Parkview Manor Nursing Home

F-F726

Findings include:

Interview on 6/24/24 at 2:56 p.m., with administrator identified he had spoken to the director of nursing (DON) about the facility assessment just this morning as they were unsure when it had been last updated.

She revealed he had just finished working on the facility assessment about a half hour ago and he would provide what they had at this time. He reported he was unable to find the old facility assessment and he started a new one.

Interview on 6/25/24 at 4:18 p.m., with nursing assistant (NA)-A identified there was no review of skills or competencies where someone watched them however, they did complete training on-line.

Interview on 6/26/24 at 7:46 a.m. with director of nursing (DON) identified department heads had not been completing annual evaluations however, the previous administrator completed evaluations on all the department heads. She identified that was something the facility would be working on. She further revealed

she had not completed any skills training or competencies with staff other than the lift company that came in once a year to cover proper use of the mechanical lifts. She also identified she had not completed any competencies with any nursing staff but wished she had more time to do get those types of things.

Review of the 6/24/24, facility assessment tool identified staff education and competencies were necessary to support the care needed for the residents, including certifications as applicable. The facility assessment identified a list of training and competencies which was not all inclusive that included communication, resident's rights, abuse, neglect, and exploitation, culture change, and infection control which included procedures for infection control. The infection control competencies included hand hygiene, standard precautions, isolation, use of personal protective equipment, and environmental cleaning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 245553 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245553 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Manor Nursing Home 308 Sherman Avenue Ellsworth, MN 56129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 38687 potential for actual harm Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Residents Affected - Many Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 28 residents.

Findings include:

Review of QAPI minutes from 6/14/24 identified QAPI was lacking documentation of facility goals and analysis. There was also no response for how facility would meet goals, or that previous goals were evaluated to identify if current measures were met or new processes had been identified.

Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON identified she was agreed there was no analysis of the data brought forth to QAPI, measurable goals set, or if goals were not met, or what actions

the facility was going to take to meet their goals. There was no formal process for staff or residents and/or their families to provide feedback to improve areas identified in QAPI.

Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no mention of measurable goals, or analysis of data to ensure new areas were identified or if older area benchmarks would be achieved or how compliance would be identified. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 245553 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245553 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Manor Nursing Home 308 Sherman Avenue Ellsworth, MN 56129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 38687

Residents Affected - Many Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 28 residents.

Findings include:

Review of QAPI minutes from 6/14/24 identified No PIP projects were noted.

Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON) identified the facility had not done a PIP project, as their new administrator had opted not to participate in that project. She agreed PIP projects were crucial in identifying high level areas of concern to provide the highest care possible to residents.

Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no indication how QAPI would identify PIP projects or how that information would be educated to staff and residents and their families so input could be achieved and PIP measured to see if goals would be accomplished or how compliance would be achieved. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 245553 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245553 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Manor Nursing Home 308 Sherman Avenue Ellsworth, MN 56129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49336 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure 2 of 2 observed nurse Residents Affected - Few aides (NA) (NA-B and NA-C) appropriately cleaned and disinfected 1 of 1 whirlpool tub according to manufacturer's guidelines and use personal protective equipment (gown an gloves) (PPE) while cleaning and disinfecting the whirlpool tub. This affected 2 of 2 current residents (Resident R3 and Resident R11) who utilized the whirlpool tub for bathing.

Findings include:

Observation and interview on [DATE REDACTED] at 9:04 a.m., with NA-B on the north unit shower room identified she retrieved a spray bottle labeled Clorox Fuzion cleaner/disinfectant. She then sprayed the inside of the whirlpool tub and had reached for a white long handled brush and scrubbed the inside of the tub. NA-B waited 1 minute and pressed the FILL button. When pressed water came out of the jet and was flushed to

the floor of the whirlpool tub down to the drain. She pressed and held the DISINFECT button for 30 seconds. When pressed, a small amount of clear water came from the jet to the floor of the whirlpool down to the drain. She grabbed the brush and scrubbed the interior whirlpool with the water from the floor of the whirlpool tub. She pressed the RINSE button and used the water sprayer to rinse the solution inside the whirlpool for 3 minutes. NA-B was unaware how long the disinfecting the whirlpool would take or if there was any disinfecting solution coming out of the jets at all. NA-B was shown to perform the procedure as noted, however, she felt the spray solution was actually disinfecting the tub. NA-B wore no PPE while performing that task.

Review of the posted Cascade Aqua-Aire Tube Operation System guidelines identified staff were to:

1) Close and lock the door.

2) Remove any viable tissue, residue, or fluids from the tub by pressing the SHOWER button and rinsing the inside tub surfaces with the shower sprayer.

3) Press the FILL button and turn the TEMPERATURE control knob to the left to its warmest level to heat the disinfectant solution.

4) Press the FILL button again to turn off the water.

5) Place drain plug over the drain.

6) Press and hold the DISINFECT button. While the disinfect button was held down, the cleaning solution would run through the air injection system and out the air jets.

7) Release the button after seeing solution coming out of all the air jets.

8) Solution that remained in the foot well of the tub should be cleaned with long-handled brush to scrub all interior surfaces of the tub. Staff were to scrub around the door seal area and temperature probe area and allow the disinfectant to stay on surface for 10 minutes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 245553 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245553 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Manor Nursing Home 308 Sherman Avenue Ellsworth, MN 56129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 9) Remove plug from the drain.

Level of Harm - Minimal harm or 10) Finish rinsing the interior surfaces of the tub with the shower sprayer. potential for actual harm 11) Press the Aqua-Aire button to start the air blower and run it for 30 seconds and then turn off the air Residents Affected - Few blower.

