Every finding on record at Birchwood Care Home

Based on observation, interview, and document review, the facility failed to ensure episodes of leaving the building unsupervised were evaluated or assessed to determine what, if any, additional supervision or monitoring was needed to help prevent subsequent exits from the building for 1 of 3 residents (R1) reviewed for elopement and whom had cognitive impairment. R1 left the care center without staff knowledge was found outside in an adjacent alleyway.Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS outlined R1 demonstrated no wandering behaviors, however, did have dementia and Alzheimer's Disease. Further, the MDS recorded R1 as being independent with most mobility tasks (i.e., walking, transferring). R1's Wander Risk Assessment, dated 3/6/25, identified R1 had been in the care center for less than 30 days, was un-familiar with the surrounding area(s), and had both short and long-term memory loss. The evaluation identified R1 was unable to safely cross streets and did not have the skills to navigate independently in the community. The evaluation added these points and others for a combined score which read, 25 pts [points], with dictation adjacent, High Risk. A summary was listed which read, Resident high risk, she is unable to leave facility unsupervised. The evaluation outlined R1's care plan was updated with this information on 3/13/25.R1's care plan, printed 7/29/25, identified R1's actual or potential problems as of that date along with each' respective initiation and revision date. The care plan outlined a section labeled, ASSESSMENT OF RESIDENT'S ABILITY TO LEAVE THE FACILITY SAFELY, which dictated R1 was deemed unsafe to leave the facility unsupervised. The care plan outlined, 5/22/25 Deemed unable to sit outside unsupervised. The care plan listed several interventions to help ensure R1 didn't leave the facility unsupervised including having social services provide reminders to R1, working to find a memory care setting and, SS [social services] and TR [therapeutic recreation] will do Wandering Risk Assessment Annually [sic] and/or as needed. IDT [interdisciplinary team] will determine if resident is able to leave the facility unsupervised. This section was last revised on 6/11/25; with no interventions being revised since 3/13/25.The care plan continued and outlined a section labeled, VULNERABLE ADULT STATUS, which dictated, 7/17/25: Resident found coming out of alley off facility property by SSD [social services director]. Brought to nurses station. The interventions listed outlined R1 as being on hourly checks and reminders since 4/10/25 and reporting incidents to the common entry point (CEP) as required. On 7/17/25, an intervention which read, Staff will stay with resident at all times when door is unlocked, was initiated.On 7/29/25 at 9:12 a.m., a tour of the second floor of the care center was completed. The unit consisted of a single, long hallway with resident' rooms on each side and a central commons area. The North side of the hallway opened into an open stairwell which lead to the main entrance of the care center. The main entrance had signage posted which directed residents to sign out before leaving, and about hours which the door would best be used for safety reasons. The South side of the unit had a closed, un-alarmed door which opened to another stairwell. This lead down to an exterior door which opened to a back alleyway with cars parked outside. The exterior door had a red-colored, alarm-type stop sign placed which was deactivated at this time. An unidentified male resident was seen walking through the door to outside and the door did not alarm. R1's progress notes, dated 3/1/25 to 7/21/25, identified the following: On 3/1/25, R1 admitted to the care center and presented as confused and/or forgetful. The note outlined R1 was placed on hourly checks. On 3/13/25, the IDT met to review R1's Wandering Risk Assessment. R1 was determined to be unsafe to leave the facility unsupervised. On 3/17/25, R1 was found sitting outside the facility on a bench around 6:25 a.m. without staff present. The note outlined R1 was looking for a lighter and added, . was reminded that she cannot be out smoking without staff . came into building with staff. On 4/3/25, R1 was . up a number of times going into other rooms looking for cigarettes . was redirected to go back in her room. On 5/22/25, the IDT reviewed R1's ability to leave the facility unsupervised or sit outside without staff present. The note outlined, . in consensus that she would not be safe unsupervised . will incorporate supervised times to sit outside and encourage to participate in TR activities and walking. On 6/10/25, R1 was again found outside in front of the building. The note outlined, . reminded [R1] that she is unable to sit outside unsupervised . redirected and came inside of the building right away. On 7/17/25, R1 was seen outside without staff coming out of the alley way onto the sidewalk next to an adjacent building. R1 stated she was going for a walk. A subsequent note, dated 7/17/25, identified the IDT discussed R1 leaving the facility unsupervised to go for a walk adding, SS director will follow up with [R1] family about placement and will continue looking for placement. On 7/24/25, R1 was discharged from the care center to another venue. However, R1's medical record was reviewed and lacked evidence R1 had been comprehensively reassessed or evaluated for what, if any, additional interventions had been needed or discussed after R1 was found outside on 6/10/25. There was no evidence documented in the record to support the IDT had reviewed this incident; nor any rationale for what, if any, changes to the interventions in place were considered to reduce the risk of subsequent incidents despite R1 being found unsupervised outside again. When interviewed on 7/29/25 at 9:23 a.m., nursing assistant (NA)-A stated they had worked with R1 multiple times and described her as having a memory problem, adding R1 would likely not have known how to find her way back if she'd ever have left the campus unsupervised. NA-A explained when a resident was on hourly checks, then staff would pop in and check on them just to ensure they were onsite, and these were tracked on a paper flow sheet which were saved by the care team. NA-A stated the building was not locked and there was no full-time wander/exit alarms to secure it (i.e., Wander-guard System). NA-A recalled the care team trying to find new placement for R1 as Birchwood was not a memory ward unit. NA-A stated they were aware R1 had been found outside in the alleyway (7/17/25), however, was unaware of the other incidents adding, I think it was only one time [found outside]. NA-A stated after R1 was found outside on 7/17/25, the activities staff then got more directly involved with R1. When interviewed on 7/29/25 10:05 a.m., activities aide (AA)-A stated they had worked at the campus only a few weeks, but recalled working with R1. AA-A stated R1 would repeatedly want to go outside and smoke adding, She [kept] wanting to go smoke outside. AA-A stated they often tried to keep R1 entertained with card games but, again, would often ask about smoking. AA-A stated they were not working when R1 was found outside on 7/17/25, however, expressed they did not recall any changes to their (activities) approach with R1 for the duration of her stay. At 10:11 a.m., the activities director (AD) joined the interview and expressed it was just that last week R1 was there when activities increased their one-to-one and oversight of R1. Prior to 7/17/25, AD stated activities staff would go outside to smoke with R1 but didn't always remain with her. AD verified the one-to-ones were added due to R1 being found outside on 7/17/25, as they determined they gotta do something here.On 7/29/25 at 10:32 a.m., licensed practical nurse (LPN)-A and LPN-B were interviewed, and LPN-A verified they helped to oversee the entire building. LPN-A explained residents were evaluated upon admission to determine if they could leave the building unsupervised. LPN-A stated the 'Wandering Risk Assessment' would be completed by social services and then reviewed by the IDT and, from there, the care plan would be developed. LPN-A recalled R1 had memory issues and the IDT had determined in the very beginning that she was unable to safely leave the building or campus without supervision. LPN-A verified the building was not locked or armed with a wandering system, and explained R1 had been placed on hourly checks for a long time prior to 7/17/25 due to her cognition. LPN-A acknowledged R1 as being found outside multiple times unsupervised and expressed social services had been actively working to get other placement for R1 in addition to the ongoing hourly checks being done. LPN-A reviewed the medical record and verified the progress note (6/10/25) which R1 was found outside the building unsupervised. LPN-A and LPN-B both expressed that would have been reviewed by the IDT. However, LPN-A verified there was no documented progress note in the record to support that had happened. LPN-B reviewed the collected IDT meeting minutes which were contained in a white-colored binder, and expressed they were unable to locate evidence R1's incident of being found outside unsupervised was discussed or reviewed by the IDT. LPN-A and LPN-B both felt it had been discussed in the IDT; however, LPN-A confirmed the IDT discussion and/or review would typically be recorded in the progress notes, too. The interview continued and LPN-A stated on 7/17/25, the social worker (SW)-A was coming into work and found R1 outside in the alleyway. LPN-A stated it was at that point the IDT determined R1 needed more one-to-one oversight so they had AA-A coming in to just sit more with R1 and keep closer supervision on her. At 10:57 a.m., SW-A joined the interview. SW-A explained R1 had been on hourly checks since she admitted to the care center, and they had been attempting to find better placement throughout her stay. SW-A expressed re-doing the Wandering Risk Assessment after the 6/10/25 incident likely wouldn't have changed their approach or interventions. SW-A stated after the 7/17/25 incident is when they decided a more secured unit was needed and accelerated R1's discharge planning process. SW-A stated the incidents prior to the 7/17/25 incident would have triggered new interventions as R1 wasn't leaving the grounds. SW-A verified the incidents of being found outside were something that would typically be reviewed by the IDT, and they expressed they thought such had been done. However, SW-A and LPN-A both verified the lack of medical record documentation to support this had happened, and LPN-A added aloud, I think something got missed. SW-A stated the incident on 7/17/25 triggered a more immediate response as R1 was then attempting to leave the physical grounds instead of just sitting outside unsupervised. LPN-A reiterated the interventions already in place throughout R1's admission but acknowledged, Maybe we did not get everything we should have in there [record], but we did do it. Further, SW-A stated ensuring residents were properly supervised was important to keep them safe. On 7/29/25 at 11:18 a.m., the director of nursing (DON) was interviewed. DON stated any incident, including elopements, were reviewed by the IDT and a progress note was typically entered into the medical record with their evaluation or decision-making on it. DON reviewed R1's medical record and verified it lacked such evidence about the 6/10/25 incident when R1 was found outside unsupervised adding aloud, I don't see anything. DON stated it was important to ensure the IDT reviewed incidents and recorded them in the record as it was all part of keeping her safe. DON added, It's the process we have in place to make sure we're addressing it [incident]. A facility-provided Elopement Risk Assessment Policy, dated 1/2025, identified the facility would assess upon admission, quarterly and as needed for this risk adding, Elopement is wandering away from the facility and is dangerous for the resident. The policy outlined any resident with a score of 7 or higher would have a safety plan incorporated into their care plan adding, IDT will meet during weekly meeting to discuss ability to keep safe and determine if the resident needs a higher level of care if they score greater than 7 on the Wandering Elopement Risk Assessment. In addition, a facility-provided Birchwood/Grand Avenue IDT Policy, dated 4/2025, identified the team would meet daily (Mon-Fri) and discuss falls or behaviors. The policy directed, 6. A progress note will be put in the residents chart with interventions put in place.

Based on observation, interview, and document review, the facility failed to ensure food items were properly stored, labeled, and dated to reduce the risk of physical cross-contamination and potential foodborne illness. This had the potential to affect all 59 residents, staff, and visitors who consumed food from the kitchen. Findings include: On 3/17/25 at 12:11 p.m., an initial kitchen tour was completed with dietary aid (DA)-A. In the walking refrigerator a sheet pan cart with several unwrapped and undated trays contained the following items: * Three trays with about 20 cheese and eggs English muffin sandwiches with a piece of parchment paper on top * Two trays with tater tots with a piece of parchment paper on top * Two trays with apple bran bowls, each containing about 35 bowls with a piece of parchment paper on top. * One tray of mint and chocolate dessert with a piece of parchment paper on top * In the bottom of the cart there were two trays of breaded pieces of chicken, with no parchment paper on top. During interview on 3/17/25 DA-A verified the unwrapped and undated trays and stated, The cook should wrap the trays before she puts them on the freezer. DA-A stated the trays have food prepared in advanced. The food on the trays will be cooked and served for dinner tonight or the next day. During interview on 3/18/25 at 8:15 a.m., the director of nutritional services (DNS) stated we didn't know we had to wrap the trays. DNS stated storing unwrapped food items could posed a risk for cross contamination, especially if something drips. During interview on 3/20/25 at 9:46 a.m. the administrator stated all the food should be labeled with dates and wrapped. It's an infection control issue due to contamination and the risk for foodborne illnesses. Administrator added It's not acceptable. A Food Storage policy was requested but was not provided.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 5 of 5 residents (R9) reviewed for restraints, (R26) reviewed for dialysis and Preadmission Screening and Resident Review (PASARR), and (R27, R53) reviewed for falls. Findings include: The Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2024, directed staff under section J to identify whether a resident had any falls since admission, entry or reentry or prior Assessment (OBRA or Scheduled PPS), whichever was more recent. If a resident fell , the RAI directed staff to continue to J1900, number of falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). The RAI further defined prior assessment as the most recent minimum data set (MDS) assessment that reported on falls. J1900 directed staff to code either none, one, or two or more falls in three separate boxes that included: 1. No Injury, defined as no evidence of injury was noted on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident, no change in the resident's behavior is noted after the fall, 2. Injury (except major) defined as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain of pain, and 3. Major Injury defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematoma. R27's annual MDS dated [DATE], indicated R27 had moderate cognitive impairment, and had not fallen since admission or prior assessment. R27's quarterly MDS dated [DATE], indicated R27 had severe cognitive impairment, had falls since admission, entry or reentry or prior assessment (OBRA or Scheduled PPS) whichever was more recent, had two or more falls without injury, had 2 or more falls with injury (except major), and had 2 or more falls with a major injury. R27's care plan dated 9/15/24, indicated R27 was at risk for falls due to multiple risk factors. Interventions indicated R27 had fallen on 12/3/24, 12/24/24, and 12/29/24. The fall on 12/3/24 resulted in no injuries noted. The interdisciplinary team (IDT) discussed R27's falls on 12/24/24, and 12/29/24, and R27 was encouraged to call for assistance upon ambulation and was educated to stay in bed during ECT treatment and to call for assist if she required help. The care plan lacked information whether R27 received any injuries on 12/24/24, and 12/29/24. R27's physician's orders dated 8/28/23, indicated to monitor for falls and unsteady gait every shift. R27's progress notes dated 12/3/24 at 11:27 a.m., indicated R27 fell on [DATE], and denied any pain or discomfort, was assessed and found to have no injuries. R27's progress notes dated 12/24/24 at 9:45 a.m., indicated R27 fell at ECT (electroconvulsive therapy) and there were no signs of acute injury, R27 had full range of motion, R27 dug her fingernails into her arm and injured a fingernail that was wrapped. R27 denied pain or discomfort. R27's progress notes dated 12/29/24 at 4:35 p.m., indicated R27 had a questionable fall and directed staff to see the risk assessment for further information. R27's Fall Risk Assessments located under the Assessments tab indicated the most recent fall risk assessment was dated 1/3/25, and then again on 10/4/24. R27's Fall Risk assessment dated [DATE], indicated R27 was mostly steady during transitions from sitting to standing, walking, turning, and transferring on and off the toilet and was independent with all mobility without any device. R27 had no functional limitation in range of motion. After ECT treatments, R27 can sway or not fully watch where she is going and can be tired and obtunded and had every shift orders to monitor for gait and stability changes. The form lacked information pertaining to falls and injuries. R27's Fall reports dated 12/3/24, 12/24/24, and 12/29/24, were reviewed and R27 had no injuries on 12/3/24. On 12/24/24, R27 dug her fingernails into her arm and injured a fingernail and otherwise was documented as having no acute injury. On 12/29/24, R27 was on the floor and no injuries were noted. During interview on 3/19/25 at 9:25 a.m., registered nurse (RN)-A stated she was the MDS nurse and was still training and working with the director of nursing and took over the MDS in August or September and stated she completed the coding and helped with the care plan. During interview on 3/19/25 at 11:26 a.m., licensed practical nurse (LPN)-A stated when a resident falls, they are assessed and if injured, call 911 and send the resident to the hospital and complete a risk assessment. LPN-A stated the risk assessment was documented under care management and stated she saw R27 had two falls dated 12/3/24 and 12/29/24. LPN-A stated R27 did not have any injuries from the falls and further stated R27 had not had any falls she was aware of that resulted in injury. LPN-A stated the MDS may be documented in error. During interview on 3/19/25 at 11:43 a.m., registered nurse (RN)-A stated if a resident fell , the facility assesses the resident and if the fall was unwitnessed, complete neuro checks, update the family, doctor, director of nursing, and complete a progress note. Further, they care plan and discuss at IDT in order to create fall interventions. RN-A viewed the risk management reports since 10/4/24, and stated R27 had a fall on 12/3/24, 12/24/24, and 12/29/24. RN-A stated R27 had no injuries after viewing each of the notes and verified R27 had three falls since October. Both RN-A and the director of nursing (DON) verified R27 had no injuries and the DON stated the MDS should have indicated R27 had no injuries. A policy, Interdepartmental MDS Review, dated January 2025, indicated it was the policy of the facility to ensure that each resident's MDS will be completed on admission, quarterly, annually and significant change using current, accurate documentation and assessments specific to that resident. Each resident will be assessed on admission, quarterly, annually and significant change for the purpose of the completion of the MD. Each department represented by the IDT will complete the following assessments for the purpose of gathering the most accurate information specific to each resident. Nursing will complete bowel and bladder assessment with summary note, monthly self administration of medication with summary note, pain, falls, EPSE, foot, DISCUS assessments, care plan initiation, review and updating, nursing will review MDS/Care Conference schedule and distribute to all IDT members on a quarterly basis. Documentation in progress notes upon completion of the MDS interviews. Nursing will be responsible for the MDS sections B, GG, H, I, J, L, M, N, O, P, plus CAAs (care area assessments) triggered for these areas. Nursing is also responsible for sections J and L. 48065 R53 R53's quarterly Minimum Data Set (MDS) dated [DATE] indicated R53 was cognitively intact, had delusions, hallucinations, had no behaviors, was independent with activities of daily living but needed set up for eating and showers. MDS indicated R53 had a fall with major injury. R53's clinical diagnosis report printed 3/20/25, indicated schizoaffective disorder, bipolar disorder, anxiety and renal disease. R53's progress note dated 1/23/25, indicated R53 reported she fell in her room at 2:00 a.m. R53 stated she fell by her bed on her way to the bathroom and did not hit her head. Progress note indicated a head-to-toe assessment was completed and no injuries were noted. During interview on 3/17/25 at 1:33 p.m., R53 stated she fell , didn't harm herself, and added I took responsibility, but I don't want to talk about it. During interview on 3/19/25 at 2:09 p.m., registered nurse (RN)-A stated she started to do the MDS assessments in September 2024 and was still learning the MDS process. RN-A indicated she completed R53's MDS. RN-A reviewed the R53's record, and verified R53 didn't injured herself when she fell . RN-A stated it was a coding error. 49617 R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and diagnoses of anxiety and schizophrenia (a chronic mental condition that affects a person's ability to think, feel, and behave clearly). Her MDS further indicated she utilized a limb restraint less than daily. R9's order summary report printed 3/21/25, showed her active orders as of 12/1/24 and lacked an order for a limb restraint. R9's assessments were reviewed 3/19/25 and lacked documentation of an assessment for a restraint. R9's care plan was reviewed 3/19/25 and lacked documentation of the use of a limb restraint. R9's electronic health record (EHR) was reviewed on 3/19/25 and lacked documentation of the use of a limb restraint. Per interview on 3/19/25 at 11:46 a.m. with licensed practical nurse (LPN)-A, there was no use of restraints in the facility. Furthermore, LPN-A stated R9 gets anxiety and gets nervous, but is nobody that would ever need to be restrained. LPN-A could not think of any device that would be considered a restraint for R9. During interview on 3/19/25 at 2:43 p.m., registered nurse (RN)-A verified completing R9's quarterly MDS dated [DATE] and the affirmative response to the use of a restraint for R9. RN-A stated, nobody here uses a restraint. This was an error. R26 R26's annual Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and had diagnoses of cirrhosis (chronic liver disease), kidney failure, kidney stones, liver failure, and diabetes. The MDS also indicated he was considered by the state level II Preadmission Screening and Resident Review (PASARR) process to have a serious mental illness. Furthermore, the MDS reported he was not receiving dialysis. R26's order summary report printed 3/19/25, included the following orders: - assess thrill ad [sic] bruit each shift. If not present, notify MD. No blood pressure on left arm, dated 11/18/08. - daily weight one time a day for dialysis, dated 11/16/24. R26's care plan dated 2/9/24, identified his risk for complications related to chronic kidney disease and indicated he was receiving dialysis on Mondays, Wednesday, and Fridays. Additionally, his care plan identified his potential for complication related to his permcath (a type of long-term venous access to the bloodstream used for hemodialysis) hemodialysis access, which was placed in the hospital on 12/14/23. A Davita treatment details report dated 1/2/25, indicated R26 received hemodialysis treatment on 1/2/25. A Davita treatment details report dated 1/4/25, indicated he received hemodialysis treatment on 1/4/25. A Davita treatment details report dated 1/6/25, indicated he received hemodialysis treatment on 1/6/25. A Davita treatment details report dated 1/13/25, indicated he received hemodialysis treatment on 1/13/25. A Level I: Screening for Mental Illness or Mental Retardation dated 11/17/08, indicated R26 did not meet the requirements to be referred for a level II evaluation and determination. R26's electronic health record (EHR) was reviewed 3/19/25 at lacked documentation of a level II PASAAR. Per interview on 3/17/25 at 6:39 p.m., R26 confirmed he went to dialysis three times per week, on Mondays, Wednesdays, and Fridays. Per interview on 3/19/25 at 11:42 a.m. with licensed practical nurse (LPN)-A, R26 had been on dialysis for about a year. During interview on 3/19/24 at 2:44 p.m., registered nurse (RN)-A verified completing his annual MDS dated [DATE] and confirmed he was on dialysis. RN-A stated R26's MDS should have identified his use of dialysis. A request was made for R26's level II PASARR on 3/19/25 at 2:39 p.m. During interview on 3/19/25 at 3:18 p.m., social worker (SW)-A stated he did not have a level II PASARR because he did not require one. SW-A reviewed his annual MDS dated [DATE] and verified the incorrect data and stated, that was coded wrong, it should have been no. A facility policy pertaining to MDS accuracy was requested, but the director of nursing (DON) stated the facility did not have one.

