face mask with medication container attached and returned it to hang on the machine without disconnecting the nebulizer and rinsing the medication cup. She reported the mask, and nebulizer was changed weekly. She then hung by the mask strap on the nebulizer machine without first rinsing disassembling the mask and cup and rinsing the medication cup. When asked about the nebulizer, she fshe noted when she went to administer a nebulizer treatment, she usually found the mask with the medication container attached. RN-A then exited the room. When asked about the lack of rinsing of the medication cup, she reported she would return to R27's room and disassemble the nebulizer equipment and rinse the cup. She took the nebulizer mask, medication cup and mouth piece to the bathroom and applied gloves, took the pieces apart, rinsed them at the sink, and placed on a paper towel on the shelf located above the sink to air dry the parts. RN-A noted she had not been rinsing the nebulizer set following each use and was not certain what the policy directed, and stated she was not certain if other staff knew to perform this procedure after administration either. Interview on 8/26/25 at 11:53 a.m. with the DON, identified the nebulizer mask, medication container and mouthpiece were reusable and changed weekly, but the compressor surface was wiped daily with Sani-Cloths. She was not aware of any necessary cleaning/rinsing of the equipment following use, other than the weekly change. She would need to review the facility policy to determine if the reusable set up equipment was to be handled differently. Subsequent interview on 8/26/25 at 1:15 p.m. with the DON following review of both the policy and manufacturer’s instructions identified the mask and medication container were to be rinsed and allowed to air dry following each use. The DON confirmed the facility policy failed to include this information and would need to be updated to follow the direction in the manufacturer’s instructions for cleaning. Interview on 8/27/25 at 7:15 a.m. with the IP identified she was aware the setup used for administration of nebulized medication was to be rinsed following each use and allowed to air dry. She was unaware of what the policy stated or that staff were not rinsing the nebulizer setup following each use. The IP expected nebulizer equipment including the mouthpiece, mask, and medication container to be rinsed and placed on a paper towel following each use and allowed to air dry. Information regarding staff training was requested but not received. Review of the July 10, 25 Nebulizer Treatment Procedure of the Tuff Memorial Home failed to include instructions for cleansing of the nebulizer reusable mask, mouthpiece and medication container after each use. Review of the DeVilbiss Pulmo-Aide Compact Compressor/Nebulizer Instruction Guide - Nebulizer cleaning listed all parts of the nebulizer, except tubing should be cleaned according to the instructions. A warning identified to prevent possible risk of infection from contaminated medication, cleaning of the nebulizer is recommended after each treatment. Disinfecting was recommended once a day. Instructions noted were to clean after every use. Instructions listed were: 1. With power switch in the “Off” position, unplug power cord from wall outlet.2. Disconnect tubing from the air-inlet connector and set aside.3. Disassemble mouthpiece or mask from cap. Open nebulizer by turning capcounterclockwise and removing baffle.4. Wash all items, except tubing, in a warm water/dishwashing detergent solution. Rinseunder warm tap water for 30 seconds to remove detergent residue. Allow to air dry. DINING Observation on 8/26/25 at 11:24 a.m., in the dining room identified NA-C was assisting 5 residents with eating dinner. NA-C had gloves on and was sitting between R2 and R16. A kitchen staff person delivered food to the table and placed it in front of each resident. The table had 4 residents and another table off to the side had 1 resident seated awaiting their meals. NA-C offered R2 a bite to eat. She then turned to her left and using her right hand again she offered a bite of food to R16. She then rolled on her chair to the other side of the table next to R35. Using her same gloved hand, she rubbed R35's chest and arm to arouse her. She offered R35 a bite of food using a fork and picked up R35’s glass to give her a drink. She then turned toward R16 and gave her a bite of her food. NA-C then rolled her chair across the floor to another table where R11 was seated and asked him if he was doing okay. She then rolled her chair back between R2 and R16. Without removing her gloves and performing hand hygiene, she wiped R2’s mouth using R2’s clothing. NA-C failed to change gloves or perform hand hygiene during the meal service between tasks for residents. R2’s 4/15/25, quarterly Minimum Data Set assessment identified she was dependent on staff (Staff does all the effort) with eating and drinking and has diagnosis of Alzheimer’s Disease, arthritis, and degenerative joint disease. R2’s undated, current care plan identified staff were to assist with intake as needed. R2’s level of ability with eating may vary from day to day. R16’s 6/24/25, significant change Minimum Data Set assessment identified she required substantial (staff does more than half the effort) assistance with eating and diagnoses of dementia, anxiety, depression, and COPD. R16’s undated, current care plan identified her ability to feed herself varies from day to day. She at times can eat independently and at times is dependent on staff to eat. R35’s 6/17/25, quarterly Minimum Data Set assessment identified she required substantial assistance from staff while eating and had a diagnosis of a neurological condition. R35’s undated current care plan identified she was able to eat independently after set-up. R21’s 4/15/25, annual Minimum Data Set assessment identified he required supervision or touching with meals. Helper provides verbal cues or steadying assistance. R21 had diagnoses of traumatic brain dysfunction, arthritis, and depression. R21’s undated, current care plan identified staff were to assist R21 with using utensils and finger foods. R21 could drink independently after staff placed the glass in his hand. R11’s 6/24/25, quarterly Minimum Data Set assessment identified he required supervision or touching assistance with meals and had a diagnosis of non-traumatic brain dysfunction and dementia. Interview on 8/26/25, at 1:03 p.m., with NA-C identified the facility normally had 2 staff ithe dining room to assist residents with eating but they didn’t come in today so I just did it on my own”. She was unable to recall the last time she had infection control training. Interview on 8/27/25 at 8:55 a.m. with the IP identified staff have been trained to use hand sanitizer and change their gloves between residents when feeding. The IP noted NA-C should not be feeding 2 residents with the same gloved hand without first performing hand hygiene. The IP agreed the lack of appropriate infection control practices can put residents at risk for cross contamination, especially gastrointestinal (stomach) infections. Staff were required to complete online infection control training. She had done some in-person training with hand washing and PPE use. It had been about a year since the last time she audited the dining room for appropriate staff hand hygiene. Review of the July 2025, Promoting/Maintaining Resident Dignity During Mealtimes policy identified staff were to only assist 1 resident at a time. The policy made no mention of how to safely maintain infection control while assisting multiple residents with meals.

Based on observation, interview, and document review, the facility failed to maintain 1 of 13 ceiling vents in a sanitary manner.Findings include: Observation on 8/25/2025 at 12:19 p.m., of the facility beauty salon vent identified to have an appearance of black spotted substances, appeared to look like mold and rust scattered throughout the inside and outside of the vent. Observation and interview on 8/25/2025 at 3:32 p.m., with both the administrator and the maintenance director in the beauty salon room to observe the vent identified the maintenance director had scraped the vent with a paper towel and stated the black substance was removable from the vent and had voiced that this room received humidity and high temperatures of heat throughout the summer, possibly contributing to buildup of the black substance on the vents. Maintenance stated the vents in the facility were cleaned every two months on a routine basis. Both the administrator and maintenance director voiced the vent had the appearance of a black mold-like substance. Observation on 8/25/2025 at 3:59 p.m., of the other facility 12 vents throughout the facility halls and corridors appeared to be clean and free of debris. Review of 7/07/25, Maintenance log for 10-inch(in) BI fan/all air vents check was last completed 7/07/25. Further interview on 8/27/2025 at 9:27 a.m., with maintenance director identified the vent should have been addressed during monthly maintenance checks. He agreed the condition of the beauty salon vent appeared to be dirty and unkempt and should have been cleaned when checked on rounds. There was no record for August 2025. Interview on 8/27/2025 9:46 a.m., with salon technician identified she was made aware (unknown date) by an (unknown) resident, who had pointed to the ceiling and stated the ceiling appeared to need repairs. The salon technician had not informed the administration of the concern brought up from the resident and was not aware of the of the condition of the vent before being identified by a resident of the vent when she worked in the salon. Review of August 2025, Preventative Maintenance Program policy identified the facility was to ensure a safe functional and sanitary environment for residents, staff, and visitors. The maintenance director was responsible for developing and maintaining service to assess the physical plant to determine if maintenance was required, decide on tasks that needed to be completed and how often, and develop a calendar to assist with keeping track of all tasks. Request of August salon fan cleaning record was requested and not received during survey period.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 1 of 5 resident (R12) who had an order for an antibiotic with no end date. Findings include: R12's 6/4/24, Significant Change Minimum Data Set (MDS) assessment identified her cognition was intact, she used a walker for mobility, and was independent with activities of daily living (ADL's). Review of R12's current diagnosis list identified a diagnosis of chronic cystitis without hematuria (inflammation of the bladder that can predispose patient to bladder infections). R12's current medication administration record identified she has been taking cephalexin (antibiotic) 250 milligrams (mg) daily for a diagnosis of chronic cystitis starting upon admission in January of 2024. Review of R12's current care plan identified she was on antibiotic therapy related to chronic bladder infections. Staff were to monitor adverse reactions or signs and symptoms of secondary infections related to antibiotic therapy. The care plan made no mention that staff should monitor for effectiveness, or review to ensure the long-term antibiotic therapy remained appropriate. There was no documentation to support other methods of prevention, such as cranberry juice or diet changes had been attempted, nor that it was being overseen by a specialist or medical provider routinely. Review of the June 2024 Quality Assurance and Performance Improvement (QAPI) minutes identified that 2 residents R6 and R15 had received antibiotic therapy, the minutes included the type of antibiotic, duration, and the indication for use. The minutes made no mention of R12's use of chronic antibiotics. Review of the facilities infection surveillance monthly report identified they had been tracking infections and antibiotic use in the facility; however, the report did not include any tracking for R12's use of a prophylactic antibiotic cephalexin oral capsule 250 mg daily for a diagnosis of chronic cystitis without hematuria (bladder infection). Interview on 7/30/24, at 10:02 a.m., with the infection preventionist (IP) identified R12 had an order for antibiotics in place when she was admitted to the facility in January of 2024. The order did not include an end date, and she had not followed up to obtain one. She thought the order came from a previous doctor but was not certain and did not have a copy of the original order. They had no documentation that the antibiotic had been monitored for effectiveness, had not completed a time out, and had not followed up with the primary physician to see if the medication should be reviewed by a urologist to ensure it remained an appropriate treatment. She identified that they did not have an end date because it was used prophylactically to prevent infection. She had not included it in her monthly infection report or the QAPI facility antibiotic use report because although R12 is taking an antibiotic, she does not have an active infection. She identified that R12 has not had any complaints of pain or discomfort and has had no recent infections. R12 is seen by her primary doctor every 60 days at the facility, however, she was unable to provide any documentation that the physician had reviewed the long term antibiotic or any documented rationale for the continued use of the antibiotic. R12's primary physician was not available for interview during the survey period. Review of the 11/14/23, Antibiotic Stewardship Program policy identified that all prescriptions for antibiotics shall specify the dose, duration, and indication for use. Staff will monitor the response to antibiotics, and laboratory results when available, and consult with the physician to determine if the antibiotic is still indicated or adjustments should be made. Antibiotics upon admission weather a new admission or a re-admission to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R32) reviewed for prosthetics. Findings include: R32's, Face sheet identified he had a diagnoses of Transient Ischemic Attack (stroke), absence of left leg below knee amputation, anxiety and depression. R32's, 5/14/24 Significant change Minimum Data Set (MDS) identified R32 was cognitively intact, had used substantial/maximal assistance with activities of daily living and was dependent with mobility and transfers. R32's MDS, section GG, did not identify R32 had a left leg below the knee prosthetic. R32's, undated, current care plan identified he had a self-care performance deficit related to his left leg below knee amputation. The goal was for R32 to maintain current level of function. Interventions were for staff to apply the left leg stump shrinker sleeve and prosthetic to his left lower extremity for transfers, standing and/or pivoting with his hemi-walker, and to remove the left leg prosthetic when R32's request. Observation and interview on 7/28/24 at 6:56 p.m., identified R32 had a left leg prosthetic along with his left stump shrinker sleeve stored next to his recliner. He stated he had received his first below the knee prosthetic approximately 2 years ago from Sioux Falls Orthopedic Institute and had recently received a newer left leg prosthetic that would assist him with ambulation and transfers. Interview on 7/30/24 at 10:58 a.m., with registered nurse (RN)-A stated she did not code R32's prosthetic accurately on his current MDS. She stated she would make a modification on R32's MDS. Interview on 07/30/24 03:53 p.m., with director of nursing (DON) would expect accurate coding on the MDS and plan to implement a verification process to prevent MDS errors from reoccurring. Review of 7/29/24, MDS policy identified MDS would be completed within the time frame guidelines and would refer to RAI (Resident assessment instrument) manual for updates. The policy lacked direction on how to correct and/or identify changes to the MDS when an error would occur.

