Every finding on record at Bywood East Health Care

Based on observation, interview and document review, the facility failed to ensure appropriate infection control while providing laundry services as well as failed to review the facility Infection Prevention Program policy annually. These deficient practices had the ability to affect all residents who resided in the facility.Findings include:Laundry:During a laundry room tour and interview on 5/6/26 at 8:10 a.m., other staff (O)-E stated they put a personal T-shirt on over their clothes when handling dirty laundry and used the same T-shirt when hanging clean laundry. O-E stated they used disposable gowns when handling laundry of a resident with an infection. They stated they had no concerns wearing the same clothing for clean and dirty laundry if the resident did not have an infection.During an interview on 5/7/26 at 12:40 p.m., the director of maintenance (M)-A stated that they work with an external company for on-site laundry and housekeeping services. M-A stated they thought laundry staff wore gloves and a gown when handling dirty laundry, but they were not concerned if no gown was worn if staff's clothing did not touch the dirty clothing. M-A stated they would provide more disposable gowns if needed.Policy Review:Bywood East infection Control and Prevention Program dated 4/26/24, had no indication of an annual review.During an interview on 5/7/26 at 8:09 a.m., the director of nursing (DON) stated they were aware that the infection prevention program policy was overdue for review, and they were working on a process for an annual review of all infection prevention policies.

Based on observation, interview and document review the facility failed to provide a safe, sanitary and comfortable environment for 7 of 7 residents (R24, R33, R62, R9, R56, R12, R20) reviewed for environment. Findings include:R24R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diagnoses which included schizophrenia and depression. In addition, R24's MDS identified she was moderately cognitively intact.R24's care plan dated 1/12/26, identified R24 had significant mental health issues. Interventions included to encourage her to not have food in her room, staff were to tell her keeping food out of her room would help keep the mice out of the traps as she identified the mice as her friends.During an interview on 5/7/26 at 9:08 a.m., the infection preventionist (IP) stated they were aware that R24 was trying to feed the mice. The IP stated they would try to get her to eat in the day room and on every shift, staff were supposed to look for food in her room. In addition, housekeeping staff were supposed to be cleaning her room twice a day.During an observation on 5/7/26 at 9:14 a.m., the IP went to the room and looked under the bed. Near the head of the bed on the side facing the inside of the room was a large amount of black crumbs, the IP said it looked like chocolate cake. The pile was about four inches by six inches. There were also two patties of what looked like white meat.A review of the menus for the past two weeks identified a turkey swiss grilled sandwich was served on 5/6/26, at the evening meal. Breaded pork chops were served on 4/29/26, at the evening meal, on 4/28/26, a caramel brownie was served at the lunch meal, and on 4/27/26, chocolate mousse cake was served at the evening meal.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the following:R24's room was not checked during the month of 4/2026R24's room was not checked during the month of 3/2026R24's room was checked and serviced in the month of 2/2026, with light activity noted (rodent activity)R24's room was not checked during the month of 1/2026R24's room was not checked during the month of 12/2025R24's room was not checked during the month of 11/2025During an interview on 5/7/26 at 9:43 a.m., the maintenance director (MD) stated there were bait stations in some resident rooms, he stated there was not a master list of which rooms. MD verified during the month of 4/2026, none of the bait stations in any rooms were serviced. In addition, MD stated housekeeping was supposed to clean R24's room after breakfast and lunch.During an interview on 5/7/26 at 12:51 p.m., the director of nursing (DON) stated they were aware that R24 was trying to feed the mice. The DON stated she expected staff to check at least daily under R24's bed for food. The DON stated this would be important as food under beds had the potential to attract mice.R33R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 had diagnoses which included delusional disorder. R33's MDS identified she was cognitively intact and had behaviors that included rejection of cares four to six days a week but less than daily.R33's care plan did not address room clutter and/or overcrowded with belongings.During an interview on 5/4/26 at 1:09 p.m., R33 stated she had recently found mouse droppings on her bed, she stated her roommate had garbage in their room and that she hoarded food. R33 stated she had been talking to staff at the facility since she arrived in October of 2025, about this concern. R33 stated she had seen mice in the room, and she was concerned the mice might carry diseases.During an observation/interview on 5/4/26 at 12:40 p.m., next to R33's bed were two plastic bins with covers stacked one on top of the other, two bedside stands, an overbed table with a coffee maker and a fruit tray wrapped in plastic. On the floor there was a shopping type bag filled with personal items. R33 also stated the garbage was not removed daily and stated they did not clean on weekends.During an interview on 5/6/26 at 1:43 p.m., the maintenance director (MD) stated he had seen mouse droppings in R33's room and they had pest control traps in that room.A review of the [NAME] service summary records dated 11/2025-4/2026, identified there were not any rodent bait stations in R33's room.R62R62's quarterly MDS dated [DATE], identified R62 had diagnoses which included paranoid schizophrenia. In addition, R62's MDS identified she was cognitively intact and had behaviors that included rejection of cares four to six days a week but less than daily.R62's care plan dated 2/3/26, identified rejection of care, the plan did not address a plan for not allowing housekeeping staff to clean her room or hoarding food.During an observation on 5/4/26 at 1:31 p.m., there were several plastic bags on the floor next to the bed and on top of one plastic bag was a piece of pie on a plate uncovered.