Based on observation, interview, and document review, the facility failed to ensure grievances were acted upon and if needed investigated or resolved for 1 of 1 residents (R46) reviewed for grievances. Findings include: R46's Annual Minimum Data Set (MDS) dated [DATE], indicated it was very important to choose what clothes to wear, take care of personal belongings. R46's quarterly MDS dated [DATE], indicated intact cognition, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have hallucinations or delusions, behaviors, and did not reject cares. R46's progress notes were reviewed from 8/7/2023, and lacked information R46 was missing clothing items. R46's progress notes dated 10/4/23, indicated R46 reported missing money and a vulnerable adult report and online police report were completed. R46's care plan dated 2/4/25, indicated R46 had intact cognition. During interview on 3/17/25 at 3:52 p.m., R46 stated when he first came, his clothes were missing and never got them back. R46 stated he reported it and thought he completed a form and stated he was missing two pairs of shorts and a number of shirts adding his memory was not the greatest and further stated he asked to be reimbursed, but nothing came of it and stated his clothes were old, but he had no income for replacing them. During interview and observation on 3/18/25 at 11:37 a.m., the laundry assistant (LA)-A stated if a resident reported missing items, she had a list she wrote down and stated she would search in closets and had a 90% success rate in finding items and stated missing clothing happened a lot. LA-A provided a handwritten list located in the laundry room that indicated a date, 9/25/24, with R46's name and a list that contained a shirt, shorts, and boxer shorts and stated she had not yet been able to locate the items and further stated if she cannot locate something, she updates the supervisor. During interview on 3/19/25 at 8:57 a.m., nursing assistant (NA)-B stated R46 was an accurate historian and if residents reported missing items, they look for the missing items and if they cannot locate them, report to social services. During interview on 3/19/25 between 12:54 p.m., and 12:56 p.m., social worker (SW)-A stated they try to locate missing items and sometimes residents miss place items and they try to track steps when they last saw the missing item. SW-A stated she has residents make a list and if they are unable to locate it, a notification is sent to maintenance, and nursing. At 12:56 p.m., social services assistant (SSA)-B stated a grievance form was normally completed in order to track it and asks to conduct a room search, and if items are clothing articles, goes to the laundry room and documents on the grievance form. SW-A and SSA-B stated they don't always document other than on a grievance form. SSA-B viewed the grievance log and stated she did not recall R46 reporting missing clothing items and verified there were no grievances in the grievance log for R46. SW-A stated she was not aware of R46 missing any items. SW-A further stated they completed an inservice on grievances and stated staff were supposed to report to her or SSA-B. During interview on 3/19/25 between 1:04 p.m., and 1:07 p.m., with LA-A and SW-A, LA-A stated she informed SW-A of the missing items and showed SW-A the missing items list dated 9/25/24, and read off the missing items stating R46 was missing a green shirt with gray on the back, a pair of white shorts with blue stripes and a pair of boxer underwear. LA-A further stated R46 was looking for reimbursement for the items. At 1:07 p.m., SW-A stated she did not recall being informed of missing items and stated there should have been a grievance form completed by now. SW-A viewed R46's chart and verified there was no documentation regarding missing clothing items and stated the facility reimbursed if they determine they were responsible for losing items and stated it was important to complete a grievance form in order to follow through on missing items. During interview on 3/19/25 at 1:34 p.m., LA-A stated R46 reported the missing items on 9/25/24, and added she thought R46 completed a grievance form, but stated SW-A could not recall. During interview on 3/19/25 at 1:50 p.m., the director of nursing (DON) stated a grievance form is completed when a resident reports missing items and staff update social services and try to locate the missing items and follow up as soon as possible. The DON further stated it was important to complete the grievance in order to follow up. A policy, Procedure for Missing Items dated 6/23/24, indicated it was the policy of the facility that all missing items were acknowledged and investigated. When a resident reports a missing item or money, staff will assist resident to search for it in all appropriate locations, including but not limited to talking to other staff members. This will be completed within 24 hours of original complaint and documented in resident's chart. If the item is not found upon the initial search, staff will complete a grievance form and turn it into the grievance officer and or designee. Social services director or designee will make copies of the grievance form and forward them to the appropriate department for further follow up. The department manager(s) that receive a grievance form will do a thorough search and or investigation regarding missing item, money, etc and complete the grievance form and return it to social service director and or designee within 72 hours of receiving the grievance form. the director of social services and or designee and appropriate staff will discuss possible actions to take to prevent re-occurrences, room changes, labeling clothing, putting money in a trust fund etc, final outcome and actions will be documented in resident's chart and care planned for as deemed appropriate. The director of social services and or designee will maintain a log of all missing items in order to monitor for trends and or patterns. A policy, Grievances, dated 8/8/23, indicated the facility will make every effort to resolve the issue within three working days of receipt of the grievance or complaint, and the resolution will be communicated to the resident, resident representative, family member, friend, or health care agent who originated it. A copy of the written response with proposed resolutions may be given to the grievant if the resident, family, friends, or health care agent does not accept the proposed resolution, an appointed administrative designee may request an appropriate advocacy organization to intervene. All files and information pertaining to the grievances are confidential and will be kept by the grievance official and administrator or designee and the facility will maintain original written responses and three years of grievance records and logs. All grievances will be reviewed with resident voicing concern to ensure they are satisfied with the resolution.

Based on interview and document review, the facility failed to ensure physician's orders were in place for 1 of 1 resident (R46) who self catheterized. Findings include: R46's Optional State Assessment (OSA) dated 2/7/25, indicated intact cognition, did not have hallucinations, delusions, or behaviors, and did not reject cares. The OSA further indicated R46 was independent with activities of daily living (ADLs), was not on a urinary or bowel toileting program. R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 did not have an indwelling catheter, external catheter, ostomy, or had intermittent catheterizations and was always continent of bowel and bladder. R46's Medical Diagnosis form indicated R46 had the following diagnoses: fusion of the spine, lumbar region, and an unspecified disorder of the prostate. R46's Orders form was reviewed and lacked physician orders on how R46 self catheterized, why R46 self catheterized, what type of catheter was used, how often catheterization was required, or where R46 obtained catheter supplies from. R46's medication administration record (MAR), and treatment administration record (TAR), was reviewed for January 2024, February 2024, and March 2024, and lacked information how R46 self catheterized, why R46 self catheterized, what type of catheter was used, how often catheterization was required, or where R46 obtained catheter supplies from. R46's care plan dated 2/4/25, indicated R46 had intact cognition. R46's care plan dated 8/24/23, indicated R46 was continent of bowel and bladder, would remain continent of bowel and bladder and interventions included to review and assess on a quarterly and annual basis. Further, R46 self catheterized due to a medical history and retention. R46's goal indicated he would report no difficulties in self catheterization and stay free from infection. Interventions included staff would make and alert R46 of urinary and urology appointments, and staff will report any difficulties that resident expresses to urology. The care plan lacked information what type of catheter R46 used, how often R46 self catheterized, and where R46 obtained catheter supplies. R46's Bladder Assessment Documentation dated 2/7/25, indicated no further assessment was necessary and further, R46 performed self catheterizations, but was continent of bladder. Under a heading, Potentially Reversible Causes of Urinary Incontinence a check box was marked for a history of urinary retention. The assessment further indicated R46 had prostatitis (inflammation of the prostate gland)/BPH (benign prostatic hyperplasia). The form indicated a physical exam was not performed and recorded and registered nurse (RN)-A attempted the examination for the second time on 2/7/2027 and was not appropriate for toileting or a retraining program. Under the heading, Progress note indicated R46 was continent of his bladder and intermittently self catheterized when having a CRPS (complex regional pain syndrome) flair and was in severe pain due to retention. No further assessment or examination needed at this time, no concerns at time of assessment. R46's Care Area Assessment (CAA) Summary form dated 8/9/24, indicated urinary incontinence and indwelling catheter was not triggered for a care planning decision. R46's History and Physical dated 3/18/25, indicated R46 had a status post lumbar fusion, complex regional pain syndrome type two (CRPS) of the left lower extremity (a chronic pain condition that causes severe, persistent pain, along with other symptoms like swelling, skin temperature changes, and sensitivity to touch in the affected limb), BPH with urinary hesitancy, and urinary retention. R46's admission progress note dated 8/7/23, indicated R46 did not urinate on his own, and straight cathed himself when he knows he needs to empty his bladder. R46's Care Conference note dated 5/22/24, indicated R46 straight cathed for his bladder. R46's Care Conference note dated 8/21/24, indicated NA under the heading Urology. R46's Care Conference note dated 11/20/24, indicated R46 straight cathed for his bladder. R46's Aide Task form did not include a task for self catheterization. During interview on 3/17/25 at 3:57 p.m., R46 stated he self catheterized 3 times a week due to his CRPS affecting his groin area. R46 stated it didn't matter how full his bladder was, he was unable to urinate and added he does void sometimes. During interview on 3/19/25 at 8:57 a.m., nursing assistant (NA)-B stated she was not aware R46 self catheterized and stated LPN-A ordered supplies and further stated R46 was alert, an accurate historian, but had pain all the time and needed encouragement, but was cooperative. During interview on 3/19/25 at 9:10 a.m., licensed practical nurse (LPN)-A stated the facility did not have any paper charts and doctor visits were located in the computer and it was determined what medical supplies were needed based on the physician orders. LPN-A further stated staff knew what cares a resident required based on the care plan, but was more a tool the social worker used and staff looked at the orders. LPN-A stated she was responsible for ordering supplies and added they did not have catheters at the facility and added R46 self catheterized himself as needed three to four times a day and obtained his own supplies adding that R46 was completely with it. LPN-A stated R46 had been self catheterizing since prior to admission to the facility. During interview on 3/19/25 at 9:25 a.m., registered nurse (RN)-A stated R46 self catheterized, and staff did not assist and did not know how often R46 self cathed, what size catheter, and stated they did not have an order and added it would be helpful for nursing to know because if they had the physician's order they would know there is an issue and when R46 would be out of supplies and could follow up. During interview on 3/19/25 at 9:41 a.m., the director of nursing stated R46 did not self cath, then reviewed R46's bladder assessment and RN-A verified the assessment indicated R46 self catheterized and stated R46 should have an order in the chart for the nurse to supervise and stated it was important to ensure it was going well and if there were any complications and would need to know the catheter type. A policy, Catheter Use, dated 1/25/25, indicated resident self-catheterization may be done by a resident to relieve the bladder of residual urine if approved by a urologist and performed with nursing supervision. The nurse supervises and promotes techniques to allow for correct procedure and reduced chance of infection. Both the nurse and the resident will wash hands prior to procedure in accordance with infection control policy. Nurse will wear gloves during this procedure. Position the resident on the toilet with enough room to allow end of catheter to drain into the toilet freely. The nurse will remove sterile wipe from the package and hand to the resident. The resident will open the wipe by shaking and cleanse peri area by wiping front to back. The nurse will remove the lubricant packet being careful not to touch the tip or end of the catheter. The resident will open the lubricant packet and the nurse will place the tip of the catheter into the lubricant, then hand the catheter to the resident. The resident will place the tip of the catheter into the urinary meatus allowing end of catheter to drain residual urine while the nurse ensures that the catheter is draining into the toilet. When the draining stops, the catheter will be removed by the resident and placed into the waste receptacle. Both the resident and the nurse wash hands after the procedure is complete.

Based on interview, observation, and document review, the facility failed to ensure interventions for safe smoking were implemented for 1 of 2 residents (R6) reviewed for smoking. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have range of motion impairment to upper extremities, did not have physical or verbal behaviors directed towards others, and did not reject care. R6's Medical Diagnoses form indicated the following diagnoses: tobacco use, and mild intellectual disabilities, and schizophrenia. R6's Orders form was reviewed and lacked information regarding safe smoking. R6's care plan dated 12/26/24, indicated R6 had moderate cataracts and a surgical consult was provided, however R6 declined treatment, interventions included staff to observe for visual changes or ability to maneuver safely in the environment. R6's care plan dated 12/26/24, indicated R6 heard voices and had paranoid accusations others wanted R6's money or were in her business. R6's care plan dated 12/26/24, indicated R6 was a safe cigarette smoker with proper safety interventions. R6 had burned fingertips and nose and had been observed with holes in clothes and was encouraged to use a smoking apron, refused a cigarette holder, and was able to light her own cigarette with a no-flame lighter, or staff would light R6's cigarettes. Interventions included assessing smoking safety upon admission, significant change, and annually, and staff would offer praise to R6 for safe smoking and redirection as needed. R6's care plan dated 3/6/25, indicated R6 required re-direction and cuing to make appropriate decisions related to mild intellectual disabilities and interventions included staff conducting one to one visits to re-direct and cue when R6 made poor decisions as needed and as resident allowed. R6's care conference progress note dated 9/11/24, indicated R6 smoked, and a policy was explained to R6 and R6 agreed and was reminded of interventions rec. Apron/ no flame lighter. [NAME] Smoking review completed 8/2024. R6's care conference progress note dated 12/11/24, indicated R6 smoked, and a policy was explained to R6 and R6 agreed and was reminded of interventions rec. Apron/ no flame lighter. Safe smoking review completed 8/16/24. Resident is safe to smoke unsupervised. Resident now pays the facility to purchase her cigarettes, tubes and roll her cigarettes. Resident receives 20 cigarettes/day. R6's progress note dated 3/7/25, indicated staff witnessed resident providing a cigarette to another resident. R6's care conference progress note dated 3/12/25, indicated R6 smoked, and a policy was explained to R6 and R6 agreed, interventions included rec. Apron/ no flame lighter. Safe Smoking review completed 8/16/24. Resident is safe to smoke unsupervised. Resident now pays the facility to purchase her cigarettes, tubes and roll her cigarettes. Resident receives 20 cigarettes/day. R6's Safe Smoking Evaluation form dated 8/16/24, indicated R6 smoked, had cognitive loss, did not have a vision deficit, could light her own cigarette, smoked only in designated areas, did not have a history of injuries secondary to smoking, did not need a lighter and cigarettes stored by the facility, check boxes for whether R6 required adaptive equipment were left unmarked. The adaptive equipment check boxes included smoking apron, cigarette holder, supervision, and one on one assistance. Further, the assessment indicated R6's clothing had burn holes and additional check boxes were included under clothing condition if clothing had burn holes. The check boxes included what R6 wanted to do with the clothing if R6 had burn holes: throw away the clothing, keep and continue to wear clothing, and N/A. Not Applicable. N/A was documented. The assessment further indicated R6 knew how to put cigarettes out correctly, knew not to save cigarettes and put them out half way, and was given the risk and benefits of smoking. During interview and observation on 3/17/25 at 3:06 p.m., R6 stated she kept cigarettes with her all the time and was wearing a dark gray sweater with a burn hole and a few smaller holes. R6 stated she didn't burn herself, and put cigarette butts out in the pail and pointed to a small green canister with a small circular opening located on the floor in her room and stated she could not smoke in her room and used the canister for smoking on the third floor. During interview and observation between 3/18/25 at 11:51 a.m., and 11:59 a.m., R6 was at the dining room table and at 11:55 a.m., got up, filled a cup near the water dispenser and left the dining room. At 11:57 a.m., R6 went out the front door, took out a roll of several cigarettes and lit a cigarette with a lighter that had an obvious flame. R6 was wearing a gray shirt that contained burn holes and was not wearing a smoking apron. R6 took out a light blue lighter to light the cigarette. No staff were located outside. At 11:59 a.m., social worker (SW)-A, came outside assisting another resident. SW-A did not ask or encourage R6 to use an apron. During interview and observation on 3/18/25 between 12:05 p.m., and 12:20 p.m., SW-A stated staff looked to care plans to know what cares a resident required and stated R6 was supposed to use an apron in the smoke room if there was one available because R6 got ashes on herself, but because R6 had an ashtray in her room, staff were going to have another smoking assessment completed. Social services assistant (SSA)-B stated she planned to complete the smoking assessment. SW-A verified R6 was not wearing a smoking apron when outside smoking and stated it would be important to encourage the apron because R6 had burn holes on her clothing and the apron prevented cigarette holes because R6 dropped on her clothing. SSA-B stated a no flame lighter was an electric lighter and added she never used or saw a no flame lighter. At 12:15 p.m., SSA-B stated they had an apron that hung in the smoking room, but staff didn't do anything if residents went outside. At 12:19 p.m., R6 pulled out a BIC blue lighter and SSA-B verified R6's lighter was not a flameless lighter at 12:20 p.m., and would look for the flameless lighter identified on the care plan. During interview on 3/18/25 at 12:27 p.m., the director of nursing stated she expected care plans be followed and was important to have an apron to protect R6's clothing and the possibility of burns and planned to follow up as to why R6 did not have an apron and stated they should be closely monitoring. A policy, Resident Smoking, revised 3/18/25, indicated residents will be safe while smoking, policies will be reviewed upon admission and annually with residents, a smoking assessment will be completed at admission and annually for each resident. Additional assessments will be completed upon significant change or if any safety concerns are identified. The care plan will reflect outcomes of the safe smoking assessment. If there are suspected safety concerns staff will follow up immediately interventions included remind and encourage safe smoking practices, request another safe smoking assessment, document the behavior in the electronic medical record, use of smoking apron, supervised smoking, regulated use of smoking materials, and discharge.