Based on interview and document review, the facility failed to appropriately discharge 1 of 1 resident (R1) with known neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness), with behaviors. The facility also failed to ensure policies related to Discharge and Transfer were reviewed yearly for appropriateness and accuracy. Findings include: Review of the 12/4/23 at 10:40 a.m., State Agency Report (SA) identified R1 was seated in his wheelchair located by a table in the dining room at 11:25 a.m . R2 was wheeled by staff by R1. R2's foot pedal bumped R1's wheelchair. R1 turned and grabbed R2 by the face, knocking her glasses off, and causing scratches to the right side of the neck, right and left sides of her nose, the right corner of her eye and cheek, and right ear lobe. R1 reached for R2 again but contact was blocked by staff in attendance. R2 was screaming and crying and was taken back to her room for assessment. R1 turned back around and was removed from the dining room to his room by licensed practical nurse (LPN)- and a second unidentified nurse aide (NA) and assisted to his room. R1 had no response and no expression when questioned about what had happened or why he had done that. The director of nursing (DON) and administrator were notified of the incident and gave instruction to contact the sheriff's office to report the incident and obtain direction. Local emergency medical services (EMS) were notified of a non-emergency transfer to the the regional behavioral hospital in Sioux Falls, SD for evaluation. Family members of both R1 and R2 were contacted to inform them of the incident. R1's 11/14/23 Quarterly Minimum Data Set (MDS) identified his cognition was intact, and there were no behaviors documented. Activities of daily living (ADLs) were identified as independent with eating, and hygiene, and required partial assistance from staff for transfers, toileting, and dressing, and used a wheelchair for mobility. R1 received medications of an anti-psychotic, anti-depressant, water pill, and an anti-platelet ( used to thin the blood to prevent clots) medication. R1's diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, major depressive disorder, and anxiety disorder. R1's 8/13/23 incident report identified a resident to employee incident occurred. R1 became aggressive toward an unidentified NA. The facility implemented 2 staff members to be in attendance with interactions with R1. R1 was scheduled to be seen by psychiatric services. At that time, there was discussion with R1's physician (MD) who agreed R1 could remain in the facility at that time but ensure 2 staff were present with cares. He was to be sent to the regional psychiatric hospital in Sioux Falls, SD if needed or he displayed an aggressive change in behavior. R1's 8/23/23 at 5:11 p.m., incident report identified he had history of an incident when an unidentified NA reported an unidentified resident was in R1's room attempting to get into his closet. R1 was swatting at other resident but no contact was noted. That resident was removed from the room and R1 questioned why the resident had come to his room. Appropriate notifications completed and intervention to close R1's room door and keep other resident on other wing. No injuries to either resident noted. there was no mention on the care plan of any heightened measures staff should take when it came to other residents being at risk. Interview on 12/11/23 at 11:41 a.m. with NA-A reported she was working on 12/3/23 in the dining room when she observed NA-B pushing R2 through the dining room. R2's wheelchair barely bumped R1's wheelchair as she was going passed. R1 swung out from the table and began swinging both arms and slapped R2 as she was being pushed past him. NA-B got between R1 and R2 to separate them and R1 attempted to grab NA-B's leg as she was separating the residents and NA-A yelled for the charge nurse. Licensed practical nurse (LPN)-A ran to the dining room and assisted with removing R2 to her room for assessment and to attempt to calm her. R2 was also escorted to his room by 2 staff persons. NA-A reported R1 had previously attempted to choke a staff member as she was attempting to toilet him and had episodes of agitation previously, with no specific triggers that she was aware of. She reported R1 had seemed paranoid during COVID and would pace in and out of his room doorway and had also entered other resident rooms and taken objects. NA-B reported she was not aware of any previous altercations with other residents. NA-B reported R1 rarely spoke and was alert but she was not certain if he was oriented. She reported due to the incident that had occurred between a staff member and R1 his care plan had been updated to have 2 staff present when providing cares and he was on 15-minute safety checks immediately following the incident, but the time had been extended when there had been no additional incidents. R1's current, undated care plan identified he a potential behavior problem due to history of smearing body fluids in room/bathroom and inappropriate voiding and defecation on the floor or in trash can and refusal to change soiled clothing. R1 was to have 2 staff when providing cares in his room related to behavioral changes with an incident occurring on 8/13/23. R1 would go to the dining room for meals and then preferred to return to his room. R1 had a history of behavior problem of delusions directed towards staff. Staff were to anticipate and meet the resident's needs, monitor behavior episodes, and report to charge nurse, provide psychotherapy sessions on a biweekly basis, and see psychology. R1's 11/15/23 through 12/2/23 progress notes identified R1 had no aggressive behaviors and was cooperative with staff other than grabbing at overnight NA's arms during assistance with morning cares. The notes identified a telehealth visit with psychotherapy was performed on 11/29/23. Email response from the Ombudsman on 12/11/23 at 8:04 a.m. identified the facility had sent R1 to the ER for behaviors and then R1 was subsequently discharged . The facility and the Ombudsman had a care conference to discuss potential re-admission. The psychiatric MD at the regional behavioral psychiatric hospital stated R1 was clinically cleared to return to the facility as his acute episode of aggression and was clinically stable to return. The psychiatric hospital had reviewed R1's medications and had decreased some of his medications as the MD felt R1 may have been overly sedated. Interview on 12/11/23 at 12:20 p.m., with R1's power of attorney (POA) reported R1 had a history of odd behaviors since he had been in his 20's. She reported R1's behavior had been discussed with geriatric psychiatry and following review of laboratory results he was diagnosed with hyperparathyroidism and resulting eye issues, which had caused some paranoia. R1 had multiple medical issues and following surgery and development of Tetanus and he had never been right after that. The POA reported R1 had a history of psychiatric issues and some aggression issues prior to his surgery, but nothing since until the complaints at the nursing home. R1 liked to be alone and enjoyed watching TV in is room. She reported R1 was very quiet and had a history of minimal interaction with other persons. The POA reported she thought the staff incident could have been caused by R1 having a strong fear of falling and he did not like showers, which the NA was trying to do when the incident occurred. She thought R1 could have been grabbing out due to fear of falling when the incident occurred. The POA reported R1 was receiving tub baths since that time and there had not been any further issues. She reported that on 12/3/23 she had been notified that a resident had run into his wheelchair, and he had lashed out and he was being transferred to the psychiatric hospital for evaluation. Interview on 12/11/23 at 4:47 p.m., with the interim administrator reported the decision not to accept R1 back to the facility was based on the rights of other facility residents and their representatives. The interim administrator reported she had not had any communication with either [NAME] Behavioral Health or R1's family members. She reported she was aware of the regulation for reassessment of a resident prior to determining status of a readmission, but due to concerns for the safety of other residents in the facility he would not be allowed to return. She confirmed there had been no attempt made to reassess R1 since he left the faciity on [DATE]. The facility did not have the ability to meet R1's emotional needs and the decision to not allow R1 to return was based on the incident preceding his transfer on 12/3/23, in addition to previous aggressive incidents directed toward staff. The interim administrator was aware of the need to not base refusal of re-admission on R1's status prior to his transfer to the psychiatric hospital, but how R1 was at the current time he would tentatively be returning. Review of the July 28, 2021, facility policy Resident Transfer & Discharge Policy identified it was the facility policy to make attempts to allow a resident to remain in the facility. Prior to transfer or discharge of a resident the facility was to notify the resident or their representative of the transfer and/or discharge along with the reasons in writing and in an understandable manner. The reasons for transfer and/or discharge were to be recorded in the resident's medical record. The notice of discharge or transfer was also to include a statement of the right to appeal the transfer or discharge along with the information on how to complete the request.

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 39 residents. Findings include: Review of the monthly QAPI meeting minutes from March 2023 through July 2023 identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, elopements, incident reports etc, however, there was no documented benchmarks for goals the facility was trying to achieve, nor analysis of data brought forth, identified actions the facility was going to take to achieve their goals, and monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Interview on 9/27/23 at 8:11 a.m., with the director of nursing identified she agreed the QAPI program was not thorough in its efforts to identify concerns, have benchmarks to know what goal was to be achieved, or appropriate analysis of the data brought forth each month, and identify corrective action. Review of the 1/1/23 QAPI policy identified QAPI was to develop and implement appropriate plans of action to correct identified quality deficiencies and regularly review and analyze data and act on that data to make improvements. QAPI was to: 1) Track and measuring its' performance. 2) Establish goals and thresholds for performance improvements. 3) Identify and prioritize quality deficiencies. 4) Systematically analyze underlying causes of systemic quality deficiencies. 5) Develop and implementing corrective action or performance improvement activities. 6) Monitor and evaluate the effectiveness of corrective action/performance improvement activities and revise as needed. The governing body and/or executive leadership was responsible and accountable for the QAPI program

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the staffing schedules and timecard verifications for 42 randomly selected days from June 2023 through September 2023 identified the facility had licensed nursing staff, 24 hours per day 7 days per week, and 8 consecutive hours per 24 hours of registered nurse (RN) coverage documented. Interview on 9/25/23 at 11:30 a.m., with the director (DON) and the interim administrator identified the DON was aware of concerns with Provider Based Journal (PBJ) submissions and lack thereof. She was unsure if the facility was always submitting data, but had no documentation to support data had been submitted at all, as it was triggered on the [NAME] 1705D report for Quarter 3, FY23. Review of the 9/12/23, Payroll Based Journal policy identified the facility was to submit timely and accurately, all direct care staff information, including agency and contracted staff to CMS per thier specifications.

Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific QAPI Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. Findings include: Interview on 9/27/23 at 7:07 a.m., with the dietary manager (DM) identified she was unaware of training provided to staff on the facility's QAPI program. Staff received a yearly overall training about what QAPI was, however nothing specific to the facility was performed. Interview on 9/27/23 at 7:24 a.m., with the laundry supervisor identified she was unaware of training provided to staff on the facility's QAPI program. Staff received a yearly overall training about what QAPI was, however nothing specific to the facility was performed. Interview on 9/27/23 at 7:28 a.m., with the infection preventionist identified identified she was unaware of training provided to staff on the facility's QAPI program. Staff received a yearly overall training about what QAPI was, however nothing specific to the facility was performed. Review of the 1/1/23 QAPI policy identified QAPI training was to be provided that outlined and informs staff of the elements of QAPI and goals of the facility and was to be mandatory for all staff.

Based on observation, interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 39 residents. Findings include: Observation on 9/26/23 at 5:41 p.m. of the facility identified there was no information posted about any PIP project the facility was actively working on. Interview on 9/27/23 at 7:07 a.m., with the dietary manager (DM) identified she was unaware of any PIP project the facilities QAPI committee had in place. She attends QAPI. Department heads bring data, however she is unsure if the committee analyzed their data, or what goals were. Interview on 9/27/23 at 7:24 a.m., with the laundry supervisor identified she was also unsure of any specific PIP QAPI had determined it would apply a special focus to. Interview on 9/27/23 at 7:28 a.m., with the infection preventionist identified she was also unaware of any PIP project QAPI was overseeing. Review of the QAPI meeting minutes from March 2023 through July 2023 identified there was no mention of a PIP project identified through QAPI. Interview on 9/27/23 at 8:11 a.m., with the DON identified could not recall what her PIP project was. She could not find documentation to support a PIP project was identified and performed. Review of the 1/1/3, QAPI policy identified a PIP was the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. There was no mention of the need to complete a PIP at least annually with a project that focused on high risk or problem-prone areas identified through the data collection and analysis.