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the there were not any rodent bait stations in R62's room.During an interview on 5/6/26 at 12:55 p.m., trained medication aide (TMA)-B stated residents could bring food from meals to their rooms. TMA-B stated R62 hoarded food and when she was out of the room staff would go in and try to collect garbage.During an interview on 5/7/26 at 8:52 a.m., the infection preventionist (IP) stated she was not aware of concerns about mice in the building. The IP stated they had started Spring cleaning on 4/27/26, and said storing belongings in garbage bags was not a good way to store items. The IP stated they were trying to get R62 to move her belongings into bins. The IP verified the rooms were crowded.R9R9's comprehensive MDS dated [DATE], identified R9 had diagnoses which included post-traumatic stress disorder (PTSD). In addition, R9's MDS identified she was cognitively intact.R9's care plan dated 1/14/26, did not address room clutter and/or overcrowded with belongings.During an observation on 5/6/26, R9's room had bins on the floor which were overflowing onto the floor.R56R56's quarterly MDS dated [DATE], identified R56 had diagnoses which included paranoid schizophrenia, anxiety, depression, and PTSD. In addition, R56's MDS identified she was cognitively intact.R56's care plan dated 3/2/26, did not address room clutter and/or overcrowded with belongings.During an observation on 5/6/26, R56's room had bins on the floor which were overflowing onto the floor.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the following:R56's room was not checked during the month of 4/2026R56's room was checked during the month of 3/2026, with light activity notedR56's room was checked and serviced during the month of 2/2026, with light activity notedR56's room was not checked during the month of 1/2026R56's room was not checked during the month of 12/2025, with light activity notedR56's room was not checked during the month of 11/2025, with light activity notedR12R12's quarterly MDS dated [DATE], identified R12 had diagnoses which included depression and homelessness. In addition, R12's MDS identified he was cognitively intact.R12's care plan dated 3/2/26, did not address room clutter and/or overcrowded with belongings.During an observation and interview on 5/6/26 at 12:36 p.m., R12 talked about Spring cleaning and said he was trying to organize his belongings and maybe throw some things out. R12 was using all of the available space in the first and second bed areas. R12 was using all of the open closet space and cupboards for his belongings.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the there were not any rodent bait stations in R12's room.R20R20's quarterly MDS dated [DATE], identified R20 had diagnoses which included depression, bipolar depression, and schizophrenia. In addition, R20's MDS identified he was cognitively intact.During an observation on 5/4/26 at 2:11 p.m., it was noted the light over his bed was missing the cover.During an observation and interview on 5/7/26 at 10:05 a.m., R20 stated the light was pretty bright without the cover and suggested they take the cover off the light in the middle bed area because it was empty.During an interview on 5/6/26 at 11:23 a.m., the owner stated it was bad if there was pie sitting uncovered in a resident room. The owner stated it was not okay for residents to bring food/desserts to their rooms, stated there was a concern with pest control.During an interview on 5/6/26 at 12:55 p.m., trained medication aide (TMA)-B stated she had never seen mice or mouse droppings in the resident rooms. TMA-B stated residents could bring food from meals to their rooms. TMA-B stated R33's roommate hoarded food and when she was out of the room staff would go in and try to collect garbage. TMA-B stated there was a place for residents to safely store belongings in the building next to their building. TMA-B had noted the light cover was missing over R20's bed, she thought it had been about two months since it had been missing. TMA-B verified they used to let residents go into the third-floor conference room to sit and read and just be in a quiet space, but now the room was locked. TMA-B verified there was not any area in the building for a space to be alone.During an interview on 5/6/26 at 1:43 p.m., the maintenance director (MD) stated he had seen mouse droppings in R33's room and they had pest control traps in that room.During an interview on 5/6/26 at 2:27 p.m., chief financial officer and human resource director stated they were storing resident belongings in the garage that was on the property.During an interview on 5/6/26 at 11:23 a.m., the owner stated it was bad if there was pie sitting uncovered in a resident room. The owner stated it was not okay for residents to bring food/desserts to their rooms, stated there was a concern with pest control.During an interview on 5/6/26 at 1:43 p.m., MD stated there were residents who would not allow housekeeping staff to come in and clean their room. MD stated he had talked with the owner about this concern. He stated R33, R62, R12, were some of the residents who would not allow cleaning. He stated they remove food from under the R24's bed daily.During an interview on 5/7/26 at 9:26 a.m., a representative from the pest control company stated they came to the facility monthly and would fill the bait stations in resident rooms only when management told them to do this. The representative stated poor sanitation and clutter were things that contributed to pest problemsDuring an interview on 5/7/26 at 8:52 a.m., the infection preventionist (IP) stated she was not