Based on observation, interview, and document review, failed to ensure the posted nurse staffing information included the daily census. Additionally, the facility failed to ensure the posted nurse staffing information reflected accurate total number and actual hours worked per shift for licensed and registered staff for each shift on a daily basis. This had potential to affect all 56 residents or visitors who wished to review the information. Findings include: During observation on 3/18/25 at 9:48 a.m., the posted nurse staffing information was hung above the main reception area and lacked the facility's daily census. The facility's posted nurse staffing information dated 2/17/25 - 3/18/25 were reviewed on 3/20/25 at 8:19 a.m. and indicated no registered nurse (RN) hours worked for day, evening or night shift on the following dates: 3/8/25, 3/9/25, 3/13/25, and 3/16/25. Additionally, the posted nurse staffing information lacked daily census on all reviewed dates. The facility's staffing schedule dated 2/17/25 - 3/18/25 was reviewed on 3/20/25 at 8:19 a.m., and indicated there was RN coverage on 3/8/25 during the evening shift and on 3/13/25 during the day shift. The facility's employee timecards dated 3/8/25 - 3/9/25 verified RN coverage for 3/8/25 and 3/9/25. The facility's employee timecards dated 3/10/25 - 3/20/25 verified RN coverage for 3/13/25 and 3/16/25. During interview on 3/20/25 at 10:54 a.m. with the director of nursing (DON), the employee timecards dated 3/8/25 3/9/25 and 3/10/25 - 3/20/25 were reviewed. The DON confirmed RN coverage for the dates 3/8/25, 3/9/25, 3/13/25, and 3/17/25. The DON further confirmed the posted nurse staffing information lacked accurate data to reflect the total number and actual hours in addition to lacking the facility's daily census. A facility policy pertaining to posted nurse staffing information was requested; however, the administrator did not believe they had one.

Based on interview and document review, the facility failed to ensure one of three residents (R2) reviewed was free from significant medication errors. This resulted in actual harm for R2 when he became heavily sedated by a psychotropic medication and required treatment in the hospital. Findings include: Minimum Data Set (MDS) admission assessment dated [DATE] indicated R1 admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS) had a score of 15, indicating she was cognitively intact. R1's relevant diagnoses included schizoid personality disorder, borderline intellectual functioning, and unspecified urinary incontinence. R1's medication order, dated 6/9/22, indicated R1 received clozapine 600 milligrams (mg) by mouth at 8:00 p.m. nightly for schizophrenia. R1's medication order, dated 6/9/22, indicated R1 received desmopressin acetate 0.2 mg by mouth at 8:00 p.m. nightly for urinary incontinence. R2's MDS admission assessment, dated 2/5/24, indicated R2 admitted to the facility on [DATE]. R2's BIMS had a score of 15, indicating he was cognitively intact. R2's relevant diagnoses included schizoid personality disorder, diabetes mellitus type II, chronic kidney disease stage 5, hyperlipidemia, and hypertension. R2's medication order, dated 1/29/20, indicated R2 received quetiapine fumarate 50 mg by mouth at 8:00 p.m. nightly for schizoid personality disorder. R2's medication order, dated 1/30/24, indicated R2 received atorvastatin calcium 80 mg by mouth at 8:00 p.m. nightly for hyperlipidemia. R2's medication order, dated 1/30/24, indicated R2 received carvedilol 25 mg by mouth twice per day, at 8:00 a.m. and 8:00 p.m., for hypertension. R2's medication order, dated 3/16/24, indicated R1 received olanzapine 5 mg by mouth twice per day, 8:00 a.m. and 8:00 p.m., for schizophrenia. R2's care plan, dated 2/9/24, indicated a nursing intervention was to administer all medications as ordered. A nursing note written dated 6/30/24 at 11:42 p.m., indicated on 6/30/24 at approximately 9:30 p.m., R2 received R1's scheduled medications. The note indicated the provider and the provider's clinic nurse were notified and gave instructions to administer R2's scheduled atorvastatin 80 mg and carvedilol 25 mg, and to hold the quetiapine fumarate 50 mg. R2 was conversational at the time and took the medications without issue. Nursing aide (NAR)-A was leaving the facility at approximately 10:40 p.m. when they discovered R2 heavily sedated, but able to respond to verbal stimuli. Staff moved R2 to the floor and called emergency medical services (EMS). R2 was transported by EMS to a local hospital, and R2's family, the director of nursing (DON), nurse manager, and social services director were notified. A Medication Error Report indicated registered nurse (RN)-A gave R2 R1's medication cup at 9:30 p.m. The report indicated R1 and R2's medications had been sitting in plastic cups near each other, and RN-A picked up the wrong cup and gave it to R2. R2 experienced increased sedation because of the medication error and was transported to the hospital for treatment. A hospital note dated 7/1/24 at 6:40 p.m. indicated R2 was seen in the emergency room following the unintentional administration of clozapine 600 mg, desmopressin 0.2 mg, and olanzapine 5 mg. The note indicated he was admitted to the hospital from the emergency department to the observation unit on 7/1/24 at 12:24 p.m., and then transferred to the intensive care unit (ICU) at 4:40 p.m. R2 was experiencing acute toxic metabolic encephalopathy and acute hypoxemic respiratory failure related to the high dose of clozapine he received. R2 was intubated and sedated for airway protection at an unknown time. On 7/3/24 at 9:06 a.m., an observation of a medication pass revealed no medication administration errors were made. During an interview on 7/3/24 at 9:23 a.m., trained medication assistant (TMA) -A stated prior to administering medication she verifies the identity of the resident. TMA-A stated she verifies the correct resident, the medication, the dose of the medication, the time the medication is to be administered, and the route of administration. TMA-A stated she only administers one resident's medications at a time to avoid making any errors. During an interview on 7/3/24 at 9:57 a.m., RN-B stated he verifies residents by the first and last name. RN-B stated if two residents have the same name, he will use their date of birth as an identifying factor as well. RN-B stated if a resident does not know their date of birth or are unable to answer, he used the room number of the resident to verify their identity. RN-B stated he verifies the five rights of medication administration prior to administering any medication. RN-B stated he only administers one resident's medication at a time. During an interview on 7/3/24 at 10:37 a.m., NAR-A stated she was leaving the facility on 6/30/24 at approximately 10:40 p.m. when she walked by R2, who was seated in the common area. TMA-A stated she said goodnight to R2, who did not respond. TMA-A tried to speak with R2, he was unable to respond. TMA-A stated she ran and told RN-A and together they moved R2 to the floor. TMA-A stated she held R2 while RN-A called for EMS. TMA-A stated she knew there had been a medication error with R2 earlier that evening, but R2 was not exhibiting any abnormal symptoms prior to 10:40 p.m. During an interview on 7/3/24 at 11:39 p.m., the nurse manager stated all staff who worked since the incident was discovered have been retrained on how to administer medications. The nurse manager stated all nursing staff must verify the five rights of medication administration - right patient, route, medication, dose, and time - prior to administering medications. The nurse manager stated a patient's medications should be prepared individually and no medications can be preset prior to administering. The nurse manager stated presetting medications in batches is not a practice at their facility. The nurse manager stated she completed the educational training for herself under the direction of the clinical compliance nurse. During an interview on 7/3/24 at 12:04 p.m., RN-C stated prior to administering medications, you must verify the five rights of medication administration. RN-C stated any medication errors must be reported immediately to the DON, the provider, the resident, and the resident's family. During an interview on 7/3/24 at 12:15 p.m., the clinical compliance nurse stated she observes nursing staff preparing individual medications. The clinical compliance nurse stated when she watches her staff, she is making sure they are working on medications individually and are verifying the five rights of medication administration. The clinical compliance nurse stated overnight nursing staff are being tested out by the nursing manager or charge nurse prior to working. During an interview at 12:45 p.m., the nurse manager stated the hospital informed them R2 will be returning to the facility later today directly from the ICU without any changes in baseline functioning or medication changes. During an interview on 7/3/24 at 1:40 p.m., the direct of social services stated RN-C texted her on 7/1/24 at approximately 1:30 a.m. regarding the medication error. The direct or social services stated on the morning of 7/1/24, she contacted the administrator immediately and determined it was a reportable event. During an interview on 7/3/24 at 1:45 p.m., the DON stated she received a text from RN-A on 6/30/24 at approximately 12:00 a.m. regarding the medication error and subsequent hospitalization . The DON stated she attempted to interview RN-A multiple times about the incident, however, she has not received any calls back. The DON stated due to RN-A not reporting the medication error to administration immediately and RN-A not complying with their internal investigation, it was decided to terminate RN-A's employment. The DON stated this was RN-A's first medication error. The DON stated the DON from their sister facility had designed the reeducation materials as she was on vacation. During an interview on 7/3/24 at 1:59 p.m., the DON of the sister facility stated he immediately implemented a reeducation competency and began training staff on 7/1/24. The sister facility's DON stated all staff who administer medication will have to complete reeducation prior to working in the facility and cannot work until it is complete. The sister facility's DON stated he and the clinical compliance nurse watch staff administer medications and ensure they are verifying the five rights with each resident. RN-A could not be reached for an interview. A facility document, titled TMA Orientation to Medication Administration, indicated nursing staff must verify the five rights (right resident, drug, dose, time, and route). This form was completed for all nursing staff who worked following the medication error on 6/30/24. A policy titled Medication Administration Policy, indicated medication will be set up for each resident individually immediately prior to administration.

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of one resident (R1) when reviewed for care plans. R1 did not have adequate interventions in place after a history of eloping/wandering from the facility. Findings include: R1's Admission Record printed on 6/17/24 indicated R1 was admitted to the facility on [DATE]. The Admission Record stated R1's medical diagnosis included schizoaffective disorder. R1's minimum data set (MDS) dated [DATE] indicated R1 had a brief interview for mental status (BIMS) score of 15, which indicated R1 was cognitively intact. R1's care plan dated 2/14/24 indicated R1 has command voices that are loud, whispers that can be intense that tell him things to do and if he is decompensating, he will act on those commands. Interventions indicated staff to ask questions to bring R1 back to reality such as 1. Are you having whispers, intense, or screaming voices? And 2. What are the voices telling you? The intervention indicated to remind R1 that it is not ok to take off his clothing and that he is not going to hell if he does throw away his clothing. Another intervention indicated staff will ask R1 on every shift if he hears voices. The care plan does not indicate what staff are to do when R1 is hearing command voices. R1's care plan dated 2/14/24 indicated R1 is not safe leaving the facility unsupervised when command voices are present. The indicated goals were R1 would be safe when in the community, R1 will notify charge nurse when leaving building and when returning, and R1 will use the sign out book when leaving the facility. The intervention indicated staff would provide hourly checks on R1 as needed when R1 has increased symptoms of hearing command voices related to the diagnosis of schizophrenia, staff would assess resident psychotic symptoms every shift, and staff would remind R1 to notify nurse when leaving building and when he returns. The care plan does not indicate what staff are to do when R1 is hearing command voices or how to assess if R1 is hearing command voices. R1's care plan dated 2/14/24 indicated R1 self-isolates and does not ask for as-needed medications when he hears command voices. The care plan indicated R1 decompensates rapidly if R1 does not take his as-needed medication when he is hearing command voices. The care plan does not indicate signs to look for when R1 is decompensating or interventions when R1 is decompensating. R1's care plan dated 2/14/24 indicated R1 currently uses a GPS tracker to monitor R1's whereabouts. The care plan stated R1 gets the tracker from the charge nurse and the charge nurse will turn on the GPS tracker. The care plan stated R1 confirms he has his cell phone on. The care plan stated R1 left the facility due to his command voices telling him to leave on 3/9/24 and 3/11/24 without the GPS tracker. The care plan indicated R1 returned both of those instances with no injury. The interventions included R1 seeing Associated Clinic of Psychology (ACP) therapist weekly or bi-weekly, the staff would call R1's cell phone if he does not return to the facility when he stated he would, staff would follow the missing person/wandering resident policy and procedure, staff would monitor resident whereabouts hourly and document on hourly monitoring sheets whereabouts and visible symptoms of increased command voices, and when R1 went to the nurse to request a tracking device the nurse would have R1 fill out a worksheet that asked: 1. Do you have a specific destination in mind? If yes, where? 2. Are your voices telling you not to return? 3. Do you feel like you have to listen to the voices? 4. Do you feel safe? and if R1 indicated a yes to any of those questions the nurse would complete flow chart for elopement risk assessment and management and follow interventions as listed. The care plan does not indicate what staff should do if R1 has high intensity command voices. An interview was attempted with R1 on 6/17/24 at 11:08 a.m. and R1 declined to be interviewed. During an interview on 6/17/24 at 11:31 a.m., the director of social services stated when there is more activity going on in the facility, is when R1 starts to hear more command voices and he gets overwhelmed. The director of social services stated if R1 gets overwhelmed, he will not sign out in the sign out book and he will not grab his GPS tracker. The director of social services stated there is nothing the facility can do to stop R1 from leaving. During an interview with registered nurse (RN)-A on 6/18/24 at 9:16 a.m., RN-A stated the facility needs to be able to help him control his command voices when his command voices are too loud because that is when he gets overwhelmed and leaves the facility without signing out in the sign out book or getting his GPS tracker from the nurse's station. During an interview with the certified nursing assistant (CNA)-A on 6/18/24 at 9:29 a.m., CNA-A stated she was not sure what she should do if she found R1 in a distressed state. CNA-A stated she was unaware of interventions to be done when R1 is in a distressed state. An interview was attempted with R1 on 6/18/24 at 9:26 a.m. and R1 declined to be interviewed. During an interview with the director of nursing (DON)-A on 6/18/24 at 10:12 a.m., the DON stated R1's intervention for a GPS tracker was placed on his care plan about a year ago and does not think there has been any new interventions since his last elopement. The DON stated he has done so many elopements that it is hard to keep track on them. During an interview with the DON on 6/18/24 at 11:24 a.m., the DON stated if staff is noticing R1 having more anxious or overwhelmed behaviors, they chart those behaviors and based on those behaviors staff should figure out what to do to help R1. The facility procedure titled Missing Resident Reporting Procedure, not dated, indicated find out why the resident was missing, where they were, then document in nursing notes. The procedure did not identify the development of resident interventions to prevent future missing person incidents.

Based on interview and document review, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 60 residents which resided in the facility. Findings include: The facility's QAPI meeting minutes for the past 12 months were requested, however not received. Documentation and evidence of the facility's ongoing performance improvement projects (PIPs) was requested, however not received. Documentation and evidence of a recent performance improvement plan (PIP) was requested, however was not received. When interviewed on 5/2/24 at 5:10 p.m., the administrator stated the facility held quarterly QAPI meetings but due to being interim, he was unable to access the shared network where he believed the previous administrator saved the previous meeting minutes. The administrator stated the facility was also involved in PIPs but was unable to locate documentation of the projects during interview. The facility's QAPI plan dated 4/2024, indicated the QAPI committee, comprised of all department managers, the administrator, director of nursing, infection control and prevention officer, medical director, consulting pharmacist, and quality coordinator, would meet quarterly. The QAPI plan indicated QAPI activities and outcomes would be on the agenda of every staff meeting, and the committee would review data, suggestions, and input to prioritize opportunities for improvement. The facility's QAPI plan indicated the committee would solicit individuals from the organization to conduct PIPs and would monitor their progress. Additionally, the QAPI plan indicated the facility used a Plan-Do-Study-Act model to test actions and recognize and address unintended consequences of planned changes when working to prevent future events and promote sustained improvement.

Based on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that was effective in identifying and responding to quality deficiencies, and developing procedures for feedback, data collection and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas. This deficient practice had the potential to affect all 60 residents currently residing in the facility. Findings include: Quality tracking data was requested from the facility but was not provided. During interview on 5/7/24 at 7:24 p.m., the administrator stated, I think the last administrator had meetings, but was unsure where the meeting minutes were located. The administrator also stated he believed the facility had a PIP but was unable to locate any information regarding the project. A facility policy titled QAPI Plan - 2024 dated 4/2024, indicated the facility implement PIPs to improve processes, systems, outcomes, and satisfaction. The QAPI plan indicated the facility would conduct PIPs to revise and improve care or services in areas identified as needing attention. The QAPI plan indicated topics for PIPs were identified during quarterly review of data and input from data sources (Centers for Medicare and Medicaid Services (CMS) quality measures, falls, medication errors, rehospitalization rates, resident satisfaction, abuse, neglect, and maltreatment reports, complaints, resident council and family council, satisfaction surveys, and suggestion boxes). The plan indicated it would look at issues, concerns, and areas that need improvement as well as areas that will improve quality of life and quality of care and services for the residents. The plan also indicated PIPs would include high-risk, high-volume, or problem-prone areas that affected health outcomes and quality of care and areas that affected staff. Additionally, the plan indicated other considerations would include existing standards or guidelines, measures that could be used to monitor progress, quality measures publicly reported on Nursing Home Compare, goal areas from the Advancing Excellence in America's Nursing Homes Campaign, and projects that require system or environmental changes, and those affecting staff.

Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R360, R26) reviewed for vaccinations. Findings include: The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adults 19-[AGE] years old with chronic health conditions, such as diabetes mellitus, who received PCV13 (pneumococcal conjugate vaccine) should receive either one dose of PCV20 or one dose of PPSV23 (pneumococcal polysaccharide vaccine). The dose of PCV20 or PPSV23 should be administered at least one year after PCV13. Adults 19-[AGE] years old with chronic health conditions, such as diabetes mellitus, who received PPSV23 should receive either one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. R360's admission Minimum Data Set (MDS) dated [DATE], indicated R360 was [AGE] years old, had intact cognition and diagnosis of diabetes mellitus. Furthermore, R360's MDS indicated R360 was not up to date with pneumococcal vaccination and not offered the pneumococcal vaccine. R360's Minnesota Immunization Connection (MIIC) report undated, indicated R360 had received the Prevnar (PCV)13 on 9/13/19. Review of the current CDC pneumococcal vaccine recommendations 3/15/23, indicated R360 required one dose of PCV20 or PPSV23 at least one year after PCV13. R26's quarterly MDS dated [DATE], indicated R26 was [AGE] years old, had intact cognition and diagnoses of hypertension, renal insufficiency or failure and diabetes mellitus. Furthermore, R26's MDS indicated R26 was not up to date with pneumococcal vaccination and not offered the pneumococcal vaccine. R26's MIIC report undated, indicated R26 had received the PPSV23 on 10/7/3, 12/11/9, and 10/2/20. Review of the current CDC pneumococcal vaccine recommendations 3/15/23, indicated R26 required one dose of PCV20 or PCV15 at least one year after PPSV23. When interviewed on 5/2/24 at 12:20 p.m., registered nurse (RN)-A stated resident vaccinations were assess upon admission. Staff made sure the immunization records were up to date and called the hospital or wherever the resident was admitted from to obtain the most current immunization record. When interviewed on 5/2/24 at 12:37 p.m., RN-B, who was the infection preventionist, stated they accessed the MIIC to verify residents were up to date with vaccinations and asked residents if they wanted the pneumococcal vaccinations during their assessment interviews. RN-B checked yearly to ensure current residents were up to date with vaccines. RN-B stated if residents needed the pneumococcal vaccines they would receive from their provider or go to a pharmacy if safe to go out to community. When interviewed on 5/2/24 at 3:25 p.m., the director of nursing (DON) stated staff annually assessed which residents needed pneumococcal vaccinations following the CDC guidance. Ensuring residents were up to date on vaccines was important to minimize resident risks. The facility was asked for documentation of R360 and R26's pneumococcal vaccination offer and/or declination but did not receive.

Based on observation and interview, the facility failed to ensure resident call light cord was within reach from the shower floor for 1 of 1 multi-resident (R39, R14, R25, R32) bathroom reviewed for call light accessibility. Findings include: R39's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, had hallucinations and delusions and no refusals of care. R39 was independent with activities of daily living (ADLs) but needed substantial and/or maximal assistance with showers/bathing. R39 had diagnoses which included schizophrenia and cataracts. R39's care plan printed 5/3/24, identified R39 was a low fall risk and directed staff to educate and remind R39 to use the call light and call for staff when weak. R14's quarterly MDS dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all ADLs, including showering. R14 had diagnoses of diabetes mellitus and schizophrenia. R14's care plan printed 5/3/24, identified R14 was a low fall risk. R25's quarterly MDS dated [DATE], identified R25 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R25 had hallucinations, delusions, inattention, disorganized thinking, and altered level of consciousness. R25 did not reject cares. R25 was independent with most ADLs but required substantial and/or maximal assistance with shower. R25 had diagnosis of schizophrenia. R25's care plan printed 5/2/24, identified R25 was at moderate risk for falls and indicated call light at bedside. R32's annual MDS dated [DATE], identified R32 had intact cognition, delusions, and no behaviors nor rejection of cares. R32 was independent with ADLs and had diagnoses of diabetes mellitus and schizophrenia. R32's care plan printed 5/2/24, identified R32 was a low fall risk. During observation and interview on 4/29/24 at 12:12 p.m., R39's bathroom had a call light cord and box by the toilet. A string was tied around the call light cord, and the string went above the door frame and back down to dangle by the shower. The string with a plastic piece at the end of it was looped a couple times and approximately four feet from the ground. The string by the shower was out of reach if a resident fell in the shower or was sitting in the shower chair. R39 stated they did not have assistance with showers. During observation and interview on 5/1/24 at 8:52 a.m., nursing assistant (NA)-A stated R39 was not very stable when first getting up in the morning and needed stand by assistance and reminders to use her walker. NA-A stated R39 showered in evening so unsure of how much assistance was usually given. NA-A stated the light outside room doors turned on when a resident had their call light on. NA-A either observed call lights on and went to assist, or a phone at the nurse's station also indicated a call light was on. NA-A stated call lights needed to be within reach, including in the bathroom and shower. NA-A observed the string by the shower and agreed the call light is high and should be lower like the other call lights they have seen. NA-A grabbed the string and pulled down. The part of the string tied around the call light by the toilet slid down the call light which lengthened the amount the NA-A had to pull until the string tightened enough to turn on the call light. NA-A agreed they had to pull the string excessively to turn on the call light. During interview on 5/2/24 at 12:20 p.m., registered nurse (RN)-A stated staff looked at assignment sheets and care plans to know how much assistance residents needed. R39 did not like assistance, but staff tried to assist R39 with showers. R14 did not allow staff to assist with showers, but staff reminded R14 to try to let staff assist. R32 was independent with ADLs, but staff stood by when R32 showered for safety. R25 needed assistance with showers. During interview on 5/2/24 at 3:25 p.m., the director of nursing (DON) stated call lights should be within reach of residents, which included when in shower and using toilet. The DON stated staff may not be able to respond to or be aware of an emergency if a resident could not reach or turn on their call light. The facility policy Call Lights dated 12/23, indicated the nursing station should be equipped to receive resident calls form the resident room, bath and bathrooms.

Based on observation, interview, and document review, the facility failed to ensure a multi-resident bathroom ceiling vent fan was cleaned for 4 of 4 residents (R39, R14, R25, R32) reviewed for cleanliness of environment. Findings include: During observation on 4/29/24 at 12:24 p.m., grayish white colored dust thickly covered 50 to 75% of a bathroom ceiling vent. The ceiling vent fan ran but no air flow felt. During interview on 5/1/24 at 9:16 a.m., the administrator (admin) expected maintenance and housekeeping to keep vents and fans clean as often as necessary. Admin stated usually maintenance cleaned high vents and fans, and housekeeping cleaned lower vents and fans. The facility recently changed housekeeping from in-house to a contracted company, so a cleaning schedule was being developed. During interview on 5/1/24 at 9:22 a.m., the assistant director of maintenance (M)-B stated they cleaned vents and fans when dust was observed or when residents came and told them. M-B stated they tried to check rooms twice a month but sometimes didn't happen. M-B stated they had a log for tracking cleaning and would have to find it. During interview on 5/1/24 at 9:51 a.m., the head of maintenance (M)-A stated vents and fans should be cleaned every month. M-A stated they had an old checklist but needed to clean it up and create a checklist sheet for the whole year. M-A observed the bathroom ceiling vent fan and stated maintenance needed to clean it. M-A stated dirty vents and fan caused elements to fly around the air and were important to keep clean to improve air flow and equipment performance. The facility's Room Order Cleaning Procedure dated 8/23, directed staff to follow room order guideline and check general appearance of unit and did not mention to check and clean vents and fans.

Based on interview and document review, the facility failed to notify the medical provider of on-going medication refusals for 1 of 1 resident (R14) reviewed for notification of change. Findings include: R14's quarterly Minimum Data Set, dated dated dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all ADLs. R14 had diagnoses of diabetes mellitus and schizophrenia. R14's Care Area Assessment (CAA) dated 11/3/23, dlirium triggered for inattention and disorganized thinking. The CAA identified the symptoms were not new and had abnormal blood sugar levels due to R14's refusal to take insulin. The CAA cognitive loss triggered due to refusal of cognitive assessment and staff indicating short and long-term memory loss, poor decision making, inattention, and disorganized thinking. The CAA indicated R14 received frequent reorientation, reassurance, reminders to help make sense of things, and redirection and cues for appropriate responses and better decisions. The CAA psychotropic drug use trigged for antipsychotic use and behavioral symptoms triggered related to rejection of care and noted behavior as worse. R14's cognition care plan revised 12/8/19, indicated R14 believed they had an allergy to insulin and listed interventions such as nursing will update doctor/Psychiatrist about any reports of increased delusions, ACP therapist periodic and/or as needed, medications per doctor/psychiatrist order, social services will follow up with resident as needed with delusional beliefs, staff to attempt to re-direct when delusions are bothering self and/or other residents, and staff to offer reality based support and reassurance to R14 when experiencing delusions. R14's other cognition care plan revised 4/8/24, identified R14 had a court commitment 11/16/23 through 5/22/24, and R14 had to follow up with primary care and psychiatry and take all prescribed medications including insulin. The care plan listed an intervention for resident services to contact appropriate case manager if there is a violation of the commitment or [NAME] order. Another cognition care plan regarding decision making skills revised 12/8/15, also listed R14 as refusing insulin. Interventions included 1:1 visits to re-direct and cue when making poor decisions as needed and as resident allows, and staff to petition for guardian if resident unable to make good decisions with assistance from staff, family, and case manager. R14's behavior care plan revised 11/22/22, identified R14 refused insulin and other diabetic medications since September 2015, doctor shopping to get one to agree with them, leaves appointments if provider attempts to challenge delusional beliefs, and takes insulin at hospital but chooses not to take medication when returns to facility. Interventions included house psychologist will see as needed and/or desired, medications per doctor order, nursing will monitor resident blood sugars per doctor order, and re-direct and cue resident. The potential for complications care plan revised 4/30/24, again identified R14 was noncompliant with insulin and blood sugar checks. Interventions included to administer medication as ordered, nursing to assess resident's resistance to treatment, nursing will encourage resident to express feelings and fears and clarify misunderstandings, nursing will involve doctor/family for continued refusals, and nursing will reiterate the purpose and advantages of treatment for the resident as appropriate to cognitive understanding. R14's injection administration record (AR) identified insulin degludec subcutaneous solution 100 unit/mL with directions to inject 25 unit subcutaneously one time a day at 7 p.m. and start date of 12/20/23. The February AR identified administration until 2/24/24, which was marked with an indicator for Drug Refused. The March AR identified the injection was refused. The April AR identified the injection as refused throughout the month. The AR indicated to check R14's blood sugar three times a day with start date of 7/9/21. The February AR identified blood sugar levels until 2/26/24, which was marked as refused for the rest of the month. The March AR identified one blood sugar level of 87 on 3/3/24 for 8:00 a.m The April AR did not indicate a blood sugar level and marked as refused throughout the month. The injection AR identified insulin aspart flexpen solution pen-injector 100 unit/mL with directions to inject eight units subcutaneously three times a day and hold until after R14 ate if blood sugar was under 90 and had a start date of 12/20/23. The February AR identified blood sugar levels and administration until 2/25/24. The March AR identified R14 refused the medication throughout the month, and the April AR indicated refusals throughout the month. The injection AR identified insulin aspart penfil solution cartridge 100 unit/mL with sliding scale parameters and to inject subcutaneously three times a day and further directions for six units with meals plus coverage. The order had a start date of 10/20/22. The February AR identified consistent refusals started 2/26/24. The March AR identified refusals throughout the month. 3/24/24 identified a blood sugar of 222 and administration of one unit for 8:00 a.m The April AR identified refusals throughout the month. R14's blood sugar report dated 5/2/24, identified blood sugar levels multiple times a day until 2/25/24. 222 mg/dL was recorded on 3/24/24 at 9:02 a.m R14's facesheet dated 5/3/24, indicated nurse practitioner (NP)-A as R14's primary physician. A behavior note dated 2/25/24 at 9:38 a.m., indicated R14 started refusing insulin 2/24/24. Writer explained R14 had a [NAME] order and had to send R14 to hospital if they did not take their insulin. Writer called DON and R14's parents to notify them R14 was transported to HCMC. The progress note did not indicate a medical provider was notified. A physician visit/call note dated 2/25/24 at 8:28 p.m., indicated R14 returned from HCMC emergency room at approximately 4:15 p.m R14's blood sugar was checked before supper and was at 87. R14 refused insulin after eating and stated their feet were cold and squishy because of the insulin and was not taking insulin until they see a doctor. HCMC indicated labs were drawn and identified to follow up with primary care provider (PCP) from M Health Fairview Clinic. The progress note did not indicate a medical provider was notified. A behavior note dated 2/26/24 at 11:01 a.m., indicated R14 refused all diabetic cares. The registered nurse (RN) educated R14 about diabetes mellitus and possible outcomes and symptoms of refusing diabetic cares. The RN told R14 to notify staff if R14 was having symptoms of a diabetic emergency. The progress note did not indicate a medical provider was notified. A general condition note dated 3/8/24 at 7:16 p.m. and indicated R14 continued to decline insulin and blood glucose checks. The progress note did not indicate a medical provider was notified. A behavior note dated 3/12/24 at 5:42 p.m., indicated R14 continued to refuse blood sugar checks and insulin and did not indicate a medical provider was notified. A general condition note dated 3/26/24 at 4:40 p.m., indicated R14 declined blood sugar checks and insulin and did not indicate a medical provider was notified. A physician visit/call note dated 4/17/24 at 7:56 a.m., indicated R14 cancelled primary provider appointment for 5/20/24 and scheduled an appointment with a different provider for 6/10/24. A behavior note dated 4/23/24 at 12:53 p.m., indicated R14 complained of dizziness and lethargy and declined to have vitals taken. R14 stated the insulin made her feet spongy and was tired and ill feeling. R14 stated they had a psych appointment in June and would likely schedule an appointment with a physician after then. R14 was looking for a provider who would not endorse insulin or diagnosis of diabetes. R14 stated they would not take insulin again as it has caused their health problems. The note did not indicate a medical provider was notified. A behavior note on 4/28/24 at 12:58 p.m., indicated R14 refused insulin, and the note did not indicate a medical provider was notified. The After Visit Summary from HCMC emergency department dated 2/25/24, indicated R14 should follow up with primary care provider (PCP) from M Health Fairview Clinic, and the resident was seen for delusions and noncompliance with diabetes treatment. R14's blood sugar was 301 mg/dL. A Nursing Home Visit Encounter note dated 3/5/24, indicated R14 had no recent acute care stays, was on a commitment with mental health, required ongoing observation and support with diabetes, and in denial of diabetes and neuropathy. NP noted R14's blood sugars had been stable and tend to be a little hyper glycemic and ranged from 87 to 243. R14 had no new concerns. NP noted Northern Lights Health will take over primary care provider relationship going forward and would follow-up for routine check-up, or sooner if needed. NP would monitor patient and work with nursing staff to work towards positive patient outcomes. During interview on 4/30/24 at 1:48 p.m., nursing assistant (NA)-A stated when resident refused cares, they reapproach for a total of three attempts and then report to the director of nursing (DON) or someone else higher up. NA-A stated there were target behaviors in the application they charted in, and R14 had history of refusing insulin. NA-A stated R14 was more comfortable now with allowing NA-A to help with cares and conversing. During interview on 4/30/24 at 2:58 p.m., licensed practical nurse (LPN)-B stated when residents refused cares or medications, staff reapproached and sometimes staff had to approach in a different way to assist the resident to comply. Behaviors and refusals were charted in progress notes or under a behavior tab in their charting system. If residents refused psych medications, they notified the psychiatrist right away, so they knew what was happening and talk about refusals and behaviors in their stand-up meetings as well. Notifications and responses should be documented in progress notes. LPN-B stated R14 did not believe they were diabetic, got angry when staff spoke about R14's diagnosis, and fires every doctor. LPN-B stated R14 was sick and tried to get R14 to comply with diabetic medications. LPN-B stated R14 had the nurse practitioner (NP) as a provider, but NP would not prescribe R14 medications if they do not see R14. R14 needed to see a doctor every 60 to 90 days, and 3/5/24 was the last time NP saw R14. R14 was agreeing to take their insulin and have blood sugar checks as R14 was on a [NAME] commitment but then stopped when R14 believed the insulin made their feet mushy and cold. R14 was sent to the hospital when R14 stopped taking insulin, and the hospital sent R14 back to the facility and stated R14's [NAME] was not for insulin and only psychiatric medications and concerns. R14 stopped taking their insulin and blood sugars after they returned from the emergency room . LPN-B stated NP was aware of the insulin and blood sugar refusals. During observation on 5/2/24 at 8:19 a.m., R14 was sitting in the main dining area with beverages and breakfast. R14 was asked if their blood sugar could be checked, and R14 declined and stated the DON should have told you. During interview on 5/2/24 at 9:15 a.m., the NP stated they followed R14 every three months for compliance and started to see R14 around November 2023. The NP was aware R14 went back and forth with providers and would generally have residents choose which provider they wanted to visit. NP was at facility on Tuesdays and would attempt to see R14 three times per month. NP stated they send their after-visit notes to the facility's medical records employee. NP stated staff would either call them or place a note in their communication book if there were concerns with residents. NP stated staff should make them aware of refusals after a couple days and hadn't been notified R14 was not taking insulin or checking blood sugars. NP believed R14 had an order to send R14 to the hospital if they would not take their insulin, and R14 had a psychiatric issue which affected their health. NP stated they should have been notified to assist to develop a plan for R14's refusals. NP stated R14 was at risk for hyperglycemia, diabetic coma, and many systemic failures. NP reviewed their last visit note in March 2024, which did not note R14's insulin and blood sugar refusals. NP stated R14 had not been to the hospital since they started following R14 and would expect to be notified if R14 went to the hospital. NP reviewed R14's emergency room visit from February 2023 and stated they should know some of those things that are happening. During interview on 5/2/24 at 3:25 p.m., the DON expected staff to notify providers about changes with residents, such as medication and other refusals, as soon as possible. Not notifying the provider timely could affect residents' wellbeing, since residents were on their medications for a reason. During another interview on 5/2/24 at 5:54 p.m., the DON stated R14 did not have a primary provider at this time, since R14 tried to establish with one provider and then went to another. DON expected staff to speak with the medical director (MD) as back up when residents were between providers. DON believed MD was aware of R14 but had not consulted with R14. During follow-up interview on 5/2/24 at 6:14 p.m., the DON stated R14 did not give consent to be seen by anyone from Hennepin Health Care, which the MD was affiliated with. During interview on 5/2/24 at 6:35 p.m., the MD was not aware of R14's consistent refusals of blood sugars and insulin and the multiple changes of providers. MD stated they would want to be notified of situations such as this to assist in finding a primary provider for the resident and figure out a solution for R14's medication refusals, such as suggestions for oral diabetic management. MD stated they did not know how severe R14's diabetes was but possible complications from chronically not taking diabetic medications were hyperglycemia, diabetic ketoacidosis (DKA; a complication of diabetes in which acids build up in the blood to levels which can be life-threatening), and hyperglycemic coma. The facility's policy Medication Refusal by Resident dated August 2023, directed staff to report to the ordering physician when medications refused for more than three days. The facility's policy Acute Change in Condition- Emergency Procedure dated August 2023, directed call the doctor if resident exhibited a sudden decrease in ability to care for self and if resident had a change in mental status or level of consciousness. Staff were to call the on-call doctor if unable to reach the primary physician. If the on-call doctor was not available, staff were to call the medical director. If the resident was in acute distress or lost consciousness, staff were to call 911.