Based on interview and document review, the facility failed to ensure 3 of 5 sampled residents (R7, R16, and R35) were appropriately vaccinated against pneumonia by offering and/or providing updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old. 2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 3 of the 5 sampled residents for vaccinations identified: 1) R35 was [AGE] years old and was admitted to the facility in January 2023. R35's immunization documentation showed they had received the PCV-13 on 1/20/20, prior to admission. R35 had no documented PPSV-23. R35 should have been offered and/or provided the PCV-20 upon admission and at least 1 year after the prior PCV-13 or the PPSV-23 at least 1 year after prior PCV-13. 2) R7 was [AGE] years of age and was admitted in August 2023. R7's immunization documentation identified they had received the PCV-13 on 10/27/15 and the PPSV-23 on 10/12/17. R7 should have been offered and/or administered the PCV-20 in October 2022. 3) R16 was [AGE] years of age and was admitted to the facility in January 2020. R16's immunization documentation showed they received the PCV-13 on 7/14/17 and the PPSV-23 on 5/13/18. R16 should have been offered and/or administered the PCV-20 in May 2023. There was no information in R35's, R7's, or R16's medical record indicating a PCV-20 would be contraindicated to be offered and/or administered. Interview on 9/27/23 at 8:11 a.m., with the director of nursing (DON) identified the local pharmacy was responsible to review residents records to identify if an updated immunization was needed. Review of the 2023, Pneumococcal Vaccine (Series) policy identified it also noted the above reference CDC guidelines. Each resident was to be offered a pneumococcal vaccine unless medically contraindicated.

Based on observation, interview, and document review, the facility failed to ensure care plans were revised for 2 of 12 residents (R7 and R35) related to use of digoxin (heart medication) and managing behaviors. Findings include: R7's September 2023, Medication Administration Report (MAR) identified R7 was admitted to the facility in August 2023 with diagnoses of heart disease, Type II diabetes, mild cognitive impairment, and atrial fibrillation (abnormal heart rhythm). R7 was being administered a warfarin (blood thinning medication) tablet 2.5 milligrams (mg) and a digoxin tablet 125 micrograms (mcg). Both medications were taken for his atrial fibrillation. R7's 6/24/23 physician progress notes identified R7 had a history of orthostatic hypotension (blood pressure drops suddenly when standing or switching positions). R7 was not being overseen by cardiologist. The family wanted his primary care physician (MD) to manage his care. The MD noted R7 should be seen by cardiology related to his diagnoses and medications and his frequent orthostatic hypotension episodes. R7's laboratory reports identified he last had a digoxin level drawn on 9/14/23 which was within normal limits per the report. Review of the 11/21/19, MedScape Article: Digoxin Level, located at https://emedicine.medscape.com/article/2089975-overview?form=fpf, identified digoxin strengthens the force of contractions of weakened hearts and is absorbed quickly in the gastrointestinal tract and eliminated from the body though the kidneys. Therapeutic levels of digoxin are 0.8-2.0 ng/mL. The toxic level is >2.4 ng/mL. Review of the National Institute of Health (NIH) National Library of Medicine, 3/4/23 article Digoxin Toxicity, located at https://www.ncbi.nlm.nih.gov/books/NBK470568/#article-20525.s6, identified gastrointestinal upset is the most common symptom of digoxin toxicity. Patients also may report visual symptoms, which classically present as a yellow-green discoloration, and cardiovascular symptoms, such as palpitations, dyspnea, and syncope. Elderly patients frequently will present with vague symptoms, such as dizziness and fatigue and can lead to life threatening arrhythmias. Because digoxin toxicity can result in life threatening arrhythmias, prompt monitoring and treatment are vital. R7's September, 2023 Order Summary Report identified there were no physician's orders for routine monitoring of R7's digoxin therapy, such as a routine scheduled electrocardiogram (EKG), or kidney or liver function tests. R7's current, undated care plan identified there was no mention R7 was taking digoxin, nor what to look for with regard to digoxin toxicity, when to call the physician, or that R7 should have routing monitoring and testing to ensure no complications arose. Interview on 9/26/23 at 10:42 a.m., with the director of nursing (DON) identified she was unaware R7's care plan lacked details about signs and symptoms to watch for related to potential digoxin toxicity. She was also unaware R7 should have routing scheduled monitoring tests like an EKG, and labs to ensure appropriate monitoring was achieved. The DON agreed those items needed to be addressed and care planned. 47497 R35's 7/18/23, quarterly Minimum Data Set (MDS) identified R35's cognition was moderately impaired and needed extensive assistance with bed mobility, transfers, dressing, and toileting. R35 had diagnosis of dementia, anxiety, repeated falls, heart failure, tremor, and sleep disorder. R35's current undated care plan identified behaviors of calling out repetitive statements in the dining room, resident room, and in hallways. Care plan identified staff should redirect by turning on TV, playing music, go for a ride around facility, going outside, or look through a magazine, engage in conversation, ensure basic needs are met, monitor and report to charge nurse, provide reassurance. Care plan lacked any interventions to ensure the comfort of other resident when R35 was displaying disruptive behaviors. Observations on: 1) 9/25/23 at 11:46 a.m., R35 was seated at dining room table with 3 other residents, R35 was yelling out repeatedly Help! Help! Help!, R35 then looked at unknown resident to her right and yelled what! what! Other residents in dining room observed to be staring at R35, staff were walking by passing meal trays, no staff were observed to intervene. 2) 9/27/23 at 9:03 a.m., R35 was heard yelling out in dining room Help! Help! looking around at different staff and residents yelling What! What!. Other unknown residents observed staring at R35. Staff were observed asking as they walked by if she needed anything, R35 did not answer, and no other interventions were observed to be attempted. Review of R35's nursing progress notes dated 8/29/23 through 9/27/23, identified R35 had behaviors of yelling out repeatedly during mealtime in the dining room daily. Progress notes identified staff were unable to redirect R35 and the current interventions were ineffective. Interview on 9/27/23 at 7:14 a.m., licensed practical nurse (LPN)-A identified R35 was moved to the assist dining room because when she was in the other dining room her yelling out was disruptive to other residents and they started to make rude comments to R35. LPN-A identified R35 continues to yell out repeatedly in the assist dining room and while there is more staff in the area, it continues to be disruptive to the residents who eat their meals in the assist dining room. Interview on 9/27/23 at 8:33 a.m., social service designee (SSD) identified R35 yells out more when she is in the dining room, she further identified that she has done 1:1's in her office with R35 using sensory techniques such as touching fabric and using stress balls that she felt were effective. The SSD identified she had not added those interventions to the care plan. The SSD stated, I know the yelling out is disruptive to other residents, but we don't take her out because we don't want to isolate her. Interview on 9/27/23 at 8:48 a.m., director of nursing (DON) identified she would expect herself and her SSD to identify and care plan meaningful and effective interventions to either redirect R35 or to ensure a comfortable dining experience was maintained for other residents. Review of the 12/14/22, Comprehensive Care Plans policy identified care plans were to be reviewed and revised after each comprehensive and quarterly assessment. The care plan was to describe at a minimum services to be furnished to attain or maintain the residents physical, mental and psychosocial well-being.

Based on observation and interview, the facility failed to limit access to medications awaiting destruction by the director of nursing (DON) and the consulting pharmacist (RPh), and ensure medication boxes were permanetly affixed to a physical structure during observation of 1 of 1 medication room. Findings include: Observation on 9/26/23 at 1:30 p.m., of the medication room identified there was a small black lock box sitting on the bottom shelf against the wall. The box contained Schedule II and Schedule IV narcotics with a high potential for diversion including drugs like Morphine, oxycodone, and lorazepam. The lock box was not affixed to a permanent surface and could easily be picked up. The key was also observed to be hanging on a hook next to the door on the wall. Interview on 9/26/23 at 1:40 p.m., registered nurse (RN)-A identified a licensed nurse removes unused or discontinued narcotics from the medication cart, takes the page from the narcotic count book and places them together inside the small black locked box in the medication room. RN-A identified the key for the lock box hangs on the wall in the medication room. RN-A identified they do not count the unused narcotics in the lock box awaiting destruction. Interview on 9/26/23 at 2:30 p.m., director of nursing (DON) identified she and the pharmacist destroys unused narcotics monthly, they have always stored the discontinued medications in the small lock box kept in the medication room, she identified they have a second box in case they have overflow. DON identified the key was kept hanging on the hook on the medication room wall, and the people who have access are the RN's, licensed practical nurses (LPN), trained medication assistant's (TMA), and herself. She identified she was not aware that the box needed to be affixed to a unmovable surface or that she could not leave the key in an area that others had access to. Review of the August 2021, Destruction of Unused Drugs policy provide by the facility identified facility was to remove unused medication from their storage area to a secured location until they can be destroyed. There was no mention the box should be permanently affixed to prevent potential diversion, nor keys secured to prevent potential unauthorized access.

Based on observation, interview, and document review, the facility failed to 1) include all employee illness into their infection control program surveillance and perform daily, cumulative surveillance for COVID-19. This has the ability to affect all 37 residents. 2) In addition, the facility failed to appropriately disinfect 2 of 2 whirlpool tubs. This had the ability to affect 35 of 37 residents who received tub baths. 3) The facility also failed to ensure 1 of 1 paraffin wax warmer was appropriately cleaned and disinfected after resident use and identified appropriate for multi-resident use. 4) Furthermore, the facility failed to store lab specimen in a designated biohazard refrigerator awaiting lab transfer and not co-mingled in 1 of 1 medication refridgerator. SURVEILLANCE Review of the current August and September infection control surveillance and Staff COVID Testing Forms identified nurse aide (NA)-C and the social services designee (SSD) were noted to be positive for COVID-19 on 8/31/22. On 9/4/22, 1 staff, laundry aide (LA)-A was identified as positive for COVID-19. No staff were included in the facility infection control surveillance program data. Interview and document review on 9/07/22 at 5:12 p.m., with the infection preventionist /director of nursing (IP/DON) of the IC surveillance and employee illness sheets identified there was no daily, cumulative, surveillance of staff included into the infection control (IC) surveillance program. If staff were out ill, or when they were identified to be positive for COVID, she had not added to the tracking log to identify they were included in with the daily, cumulative surveillance. The IP/DON identified she had no documentation to support staff who were noted to be ill were kept out of work for an appropriate amount of time if they had potential symptoms of COVID. The IP/DON agreed she needed to include staff in the facility IC program surveillance. Review of the 2020, Infection Prevention and Control policy identified the intent of surveillance was to identify possible communicable diseases or infections before they can spread to other persons in the facility. The facility was to have established a system, based upon national standards of practice and the facility assessment to closely monitor all residents who exhibit signs/symptoms of infection through ongoing surveillance including a systematic method for collecting, analyzing and interpretation of data, followed by dissemination of that information to identify infections, infection risks and outbreaks to those who can improve the outcomes for quality. There was no mention of including staff, volunteers, visitors, and other individuals providing services into the surveillance program. WHIRLPOOL TUB CLEANING Observation, interview, and document review on 9/08/22 at 9:40 a.m., of bath aide (BA)-A during a whirlpool tub cleaning identified she removed the gel cushion off the whirlpool bath chair, and wiped the top side with a Sani-cloth and hung it on the handicap grab-bar mounted to the wall. The Sani-cloth chemical was observed to have dried on the gel cushion in approximately 10 seconds. BA-A was unaware how long the Sani-cloth chemical had to remain wet to disinfect the surface of an object. The label on the Sani-cloth container indicated a wet contact time of 2 minutes was required to disinfect a surface. BA-A indicated she was unaware she should disinfect all sides of a gel cushion as a residents skin comes into contact with that. BA-A then described her process as she began the cleaning process of the whirlpool tub. She only performs the cleaning process between resident use and would not perform disinfection until the end of the day. BA-A was the main bath aide and routinely used both whirlpool tubs in the facility for all 35 of 37 residents who bathed. Review of the infection control audits identified the last time the whirlpool tub cleaning and disinfection had been audited was in July of 2021. Review of the undated, [NAME] Advantage Seated Bathing System Bath Cleaning and Disinfection process was not clear for staff that cleaning only removed bio-film and debris, but disinfection would be required to kill potential infectious disease in between resident use. Interview on 9/08/22 at 11:40 a.m., with the DON identified she was unaware the whirlpool tub had not been routinely disinfected between resident use. She agreed all 35 residents who used the whirlpool tub had increased risk of infection due to improper disinfection. PARAFFIN WAX SYSTEM Observation, interview, and Hot Wax Cleaning policy review on 9/08/22 at 8:24 a.m., in the therapy room with the DON identified a paraffin wax system was kept in a wooden cupboard and used for therapy residents. Warm, liquid wax was inside. At the bottom of the wax, there were specs of dirt and debris observed in the bottom of the unit. The DON identified the unit was only cleaned 1 x per month. She was only aware of 1 resident using the wax for therapy but agreed it would be used on other residents if they wished without being appropriately disinfected. She had no manual on the paraffin wax system, but staff had an old, undated policy that stated the wax was only to be changed monthly unless visibly soiled. She agreed the wax appeared visibly soiled. She was unaware of any standard of practice for infection control to prevent cross-contamination if residents were to place thier hands or feet in the liquid wax that another resident had dipped thier hands or feet in. Review of the current, Minnesota Board of Cosmetologist Examiner, State Rule 2105.0375, located at https://mn.gov/boards/assets/Infection_Control_and_Salon_Prohibitions_Summary_tcm21- 0.pdf, identfied professional standards when using paraffin wax systems: You must dispense paraffin wax in a manner that prevents contamination of the unused supply, such as in a bag or other container for the client to use as single-service. There was no user manual or manufacturer's instructions for the paraffin wax system available. Lab Specimen Storage Observation on 9/9/22 at 9:38 a.m., of the medication room with director of nursing (DON) revealed a cooler was in the medication refrigerator that contained an urine sample. Interview on 9/9/22 at 9:45 a.m., with DON identified that the maintenance director took all lab samples over to the hospital lab when he had time during the day. She revealed the protocol had always been to place urine samples in the cooler located in the medication fridge until they could be transported to the hospital lab. The DON further confirmed all blood laboratory specimens drawn at the facility were also placed in the medication refrigerator until they could be taken to the hospital lab. The DON agreed storing specimens in the medication refridgerator had the high potential for cross-contamination and they should be stored within their own refridgerator in a soiled utility room. There was no policy pertaining to appropriate storage of laboratory specimens.