Interview on [DATE REDACTED] at 9:17 a.m., with housekeeping supervisor stated staff were to be using the Triforce spray bottle solution for cleaning and disinfecting of the whirlpool tub. The whirlpool tub manufacturer identified [NAME] Classic cleaning and disinfecting solution was to be used for the air jet whirlpool tub, but

the facility no longer used that product. The facility now used Triforce spray or the Clorox Fuzion spray. The reason the [NAME] products from the manufacturer were not used any longer was staff had no access to the door to where the solution was to be added to the compartment due to a water heater that had been placed near the whirlpool preventing access to the compartment. The compartment was what held the disinfecting solution where a specific amount would have been pumped via automated design, into the tub per manufacturer's instructions.

Observation and interview on [DATE REDACTED] at 12:37 p.m., with NA-C identified she pressed the FILL button on the whirlpool tub and sprayed the inside of the whirlpool for 30 seconds. She reached for the Triforce (bleach) solution spray bottle and sprayed the inside of the whirlpool walls and seat. NA-C noted the solution was to sit on the interior surface with a wet contact time of 5 minutes. The smell of the solution permeated the shower room and was overpowering. She pressed the FILL button and rinsed the whirlpool with shower sprayer for 30 seconds. She stated she would use the brush to scrub the inside of the door when spraying

the interior of the tub. She stated the Triforce had an irritating smell. She pressed the DISINFECT knob for 30 seconds. She then stated she would rinse the whirlpool and use the shower sprayer for another 30 seconds. She stated cleaning the whirlpool took 10 minutes total time after each resident bath. She was unaware if the spray cleaner

Interview on [DATE REDACTED] at 5:37 p.m., with director of nursing (DON) stated the maintenance director had planned to relocate the water [NAME] to another area of the facility so staff could access and utilize the correct whirlpool disinfectant solutions as indicated on the whirlpool manufacturer instructions. She stated staff would have to continue to use the available disinfectant spray solution the facility had in place for cleaning and disinfecting the whirlpool until the water heater could be relocated. The DON was unaware if staff were utilizing the correct product or if the products were appropriate to clean and disinfect the whirlpool tubs. The DON agreed staff should wear PPE while performing that task.

Interview on [DATE REDACTED] at 7:35 a.m., with BETCO specialist identified stated the Triforce solution would have a contact time of 3 minutes when wet and should be sprayed on a dry surface. Gloves and eye mask should be worn when using the spray solution and surfaces should be wiped down not rinsed with water after solution had been applied to the surface. The BETCO specialist stated the product was designed for overall cleaning and disinfection of surfaces, but agreed it was not made for the whirlpool tub specifically and could not verify it would reach all surfaces of the tub or around the jets when sprayed on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 245553 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245553 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Manor Nursing Home 308 Sherman Avenue Ellsworth, MN 56129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Observation and interview on [DATE REDACTED] at 8:04 a.m., with maintenance director identified the facility installed a water heater in the east unit shower room and confirmed the water heater had been installed in the year Level of Harm - Minimal harm or 2016. He demonstrated as he faced the whirlpool, that to the left of the tub, there is a locked compartment potential for actual harm that was to have disinfectant solutions connected to the whirlpool tub tubing. He stated the right side of the tub had another locked compartment and when opened, he could not access the solutions that were Residents Affected - Few originally stationed to the left of the whirlpool. He stated the water heater had blocked access to the left compartment and was aware that had been an issue for staff to replace the disinfectant solution as it was impossible to reach.

Further interview on [DATE REDACTED] at 9:35 a.m., with the maintenance director identified the facility had extra whirlpool tub solution stored in the maintenance director's office that was not in use. He confirmed the solution expired July of 2023 and would not be safe to use for cleaning or disinfection. He stated he was sure

the disinfectant cleaner solution connected to the whirlpool had ran dry and therefore when staff pressed the DISINFECT button, only water would have come out of the jet.

Further interview on [DATE REDACTED] at 11:15 a.m., with the DON identified the facility had no formal checklist that would include staff being trained on whirlpool use and cleaning, nor had there been documentation of competencies. She had no copies of employee training accessible on file at the facility to prove that training had been completed. NA's and would be trained on the job alongside other colleagues.

Review of the current, Triforce Disinfectant Directions for Use identified staff were to use ,d+[DATE REDACTED] ounce per gallon of water and apply to surfaces allowing them to be wet for 3 minutes. For heavily soiled areas, cleaning prior to disinfection was required. The product was not to be used for areas that may come into contact with any mucous membranes of a body.

Review of the undated, hand-typed Whirlpool Cleaning policy identified the whirlpool bath was to be routinely disinfected to ensure appropriate infection control. When a bath was completed, the entire whirlpool was to be swabbed with the whirlpool disinfectant. Staff were to then use a small white hand mop with whirlpool cleaner in a small bottle. The instructions then noted staff were to rinse thoroughly with clear water. When whirlpools were done for the day, staff were to fill a white bucket to the mark FILL TO HERE with water and 4 ounces of whirlpool cleanser and submerge the agitator mechanism in the bucket and let it run for 10 minutes. Staff would then swab the entire tub and chair with whirlpool cleanser and rinse with clear water. There was no indication how old the policy was, what tub the instructions were for, or if the solution or whirlpool tub were the same as when the policy was created.

Review of 2020, Training policy identified initial orientation would be given to all employees and the online Healthcare Academy would be provided yearly for employee training. The facility would monitor completion of training and would send the completed training to the administrator. There was no indication training was specific to the facility and not generalized overall training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 245553