Based on interview and document review, the facility failed to ensure 2 of 2 residents (R47 and R 53)'s grievances were documented, responded to and resolved in a timely manner. Findings include: R47's 2/23/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact, and he had behaviors which included hallucinations, delusions, and verbal behavior directed toward others. He had diagnoses which included Schizophrenia, major depressive disorder, dependent personality disorder, and obsessive compulsive disorder (OCD). R47 was independent with activities of daily living (ADLs), but needed redirection and cueing to correct daily routines. R47's current undated care plan identified target behaviors of hallucinations, thought blocking delusions, paranoia and disorganized thinking. Interventions included validation when he expressed delusional content, Associated Clinic of psychology (ACP) services weekly and as needed (PRN), 1:1 visits to allow R47 to vent his feelings. Medications as ordered, with monitoring for side effects and effectiveness. Observation/interview on 4/29/24 at 3:20 p.m. with R47 as he sat in a wheel chair facing the wall with the curtain divider pulled between the two beds. R47 verbalized acceptance to being interviewed, reported he was not concerned that his room mate was in the room, and was offered to use a different location. R47 began answering questions and reported he had no issues with other residents, felt safe, and had not been abused in any way. He then reported he was done and did not want to answer any more questions, laid back on his bed and closed his eyes. R53's 2/9/24 quarterly MDS identified his cognition was intact, he was independent with ADLS and had behaviors identified as hallucinations, delusions, and self isolation due to pain. He had diagnosis of Complex Regional pain syndrome (a chronic condition that causes severe, debilitating pain in an arm, hand, leg or foot after an injury), major depressive disorder, low back pain, anorexia, prediabetes, and history of suicidal ideations with no current plan. R53 was able to direct his own care and chose if he wanted to move around in the facility or remain in his room based on his level of pain. R53's current undated care plan identified psychotropic medication usage with Interdisciplinary Team (IDT) monitoring for effectiveness and any side effects to be completed quarterly and PRN. R53 reported he had an intrathecal pain pump (a surgically implanted device that delivers medication into the spinal fluid to treat chronic pain or spasticity). The device was managed by his pain clinic who provided maintenance and refilled the device. Observation/Interview on 4/29/24 at 3:40 p.m., with R53 who was lying on his bed with the divider curtain closed around his bed. The TV was on and R53 lowered volume and agreed to interview. During interview the TV on R53's side of the room, changed channels and the volume increased. R53's TV remote was lying on the bed beside him, and he was observed not touching the control. R53 reported this happened all the time, especially if R47 was upset with him and would change channels or adjust the volume with his control. R53 reported R47 liked to follow where ever he went and identified he had even recorded a previous incident when R47 was yelling and made allegation that R53 had beat on him. R53 reported he had asked R47 to clean up after himself in the bathroom after smearing BM all over the the toilet seat, and R47 had become upset and started yelling. He reported he had never touched R47 and would not do so. He stated he was fearful he would be in trouble due to R47 making allegations. R53 reported he had informed multiple staff (unable to identify who he had spoken with), about his concerns and had requested a room change, but no one had ever gotten back to him, or offered to file a grievance or report about his concerns. R53 also stated due to his physical condition he liked the room cooler, and R47 was always complaining the room was too cold. The temperature was observed set a 74 degrees, and R53 reported he had actually turned the thermostats up, to 74 but R47 was still not satisfied, and complained the room was to cold. Interview on 4/30/24 at 1:47 p.m. with LPN-B reported she was aware of the requirement for reporting of any abuse, or mistreatment and also the grievance process. She reported she was not aware of the verbal issues between R47 and R53 and would investigate further. She reported she was aware there had been some concern about cleanliness of the shared bathroom but the facility had hired a new cleaning service and she thought it would be better. LPN- reported she would also update the social worker and director of nursing of the concerns, but was not aware of any grievance forms completed by staff or residents. Interview on 4/30/24 at 2:47 p.m. with the licensed social worker (LICSW) reported resident room assignments were made dependent on bed availability and if any room changes were indicated. The LICSW reported if problems/concerns developed between room mates it was discussed at the interdisciplinary meeting (IDT) and work to make changes as they were able. She further reported it was difficult due to the number of residents and number of beds available. She reported she was aware of some conflict between R47 and R53, but had not provided a grievance form or offered to assist in completing one. Interview on 5/1/24 at 1:00 p.m., interview with R 53 reported licensed practical nurse (LPN)-B had come and spoke with him and either he or his room mate were going to be separated and he was glad about that. Stated following lunch he had placed his call light cord over the wall unit to enable him to reach it, and R47 had grabbed it and thrown it on the floor. He reported he told R47 he was not able to get it if it was on the floor. R53 reported when he went downstairs for his medication he had asked the nurse passing meds to talk with R47 about the call light and she had done so. R53 reported R47 had left the call light alone after that, but had been continuously complaining the room was too cold. Review of the 4/29/24 at 10:37 a.m., Progress notes identified R53 had talked about issues with his roommate, reported he followed him when he left his room, put on the same TV station and then turn up the volume. R53 reported he tried to ignore him, but R53 reported he thought R47 did those things just to aggravate him. R53 reported he liked his room and didn't want to move so he just tolerated R47. Interview on 5/1/24 at 1:30 p.m. with the director of nursing (DON) reported she was aware the facility had a grievance policy, but was not aware of any grievances or concerns voiced between R47 and R53. She was not able to provide either a log of grievances or a policy which had been requested and was not provided.

Based on observation, interview and document review, the facility failed to ensure allegations of potential abuse were reported to the administrator and State Agency (SA) immediately, but not later than 2 hours after the allegation is made, for 1 of 1 residents (R45) reviewed for resident-to-resident verbal altercation. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication dated 7/7/23, indicated R28 had loose associations and was being treated with medications for active delusional symptoms. R28's CAA for psychosocial well-being dated 7/7/23, indicated he had a long-standing diagnosis of schizophrenia and had been treated over the years for his symptoms, which had impacted his communication. The CAA indicated other disciplines were working with R28 for improvement with staff interventions in place to address his psychosocial well-being. R28's care plan dated 10/27/20, indicated tangential speech that did not make sense as evidence by R28 responding to internal stimuli and becoming paranoid over the TV/radio and believing he is being harassed. Interventions identified by the care plan included providing medications as ordered, redirection and cueing. The care plan also indicated R28 had verbally abusive behaviors and identified that he was short-tempered with staff peers, and strangers. The care plan identified behaviors such as cussing and yelling at other residents in R28's way. The care plan listed interventions of contacting a mobile crisis unit, administering medications as ordered, and updating his psychiatrist and case manager of behaviors. A progress note dated 3/27/24, indicated the interdisciplinary team (IDT) met to discuss R28's behaviors after peers complaints related to inappropriate comments and yelling to other residents. The progress note indicated staff needed to make attempts to redirect R28 when he was yelling or screaming at other residents. The progress note lacked documentation of any specific incident or if a grievance was offered or filed in relation to R28's behaviors. A progress note dated 4/3/24, indicated R28 had been very abusive towards staffs and other residents. He was at some point found using the 'N' word in the dining area. The progress note lacked indication of a grievance being offered or filed. A social service MDS progress note dated 4/3/24, indicated R28 had a history of aggressive behaviors towards other residents. The progress note indicated during a nurse interview, R28 was reported to be at his baseline and continued verbal aggression towards staff and residents. Furthermore, the progress note indicated during a nursing assistant (NA) interview R28 had been verbally aggressive towards certain residents. On 4/30/24 at 8:52 a.m., R28 was not available for interview. On 4/30/24 at 9:14 a.m., R28 was not available for interview. R45's admission MDS dated [DATE], indicated intact cognition with adequate hearing, the ability to make herself understood and to understand others. MDS indicated no hallucinations or delusions and no behavioral symptoms directed towards self or others. R45's diagnoses included anxiety, bipolar disorder, and post-traumatic stress disorder (PTSD, or a disorder that can bring back memories of a traumatic experience accompanied by intense emotional and physical reactions). R45's care plan lacked documentation of a focus, goal, and interventions to keep her safe from the potential for abuse, neglect and/or exploitation. A review of R45's progress notes did not reveal any documented complaints by R45. During interview on 4/29/24 at 4:53 p.m., R45 stated there was another resident who was verbally confrontational with her. R45 stated one resident, R28, made racist and sexist comments towards her. R45 stated R28 called her a black cunt bitch, and had used racial slurs, such as the N word, when referring to her and other residents of color. R45 stated she felt R28 was directing what he was saying towards her and other residents because of the racial and sexist connotations. She stated his words felt disrespectful and abusive. R45 stated she reported R28 to staff and felt they gave the name calling a go-pass and brushed it under the rug. She stated no staff had follow up with her, offered to file a grievance, or provided a phone number for her to make a formal complaint. R45 stated she brought this up on multiple occasions, including at her first care conference. She stated she felt hurt by R28's comments and it felt like a disservice to her. Additionally, she stated it did not feel fair that staff knew about the situation and had not done anything to protect her or the other residents. A care conference progress note dated 3/27/24, lacked documentation of complaints or reported behaviors by R45. During interview on 4/29/24 at 6:36 p.m., the administrator denied being aware of any complaints from R45 but stated that may be due to his short-term presence in the facility. The administrator stated if staff heard something like that, they would report it. The administrator stated R28 was always grumbling about something to everyone. He's just a grumpy old man. A review of Aspen Complaints/Incidents Tracking System (ACTS) on 4/30/24 at approximately 11:00 a.m., did not reveal reported events regarding R45's complaints. R45 declined further interview on 5/1/24 at 11:17 a.m., and on 5/2/24 at 11:29 a.m. During interview on 4/30/24 at 1:30 p.m., the administrator stated some issues needed to be reported within 24 hours and other issues where there was no physical harm or altercation could be reported within five days. The administrator stated during a recent standup meeting, the team discussed that if in doubt, it would be better to over-report than to not report. The administrator verified other staff, including the director of nursing (DON), were aware of the incident prior to 4/29/24. The administrator stated the facility should take R45's complaints seriously, but after collaboration with the IDT, did not feel the resident-to-resident verbal altercation was reportable. The administrator stated LPN-B talked to R45 and provided reassurance and apologized. When asked to describe the investigation process, the administrator stated there was not a formal process until the team collaborated and decided if the incident was reportable or not. If the incident was deemed reportable, then the investigation would become more of a formal process. The administrator stated staff were really good about monitoring for potential or actual reported allegations of abuse by reviewing incidents from each resident throughout the shift and either reporting them or bringing them up during standup meetings. The administrator stated the DON was responsible for supervising and monitoring bedside care delivery. During interview on 4/30/24 at 2:15 p.m., activities staff (AS)-A verified becoming aware of R45's complaint about R28's verbal behaviors during her care conference. AS-A stated R45's complaint was what prompted the IDT meeting to address R28's behaviors and interventions. AS-A stated what was discussed would be shared under the communications tab in Point Click Care (PCC) and all staff should be checking that daily. Additionally, AS-A stated the information from the IDT meeting was shared during daily standup meetings and managers were responsible for sharing that information to their shift. AS-A stated the incident was addressed with R45 and R28's interventions were documented in his care plan. AS-A stated it was difficult to determine if R45's behavior changed after the incident since she was a newer admission to the facility. AS-A stated R28's baseline behavior was sitting in a general area and, making slurs about whoever is passing by. AS-A stated if a problem is brought to staff's attention, the first step is to get the full report either from a progress note or from a verbal report. AS-A stated most of the time it goes to social services (SS), who would determine if it was reportable. If the incident was reportable, SS would make the report. AS-A stated the most recent abuse identification, prevention, and reporting requirement training was completed last January. During interview on 4/30/24 at 2:52 p.m., NA-A stated R45 reported R28 made unprovoked racist comments towards her about a month ago and it really had her down. NA-A stated the incident was reported to the charge nurse on duty. NA-A was unaware of recent abuse training, but stated, if you see something, say something so things don't escalate beyond that. During interview on 4/30/24 at 3:26 p.m., LPN-B verified being aware of the incident and stated, I became aware of the situation because she came and told me after it happened. LPN-B stated, I did what I was supposed to do, and stated the incident was reported to SS during that morning's standup meeting. LPN-B stated if there were concerns for abuse, staff should never worry about being wrong and need to report incidents. LPN-B stated for instances with physical contact, a report needed to be made within 24 hours. During interview on 5/1/24 at 9:43 a.m., SS-A stated if there was serious injury, an event would need to be reported immediately or within an hour. If no serious injury occurred, it should be reported within 24 hours. SS-A stated the investigative process included gathering details, talking to the administrator and DON, and moving forward to report the event if it was deemed reportable. SS-A verified being aware of the incident involving R28 and R45 during risk management after R45's care conference. SS-A stated interventions were aimed at R28's behaviors and how staff should be attentive to him. SS-A stated R45's complaint was not documented in the care conference note nor was it brought up as a resident-specific complaint. SS-A stated R45's complaint was not reported because it was brought up as more as a general concern and not a resident-specific complaint. During interview on 5/1/24 at 1:17 p.m., LPN-A stated after gathering the details of a resident's complaint or concern, I would get social services involved. LPN-A stated most residents come to staff directly with concerns. During off-hours, if a resident had a complaint or concern, LPN-A stated the expectation was to document the issue in a progress note or in the communications tab in PCC under that specific resident. If the issue was urgent, LPN-A stated staff were expected to contact the on-call manager. If a resident complained about another resident making offensive comments, LPN-A stated, I would probably speak to both of them to determine what was going on, document that and then get SS involved. LPN-A stated incidents involving physical aggression needed to be reported within 24 hours but was unsure about other types of reportable events. During interview on 5/2/24 at 12:26 p.m., the DON stated when a resident had a complaint, staff should first determine if it involved a safety issue that needed to be addressed immediately. If not, the DON stated a grievance form could be filled out. The DON stated, when the grievance form is filled out, it can be discussed amongst the departments involved and we can resolve it. The DON stated the expectation was for staff to document what the situation was and what interventions were provided. The DON stated the key was to make sure the resident felt reassured even after reporting an incident, staff should ensure the resident received the help they needed and followed up. A facility policy titled Vulnerable Adult Information last updated 6/23/17, indicated the facility's objective was to assure protection of each resident from possible maltreatment. The policy indicated any situation where you have reason to believe a vulnerable adult is being or has been mistreated is a situation to report. Furthermore, the policy identified with any suspicion of a vulnerable adult incident a staff member shall inform their supervisor and/or charge nurse, the director of resident services, director of nursing, MDS coordinator, and/or therapeutic recreation director. Additionally, the policy directed staff to call [PHONE NUMBER] to make a verbal report. The policy also indicated staff should immediately make the initial report at the SA website and to the administrator. A facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/21/23, identified abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy indicated instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse and mantal abuse including abuse facilitated or enabled through the use of technology. Furthermore, the policy defined verbal abuse as the use or oral, written or gestured language that willfully includes disparaging and derogatory terms to resident and families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy indicated the purpose was to ensure all residents that live at the Birchwood Care Home (BCH) and Grand Avenue Rest Home (GARH) are protected from any and all abuse, neglect, misappropriate of resident property, exploitation, and harm in accordance with federal law and state statute that they maintain the highest practical physical, mental and psychosocial well-being of each resident. The policy indicated it was the policy of BCH and GARH that all reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy advised the designated facility personnel will begin the investigation immediately. For an investigation of abuse, when an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include the following key elements: a. Who was involved? b. resident statements - for non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to interaction and document findings. c. Resident's roommate statements, if possible. d. Involved staff and witness statements of events. e. A description of the resident's behavior and environment at the time of the incident. f. Injuries present. g. Observation of resident and staff behaviors during the investigation. h. Environmental considerations. The policy indicated the resident(s) will be protected from the alleged offender(s) and immediately upon receiving a report of abuse, neglect and/or harm, the administrator (or designee) will coordinate delivery of appropriate medical and/or psychological care as well as any attention needed to provide for the safety of other residents. The policy indicated the guidelines were to immediately remove the resident from the situation, examine and interview the resident to ensure proper documentation of any injury. If the resident could be at risk in the same environment, the policy indicated staff should evaluate the situation and consider some options including a room change, roommate change and/or risks of resident self-abuse. The policy indicated the resident and/or representative should be notified of the completion of the investigation and whether the incident was substantiated. Information would be provided according to the agency policy and guidelines. The policy identified that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source misappropriate of resident property) are reported per federal and state law and the facility will ensure that all alleged violations involving abuse are reported immediately. Employees will report the above examples immediately to their supervisor or person in charge and reports would be made to the administrator and other individuals as identified, including state agency in accordance with state and federal law. The policy includes reporting timelines for what to report, to whom, and when to report. The policy guides any covered individual (including the owner, operator, employee, manager, and agency or contractor of the facility) to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the facility administrator and to the other officials in accordance with State law, including the State Survey Agency (SA) and the adult protective services where state law provides jurisdiction in long-term care facilities. The policy indicated staff must report all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury.