Based on interview and document review, the facility failed to appropriately inform residents, their representatives, and families by 5:00 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection, or when 3 or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other during the facility's outbreak. This had potential to affect all 37 residents residing in the facility, their families, and representatives. Interview on 9/08/22 at 11:35 a.m., with the administrator identified the facility utilized a one-call type system to notify residents and families of positive cases. Review of the Staff COVID Testing Forms identified on: 1) 8/9/22, nurse aide (NA)-F was identified as positive for COVID. 2) 8/31/22, NA-C and the social services designee (SSD) were noted to be positive for COVID. 3) 9/4/22, laundry aide (LA)-A was identified as positive for COVID. Review of the August and September, 2022 notification log identified for august 2022, there was no mention of the 8/9/22 positive case notification being sent to residents and families. Only 1 staff was identified as positive for COVID on 8/31/22 and reported through the one call system. There was no notification sent on 9/4/22 for the positive case identified that day. No policy regarding notifications was provided by the end of the survey.

Based on interview and document review the facility failed to perform a root cause analysis and identify or implement appropriate interventions to prevent multiple recurrent falls for 3 of 3 residents (R1, R7 and R35). Findings include: R1 Review of the 8/18/22 at 8:35 a.m., report to the State Agency (SA) identified R1 had an unwitnessed fall on 8/17/22 at 3:05 p.m. in R1's room. R1 was found on the right side of his recliner with his head/back underneath the bedside table leaning up against the wall. R1 was wearing shoes, the floor was dry, and he was seated in the recliner prior to the fall. R1's wheelchair was in the hall and his walker was positioned at the end of the bed. R1 had severe cognitive impairment and a history of 2 previous falls without injury since the previous assessment. R1 was transferred into bed and complained of pain in his right leg and hip, was transferred to the Emergency Department (ED) where he was found to have a fractured right hip. The report noted it was unknown if the facility had completed a root cause analysis of the falls to implement individualized interventions to prevent reoccurrence of falls. Review of the 8/22/22 at 4:28 p.m., 5-day report noted the fall policy had been followed and had no effect on the cause of the fall with significant injury. The report identified the fall committee was to meet in the furuture to assess the fall and potential interventions, but there was no documented analysis of the fall with action taken to prevent reoccurrence of a fall was to encourage R1 to use his call light and reassess the level of care needed upon his readmission. The report further identified R1 had experienced 3 falls in the last 6 months all unwitnessed and without injury. R1's 8/29/22, Significant change Minimum Data Set (MDS) assessment identified he had severe cognitive impairment, had physical behaviors and other behaviors 4-6 days during the assessment period identified as interfering with resident care. The MDS identified R1's, behaviors had worsened from the previous assessment. R1's activities of daily living (ADLs) required Extensive assistance of 1-2 staff and limited assistance for eating. R1 had diagnoses of a right femur fracture, high blood pressure, and non-Alzheimer's dementia. R1's undated care plan identified episodes of hollering out regarding needing to use the bathroom or letting out loud bellows and sighs without expressing his needs. Interventions included distraction techniques and to anticipate R1's needs. R1 had ADL self-care performance deficit r/t Impaired balance, cognitive decline, memory deficit, and a right hip fracture r/t fall on 8/17/22. Interventions in place prior to his fall with fracture included gripper at his bedside and in front of his recliner in addition to offering toileting every (Q) 2 hours (H). R1 had experienced 3 previous falls because of attempts of self-transferring. Interview on 9/08/22 at 8:33 a.m., with nursing assistant (NA)-A reported safety measures in place were frequent checks when passing room and at least hourly, but she did not think there were scheduled documented checks, but she did check on him when she was passing his room. NA-A reported R1's bed was placed in the low position, and prior to his fall he required limited assistance with his ADLs. NA-reported R1 did not consistently use his call light and would yell out and attempt to self-transfer when he wanted to transfer from either the bed or chair. Interview on 9/08/22 at 8:48 a.m., with trained medication aid (TMA)-A identified R1 had a history of yelling out for any needs rather than using his call light and he would attempt to self-transfer at times or would yell out for his spouse who was in the room next door. Interview on 9/08/22 at 11:26 a.m., with registered nurse (RN)-A reported R1 had fallen on 8/17/22 when he attempted to self-transfer from his recliner and was found lying on the floor of his room. R1 was sent to the emergency room for evaluation and diagnosed with a right hip fracture. RN-A reported she was not aware of what had happened with previous falls, or any additional interventions put into place, but stated R1 had self-transferred previously when he decided he wanted to go to the bathroom. RN-A reported she thought R1 had a wander guard but was not aware of any motion monitors in place prior to his fall with fracture. . Interview on 9/08/22 at 1:30 p.m., with the director of nursing (DON) identified she had become aware of the incident when R1 was transferred to the hospital and spoken with the administrator who advised her to wait to report the incident to the SA until the ED evaluation was completed. The DON stated she had not been notified of the results of R1's ED evaluation and did not become aware of his fracture until the morning of 8/18/22. The DON reported she understood the administrator was responsible for making a report to the SA and thought he would have done so following the fall on 8/17/22. The DON identified the facility did not complete a full investigation of incidents to determine the root cause and implement interventions to prevent a repeat fall. She reported her documentation provided lacked details of the incident which would have been beneficial in the identification of possible causes and interventions. The DON identified the facility had a fall committee that previously met every Thursday at 2:00 p.m. for review of falls that have occurred since the previous meeting. These meetings had not been occurring on a weekly basis and was something she wanted to get started again. Interview on 9/08/22 at 2:18 p.m., the facility administrator agreed R1's fall with fracture should have been reported within the 2-hour time frame due to significant injury and it had not been reported until the following morning. R7 Review of the 6/7/22, report to the State Agency (SA) identified the trained medication aide (TMA) notified the nurse that R7 was on the floor in her room next to the bed at 7:20 p.m. on 6/6/22. R7 had been moving between her chair and the bed and last seen sitting on her bed prior to the fall. R7 was unable to say how or why she fell . R7 range of motion was intact however, she complained of pain on her right lower side and then right lower mid shoulder. R7's first POA was contacted and notified of fall and ice had been applied to right lower back and shoulder. POA had told staff to wait until tomorrow before sending to see how resident was doing. Second POA arrived at the facility to visit and agreed to send resident into hospital for an evaluation. Ambulance arrived at 8:50 p.m., and resident stood with 2 staff assistance and transferred onto the stretcher with complaints of pain. R7 was taken to emergency room in Luverne, MN. At 1:00 a.m., Luverne [NAME] called and reported that R7 was being transported to [NAME] Sioux Falls with rib fractures and hemothorax. The 5 day investigation noted R7 was found on the floor next to her bed with no shoes on, wearing her socks. R7 had been moving between her chair and bed and last seen sitting on end of her bed. Her weight was not directly on the bed pad alarm due to her sitting at end of bed with resulted in the alarm not sounding over the nursing assistance radios system when she stood up. No abuse or neglect suspected. Action taken to prevent reoccurrence the fall committee will continue to meet and attempt to come up with interventions to prevent falls. Facility will evaluate when R7 returns from hospital. The investigation identified 5 falls in last 6 months with no major injuries. R7's 3/31/22, admission Minimum Data Set (MDS) assessment identified R7 had severe cognitive impairment. R7 had no behaviors and needed supervision with cares including transfers and ambulation. R7 was identified to have no falls since admission or prior to admission. R7's undated, current care plan identified beginning 3/25/22, R7 was at risk for falls related to unsteady balance, new environment, and history of falls at assisted living. The current care plan for falls had last been updated on 7/3/22. Interventions prior to fall on 6/6/22, included call light within reach, encourage to use walker for balance and stability often forgets, silent bed pad alarm on bed to alert to staff radio, resident often removes alarm from bed and throws on floor or places on another piece of furniture, and use cotton fabric bedspreads on bed. Falls since admission 5/4/22, 5/8/22, 5/22/22, 5/24/22, 5/25/22, then 6/6/22 with additional falls on 7/6/22, 7/7/22, 7/25/22, 7/30/22, and 8/27/22. New interventions after 6/6/22, fall included adhesive gripper strips on floor by bed, chair, and in bathroom. Additional interventions following that included remove black slip-on shoes and lipped mattress with exit opening. The current care plan also identified R7 was independent bed mobility, dressing, personal hygiene, toileting, and transfers. R7 had a restorative program and was able to ambulate to all destinations with encouragement to use walker. R7's Fall Investigative Summary following each fall identified the same information that was entered on the fall report. There was no indication that staff completed a thorough investigation and analyzed the information to obtain a root cause for the falls to identify why the fall had happened. The fall committee information was a copy of the fall report and the investigative summary that was completed by the nurse on duty at the time. There was no indication that the fall was further investigated during the fall committee meeting or if interventions were reviewed and/or changed if needed. Observation on 9/7/22 at 12:49 p.m., R7 was walking with her walker in the hallway independently, staff approached her and asked if she needed anything, and she stated she was just going back to her room. Interview on 9/7/22 at 2:19 p.m., with nursing assistant (NA)-E identified R7 wanders up and down the halls, staff redirect her, staff make sure she has her walker with her and that she is safe. She reported R7 had a bed alarm that alerts to staff radio, so they knew when she was getting up from her bed. She confirmed she was independent while in her room and staff attempt to walk with her out in the hallway, but she can walk on her own there also. Observation on 9/8/22 at 7:33 a.m., R7 was sitting at breakfast table in dining room with her walker parked next to her. Observation on 9/8/22 at 10:48 a.m., R7 was laying on her bed with her walker parked next to her. Interview on 9/8/22 at 1:42 p.m., with registered nurse (RN)-C who was also the MDS nurse identified that the facility had a fall committee of department managers including herself that review falls and what happened prior to the fall. She confirmed R7 had multiple falls and stated she felt the facility had done multiple interventions revealing she did not know what else the facility could do. She confirmed that the provider was made aware and they review falls during their QAPI meetings. Interview on 9/9/22 at 11:30 a.m., with director of nursing (DON) agreed that the facility had not completed a thorough investigation and that there had not been any root cause analyses identified for R7's falls. She stated that she was already working with the interim administrator on revising the process and obtaining a new form for the charge nurse to follow. She revealed the process needed to be revised so that the charge nurse on duty would complete interviews at the time of the fall and finding out why the fall potentially occurred by asking specific questions. R35 R35's 5/31/22, quarterly Minimum Data Set (MDS) assessment identified R35 had severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, and toileting. R35 used a walker or wheelchair for mobility. There were no recent falls identified. R35's undated, care plan identified on 3/1/22, fall intervention of a TAB's alarm on bed. The care plan listed all falls since admission with the 6/30/22 fall and the previous fall being on 5/24/21 over a year prior. R35's 6/30/22, Un-witnessed fall report identified that staff entered R35's room to don hand grips and found R35 laying on her right side on floor next to bed. There was no alarm sounding and the alarm was not located on the bed frame. R35 was assessed by the nurse and found to have no injuries. R35 was assisted back into bed with a mechanical lift and three staff. The report identified staff placed the TAB's alarm on the resident and would be obtaining a body pillow as well. Manager review on 7/1/22, identified that the TAB's alarm was not on bed frame, staff were educated to not move alarms from surface to surface, and a body pillow next to resident when in bed was added. Interview on 9/7/22 at 10:12 a.m., with trained medication aide (TMA)-B identified that R35 had falls in the past and that was why she had a TAB's alarm to alert staff she was getting up however, she has now declined and does not really attempt to get up any longer. Interview on 9/7/22 at 4:26 p.m., with RN-C who was the MDS nurse confirmed that staff had not followed R35's care plan on 6/30/22 as they failed to place the TAB's alarm on the bed that evening. RN-C identified there was an educational reminder in the staff communication book but also education was done at time of fall with the staff on duty. RN-C revealed that the fall intervention of a TAB's alarm on the bed had been initiated on 3/1/22, and would have expected staff to follow the care plan. Review of 8/22/22 Comprehensive Care Plans policy identified staff were to implement personalized developed care plans to meet the residents needs. The 8/2021, Fall Risk Assessment policy identified would provide supervision along with assistive devices to each resident to prevent avoidable accident. Staff were to complete a risk assessment that identified environmental hazards, the resident's risk, if supervision was needed and care plan accordingly. Staff were to monitor effectiveness of care plan interventions and modify as needed in accordance with current standards of practice. The August 2021, Fall Prevention Program policy identified staff were to assess resident fall risk and individualize services to minimize the likelihood of falls. The nurse was to reference the facility high risk or low risk for falls protocol when determining fall interventions. Staff were to place a star indicator on the resident door frame of their room if they were at risk for falls. The nursing staff were to assess any resident who experienced a fall and document on a fall report, notify physician and family along with documenting all assessments and actions taken. There was no mention that the facility would complete a root cause analysis or review of the interventions to ensure interventions were appropriate.

Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medications were limited to 14 days of use or re-evaluated in-person by the medical provider to ensure necessity and reduce the risk of complications for 1 of 5 resident's (R23). In addition, the facility failed to ensure target behaviors were identified for psychoactive medications for 2 of 5 resident's (R7 and R26) reviewed for [CONDITION(S)] medication use. Findings include: R23's Admission Record printed 9/8/22, indicated R23 was admitted on [DATE], with the diagnosis of dementia with behavioral disturbance, adult failure to thrive, [CONDITION(S)], weakness, [CONDITION(S)], low back pain, and [CONDITION(S)] ([CONDITION(S)] joint disease). R23's 5/5/22, admission Minimum Data Set (MDS) assessment identified R23 severe cognitive impairment, had behaviors 1 to 3 days of physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others. The behaviors interfered with R23's cares but did not interfere with other residents. R23 rejected care 4-6 days during the assessment period. R23 required limited assist of one staff with cares and ambulation. R23 had no psychiatric/mood disorder identified as a diagnosis on the MDS however, took an antipsychotic daily during the assessment period. R23's 7/26/22, MDS assessment identified R23 had severe cognitive impairment, had no behaviors, no psychiatric/mood disorder identified however, took an antipsychotic daily during the assessment period. Review 7/6/22, provider in-person visit identified PRN antipsychotic's were discussed. Review of 7/20/22, fax to the provider related to a 14-day evaluation due to PRN [MEDICATION(S)] with provider who responded to continue [MEDICATION(S)] for another 14 days via fax without completing an in-person evaluation. R23's Medication Review Report dated 7/27/22, identified an in-person routine visit however, there was no documentation that the provider reviewed the PRN [MEDICATION(S)] to ensure necessity and reduce the risk of complications. Review of 8/3/22, fax to provider with update of PRN [MEDICATION(S)] use, provider responded to discontinue the PRN [MEDICATION(S)]. Provider completed an in-person visit the next day. R7's Admission Record printed 9/8/22, identified admitted [DATE], with the diagnosis of [CONDITION(S)], major depressive disorder, [CONDITION(S)], carpal tunnel syndrome right limb, hypertension, irritable bowel syndrome, rosacea, spinal stenosis, chronic kidney disease, [CONDITION(S)], and [CONDITION(S)]. On 5/4/22, R7 was identified with a new diagnosis of vascular dementia with behavioral disturbance, and delusional disorders. R7's 6/21/22, significant change Minimum Data Set (MDS) assessment identified R7 had severe impaired cognition, with no behaviors exhibited. R7 required limited assistance from staff for all care needs, R7's balance was not steady but R7 was able to stabilize without staff assistance. Section I Active diagnoses identified depression and psychotic disorder. Section N 0410 Medications identified R7 had antipsychotic 7 days during the assessment period. R7 diagnosis list identified on 5/4/22, a new diagnosis of delusional disorder and vascular dementia with behavioral disturbance. R7's September 2022, medication administration and treatment record identified to chart mood and behaviors for [CONDITION(S)] medication and changes every shift related to delusional disorder. There were no target behaviors identified as to what the medication was being used for. R7's undated, care plan identified R7 used antidepressant medication [MEDICATION(S)] related to depression. There were no identifying target behaviors for use of [MEDICATION(S)]. Care plan addressed be free form discomfort or adverse reactions related to antidepressant use. The care plan further identified R7 used a [CONDITION(S)] medication of [MEDICATION(S)] related to vascular dementia and depression. There were no identified target behaviors for use of [MEDICATION(S)]. The care plan identified R7 will be/remain free of [CONDITION(S)] drug related complications. Staff were to monitor mood and behaviors and report them to the charge nurse. R26 Admission Record printed 9/8/22, identified admitted [DATE] and diagnosis of [CONDITION(S)], chronic obstructive pulmonary disease, malignant neoplasm of larynx, [CONDITION(S)], anxiety, hypertension, [CONDITION(S)], urine retention, encounter for attention [CONDITION(S)], and long-term use of anticoagulants. R26's 9/1/22, significant change of condition MDS assessment identified intact cognition, no behaviors, required extensive assist with cares, had anxiety disorder, took an antianxiety medication 6 days, and took antidepressant 7 days during assessment period. R26's September 2022, medication administration and treatment record identified R26 took [MEDICATION(S)] ([MEDICATION(S)]) daily in the evening and [MEDICATION(S)] ([MEDICATION(S)]) every morning. Neither medication had target behaviors identified as to what the medication was being used for. R26's undated, care plan identified R26 took an antianxiety medication related to anxiety there were no target behaviors identified for use of the anxiety medication. There was no antidepressant identified with target behaviors for use of the antidepressant medication. Interview on 9/8/22 at 8:56 a.m., with the director of nursing (DON) revealed she was unaware that the provider needed to evaluate a resident on a PRN antipsychotic medication in-person every 14 days to evaluate the necessity of the medication and to reduce the risk of complications to continue the PRN medication. She further revealed she was unaware the provider needed to document the rational for use. She confirmed that the facility MDS nurse had been faxing the provider to continue the PRN antipsychotic orders between routine visits to continue the order for an additional 14 days. Interview on 9/8/22 at 1:46 p.m., with registered nurse (RN)-C who is also the MDS nurse confirmed there were not target behaviors for either R7 or R26 that identified why the psychoactive medication was prescribed and what behaviors the medication was to be improving. She identified she must have missed adding the target behaviors as she normally would do that. She further agreed that without having target behaviors identified it would be hard to tell if the medication was working or not. Interview on 9/9/22 at 11:30 a.m., with director of nursing agreed that R7 and R26 did not have target behaviors identified for the psychoactive medication ordered as to why it had been ordered and what behaviors the medication was intended to improve. She confirmed all residents that use psychoactive medications should have identified target behaviors that the medication was to treat to enable a thorough review to see if the medication was effective or not. The 7/29/21, [CONDITION(S)] Medication policy identified medication that are used only as needed, would have side effects monitored and ensure the family was made aware of risk/benefit of those medications. The policy identified ordered PRN antipsychotic medication will have the effectiveness, non-pharmacological interventions, and side effect monitored at 14 days, one month and two months. The nurse when entering an order for a PRN [CONDITION(S)] medication will enter a stop date at 14 days. The provider will be contacted before the 14 days on antidepressants, antianxiety, and hypnotics only the antipsychotic orders are reviewed every 14 days with a mandatory stop date, refer to drug class in this policy. There was no attached drug class reference in the policy. The policy lacked identification that an in-person evaluation was required to continue a PRN antipsychotic medication. The policy further lacked identification that target behaviors should be identified for use of psychoactive medication orders to monitor for effectiveness.

Based on observation, interview, and document review, the facility failed to administer medication according to manufactures instructions during 3 of 25 observations, resulting in a 12% medication error rate. Findings include: Observation and on 9/7/22 at 8:53 a.m., of R33's medication pass with trained medication aide (TMA)-B who gathered R33's medications including her [MEDICATION(S)] ([CONDITION(S)] medication) 50 micrograms (mcg) and administered her medications. Observation on 9/7/22 at 9:10 a.m., of R26's medication pass with TMA-B who gathered R26's medications including his [MEDICATION(S)] 12 mcg and administered his medications. Interview on 9/7/22 at 9:52 a.m., with TMA-B confirmed that R33 and R26 had already received their breakfast before getting their morning medications. TMA-B was unaware of any medications that needed to be given on an empty stomach. TMA-B revealed medications that are given on an empty stomach would be given by the nurse. Interview on 9/7/22 at 10:00 a.m., with registered nurse (RN)-B identified [MEDICATION(S)] should be given on an empty stomach and the facility usually gives at 5:00 a.m. unless the resident does not want to be woken up then it is given before breakfast. RN-B confirmed that both R33 and R26 had eaten their breakfast before TMA-B had administered their medication. RN-B revealed R33's [MEDICATION(S)] was scheduled at 8:00 a.m. and R26's [MEDICATION(S)] was scheduled at 9:00 a.m. and both should be scheduled before breakfast time. Observation on 9/8/22 at 8:06 a.m., of R13's medication pass with TMA-A who gathered R13's medications including [MEDICATION(S)] 75 mcg and administered her medications. Interview on 9/8/22 at 8:13 a.m., with TMA-A identified the only medications she was aware of that needed to be given on an empty stomach was Docycycline. TMA-A confirmed R13 had already eaten breakfast prior to getting her morning medications. TMA-A then revealed [CONDITION(S)] medication used to be scheduled to be given before breakfast but the facility had quit doing that. Interview on 9/9/22 at 10:58 a.m., with consultant pharmacist who agreed that [MEDICATION(S)] should be administered on an empty stomach unless the medical provider specifically ordered the medication to be given at an alternative time. She was unaware of R13, R33, or R26 having an order to give their [MEDICATION(S)] at a different time and she confirmed the medication worked best if given on an empty stomach prior to breakfast. Review of the manufacturer's instructions located at https://www.drugs.com/[MEDICATION(S)].html, identified [MEDICATION(S)] worked best if taken on an empty stomach, 30 to 60 minutes before breakfast. Staff were to follow doctor's dosing instructions and try to take the medicine at the same time each day. Review of August 2021, Medication Administration policy identified medications were to be given as ordered by the physician and in accordance with professional standards of practice. Staff were to administer medications as ordered in accordance with the manufacturer specifications.

Based on observation, interview, and document review the facility failed to ensure appropriate infection control technique was maintained during 1 of 1 meal service when a room tray that had been served to 1 of 1 resident (R3) was returned to serving line and not disposed of in the dirty sink area in the kitchen. Findings include: Observation on 9/6/22 at 5: 08 p.m., during serving of the supper meal service with cook-A identified an area of concern when at 5:22 p.m., nursing assistant (NA)-B returned to the dining room with a plate containing the casserole and bread that had been plated by cook-A and served on a room tray. Cook- A took the plate with her gloved hands and placed it on the counter beside the steam table. She did not change her gloves and continued to dish the supper meal, and place slices of buttered bread on each plate with her contaminated gloved hands that had handled both the plate and cover. Cook-A did not remove her gloves and perform hand hygiene until she had finished serving the meal. Cook-A then removed her gloves, washed her hands, and retrieved a can of soup to prepare for the resident who had requested an alternate food choice. Interview on 9/06/22 at 5:43 p.m., with NA-B identified she had served the room tray to R3 and had placed the tray on her lap as she had requested. R3 lifted the plate cover, replaced it, and stated she wanted something different. NA-B took the plate from the R3 and carried the covered plate in her gloved hands, back to the serving window where she handed it through the serving window to cook-A, who took it from her and set the plate on the serving counter. NA-B reported this was her usual practice if a resident didn't want what was served. She was not aware once food left the kitchen it should not be returned to the clean serving area of the kitchen and should have returned the plate to the soiled dish area. Interview on 9/06/22 at 5:39 p.m., with the certified dietary manager (CDM) confirmed when a plate of food was taken from the kitchen, it could not be returned to the serving area, but had to be returned to the dish room. The CDM reported cook-A should not have accepted the plate and directed NA-B to take it to the dishwashing area. Interview on 9/6/22 at :50 p.m., with cook-A reported she should have known not to take the plate back into the serving area but had not thought about it when she accepted the plate and set it on the counter. She reported she had not thought about needing to change her gloves or performing hand hygiene. Review of the undated, Sanitation an Infection Control policy identified food returned on a soiled plate should be immediately disposed of, but there was no information on infection control about handling and how it was to be managed.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 1 wandering resident (R1), who accessed the kitchen area when staff left the door open and kitchen unattended, and fell down the back stairwell. This resulted in actual harm as R1 sustained fractures of her shoulder blade, wrist, 5 ribs, a laceration to the left side of her head and bleeding on her brain. The immediate jeopardy began on 11/22/21, when the facility failed to provide adequate supervision for R1 who was able to access a restricted area through the kitchen in her wheelchair and fell down a stairwell resulting in fractures of shoulder blade, wrist, and 5 ribs including a laceration to the left side of her head and was identified on 11/30/21. The administrator and DON were notified of the immediate jeopardy on 11/30/21 at 2:15 p.m. The immediate jeopardy was removed, and the deficient practice corrected on 11/28/21, prior to the start of the survey and was therefore Past Noncompliance. Findings include: Review of the 11/22/21 at 4:33 p.m., report to the State Agency (SA) identified R1 had entered the kitchen without being seen. The evening cook was heading to the pantry and heard R1 around the corner in the stairwell. The cook went to investigate and saw R1 lying on the lower stairwell platform, 5 steps down. The cook proceeded to get help. The nurse called 911 and R1 was sent to emergency room for evaluation. Initial injuries identified were bruising to her forehead with an open area, and possible fracture of her arm and hip. R1 was alert and responded to prompts and was able to verbalize pain symptoms. The facilities 5-day summary identified all actions taken to prevent reoccurrence (as noted above). R1's 6/1/21, Elopement report identified the front door Wander Guard alert sounded. R1 was observed to be across the driveway sitting on the grass in front of her wheelchair. R1 was still on facility grounds. Prior to R1 eloping out front door she was upset stating she wanted to take her cat home. R1 had been reminded her family would be coming to visit shortly. R1 had been assisted to her room shortly before she went out the door. R1 was confused and talked about going home multiple times during the day. The report provided identified R1's family member and physician had been notified. There was no mention any new interventions were implemented to protect R1 from harm. R1's 8/31/21, quarterly Minimum Data Set (MDS) identified R1's had moderately impaired cognition and wandered daily. R1 was able to walk in the corridor with limited assistance and used a walker or wheelchair for locomotion. R1 had a bed alarm, chair alarm, and a wander/elopement alarm. R1 had a diagnosis of dementia. R1's 6/8/21, Care Area Assessment (CAA) identified R1 had behaviors symptoms of wandering 1 to 3 days during the assessment period. Staff were to ensure R1 was to safely wander through facility in her wheelchair. Staff were to redirect R1 and take back to her room to visit about her cat, her flowers, or the weather. R1 had a history of prior unsafe behavior of elopement by leaving the facility out the front door after attempting to return home. R1's 9/14/21, Elopement Assessment identified R1 attempted to elope monthly. R1 had not had any successful elopement attempts off campus. R1 had impaired cognition and a diagnosis of dementia. R1 displayed wandering and exit seeking behaviors. R1 verbalized a desire to go home and look for people. R1's current, undated care plan identified R1 was forgetful, had impaired safety awareness, wandered in her wheelchair looking for family and had wanted to go home. Staff were to disguise exits, use stop signs on front exit door, northeast door, and the northwest door. Staff were to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. R1 had worked at a hardware store and staff were to visit with her about her past work. Staff were to monitor her whereabouts every 2 hours and document her location. If staff were unable to locate R1, staff were to notify the charge nurse immediately. R1's triggers for wandering and elopement behavior were wanting to go home and looking for family. R1's behaviors could be de-escalated by letting R1 know what time family would be coming, remind her they knew where she was, and show R1 her room with her name outside of it. R1 had a WanderGuard applied to her wheelchair and used a tabs alarm to alert staff if she attempted to stand on her own. R1 had a fall risk related to history of falls, unsteady gait, and unaware of safety needs. Staff were to anticipate her needs, have call light within reach, alarm on bed and in her wheelchair, ensure she had appropriate footwear on and encourage her to participate in restorative therapy along with activities. R1's progress notes identified staff documented on: 1) 6/1/21, the facility front door wander-guard alert sounded. R1 was observed across the driveway sitting on the grass in front of the wheelchair. R1 had been upset prior to the incident and stated she wanted to take her cat home. 2) 6/2/21, R1 attempted to leave the facility after supper. 3) 7/20/21, R1 attempted to exit facility 2 times. R1 had been looking for a way to get out of the building and go home. 4) 8/2/21, R1 had been wandering in the hallway all day. Staff noted R1 fell in her bathroom. Staff were to remind R1 to wait for help. Staff were to ensure they stayed with R1 when toileting. 5) 10/19/21, R1 was noted to be in the hallway trying to find a door to go home. 6) 11/21/21, R1 fell out of her wheelchair while in dining room by the table. Staff noted they were unable to intervene before she fell to the floor. 7) 11/22/21, R1 had fallen down stairwell in restricted area, was sent to emergency room for evaluation and admitted to the hospital. 8) 11/30/21, R1 was readmitted to facility with bilateral splints extending from hands to below her elbows. Multiple bruises were noted. She had sutures to left forehead, and had orders for hospice and pain management. R1 was currently bedridden with interventions in place. Observation and interview on 11/29/21 at 1:00 p.m., of the kitchen doors with the dietary manager (DM) identified the door which led into the dishwashing room was shut but not locked, however staff were just inside the door. All remaining kitchen doors not immediately attended were confirmed to be locked. The DM identified R1 had gone through door A. Door A was open as the cook had been in and out during coffee time assisting residents after BINGO. R1 was able to wheel herself into the kitchen through door A, then through door-B and down the hallway before entering door-D which led to the outside directly in front of exit door was an open stairwell to the left. The staircase was observed to have 5 steps leading down to a platform with additional steps leading down to the basement area. DM revealed door-D had no lock and had been left open during the loading of meals into the van for delivery to the another facility building. The DM confirmed door-D was not to be left open a any time. R1 was in her wheelchair and had gone through door-D. It was assumed R1 attempted to open the locked outside door. Staff felt when R1 was unsuccessful, she likely tried to turn around and fell down the open stairwell. Cook (C)-A was on the way to the pantry when she heard an alarm and went to investigate. C-A found R1 with part of her body on the platform and the rest on the steps. C-A came running out and summoned assistance. One of the nurses called 911 and the ambulance arrived. The DM confirmed R1 was an exit seeker. Staff had to redirect her often. Interview on 11/29/21 at 1:46 p.m., with C-A identified she had been the evening cook on 11/22/21. She had been assisting with serving coffee after BINGO in the dining room, which was also used for activities. Door-A was usually open when staff were serving residents. She went back into the kitchen and was on her way to the pantry across from door D to get more cups when she heard a beeping sound. C-A thought it was the back exit door alarm. When she entered through door-D, she saw R1 lying on the steps with her wheelchair on top of her. She ran for help and returned with the activity director (AD) who assisted her to get the wheelchair off of R1. Prior to the incident, she recalled R1 had been sitting at the table directly across the room from door-A. She did not see R1 leave the table or go towards the kitchen. R1 was known to roam around and somehow had gotten into the kitchen unobserved. Activity aid (AA)-B was also in dining room helping serve coffee. The activity director (AD) who had just finished BINGO, was not directly in the area of the dining room at the time of the incident, but was back by DM office. C-A confirmed R1 had went through door-A as she had left it open while she was going in and out of the kitchen. Since the incident, staff were to make sure all kitchen doors were shut and locked. Door-A could only be open during the 3 main mealtimes while staff were present. Interview on 11/29/21 at 2:05 p.m., with the AD identified BINGO ended around 2:45 p.m At the time of the incident, she was standing in the doorway of the DM office talking to the DM when C-A ran out of the door yelling for help. She went to assist C-A while the DM found additional help and someone to call 911. She described R1's position as her bottom laying on the platform of the stairway and her head on the first step down from there. R1 was bleeding and had her wheelchair on top of her. Once they got the wheelchair off R1, she was able to kneel on the steps and apply pressure to R1's head to stop the bleeding and support her with her body. Several other staff arrived and medical aid was provided while they waited for the ambulance. No staff had seen R1 enter the kitchen. She confirmed door-A was normally closed, but during coffee or activity time it was open. R1 would talk about leaving the facility but usually just looked out the window for her family's truck as they came daily to visit. The AD revealed if door-A had been closed this would have never happened. The AD had re-educated activity staff after the incident to ensure no residents were left unattended in the dining room and that all kitchen doors were to be locked at all times unless during a meal service. Interview on 11/29/21 at 2:48 p.m., with AA-C identified AA-C was assisting with BINGO prior to the incident. There were 3 other residents at that table and all had coffee and a snack. One of the residents had asked for a ride back to their room. There was another activity staff still in the dining room at the time when she left the dining room. At that time, R1 was still drinking her coffee when she left the dining room. As she was walking back into the dining room, the medication nurse asked her if she knew where R1 was. At that moment, the charge nurse, DON, and administrator were seen coming through the dining room and going into the kitchen. AA-C stated she thought she had only been away 5 minutes before returning to the dining room and since other staff were in the dining room at the time she left, she felt it was ok to leave. She did not coordinate with other staff to ensure someone supervised the remaining residents while other staff escorted residents back to their rooms. After the incident, she was re-educated the kitchen doors were to be closed and locked when kitchen staff were not present. No resident was to be left unsupervised in the dining room. She revealed prior to the incident, R1 was known to wheel herself around in her wheelchair throughout the facility. She had no problems getting around. Interview on 11/29/21 at 3:01 p.m. with AA-B related to the incident identified she was present in the dining room immediately prior to the incident. She did not see R1 leave the table. She was walking around the dining room handing out prizes and snack after BINGO. She had left the area for a short time to give a resident a ride back to their room and could not recall if she had seen R1 at the table or not. She confirmed she was retrained to kitchen door and supervision policies put into place after the incident. She revealed R1 was an exit seeker. She had to redirect her in the past before when she was attempting to exit seek. Surveillance footage review and interview on 11/29/21 at 3:19 p.m., with the administrator identified video footage of the inside of the kitchen was reviewed. At 3:01 p.m., C-A was seen going in and out of the pantry in the back of the kitchen near door D. At 3:04 p.m., R1 wheeled down the kitchen hallway and turned to her right through door-D. No video footage was available of the back door after R1 went through door-D. At 3:05 p.m., C-A was seen walking in the hallway, paused for a second at the pantry door, then walked to door-D. Moments later, C-A was seen running back from door D. C-A and AD are seen running back and entering door-D. From 3:06 p.m. to 3:17 p.m., staff were observed assisting with R1's care until emergency medical services arrived to take R1 via ambulance to the emergency room . On 11/29/21 at 4:15 p.m., a call was placed to the medical director and a message left to return call. The medical director did not return the call at time of survey. Interview on 11/29/21 at 4:32 p.m., with administrator identified some keypad locks were obtained last week at the local store. The store did not have enough locks at that time, so 3 doors (Door A, Door D and door F) were locked with the traditional key-type lock. The remaining keypads had been installed that morning of 11/29/21. Audits were to be done each day to ensure all kitchen access doors were secured so no residents would be able to access the restricted kitchen area. The administrator confirmed only 1 other resident had wandering and exit-seeking behaviors. The facility had already been in process of updating all alarm systems in the building. They were also installing the new WanderGuard system to the entire building. R1 had an elopement attempt at the beginning of June and set off the alarms but had not left the building that he was aware of. Further, prior to R1's fall, door-A was typically left open when staff were serving meals or coffee. His investigation identified other staff were in the dining room at the time, but may have had their back turned to R1. She was able to slip through the door without being seen. The facility changed the process now after R1's fall and all doors to the kitchen will remain shut and locked except during the 3 main meals including being shut during snack and coffee time. R1 had 2-hour checks with the last time having occurred at 2:00 p.m., just before BINGO. R1 had her WanderGuard and tabs alarm on, however, the kitchen doors had no WanderGuard installed. Observation on 11/29/21 at 5:00 p.m., of the dining room identified door-A was open with cook just inside of door plating food for staff to deliver to dining room. All other doors were locked. Interview on 11/30/21 at 8:37 a.m., with trained medication aid (TMA)-A identified R1 got around good in her wheelchair, she did wander around the building. She identified that R1 had a wander guard on, and staff were to check on her every 2 hours. When R1 got into the kitchen it had been in between their 2-hour check times. She was unaware if R1 had ever tried to enter the kitchen before but did wander in that back dining room area a lot. Interview on 11/30/21 at 8:40 a.m., with NA-A identified she had seen R1 go into the kitchen once before the incident, but she was easily redirected back out by staff. R1 usually wandered when there was down time between meals and activities. She said R1 could be quick in her wheelchair and moved fast throughout the facility. R1 had a tabs alarm and WanderGuard on her wheelchair as she was a fall risk and a high risk for elopement. She confirmed staff completed 2 our checks on R1's whereabouts each day. Review of the 7/21/21, Elopement/Missing Resident policy identified residents will be assessed upon admission, with any significant change, quarterly, or after an elopement or attempted elopement to assess intervention needs. Residents who are high risk have been identified to require a WanderGuard and have staff checks at 15-minute intervals to reduce elopement risk. If a resident had no exit seeking for a 2-week time period, the resident may have checks slowly decreased in increments of 15 minutes but was to have no fewer checks than every 2 hours. There was no mention of a facility wide safety assessment of the physical environment to be performed. The past noncompliance immediate jeopardy began on 11/22/21. The immediate jeopardy was removed and the deficient practice corrected by 11/28/21, after the facility implemented a systemic plan that included the following actions: The facility conducted a root cause analysis and installed keypad locks on the dishwasher room door (door F), the door that enters the kitchen from the staff entry-way by the time clock (door E), and the back door that goes to the stairwell (door D). Additionally, the sliding door to the kitchen (door A) was to remain closed and locked except during the 3 meals when staff served food. At all other times, door A was to remain closed and locked. The cook on-duty was to audit all doors into the kitchen, 3 times per day and document the results of those audits. All staff were educated to the new processes outlined above, and to not leave any resident unsupervised in the dining room at any time.