Based on observation, interview and document review, the facility failed to ensure allegations of resident-to-resident verbal abuse were thoroughly investigated, and protection provided for 1 of 1 residents (R45) who were involved in a resident-to-resident verbal altercation by R28. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication dated 7/7/23, indicated R28 had loose associations and was being treated with medications for active delusional symptoms. R28's CAA for psychosocial well-being dated 7/7/23, indicated he had a long-standing diagnosis of schizophrenia and had been treated over the years for his symptoms, which had impacted his communication. The CAA indicated other disciplines were working with R28 for improvement with staff interventions in place to address his psychosocial well-being. R28's care plan dated 10/27/20, indicated tangential speech that did not make sense as evidence by R28 responding to internal stimuli and becoming paranoid over the TV/radio and believing he is being harassed. Interventions identified by the care plan included providing medications as ordered, redirection and cueing. The care plan also indicated R28 had verbally abusive behaviors and identified that he was short-tempered with staff peers, and strangers. The care plan identified behaviors such as cussing and yelling at other residents in R28's way. The care plan listed interventions of contacting a mobile crisis unit, administering medications as ordered, and updating his psychiatrist and case manager of behaviors. A progress note dated 3/27/24, indicated the interdisciplinary team (IDT) met to discuss R28's behaviors after peers complaints related to inappropriate comments and yelling to other residents. The progress note indicated staff needed to make attempts to redirect R28 when he was yelling or screaming at other residents. The progress note lacked documentation of any specific incident or if a grievance was offered or filed in relation to R28's behaviors. A progress note dated 4/3/24, indicated R28 had been very abusive towards staffs and other residents. He was at some point found using the 'N' word in the dining area. The progress note lacked indication of a grievance being offered or filed. A social service MDS progress note dated 4/3/24, indicated R28 had a history of aggressive behaviors towards other residents. The progress note indicated during a nurse interview, R28 was reported to be as his baseline and continued verbal aggression towards toward staff and residents. Furthermore, the progress note indicated during a nursing assistant (NA) interview R28 had been verbally aggressive towards certain residents. On 4/30/24 at 8:52 a.m., R28 was not available for interview. On 4/30/24 at 9:14 a.m., R28 was not available for interview. During observation on 4/30/24 at 3:03 p.m., R28 walked down the hallway towards the smoking lounge. He used the handrail as he walked and was talking to himself out loud. When approached, R28 was mumbling to himself and was unable to be understood. He continued walking and went out into the smoking lounge to smoke a cigarette. At 3:13 p.m., R28 remained in the smoking lounge with his head down. During observation on 5/1/24 at 2:13 p.m., R28 was standing at the nurse's station, yelling through the glass at staff, where are my goddamn cigarettes? Unidentified staff told R28 they did not have his cigarettes. The administrator walked out of his office and followed R28 as he walked away from the nurse's station and through the dining area to the recreation room. The administrator asked R28 if there was something he needed help with. R28 walked away from the recreation room and into the bathroom. At 2:23 p.m., R28 walked back through the dining room without further verbal behaviors. R45's admission MDS dated [DATE], indicated intact cognition with adequate hearing, the ability to make herself understood and to understand others. MDS indicated no hallucinations or delusions and no behavioral symptoms directed towards self or others. R45's diagnoses included anxiety, bipolar disorder, and post-traumatic stress disorder (PTSD, or a disorder that can bring back memories of a traumatic experience accompanied by intense emotional and physical reactions). R45's care plan lacked documentation of a focus, goal, and interventions to keep her safe from the potential for abuse, neglect and/or exploitation. A review of R45's progress notes did not reveal any documented complaints or reported grievances by R45. During interview on 4/29/24 at 4:53 p.m., R45 stated there was another resident who was verbally confrontational with her. R45 stated one resident, R28, made racist and sexist comments towards her. R45 stated R28 called her a black cunt bitch, and had used racial slurs, such as the N word, when referring to her and other residents of color. R45 stated she felt R28 was directing what he was saying towards her and other residents because of the racial and sexist connotations. She stated his words felt disrespectful and abusive. R45 stated she reported R28 to staff and felt they gave the name calling a go-pass and brushed it under the rug. She stated no staff had follow up with her, offered to file a grievance, or provided a phone number for her to make a formal complaint. R45 stated she brought this up on multiple occasions, including at her first care conference. She stated she felt hurt by R28's comments and it felt like a disservice to her. Additionally, she stated it did not feel fair that staff knew about the situation and had not done anything to protect her or the other residents. A care conference progress note dated 3/27/24, lacked documentation of complaints or reported behaviors by R45. During interview on 4/29/24 at 6:36 p.m., the administrator denied being aware of any complaints from R45 but stated that may be due his short-term presence in the facility. The administrator stated if staff heard something like that, they would report it. The administrator stated R28 was always grumbling about something to everyone. He's just a grumpy old man. During interview on 4/30/24 at 1:18 p.m., R45 stated she was nervous about having reported the incident. R45 stated she feared getting into trouble because she was newer to the facility. R45 stated licensed practical nurse (LPN)-B spoke with her earlier about the incident and felt like LPN-B was trying to smooth it over. R45 declined further interview on 5/1/24 at 11:17 a.m., and on 5/2/24 at 11:29 a.m. During interview on 4/30/24 at 1:30 p.m., the administrator stated some issues needed to be reported within 24 hours and other issues where there was no physical harm or altercation could be reported within five days. The administrator stated during a recent standup meeting, the team discussed that if in doubt, it would be better to over-report than to not report. The administrator verified other staff were aware of the incident involving R28 and R45 prior to 4/29/24. The administrator acknowledged the facility should take R45's allegations seriously, but stated after collaboration with the IDT, determined it was not reportable. The administrator stated LPN-B talked to R45 and provided reassurance and apologized. When asked to describe the investigation process, the administrator stated there was not a formal process until the team collaborated and decided if the incident was reportable or not. If the incident was deemed reportable, then the investigation would become more of a formal process. The administrator stated staff were really good about monitoring for potential or actual reported allegations of abuse by reviewing incidents from each resident throughout the shift and either reporting them or bringing them up during standup meetings. The administrator identified interventions to protect R45 as watching R28, and stated, we all just watch R28. If I hear or see R28 having any interaction with someone, I'm watching him and others. We have to constantly watch all of the residents. During interview on 4/30/24 at 2:15 p.m., activities staff (AS)-A verified becoming aware of R45's complaint about R28's verbal behaviors during her care conference. AS-A stated R45's complaint was what prompted the IDT meeting to address R28's behaviors and interventions. AS-A stated what was discussed would be shared under the communications tab in Point Click Care (PCC) and all staff should be checking that daily. Additionally, AS-A stated the information from the IDT meeting was shared during daily standup meetings and managers were responsible for sharing that information to their shift. AS-A stated the incident was addressed with R45 and R28's interventions were documented in his care plan. AS-A was unable to locate documentation of R45's allegations in her electronic health record (EHR). AS-A stated, R28 always escalates, and our decision was to verbally intervene but then he immediately went to the hospital, so we never got a chance to try out interventions. He just got back not too long ago so it might not seem to R45 like we've really done anything. AS-A stated it was difficult to determine if R45's behavior changed after the incident since she was a newer admission to the facility. AS-A stated R28's baseline behavior was sitting in a general area and, making slurs about whoever is passing by. AS-A stated if a problem is brought to staff's attention, the first step is to get the full report either from a progress note or from a verbal report. AS-A stated most of the time it goes to social services (SS), who would determine if it was reportable. If the incident was reportable, SS would make the report. AS-A stated the most recent abuse identification, prevention, and reporting requirement training was completed last January. During interview on 4/30/24 at 2:52 p.m., NA-A stated R45 reported R28 made unprovoked racist comments towards her about a month ago and it really had her down. NA-A stated the incident was reported to the charge nurse on duty, LPN-B. NA-A was unaware of recent abuse training, but stated, if you see something, say something so things don't escalate beyond that. During interview on 4/30/24 at 3:26 p.m., LPN-B verified being aware of the incident and stated, I became aware of the situation because she came and told me after it happened. LPN-B stated, I did what I was supposed to do, and stated the incident was communicated to SS during that morning's standup meeting. LPN-B verbalized be unsure if the incident was reported and stated, I just know that I told them. LPN-B stated if there were concerns for abuse, staff should never worry about being wrong and need to report incidents. LPN-B stated for instances with physical contact, a report needed to be made within 24 hours. LPN-B identified interventions to de-escalate R28's behaviors and stated, if we can't get him out of the area, we get other people out of the area to make sure everyone else is okay and safe. During interview on 5/1/24 at 9:43 a.m., SS-A stated if there was serious injury, an event would need to be reported immediately or within an hour. If no serious injury occurred, it should be reported within 24 hours. SS-A stated the investigative process included gathering details, talking to the administrator and DON, and moving forward to report the event if it was deemed reportable. SS-A verified being aware of the incident involving R28 and R45 during risk management after R45's care conference. SS-A stated interventions were aimed at R28's behaviors and how staff should be attentive to him. SS-A stated R45's complaint was not documented in the care conference note nor was it brought up as a resident-specific complaint. SS-A stated R45's complaint was not reported because it was brought up as more as a general concern and not a resident-specific complaint. During interview on 5/1/24 at 1:17 p.m., LPN-A stated for grievances or complaints, I would get social services involved. LPN-A stated most residents come to staff directly with concerns. During off-hours, if a resident had a complaint or concern, LPN-A stated the expectation was to document the issue in a progress note or in the communications tab in PCC under that specific resident. If the issue was urgent, LPN-A stated staff would be expected to contact the on-call manager. If a resident complained about another resident making offensive comments, LPN-A stated, I would probably speak to both of them to determine what was going on, document that and then get SS involved. LPN-A stated incidents involving physical aggression needed to be reported within 24 hours but was unsure about other types of reportable events. During interview on 5/2/24 at 12:26 p.m., the DON stated the grievance process was to get the complaint, fill out the grievance form and if it needed to be addressed immediately, we would want to address that immediately. The DON stated, when the grievance form is filled out, it can be discussed amongst the departments involved and we can resolve it. The DON stated the expectation was for staff to document what the situation was and what interventions were provided. The DON stated the key was to make sure the resident felt reassured even after reporting an incident, staff should ensure the resident received the help they needed and followed up. During interview on 5/2/24 at 3:25 p.m., SS-A stated there was an anonymous box in the hallway with papers that were always stocked for residents to make grievances or formal complaints. SS-A stated residents were reminded of this during resident council. SS-A stated residents can either file a grievance or speak to SS directly. SS-A stated when a grievance form was received, it was reviewed and distributed to the related department. SS-A stated the department manager was responsible for proposing a resolution and after review by the team, it was proposed to the resident for approval. If the resident felt the resolution was an appropriate solution to the problem, it would then go to the administrator for implementation. SS-A stated the process for anonymous grievances would be the same without the review process by the resident. SS-A stated if the grievance was related to an abuse claim, it would be discussed in IDT and brought to the administrator and DON to discuss the next actions. A facility policy titled Vulnerable Adult Information last updated 6/23/17, indicated the facility's objective was to assure protection of each resident from possible maltreatment. The policy indicated any situation where you have reason to believe a vulnerable adult is being or has been mistreated is a situation to report. Furthermore, the policy identified with any suspicion of a vulnerable adult incident a staff member shall inform their supervisor and/or charge nurse, the director of resident services, director of nursing, MDS coordinator, and/or therapeutic recreation director. Additionally, the policy directed staff to call [PHONE NUMBER] to make a verbal report. The policy also indicated staff should immediately make the initial report at the SA website and to the administrator. A facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/21/23, identified abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy indicated instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse and mantal abuse including abuse facilitated or enabled through the use of technology. Furthermore, the policy defined verbal abuse as the use or oral, written or gestured language that willfully includes disparaging and derogatory terms to resident and families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy indicated the purpose was to ensure all residents that live at the Birchwood Care Home (BCH) and Grand Avenue Rest Home (GARH) are protected from any and all abuse, neglect, misappropriate of resident property, exploitation, and harm in accordance with federal law and state statute that they maintain the highest practical physical, mental and psychosocial well-being of each resident. The policy indicated it was the policy of BCH and GARH that all reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy advised the designated facility personnel will begin the investigation immediately. For an investigation of abuse, when an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include the following key elements: a. Who was involved? b. resident statements - for non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to interaction and document findings. c. Resident's roommate statements, if possible. d. Involved staff and witness statements of events. e. A description of the resident's behavior and environment at the time of the incident. f. Injuries present. g. Observation of resident and staff behaviors during the investigation. h. Environmental considerations. The policy indicated the resident(s) will be protected from the alleged offender(s) and immediately upon receiving a report of abuse, neglect and/or harm, the administrator (or designee) will coordinate delivery of appropriate medical and/or psychological care as well as any attention needed to provide for the safety of other residents. The policy indicated the guidelines were to immediately remove the resident from the situation, examine and interview the resident to ensure proper documentation of any injury. If the resident could be at risk in the same environment, the policy indicated staff should evaluate the situation and consider some options including a room change, roommate change and/or risks of resident self-abuse. The policy indicated the resident and/or representative should be notified of the completion of the investigation and whether the incident was substantiated. Information would be provided according to the agency policy and guidelines. The policy identified that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source misappropriate of resident property) are reported per federal and state law and the facility will ensure that all alleged violations involving abuse are reported immediately. Employees will report the above examples immediately to their supervisor or person in charge and reports would be made to the administrator and other individuals as identified, including state agency in accordance with state and federal law. The policy includes reporting timelines for what to report, to whom, and when to report. The policy guides any covered individual (including the owner, operator, employee, manager, and agency or contractor of the facility) to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the facility administrator and to the other officials in accordance with State law, including the State Survey Agency (SA) and the adult protective services where state law provides jurisdiction in long-term care facilities. The policy indicated staff must report all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident's diagnosis of post traumatic stress disorder (PTSD) (a mental health condition triggered by a traumatic event) for 2 of 2 residents (R57, R14) reviewed for MDS accuracy. Findings include: The resident assessment instrument (RAI) manual version 3.0 indicated under section I, Active Diagnoses, the items in this section were intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Section I in the RAI manual further indicated definitions of active diagnoses were physician documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7 day look back period. For the assessment, there are two look back periods: 1. Diagnosis identification is a 60 day look back period and 2. Diagnosis status: active or inactive is a 7 day look back period. The disease conditions in this section require a physician documented diagnosis or by a nurse practitioner, physician assistant, or clinical nurse specialist in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis, problem list, and other resources as available. If a diagnosis problem list is used, only diagnoses confirmed by the physician should be entered. Further, the RAI indicated once a diagnosis was identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7 day look back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7 day look back period as these would be considered inactive diagnoses. Further, the following information sources in the medical record for the past 7 days is checked to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. R57's admission MDS dated [DATE], indicated moderate cognitive impairment, had bipolar disorder, factitious disorder, and depression. Further, the MDS under section I, I6100, lacked a check mark indicating R57 had PTSD. R57's quarterly MDS dated [DATE], indicated R57 had intact cognition, had bipolar disorder, manic depression, and under section I, I6100, lacked a check mark indicating R57 had PTSD. R57's psychiatric evaluation and management note dated 12/9/23, indicated R57 had bipolar disorder, PTSD, factitious disorder, and unspecified neurocognitive disorder. R57's physician progress notes dated 12/10/23, from the hospital referral on page 33 of 103 indicated R57 had neurocognitive disorder, bipolar disorder, PTSD. The note further indicated R57 had bipolar disorder and PTSD with recent discharge and rehospitalization . R57's hospital progress notes dated 12/12/23, and signed by the physician on page 8 of 103, indicated R57 had bipolar disorder, PTSD, and factitious disorder. R57's Level II Preadmission Screening (PAS) for Persons with Mental Illness Determination for Nursing Facility Admission form dated 12/27/23, indicated a physician recommended nursing facility level of care for R57. The form further indicated R57 had current mental health diagnoses of bipolar disorder and PTSD and was receiving psychiatry services. R57's Adult Crisis Assessment social worker note dated 3/22/24, indicated the assessment was requested to assess safety, provide diagnosis, and appropriate referral. Further, the note indicated a provisional diagnosis of PTSD based on the brief crisis assessment, as well as reported by R57, and a historical diagnosis per review of records. Additionally, the note indicated R57 endorsed, displayed, or was reported to have the following symptoms: isolating self, outbursts of anger, easily startled, trouble with sleep, low energy, body or muscles tense, being on guard or constantly alert, and feeling short of breath, excessive worry, feeling restless, poor concentration, increased irritability, racing thoughts, feeling on the verge of losing control, and feared not being able to move to a more safe place to live. R57's goals were to continue to see and talk with his psychiatrist and take prescribed medications. R57's care plan dated 3/25/24, indicated R57 was short tempered, easily annoyed, emotionally labile, argumentative, irritable and impulsive and had neurocognitive disorder, bipolar, and PTSD. R57's Associated Clinic of Psychology (ACP) noted dated 4/23/24, indicated R57 had bipolar disorder, and PTSD. R57's medication administration record (MAR) dated May 2024, indicated the following diagnoses: bipolar disorder, PTSD. R57's Face Sheet indicated the following diagnoses: bipolar disorder with a date of onset on 1/5/24, PTSD with a date of onset on 1/5/24, factitious disorder with a date of onset 1/5/24, and depression with a date of onset on 12/22/23. During interview on 5/2/24 at 10:43 a.m., registered nurse (RN)-B stated she completed the MDS including section I and stated she utilized the form Medical Diagnosis, in the electronic medical record (EMR) to determine diagnoses for the MDS and stated R57 had bipolar disorder, PTSD, and factitious disorder. RN-B further stated only the diagnoses that were being treated or had ordered to treat such as medications or treatments were incorporated on the MDS and stated R57 has PTSD, but was not being treated for it and further stated PTSD was something the facility could care plan such as what the symptoms were and further stated they were not aware what R57's trauma was, but would be important to know if there were triggers. During interview on 5/2/24 at 9:52 a.m., social worker (SW)-A stated R57 had PTSD. 48299 R14 R14's annual Minimum Data Set (MDS) dated [DATE], indicated R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had diagnoses of schizophrenia and depression. Further, the MDS under section I, I6100, lacked a check mark indicating R14 had post-traumatic stress disorder (PTSD). R14's quarterly MDS dated [DATE], indicated R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had diagnosis of schizophrenia. Further, the MDS under section I, I6100, lacked a check mark indicating R14 had PTSD. R14's cognition care plan related to psychosis and delusions and behavioral care plan related to delusions revised 12/8/19, indicated R14 had schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. R14's annual social service MDS documentation dated 8/18/23 at 3:01 p.m., indicated R14 had diagnoses of schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. A Nursing Home Visit Encounter with R14's nurse practitioner dated 3/5/24, indicated R14 had schizophrenia, PTSD, major depressive disorder, among other diagnoses. R14's Face Sheet indicated the following diagnoses: schizophrenia with a date of onset on 8/19/15, major depressive disorder with a date of onset on 8/19/15, PTSD with a date of onset on 8/19/15, among other diagnoses. During interview on 4/30/24 at 1:48 p.m., nursing assistant (NA)-A stated their charting identified triggers and behaviors for residents. NA-A reviewed R14's target behaviors were refusing insulin and carrying belongings. NA-A reviewed R14 had no information on triggers of trauma. NA-A stated R14 believed people were trying to do things to them like poison them. NA-A stated R14 was more comfortable with them now and allowed NA-A to help with cares when needed compared to when NA-A was a newer employee. During interview on 4/30/24 at 2:58 p.m., registered nurse (RN)-C stated staff gave each other report between shifts on resident behavior and interventions completed in response. Besides report, the medical record had a communications area where they could record such information. RN-C stated care plans showed behavior plans for residents. During same interview on 4/30/24 at 2:58 p.m., licensed practical nurse (LPN)-B stated they believed R14 was abused and spoke about someone stalking them and was frightened and jumpy at times thinking someone was watching them. LPN-B stated residents had care plans related to trauma if they were open enough to talk about it, or residents' care plans reflected staff observations. LPN-B said the social work or MDS nurse completed trauma-based assessments. During interview on 5/2/24 at 9:53 a.m., the social worker (SW)-A stated R57 had PTSD. SW-A reviewed the care plan and stated R14 did not have specific information related to PTSD like triggers. During interview on 5/2/24 at 10:43 a.m., RN-B stated they completed the MDS including section I and utilized the form Medical Diagnosis, in the electronic medical record (EMR) to determine diagnoses for the MDS and stated R14 had schizophrenia, PTSD, major depressive disorder, among others. RN-B further stated only the diagnoses being treated or had orders to treat, such as medications or treatments, were incorporated on the MDS and stated R14 had PTSD but was not being treated for it and further stated PTSD was something the facility could care plan, such as what the symptoms and triggers were. During interview on 5/2/24 at 3:05 p.m., the director of nursing stated they expected PTSD diagnosis to be included on the MDS and expected staff to look at all the notes for diagnoses and stated it was important to have an accurate MDS in order to know what they are treating and managing. A policy, Interdepartmental MDS Review, dated August 2023, indicated each resident's MDS would be completed on admission, quarterly, annually, and significant change using current, accurate documentation and assessments specific to that resident. The interdisciplinary team (IDT) would review and discuss each resident during the 7 days assessment period and provide information, documentation and assessments they have from the prospective of their area of expertise. Discussions and evaluations of each resident were done for the purpose of identifying possible areas of conflict of information and to ensure accuracy of the completion of the MDS. The IDT will review the reports prepared by the resident's physicians, house psychologist and all other sources available to determine what and how the information will be used in the MDS process. Further, nursing was responsible for completion of section I of the MDS plus care area assessments triggered.