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines to prevent or minimize the transmission of COVID-19 which resulted in an ongoing facility outbreak when 13 of 40 residents (R3, R5, R6, R8, R10, R11, R12, R14, R15, R16, R21, R22, and R23), tested positive for COVID-19. The facility's failures resulted in an immediate jeopardy (IJ) situation for all 40 residents. The IJ began on 9/23/20, when it was identified the facility failed to immediately implement Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for isolation and use of transmission based precautions when residents first identified with symptoms of COVID-19. The IJ was removed on 10/12/20 at 5:05 p.m., but non-compliance remained at the lower scope and severity of F, widespread, with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: SURVEILLANCE Review of the facility's Infection Control (IC) Program Log identified it was organized by month. Each month contained an Infection Control Log, Infection Surveillance Data Collection Form, a Facility Map, and an Infection Summary. The Infection Log columns were labeled Name, Onset Date, Signs and Symptoms, Cultured Organism, Not Cultured, Antibiotic Ordered, Corrective Action, Date Resolved, and Exhibited By. The Surveillance Data Collection Form consisted of individual resident infection information with infection criteria definitions, and antibiotic treatment information to track antibiotic effectiveness. The facility map marked where infections were located in the facility. The Infection Summary contained a table of rows and columns to record the types and numbers of infections present in the facility for a month, and included a review of the previous month's infections. The summary also included staff infection surveillance, any trend analysis, applicable corrective actions taken and additional comments. The August 2020, IC log made no mention of any symptoms of COVID-19 present in the facility, and the September 2020, IC made no mention of any symptoms of COVID-19 present in the facility until the first positive test was recorded on 9/30/20. At that time, the log only identified residents who tested positive for COVID-19. The October 2020, IC log identified residents who tested positive for COVID-19 on 10/1/20, 10/4/20, 10/5/20, 10/7/20, and 10/8/20. The IC log made no mention of symptomatic residents who had tested negative. Review of the resident electronic medical records (EMR)s identified the following: R5's nurses' notes identified R5 had experienced loose incontinent stools between 9/9/20 and 9/10/20. On 9/21/20 and 9/28/20, R5 had increased anxiety and shortness of breath. On 9/30/20, R5 tested positive for COVID. The notes made no mention as to whether R5 was placed on transmission based precautions at the time these symptoms, consistent with COVID-19, began. R12's nurse notes identified R12 had intermittent symptoms of nausea, vomiting, headache, sore throat, and weakness, and lethargy beginning 8/19/20 through 10/7/20. On 10/7/20, R12 tested positive for COVID. The notes made no mention R12 was placed on transmission based precautions at the onset of symptoms to prevent potential spread of COVID. R3's nurses' notes identified R3 experienced intermittent loose stools between 8/19 and 9/4/20. On 9/5/20, R3 experienced shortness of breath while ambulating. On 9/30/20, R3 tested positive for COVID. R3's nurses' notes made no mention as to whether R3 was placed on transmission based precautions when R3 exhibited these symptoms consistent with COVID. R6's bowel records identified R6 experienced loose stools between 9/12 and 9/20/20. R6's nurses' notes indicated R6 tested positive for COVID on 10/5/20. The notes made no mention whether R6 was placed on transmission based precautions when the diarrhea, a potential symptom of COVID, developed. R21's nurses' notes identified between 9/23 and 9/26/20, R21 had loose stools. On 10/4/20, the notes indicated R21 had a mucus like discharge when using the toilet. R21 was tested for COVID on 10/6/20 with negative results. There was no mention R21 was placed on transmission based precautions at the onset of diarrhea for potential COVID-19. R10's bowel records identified between 9/26 and 10/6/20, R10 experienced intermittent loose stools. Between 9/30 and 10/5/20, R10's nurses' notes indicated R10 exhibited a dry, hacking cough, and increased confusion. On 9/30/20, R10 returned from a clinic visit and requested to be tested for COVID. R10 initially tested negative for COVID at that time, however, on 10/5/20, R10 tested positive for COVID. The notes made no mention R10 was placed on transmission based precautions at the onset of these symptoms consistent with COVID. R11's bowel record identified between 9/26 and 10/7/20, R11 experienced loose stools. On 9/30/20, R11's nurse notes identified R11 refused COVID testing. On 10/4 and 10/5/20, R11 complained of nausea. The notes made no mention R11 was placed on transmission based precautions at the onset of symptoms to prevent potential spread of COVID. R8's nurses' notes identified on 9/30/20, R8 had a dry hacking cough. On 10/1/20, R8 continued with a dry, non-productive cough, and felt run-down and staff were to continue to monitor. On 10/2/20, R8 felt like he was going to throw up. On 10/8/20, R8 tested positive for COVID related to having symptoms of weakness, diarrhea at request of family. The notes made no mention R8 was placed on transmission based precautions at the onset of his symptoms. R14's nurse notes identified on 9/30/20 at 8:30 a.m., R14 had a non-productive cough, hoarseness, and loss of taste during the night shift. On 9/30/20 at 3:50 p.m., R14 tested positive for COVID. The notes made no mention R14 was immediately placed on transmission based precautions when symptoms were identified. R15's nurses' notes identified between 10/2 and 10/5/20, R15 had symptoms of not feeling well, weakness, shakiness, orange-colored loose stools, nausea and yellow-colored vomit. On 10/5/20, R15 tested positive for COVID. The notes made no mention R15 was placed on transmission based precautions at the onset of symptoms consistent with COVID. R16's nurses' notes identified between 10/3 and 10/7/20, R6 was not feeling the best, had a hoarse voice, cough, chest pain, body aches, bloody stools and increased irritability. R16 was tested for COVID on 10/3/20. R6's test was negative. R6 continued to have COVID-like symptoms and was retested for COVID on 10/5/20, and 10/7/20, R16 requested to be tested for COVID again and was negative both times. On 10/7/20, R16 was transported to the emergency department (ED) for increased behaviors. R16 was tested for COVID in the ER, and was positive. The notes made no mention R16 was placed on transmission based precautions at the onset of her symptoms. R22's bowel record identified between 9/2 and 9/28/20, R22 had frequent loose stools. On 9/30/20, R22 tested positive for COVID. The notes made no mention R22 was placed on transmission based precautions at the onset of symptoms consistent with COVID. R23's nurses' notes identified on 9/30/20 at 8:21 a.m., R23 had symptoms of dry cough, wheezing, runny, stuffy nose, and chest tightness. That same day, R23 tested positive for COVID. The notes made no mention R23 was placed on transmission based precautions when R23's symptoms were identified. Interview with registered nurse (RN)-A identified she assumed the role of infection preventionist (IP) in September 2020. She assisted the director of nursing (DON) with the infection data. The DON was responsible for the IC program. Interview on 9/12/20 at 2:12 p.m., with RN-B identified the DON was out of the facility due to having COVID. The administrator, RN-A, and herself assumed responsibility for maintaining the IC program while the DON was out. The infection surveillance process included to have charge nurses enter the data on the IC Log at the nurses' desk when infection symptoms occurred. Only infections treated with antibiotics were included on the log. Other types of infections and symptoms of potential infection were documented in the nurse notes. RN-B was unsure how infections not treated with antibiotics were tracked in the facility. Charge nurses documented COVID symptoms in nursing progress notes and the Respiratory Infection Screener in the EMRs. The screener generated a score. Staff could view the screens in the assessment tab to identify if COVID symptoms were present. Upon review of the Respiratory Infection Screener with RN-B, RN-B agreed, the screener did not include the additional known symptom of diarrhea. Review of the IC Log The log with RN-B identified symptoms of COVID, and other infections were not included on the log. She agreed the log should include any symptoms of infection to be able to identify potential symptoms of infections to identify potential outbreaks. The first positive case of COVID occurred on 9/30/20. R3 had new onset diarrhea prior to testing positive for Covid, and was not placed on droplet precautions. Communal dining and group activities were discontinued. Residents were encouraged to remain in their rooms. Droplet precautions were not implemented on any residents with COVID symptoms prior to 9/30/20. TBS were implemented when residents were identified as COVID positive, not at the onset of resident symptoms. Interview on 9/12/20 at 11:00 a.m., with the administrator identified the DON was responsible for the IC program. He was not trained in IC, but expected the DON to maintain the IC program and ensure all symptoms and actual infections were tracked and actions taken immediately upon identifying potential outbreaks to prevent infection transmission. Interview on 10/12/20 at 3:21 p.m., with the medical director identified many residents had pre-existing conditions with symptoms similar to COVID. Any new respiratory symptoms, changes in respiratory status, bowel patterns, and general condition should have been documented and a physician contacted to help determine a potential COVID outbreak in the facility. A line list should have in place to identify any potential signs of COVID to identify patterns so TBP's could have been implemented as soon as symptoms were identified to prevent transmission of COVID. PPE Observation on 10/9/20 at 10:00 a.m., of the West and East wing PPE carts identified multiple carts were placed in the hallways. The carts containing PPE were uncovered. Folded gowns, masks, gloves, hand sanitizer and disinfecting wipes were placed on the carts. Face shields and unfolded gowns were piled on top folded gowns and supplies and were in direct contact with the cart contents. An unidentified nursing assistant (NA) walked from the front of the hallway to the rear of the hallway wearing a gown. The NA removed the gown, opened the fire extinguisher door, and hung the gown on the hook above the fire extinguisher at the end of the hallway, and left the area. Interview on 10/9/20 at 10:00 a.m., with trained medication aid (TMA)-A identified residents in the last five rooms of the West Hallway were COVID positive. Staff used washable gowns. There were no concerns with the facility's PPE supply. She was unsure if staff were able to wear gowns in all the rooms, or if they had to change gowns between each room. Staff were not to reuse gowns and were to place used gowns into the laundry bins located in each residents' room. They were not supposed to hang gowns to reuse on the hook inside the fire extinguisher door, nor place them on the clean PPE carts after using them. Observation on 10/9/20 at 10:40 a.m., on the East wing identified NA-B exited R35's room after providing personal care. NA-B walked down the hallway to a PPE cart in the East hallway removed her faceshield, wiped the shield with a disinfectant wipe and before it dried placed it directly on top of clean folded gowns on top of the PPE cart. Interview on 10/9/20 at 10:40 a.m., with NA-B identified there was no designated place to put face shields after being disinfected. Staff were either to disinfect the face shields or throw them away after use. Observation and interview on 10/12/20 at 4:30 p.m., in the West Hallway identified a gown lying on top of the clean PPE cart at the beginning of the hallway outside R9's room. There were both positive and negative COVID residing in the area of the West wing. NA-B was unsure who placed the gown on top of the clean PPE, and removed it an placed the gown in R9's room. NA-C identified R9 was COVID positive, so it didn't matter if the gown was in his room or not. Staff could use it later. Interview on 10/12/20 at 4:35 p.m., with the administrator identified there were no concerns of gown shortages at the present time. Staff were able to wear gowns between COVID positive rooms. Staff were not to store soiled gowns on the PPE carts or in rooms for reuse. Disposable gowns were to tossed in the trash inside resident rooms when cares were completed, and washable gowns were to be placed in the laundry bins inside resident rooms. The facility's undated Infection Prevention Surveillance policy, identified infection prevention begins with ongoing surveillance to identify infections causing or, have the potential to cause an outbreak. The facility was to monitor all residents exhibiting signs and symptoms of infection through ongoing surveillance. The facility was to have a systemic method of collecting, consolidating,and analyzing data concerning the frequency and cause of a disease or event followed by review of to identify areas to improve outcomes. The intent of surveillance was to identify clusters, changes in prevalent organisms, or increases in rates of infection in a timely manner. Environmental rounds were to be performed to ensure staff were in compliance with the infection control policies and procedures. The facility's 9/30/20, Pandemic COVID-19 Plan identified the IC nurse was responsible to create a system to monitor and internally review transmission of COVID-19 among residents and staff in the facility. Monitoring information was used to implement prevention interventions such as isolation, cohorting, and PPE. Staff were to don PPE upon entering the room of symptomatic residents. The facility's undated COVID-19 Community Testing Plan identified a negative COVID-19 test only indicated an individual had no [MEDICAL CONDITION] at the time of testing, and repeat tests could be required. Testing was to complement existing IC interventions but was not a replacement for good IC. The facility's undated Infection Control Program identified the program was designed to prevent the development and transmission of disease and infection. Staff were to investigate, control and prevent infections in the facility, determine what TBP's were to be placed at the time of infections, and maintain records of incidents and corrective actions related to infections. Staff were to handle, store, process, and transport linens to prevent the spread of infections. The facility's responsibility to manage infections included to (1) provide surveillance, investigation and monitoring to prevent the onset and spread of infection; (2) prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; (3) develop, implement, maintain nursing home processes using data records of incidents, corrective action taken, and staff education to improve infection outcomes; and (4) demonstrate proper storage, handling, processing, and transport of linens to minimize contamination. The IJ was removed on 10/12/20 at 5:05 p.m. after observation, interview, and document review determined the facility implemented active monitoring for COVID-like symptoms, implemented TBP if necessary. The facility educated staff to identify, document, and initiate TBP's for residents at onset of symptoms of COVID-19 and notify the provider. IC surveillance was updated to include any potential new COVID-like symptoms or [MEDICAL CONDITION] activity.