Based on interview and document review, the facility failed to develop a comprehensive care plan for psychotropic medications for 1 of 5 residents (R56) reviewed for psychotropic medications. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 had intact cognition and experienced hallucinations. MDS indicated R56 had diagnoses of diabetes, depression, and a psychotic disorder other than schizophrenia. MDS indicated R56 received an antipsychotic on a routine basis and an antidepressant medication. R56's Care Area Assessment (CAA) dated 2/14/24, for psychotropic drug use indicated R56 had mental illness diagnoses and was being treated with long-term psychotropic medications. The CAA further indicated staff would follow the plan of care to maintain R56's current level of functioning for improvement with symptom relief. R56's physician orders included the following: - Olanzapine (Zyprexa) oral tablet 7.5 milligrams (mg), Give 1 tablet orally at bedtime to treat psychotic depressive illness, dated 2/8/24. - Mirtazapine (Remeron) oral tablet 15mg, Give 1 tablet by mouth at bedtime to treat depression, dated 2/8/24. R56's care plan dated 2/8/24, indicated he had antipsychotic use and had target symptoms but lacked documentation of what antipsychotic medication was being used and lacked resident-specific target symptoms or behaviors to monitor. Interventions included staff will use non-pharmacologic interventions but lacked documentation of resident-specific non-pharmacologic interventions. Furthermore, R56's care plan lacked documentation of his antidepressant use and resident-specific target symptoms related to antidepressant use as well as related interventions. The care plan identified R56 had suicidal ideation with hospitalization and identified interventions of providing 1:1 visits with resident as needed, assisting resident to make a No Harm Contract, visiting an in-house therapist, medications as ordered, and updating the provider of increased suicidal ideation and/or plans. The care plan also identified R56's psychotropic drug use but lacked resident-specific medications and lacked documentation of resident-specific target symptoms to monitor. During interview on 5/2/24 at 12:34 p.m., the director of nursing (DON) stated the social services department was responsible for updating the care plan with the behavioral aspect of psychotropic medications. The DON stated expectations for residents on psychotropic medications were to see target behaviors and interventions in the care plan. The DON verified R56's care plan lacked resident-specific symptoms and interventions. Additionally, the DON expected R56's antidepressant medication to be identified in his care plan but verified it was not. During interview on 5/2/24 at 3:33 p.m., social services (SS)-A stated the process for monitoring psychotropic medications and related symptoms and behaviors was to review notes to determine what the medications were and what the symptoms were. SS-A stated for a new admission, it might take some time to develop resident-specific non-pharmacologic interventions because it is an interdisciplinary approach, and the ideas could come from nursing staff, providers, or therapists. SS-A stated the expectation was resident-specific symptoms and interventions should be documented in a resident's care plan if they were taking psychotropic medications. SS-A verified R56's care plan lacked resident-specific interventions and stated, his care plan was not completed. A psychotropic drug use policy was requested but not received.

Based on interview and document review, the facility failed to reassess and implement appropriate interventions in place for 2 of 2 residents (R1, R2) with a history of elopement. This resulted in an immediate jeopardy (IJ), substandard quality of care, when R1 and R2 left the facility property unsupervised and without staff awareness. The IJ began on 2/12/23, when the facility noted R1 and R2 had left the facility unsupervised. Further, R1 and R2 were not comprehensively reassessed with appropriate interventions developed to provide adequate safety after previous exit seeking behaviors. On 2/22/23, at 5:20 p.m. the director of nursing was notified of the IJ for R1 and R2. The IJ was removed on 2/24/23, at 12:28 p.m., when the facility had implemented corrective action, however noncompliance remained at a lower scope and severity (Level D) isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), hallucinations (sensory experience of something that does not actually exist and has no basis in reality) and a behavior of inattention (unable to focus). The MDS further indicated R1 was independent with all activities of daily living (ADL). R1's physician orders dated 11/9/21, indicated R1 may leave the facility unsupervised. R1's Resident's Ability to Leave the Facility Safely assessment dated [DATE], indicated R1 was safe to go out into the community unsupervised and a physician's order was in place. The assessment was completed annually. R1's Safety in the Community Evaluation dated 10/28/22, indicated R1 displayed safe behavior in the community and was safe to go out into the community unsupervised. The assessment was completed annually. R1's care plan dated 11/11/21, indicated R1 had a history of walking around the neighborhood naked, attempting self-injury (banging his head and shoulder into the wall), and responding to command voices that told him to do these things. The care plan lacked evidence of any new interventions after an elopement on 2/8/23. The care plan had an updated intervention to work with R1's case manager to initiate a treatment plan for safety after an elopement on 2/12/23. R1's progress note dated 2/8/23, 22:55 [10:55 p.m.] indicated the overnight maintenance staff saw out of the corner of his eye that someone who was naked was going out the west side door at 10:30 pm. He ran after him, put his own jacket around him and brought him back inside. Resident was given a as needed (PRN), medication of [Thorazine 50 milligrams], put some clothes back on and writer spoke with him in his room. He stated that his voices were telling him to do this. He said he just wanted to lie down. Writer started 15-minute checks immediately. Writer had the maintenance staff sit in the hallway across from resident's room. This staff reported that the resident came out of his room twice so he could leave the building within the first 10 minutes. Will continue to monitor. R1's progress note dated 2/12/23, R1 was found by the police outside three blocks away without clothes on and was hospitalized due to mental health decompensation with interventions of in-house psychologist (as needed), medications per doctor's order, nursing staff will monitor resident for auditory hallucinations (as needed) and give as needed (PRN) medication, and staff will re-direct, and cue as needed. R1's incident report dated 2/12/23, indicated R1 eloped from the facility and was last seen by his roommate a little before 8:00 a.m. Trained medication assistance (TMA)-A entered to provide medication to R1 at 9:15 a.m. and he was not in his room, then asked R1's roommate who said he was last seen a little before 8:00 a.m. Licensed practical nurse (LPN)-A called the police at 9:30 a.m. when R1 couldn't be located. LPN-A was notified R1 was found .03 miles away by police at 8:08 a.m. not wearing any clothes or shoes and was taken to the hospital. The temperature was below 20 degrees. The incident report failed to identify any interventions were put in place to address R1's elopement. R1's hospital initial encounter document dated 2/12/23, indicated R1 arrived with the Minneapolis Police Department on a transportation hold. R1 arrived naked (no clothes or shoes) and was shivering. The bottoms of his feet were bleeding and he stated he was outside for 45 minutes. R1 was transferred to the emergency department. During an interview on 2/23/23, at 8:33 a.m. licensed practical nurse (LPN)-A stated she was working the day R1 eloped from the facility and around 9:00 a.m. was informed by TMA-A who entered R1's room to provide his medications but R1 was unable to be located. LPN-A spoke to R1's roommate (R4) who stated he last saw R1 sometime before 8 a.m. LPN-A notified the director of nursing (at approximately 9:30 a.m.) who instructed her to wait to call 911. LPN-A also called R1's mom to check on R1's whereabouts because he had gone there in the past without letting anyone know. After talking to R1's mom, the DON called LPN-A back and was told to call 911. LPN-A was informed by the police R1 was found and taken to the hospital. LPN-A stated R1 wasn't very good about signing in/out of the facility and the week before he had eloped from the facility, so we were watching him. LPN-A also stated the director of nursing, and the social worker (SW-A) were responsible for assessing whether residents were safe in the community. LPN-A further stated, R1 and R2 need to be reassessed. R2 R2's admission MDS dated [DATE], indicated R2 had moderately impaired cognition, and diagnoses of schizophrenia and brief psychotic disorder (sudden, short-term display of psychotic behavior, such as hallucinations or delusions, which occurs with a stressful event) with behaviors of inattention (lack of focus), hallucinations, delusions (false fixed belief), and wandering which placed R2 at significant risk for getting to a potentially dangerous place. The MDS further indicated R2 was independent with all ADLs and used a walker for mobility. R2's Safety in the Community Evaluation dated 12/5/22, indicated R2 lacked an order to leave the facility unsupervised and deemed R2 no safe to be out in the community unsupervised. The interdisciplinary team (IDT) determined it was the best choice for R2's safety. R2's safety in the community would be reevaluated annually and as needed. R2's care plan dated 12/5/22, indicated the resident hallucinated which caused her to leave the building with interventions for medications per psychiatrist/doctor's order, nursing will update medical doctor about reports on increased hallucinations, and staff will validate and offer reality checking with resident and offer assurance she is safe in the building. The care plan lacked evidence of any new interventions after an elopement on 2/6/23. The care plan had an updated intervention to do hourly checks after an elopement on 2/12/23. R2's progress note dated 12/12/22, at 1:59 p.m. indicated R2 was last seen in the facility at approximately 6 a.m. (morning). Staff checked R2's room and noticed her coat, boots, and identification (ID) bracelet were gone, so staff notified her case manager to let her know if R2 didn't return to the facility by 9:00 p.m. (evening) they would report her as missing. R2's progress noted dated 12/12/22, 11:14 p.m. indicated R2 had not returned to the facility by 9:00 p.m. and law enforcement was called. R2's progress noted dated 12/13/22, at 2:02 p.m. social worker called local hospitals and homeless shelters in an attempt to locate R2. R2 was located at Higher Ground homeless shelter. Spoke with R2 on the phone and R2 stated she didn't want to come back to the facility and wanted to stay at the shelter. Facility staff encouraged R2 to return to the facility and social services picked her up at the homeless shelter and transported her back to the facility. R2's progress note dated 1/26/23, indicated R2 wanted the phone number for the shelter so she could leave. Social service encouraged R2 to remain in the facility due to the cold weather. R2 agreed and voiced concerns about her auditory hallucinations telling her to leave the facility. Social service informed nursing to monitor R2. R2's progress note dated 2/5/23, indicated R2 was found outside the building by staff and stated she was just getting some fresh air. R2's progress note dated 2/14/2023, indicated R2 was wearing her coat and asking for the phone number for the shelter. Social service encouraged R2 to remain in the facility and redirected her to an activity of her choice to distract from the auditory hallucinations. R2's incident report dated 2/18/23, indicated R2 eloped from the facility. Staff went to do a safety check at 3:40 p.m. and the resident was not in her room. Staff searched the building and was unable to locate her. The director of nursing (DON) was notified at the time; however, law enforcement was not notified until 8:00 p.m. During an interview on 2/22/23, at 1:48 p.m. the social worker (SW)-A stated they put R2 on hourly checks following her elopement on 12/13/22. SW-A further stated they also kept her coat with them because they were so afraid she was going to leave. During an interview on 2/22/23, at 11:58 a.m. the DON stated the facility's policy, was to wait until midnight and then report it to the police for any residents who were their own person and have left the facility without notifying staff and returned on their own. In the instance for R2, they decided to only wait until 8 p.m. to report she was missing however, didn't provide a reason for not waiting until midnight. During an interview on 2/23/23, at 9:30 a.m. LPN-C stated she started her shift on 12/12/22 at 3 p.m. and was told R2 was on hourly checks. LPN-C further stated she went to check on R2 at 3:40 p.m. but couldn't find R2 so LPN-C notified the DON. The DON instructed LPN-C to file a report at 8:00 p.m. if R2 didn't return before then, so at 8:00 p.m. LPN-C called the police. The facility's policy/procedure on missing residents dated 1/23/20, included four steps when staff suspect a resident was missing or has wandered away from the facility. 1. Tell the charge person on duty immediately 2. Establish the last time the resident was seen and what they were wearing. 3. Search the building and grounds 4. If the resident is not found and has not returned to the facility in a reasonable amount of time the family, friends, and /or establishments outside of the facility to find out if resident was there or they know of the resident's whereabouts. If the resident is not located contact the police. The IJ was removed on 2/24/23, at 12:28 p.m. when the facility developed and implemented a systemic plan which was verified by interview and document review: The plan included: - All residents were assessed/reassessed for their risk of elopement and their safety in the community. - Appropriate interventions were developed to help reduce/prevent the risk of elopement for R1, R2, R3 and were added to their care plans. The interventions were as follows: 1. Associated Clinical Psychology (ACP) therapist weekly to evaluate psychotic symptoms 2. Clinical social worker intern will see residents on weekly basis to assist with goal setting, behavior, and symptom management. 3. Medications per physician's order, nursing will notify psychiatrist with increase of symptoms. 4. Social service will petition for guardian of person. 5. Staff will give residents assurance that they are safe in the building. 6. Staff will redirect residents to an activity of their choosing when wandering. 7. Staff will send residents to Acute Psychiatric Services (APS) if psychotic symptoms do not stabilize. -All staff were re-educated on the elopement, missing resident, and safety in the community policies.

Based on observation, interview, and document review, the facility failed to comprehensively assess and provide adequate supervision for 1 of 1 resident (R2) who was cognitively impaired and mentally ill. R2 was sent to an appointment unsupervised and went missing overnight with temperatures below freezing. This resulted in an immediate jeopardy (IJ) for R2 when the facility failed to ensure appropriate supervision when R2 left the facility for an appointment and they continue to allow R2 to leave the facility without supervision. The IJ began on 10/29/19 at 10:00 a.m., when R2 was sent to an urgent care appointment out of the facility unsupervised, despite having known cognitive impairment, mental illness with hallucinations, an order for [REDACTED]. The facility administrator and director of nursing (DON) were notified of the IJ on 11/26/19 at 6:54 p.m. The IJ was removed on [DATE] at 7:47 p.m., however, noncompliance remained at the lower scope and severity of D-isolated, with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R2's 10/15/19, admission Minimum Data Set (MDS), identified R2 was admitted to the facility on [DATE] with moderate cognitive impairment. R2 had a [DIAGNOSES REDACTED]. R2 had chronic hallucinations, difficulty focusing attention, was easily distractible, had disorganized thinking, and trouble concentrating. Review of the 10/31/19, report filed to the State Agency identified R2 had a court order to stay at the facility and not to leave without staff present. On 10/29/19, at approximately 9:00 a.m., R2 had an appointment at urgent care to have an area on his thigh assessed. Staff allowed R2 to leave the facility unsupervised. R2 was treated and left the clinic at approximately 11:00 a.m. R2 was noted not to be wearing appropriate attire for cold weather conditions. R2's [DATE], Order for Commitment as a Person Who Is Mentally Ill, identified R2 had mental illness with [MEDICAL CONDITION], which is a substantial psychiatric disorder of his thought and perception, grossly impairing his judgement behavior. R2 had decreased capacity to recognize reality, and lacked the ability to reason or understand. As a consequence of his mental illness, R2 engaged in grossly disturbing behavior or experienced faulty perceptions, and posed a substantial likelihood of causing physical harm as evidenced by the following events: R2 would not take prescribed medications or attend follow up appointments. R2 had disorganized thoughts and suffered from auditory and visual hallucinations. R2 had taken a knife to himself several times, but not did not hurt himself. While hospitalized , R2 had been isolative and observed to respond to internal stimuli. R2 was homeless, would not follow through with simple tasks, such as showering, brushing his teeth, or going to the dentist. At the hospital, R2 was only able to complete one-step tasks, as opposed to multi-step tasks. R2's illness could not be adequately treated by dismissal of the Petition, voluntary inpatient, or outpatient care, the appointment of a guardian, or conditional release.The conclusion of the law identified the Court establishes by clear and convincing evidence, R2 was deemed mentally ill and was in need of commitment, as evidenced by R2's inability to obtain necessary food, clothing, shelter, or medical care as a result of the impairment. It is more probable than not that R2 will suffer substantial harm, significant psychiatric deterioration or debilitation, or serious illness, unless appropriate treatment and services are provided. R2's [DATE], Provisional Discharge order (from the hospital) identified R2 was to be compliant with medications, have no self-injurious behaviors and no threatening or dangerous behaviors towards others. R2 was to cooperate with his case manager, his treatment plan, and keep appointments. Review of R2's 10/8/19, hospital history and physical (H&P), written by inpatient psychiatry provider, identified R2 had the IQ (Intelligence quotient) of 55, normal IQ range 90-105, which classified R2 had an extremely low IQ. R2's [DATE], admission orders [REDACTED]. Review of the 10/15/19, social services assessment, documented by licensed social worker (LSW), identified R2 had a court assigned mental health case manager. R2 had deficits in short and long term memory. R2 was unable to do simple subtraction, place hour markers at the correct time on a clock, or place an X in the correct object. R2 required staff prompts and reminders and had wandered off facility grounds due to disorientation shortly after admission. R2 required redirection and prompts by staff to make good choices. R2 was easily distracted by internal stimuli (hallucinations) and struggled to focus on what was being said. R2 was unable to live independently and required a structured setting for safety. R2's Care Area Assessment (CAA) of 10/15/19, identified R2 had inattention and disorganized thinking. He responded to auditory hallucinations and would become distracted or preoccupied by his hallucinations. R2 had a developmental disability with an IQ of 55 (extremely low) with moderate cognitive impairment. R2 received frequent re-orientation, reassurance, and reminders to help make sense of things and to redirect and cue appropriate responses. R2 exhibited disorganized thinking, stammering speech, and inattention in response to auditory hallucinations and internal stimuli. R2 has a long standing [DIAGNOSES REDACTED]. R2's current, undated care plan, identified R2 had a [DIAGNOSES REDACTED]. R2 had short term and long term memory problems. On 10/29/19, R2 left for appointment and took the wrong public transport bus back to facility and got lost. A missing person's report was filed. R2 returned on 10/30/19. Interventions implemented after R2's return identified staff were to escort R2 to all medical and mental health appointments. Staff were to also perform hourly checks to ensure R2 remained in the building. Staff were to monitor and report to the doctor any changes in orientation and memory. The Order for Committment was identified on the care plan. R2 was not to engage in behaviors that violated his order for committment. R2 was not to leave the facility unescorted, however, the careplan also identified R2 was to remind staff if he left. R2's 10/10/19 at 8:21 p.m., nursing progress note identified R2's roommate notified registered nurse (RN-B) at 1:30 p.m. he saw R2 leave the facility, run and catch a bus and had not returned to the facility for approximately 2 hours. Once R2 came back to the facility, he advised RN-B he went downtown but was unable to identify where. He reported walking back to the facility as the Number 5 bus had not shown up. RN-B informed R2 he needed to stay at the facility as he had no physician's order to leave the faciltiy. R2's 10/11/19, Safety in the Community Assessment and Residents and Ability to Leave Facility Safely Assessment, performed by the activities director (AD), identified R2 was perceived by the AD during her assessment to have: 1) Been able to understand he should avoid walking at night or during inclement weather and wearing appropriate footwear and clothing while outside. 2) Understood the importance of signing the in/out book outside the nurse's station on the first floor. 3) Was able to dial 911 on cell phone if he had access, carry a photo ID, and able to recite the facility phone number and address. 4) Understood what to do in a dangerous situation. 5) Been assessed to walk independently to the corner store. The AD was aware R2 had a physician order not to leave the facility unsupervised at the time of the assessment, but the facility had completed the assessment even though they were aware of this physicians order. The assessment did not identify that had R2's poor cognitive status, decision making skills, or the Order of Commitment and Provisional Discharge by the court. There was no indication R2's leaving the facility unaccompanied by staff unsafely had been taken into consideration as part of this assessment. R2 had current [DIAGNOSES REDACTED]. Review of R2's progress notes identified the following: 1) On 10/15/19 at 2:39 p.m., R2 displayed daily behaviors of disorganized thinking, stammering speech, and responded to auditory hallucinations. R2 presented with pressured and stammering speech which was difficult to understand. 2) On [DATE] at 12:32 p.m., licensed practical nurse (LPN-B) contacted R2's primary medical provider (PAC-A) to request an order for [REDACTED]. 3) On 10/23/19 at 11:16 a.m., a care conference note identified the risks and benefits of going out into the community were explained to R2 regarding his ability to leave unsupervised. There was no mention what risks and benefits were, or how it was determined R2 was able to make an informed decision. Review of the 10/23/19, fax to the psychaitry certified nurse practioner, (CNP)-B identified the DON requested an order for [REDACTED]. CNP-B responded R2's first psychiatry appointment was on 10/24/19, and she would not give any orders until after she had seen R2 on 10/24/19. Further review of R2's progess notes identified on 10/24/19 at 3:00 p.m., LPN-D identified that staff sent R2 to a psychiatry appointment unsupervised, he returned to the facility and stated it was closed. There was no mention staff had called the office of CNP-B to notify them why R2 said he had not gone to his appointment or clarify further orders. 1) On 10/29/19 at 9:20 a.m., RN-A identified R2 had a mass to left thigh that was weeping clear fluid and was painful to touch. Resident to be seen at urgent care for further assessment. The director of medical records (MR) made an appointment with an urgent care facility. MR set up a transport service to bring R2 to the appointment, but she was unable to schedule for a return ride. She instructed R2, he would have to call for a ride home and gave him an envelope and a business card with phone numbers for the facility. R2 never called to have ride for return. 2) On 10/29/19 at 9:10 p.m., LPN-A identified R2 had left alone that morning for an urgent care appointment approximately 30 minutes from the facility. As of 8:00 p.m., R2 had not returned to the facility. LPN-A had talked to staff at the urgent care who had informed her that R2 was discharged at 11:00 a.m. to the community. LPN notified the DON and 911 was called to report R2 as a missing person. Family members (FM-A and B) were notified and would be out looking for resident. 3) On 10/30/19 at 5:23 a.m., 19.5 hours after R2 went missing. LPN-C identified the police called the facility notify them they had found an individual matching R2's description. According to the police officer, the individual was giving them different names and refusing to cooperate with law enforcement. MR told the police officer what R2 was wearing when he left the faciity on [DATE]. The individual had been found sleeping in a stairwell. The police officer was going to attempt to identify the individual using finger print analysis and would notify the facility when this was completed. 4) On 10/30/19 at 9:40 a.m., the DON received a call from a police officer. The police officer stated the previously unidentified male was positivity identified as R2. The police informed the DON they were bringing R2 to the emergency room for an evaluation after being out in the community overnight. The DON informed the officer R2 was on a commitment to (name withheld) and was on a provisional discharge to the facility. The officer agreed to take R2 to the hospital who oversaw the provisional discharge. FM-A, FM-B, FM-C, and R2's case manager were informed R2 had been found. When family was notified and advised of the person matching R2's desciption, not giving police his name, she replied. That's him. he will do that.just crawl up anywhere and go to sleep. The DON sent a staff member to the emergency room to stay with R2 until discharge. At 12:55 p.m., R2 returned to facility with staff. 5) On 10/30/19 at 3:25 p.m., the DON spoke with FM-A, FM-B, FM-C, and R2 From now on the facility would consistently provide staff to supervise R2 to and from his appointments. R2 told his family members and the DON he got on the wrong bus after his appointment and became confused. DON explained when R2 was sent to the appointment, he was given a phone number on the envelope and a business card for a staff member to call for a return ride. R2 left the appointment without calling either number. Family advised the DON, R2 had done that before. Staff were to continue with hourly checks. There was no mention the MD was notified of the incident. 6) On 10/31/19 at 11:25 a.m., MR finally contacted the psychiatry provider regarding R2's missed appointment on 10/24/19 when R2 was a no showed. A staff member at the mental health clinic stated their policy was to reschedule if a patient was a no shows for any appointment. MR informed psychiatry R2 would have an escort with him, therefore an appointment was scheduled on [DATE]. There was no mention MR advised psychiatry staff of the above 10/29/19 incident. The National Weather Service identified temperatures in the Twin Cities on 10/29/19 were between 27 and 40 degrees Fahrenheit and on 10/30/19, between 23 and 36 degrees Fahrenheit. Review of the 11/6/19, letter fax to R2's primary medical provider, physician assistant-certified (PAC-A) by the DON, identified R2 would like to be able to walk to the store on the corner and in the immediate community. R2 had a safety assessment completed on 10/11/19, when he had been accompanied and observed to be able to do this safely (by the AD). The DON requested R2's order be changed to allow him to leave the facility in the immediate community unsupervised but would be supervised to all appointments. The DON identified his upcoming appointment with psychiatry was scheduled for 12/12/19. There was no mention of the 10/10/19 incident, where R2 had taken the wrong bus, the 10/24/19 incident, where he had been sent to an apointment by staff. R2 failed to show for this appointment, or the incident on 10/29/19, when the resident failed to return to the facility after he had been sent unsupervised to an appointment. There was no documentation to support PAC-A had been notified of CNP-B's refusal to sign an order to allow R2 to leave unsupervised. Review of the 11/6/19, returned fax communication from R2's primary physician, (PAC)-A, based off the information the DON had faxed, was now authorized to leave the facility unsupervised into the immediate community until he was evaluated by psychiatry on 12/13/19. Interview on [DATE] at 3:30 p.m., (PAC-C) identified she unaware R2 went missing on 10/29/19. She had denied the request on two previous occasions when asked if R2 could be unsupervised. She received a detailed letter for a temporary order to relinquish supervision for R2 when outside the facility until he was seen by psychiatry. She would not have signed the temporary order if she had been made aware of the prior incidents of R2 getting lost in the community. On 11/14/19, the AD performed another Safety in the Community Assessment and Residents Ability to Leave Facility Safely Assessment for R2. R2 had been assessed and deemed safe to leave the facility unsupervised. Even though R2 now had a temporary order to leave into the immediate community unsupervised but needed to be accompanied by a staff member to his appointments. The assessment did not identify R2's poor cognitive status, decision making skills, or the Order of Commitment and Provisional Discharge by the court. There was no indication R2's leaving the facility unaccompanied by staff unsafely had been taken into consideration as part of this assessment. R2 had current [DIAGNOSES REDACTED]. Interview and document review on [DATE] at 10:49 p.m., with the AD identified she had completed safety assessments for approximately two years. A safety assessment was to be completed within the first seven days of admission. AD assessed R2 as he walked to a gas station about one block away with her supervision. R2 had to follow traffic laws and ensure he was safe performing those tasks. She did not consider cognitive status, diagnoses, previous incidents, or special Orders of Commitment when making her decision. She was aware of the three incidents on 10/10/10, 10/24/19 and 10/29/19, when R2 had left the facility unsupervised. After he went missing on 10/29/19, his assessment was updated to include R2 could not go to appointments unsupervised. There was no mention he required supervision any time he left the facility. After review of the additional information in R2's chart discussed above, she agreed R2 was unsafe to leave the facility unsupervised. Interview on 11/26/19 at 11:27 a.m., with registered nurse (RN)-A identified she worked the day shift on 10/29/19. R2 was sent to an urgent care appointment unsupervised. She was not comfortable sending him to his appointment alone. She volunteered to go with, but MR denied her request as RN-A was needed at the facility. She informed MR that R2 was not supposed to leave the facility unsupervised per the physician order. MR was responsible to set up the transportation and would make sure if the resident needed supervision that someone goes with them. Before RN-A left the facility at about 3:30 p.m., she noticed that R2 had not returned to the facility. RN-A informed licensed practical nurse (LPN)-A, who was beginning her shift, R2 had not returned to the facility. RN-A had not called urgent care to obtain R2's whereabouts, or inform the DON or administrator R2 had not arrived back at the facility as expected. RN-A agreed she should have intervened timely when she had first identified he had not returned. When R2 had left the facility in the past since his admission, he had not signed out or notified anyone he was going out. We never know when he leaves or when he returns. R2 had been on hourly checks since admission. RN-A agreed the Order for Commitment and physician's admission orders [REDACTED]. Interview on 11/26/19 at 11:38 a.m., with nurse assistant (NA)-A identified licensed nurses were to inform NA's if a resident was admitted with an order for [REDACTED]. Since the incident on 10/29/19, R2 was to be escorted by staff to appointments. Ever since that incident he has been escorted to appointments, but was able to go outside of the building by himself. Interview on 11/26/19 at 11:43 a.m., with FM-A identified he was contacted 8:00 p.m. on 10/29/19. FM-A and his family went to assist in search efforts. R2 had not known the bus routes or the bus system and he was unable to comprehend things and had difficulty following directions, which had been conveyed to the facility upon admission. FM-A felt the facility should not have allowed R2 to go to an appointment unsupervised. The night R2 went missing, it was very cold out and family were deeply concerned. Interview on 11/26/19 at 1:04 p.m., with LPN-A identified she was the charge nurse the evening of 10/29/19. She was informed the beginning of her shift by RN-A at 3:00 p.m., R2 had not returned from his appointment. Normal protocol was to wait until midnight before it is reported. LPN-A called the clinic to see if R2 had been at his appointment and was informed he was discharged at approximately 11:00 a.m. The appointment was in [LOCATION], which was about 30 minutes away from the facility. She was aware R2's Order of Commitment and physician's order identified he should not be in the community unsupervised. R2 was known to be very low functioning mentally. She was concerned and notified the DON and the police department. The usual process for appointments is to have a trained medication aide (TMA) or LPN escort the residents. R2 had to be told when to eat and spent most of the time in his room in bed. R2 does not interact and was very isolated. An incident report was not completed because these forms were only utilized for falls or injuries. Interview on 11/26/19 at 1:29 p.m., with MR identified R2 had an appointment on 10/29/19. He left the facility around 10:00 a.m., with special transport, but due to insurance, she was not able to set up a return ride. She explained to R2 to call the number on the envelope after his appointment. She thought R2 would be able to remember to call the number on the envelope. She was not aware of his cognitive status or orders to be supervised whenever he left the facility. She remembered asking the DON if R2 would be able to take transportation alone. The DON said he would be fine. Before she left the facility around 4:30 p.m. that day, she was aware that R2 had not returned from his appointment and informed the DON. The DON agreed R2 should not have went to the appointment unsupervised. Interview on 11/26/19 at 1:50 p.m., licensed social worker (LSW) identified the DON called her sometime in the evening on 12/29/19, and explained to her R2 had been to an appointment at urgent care earlier that morning and had not returned. The LSW was to make a report to the state agency (SA). R2 should not have been out alone and was unsure why he had been unsupervised. Interview on 11/26/19 at 2:14 p.m., with the DON identified R2 had a sore on his leg. It needed to be evaluated by a physician. Staff made an appointment on 10/29/19 with a [LOCATION] urgent care clinic. MR got an envelope together and explained to R2 he would have to call the number on the envelope after the appointment. The DON thought staff went with R2 to his appointment. She was unaware he did not return to the facility until 7:46 p.m., when LPN-A contacted her. LPN-A was to contact authorities and report immediately, and not wait until midnight per their usual protocol. She then directed staff to notifiy the authorities at that time. Staff should have notified her right away upon discovery R2 had not returned. She felt there was miscommunication that occurred with sending staff to supervise. Someone should have went with him. She agreed he had orders not to leave the facility unsupervised and expected they be followed. The DON thought the physician was notified but agreed neither R2's primary, or his mental health physician were notified. Observation and interview on 11/26/19 at 3:00 p.m. with R2 identified he could not recall much of the incident, only he was scared, cold, and worried about meds (medicine). R2 had mumbled speech, was hard to understand, and made no eye contact. R2 appeared to be having a simultaneous conversation with someone else at the same time, although no other persons were in the room. There was no other information able to be obtained during the interview. Interview on 11/26/19 at 4:31 p.m., with the administrator (A) identified facility staff scheduled appointments and was to plan staffing according for those requiring supervision. He was unaware of details regarding R2's appointment on 10/29/19. Interview on 11/26/19 at 9:16 a.m., with the public case manager (CM) identified she was notified of R2's absence from 10/29/19 the day after R2 went missing and had returned to the facility. She saw R2 once a month to follow his mental health needs. R2 was not supposed to leave the facility unsupervised and she would have expected facility staff would have gone with him to his appointments. R2 was not independent and previously lived in the community with his mother. R2's family member (FM)-D did everything for him. When she was unable to take care of him he went to live with FM-A, but FM-A was not able to provide supervision for R2. R2 had a court ordered commitment and was conditionally discharged to the facility. The CM's expectation was R2 should not be allowed to leave the facility unsupervised at any time as he was unsafe, had a low IQ, and mental health needs and [DIAGNOSES REDACTED]. Review of the facility Hourly Check documentation identified, although R2 had resided in the facility for 50 days from [DATE] until [DATE], only 26 days had been signed off by staff. Review of the undated Residents Who May Not Leave the Community Unsupervised list provided by the facility on 11/26/19, identified a list of 12 residents but failed to identify R2. Interview on [DATE] at 10:32 a.m., with the assistant administrator (AA) identified there are plenty of residents that should not go out alone and are on hourly . The facility is not a locked facility. If R2 wanted to go on a walk, he could do that. R2 was encouraged to stay at the facility, but felt staff could not keep him there. R2 had left the facility in the past to go and look for his FM-D. Interview on [DATE] at 11:44 a.m., with the medical director (MD) identified he was not aware R2 had been missing on 10/29/19, until about an hour ago. His expectation was he should be notified timely of all incidents at the facility. After being informed of the two addition incidents R2 had left the facility, he stated R2 should not have been allowed to leave unsupervised. He agreed this was a serious concern that needed to be reviewed. Interview [DATE] at 2:35 p.m., the DON agreed, staff had not documented all hourly checks and had lacked documentation to show the intervention was implemented. Interview on [DATE] at 7:14 p.m., with law enforcement officer (PD)-A identified he came to the facility on [DATE], took statements from staff and filed a missing persons report. The police found him the next morning on 10/30/19. Review of the 5/2/17, Missing Person/Wandering Resident policy identified if staff suspected a resident was missing or has wandered from the facility, they were to tell the charge person on duty immediately. Staff were to establish the last time the resident was seen and what they were wearing, and search the building and grounds. If the resident was not found and has not returned to the facility, family, friends, and outside entities, such as police, were to be contacted. Once the resident had been found, staff were to notify all parties and document notifications and any interviews from the resident and any new instructions or interventions. The immediate jeopardy that began on 10/29/19, was removed on [DATE] at 7:47 p.m., when the facility took steps to ensure R2 would not leave the facility unsupervised. R2 was checked every 15 minute by staff to ensure he would not leave unsupervised. R2 would be added to the new list of residents who were not allowed to leave unsupervised. All staff were educated on policies and procedures for missing residents, and others identified at risk. The noncompliance remained at a lower scope and severity level of D, isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.