Based on interview and record review, the facility failed to ensure that 1 of 1 resident (R10), reviewed for choking had received the therapeutic diet prescribed by the physician. This deficient practice resulted in harm, pneumonia requiring hospitalization and subsequent death. Findings include: R10 failed to receive a physician prescribed pureed diet on [DATE] and choked. According to a review of R10's record, she had been seen in the local emergency roiagnom on [DATE], due to increased lethargy and a decline in oxygen saturation (84%). R10 had been diagnosed with [REDACTED]. On [DATE], R10 had again been sent to the local emergency room due to increased congestion, inability to swallow liquids, change in personality, crackle sounds throughout the right lung, and decreased lung sounds in the lower lobe of the left lung. The resident died in the emergency room . Discharge documentation from the emergency room physician included: "The cause of death I believe is aspiration pneumonia and there are complications of urinary tract infection." R10 had been readmitted to the facility [DATE] with [DIAGNOSES REDACTED]. A nutritional assessment had been completed on [DATE] which indicated R10 needed a lot of encouragement to drink fluids. It was noted R10 was offered pureed diet for both dinner and supper. According to the nutritional assessment R10, "just picks at it (pureed food) and does not eat much at all." The assessment revealed that R10 requested regular texture foods at times, such as bacon and tomatoes and staff would reference her swallowing difficulty and "aspiration diagnosis." In addition, the assessment indicated R10 "refused to wear her dentures, so needed all foods pureed and was a risk for aspiration of foods." An annual minimum data set ((MDS) dated [DATE], identified R10 as having moderately impaired cognition, and inattentive with disorganized thinking. The MDS indicated R10 would hold food in her mouth, or had residual food in mouth after meals, and complained of difficulty or pain swallowing. A care area assessment (CAA) completed on [DATE] by the dietary manager, indicated the resident had nutritional problems as demonstrated by the need for a therapeutic diet (pureed diet), liquid supplements, drinks and extra calories for meals and between meals. A nutritional problem related to coughing or possible aspiration was documented. The CAA indicated R10 had chewing and swallowing problems with reduced ability to feed self. Additional record review indicated that R10 had a long history of problems swallowing and had undergone two evaluations by speech therapy, (one in 2005 and second in 2007). The swallowing studies by the speech therapist in 2005 indicated the resident had "a lot of difficulty with chewing and digesting foods in mouth... takes a long time for her to chew and was still unable to break down food." The speech therapist recommendations had been for the resident to receive a pureed or full liquid diet to prevent choking. The bedside swallow study from 2007 recommended a pureed diet with regular liquids and speech therapy to evaluate the resident's tolerance of the pureed foods. No evidence was found in the medical record of any additional assessment of swallowing/dietary texture recommendations. R10 had remained on the same diet and liquids since 2007. The resident's care plan, last revised [DATE], addressed nutritional deficit, food and beverage intake impairment and chewing problems. Interventions included for R10 to receive a Pureed diet. Nursing assistant (NA)-C was interviewed at 12:57 a.m. on [DATE]. NA-C reported being present in the dining room of the facility on [DATE], when R10 had choked. NA-C reported she'd heard R10 cough. NA-C stated it was a "different cough" than R10 usually had when drinking or eating food. NA-C stated R10 appeared panicky by the look in her eyes and that the resident's lips had become bluish. NA-C said she immediately called for assistance and encouraged R10 to bend forward. NA-C indicated R10 was encouraged to cough and was able to cough up a substance that looked like potatoes with chunks of fish. NA-C stated, "all staff knew R10 had problems swallowing and eating" and that had been an issue for R10 as long as she had been in the facility. NA-C stated that the nursing assistant who had been feeding R10 had stated that she did not think she'd fed R10 any fish, just potatoes and that the coughing started when the NA gave the resident liquids. NA-C also added that R10 did not like pureed food and generally only drank her liquids. An interview was completed with the facility's Director of Nursing (DON) at 2:15 p.m. on [DATE]. The DON stated she had responded to a nursing assistant's call for assistance in the facility dining room at 12:15 p.m. on [DATE]. The DON stated she'd observed R10 choking, but no interventions had to be implemented as the resident had good air exchange and continued to be able to cough. The DON confirmed the food served to R10 at that meal had not been pureed. She stated she had talked to the cook who had served the meal right after the incident. The DON said the cook had stated, "fish is hard to puree" in response to why she had not pureed it. The DON stated the cook was then told that it was critical that if the diet order was for pureed food, the food needed to be pureed. An interview was conducted with dietary assistant (DA)-B at 1:15 p.m. on [DATE]. DA-B stated she had been aware that the cook had not served R10 the correct texture meal on [DATE] at noon. She also stated she had been present when R10 had choked. DA-B reported the cook had previously served the resident the wrong texture meals, and stated she had talked to the cook about this without a positive response. DA-B indicated that the cook did not listen to the feedback and was "really nasty" afterward. DA-B stated that the dietary manager had also spoken to the cook in the past about serving residents' meals that were not the correct texture. DA-B denied having informed the dietary manager of the issue, but stated she had overheard the dietary manager speaking to the cook about this. DA-B further reported that the cook had chopped, not pureed R10's noon meal on [DATE]. DA-B stated, "all the staff knew that R10 had a problem with swallowing." An interview was completed with the dietary manager via phone at 10:14 a.m. on [DATE]. The dietary manager reported that R10 had a long history of problems chewing and swallowing problems. The dietary manager confirmed R10 was on a pureed diet. The dietary manager stated she had not been working the day that R10 had the choking incident but was aware of the incident and was involved in the decision to terminate the employment of the cook, who had served R10 the wrong textured meal on [DATE]. The dietary manager reported she had been unaware the cook had not been providing R10 with the correct texture of diet. She confirmed the cook had been terminated from employment at the facility. A phone interview was conducted at 3:45 p.m. on [DATE], with the doctor who had admitted R10 to the local hospital on [DATE]. The doctor confirmed R10 had been diagnosed with [REDACTED]. He stated that it was very possible this had been caused by aspirating food, such as the choking episode from [DATE], as the timing was "just about right".