aware of concerns about mice in the building. The IP stated they had started Spring cleaning on 4/27/26, and said storing belongings in garbage bags was not a good way to store items. The IP stated they were trying to get R33's roommate to move her belongings into bins. The IP verified the rooms were crowded and stated residents had a safe place to store items in the garage on the property. The IP stated residents could request the conference room to have a place to read and be alone, she said the charge nurse would have the key to the room.During an interview on 5/7/26 at 9:26 a.m., a representative from the pest control company stated they came to the facility monthly and would fill the bait stations in resident rooms only when management told them to. The representative stated poor sanitation and clutter were things that contributed to pest problems.During an interview on 5/7/26 at 9:58 a.m., the MD stated they did store resident belongings in the garage and verified there was not any pest control in the garage.During an interview and observation on 5/7/26 at 10:09 a.m., the MD opened the garage, all of the floor space was covered with items; a pile of plastic bags about five feet high and 10 feet in diameter, which he said were supposed to go into a dumpster. MD stated the resident had moved out two years ago and didn't want the items anymore. In addition, there were walkers, wheelchairs, a dryer, bins with Christmas decorations, mattresses, mattress springs, coolers, a grill, two racks which would be found in hotel lobbies, a suitcase and two to three bins which were storage for a current resident, among other items. MD verified there would not be any room to store any other residents' personal belongings.During an interview on 5/7/26 at 12:51 p.m., the DON stated the hazard with the rooms being cluttered was that they could attract bugs, lead to pest problems, and were a concern for infection control.A policy on housekeeping was requested but not provided.

Based on interview and document review the facility failed to ensure bait stations were monitored and serviced to prevent/reduce pest problems for 6 of 6 residents (R24, R33, R62, R9, R56, R12) reviewed for environment. This had the potential to affect all 64 residents who resided in the facility. Findings include:R24R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diagnoses which included schizophrenia and depression. In addition, R24's MDS identified she was moderately cognitively intact.During an interview on 5/7/26 at 9:08 a.m., the infection preventionist (IP) stated they were aware that R24 was trying to feed the mice. The IP stated they would try to get her to eat in the day room and on every shift, staff were supposed to look for food in her room. In addition, housekeeping staff were supposed to be cleaning her room twice a day.During an observation on 5/7/26 at 9:14 a.m., the IP went to the room and looked under the bed. Near the head of the bed on the side facing the inside of the room was a large amount of black crumbs, the IP said it looked like chocolate cake. The pile was about four inches by six inches. There were also two patties of what looked like white meat.A review of the menus for the past two weeks identified a turkey swiss grilled sandwich was served on 5/6/26, at the evening meal. Breaded pork chops were served on 4/29/26, at the evening meal, on 4/28/26, a caramel brownie was served at the lunch meal, and on 4/27/26, chocolate mousse cake was served at the evening meal.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the following:R24's room was not checked during the month of 4/2026R24's room was not checked during the month of 3/2026R24's room was checked and serviced in the month of 2/2026, with light activity noted (rodent activity)R24's room was not checked during the month of 1/2026R24's room was not checked during the month of 12/2025R24's room was not checked during the month of 11/2025During an interview on 5/7/26 at 9:43 a.m., the maintenance director (MD) stated there were bait stations in some resident rooms, he stated there was not a master list of which rooms. MD verified during the month of 4/2026, none of the bait stations in any rooms were serviced. In addition, MD stated housekeeping was supposed to clean R24's room after breakfast and lunch.R33R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 had diagnoses which included delusional disorder. R33's MDS identified she was cognitively intact and had behaviors that included rejection of cares four to six days a week but less than daily.During an interview on 5/4/26 at 1:09 p.m., R33 stated she had recently found mouse droppings on her bed, she stated her roommate had garbage in their room and that she hoarded food. R33 stated she had been talking to staff at the facility since she arrived in October of 2025, about this concern. R33 stated she had seen mice in the room, and she was concerned the mice might carry diseases.During an observation/interview on 5/4/26 at 12:40 p.m., next to R33's bed were two plastic bins with covers stacked one on top of the other, two bedside stands, an overbed table with a coffee maker and a fruit tray wrapped in plastic. On the floor there was a shopping type bag filled with personal items. R33 also stated the garbage was not removed daily and stated they did not clean on weekends.During an interview on 5/6/26 at 1:43 p.m., the maintenance director (MD) stated he had seen mouse droppings in R33's room and they had pest control traps in that room.A review of the [NAME] service summary records dated 11/2025-4/2026, identified there were not any rodent bait stations in R33's room.R62R62's quarterly MDS dated [DATE], identified R62 had diagnoses which included paranoid schizophrenia. In addition, R62's MDS identified she was cognitively intact and had behaviors that included rejection of cares four to six days a week but less than daily.During an observation on 5/4/26 at 1:31 p.m., there were several plastic bags on the floor next to the bed and on top of one plastic bag was a piece of pie on a plate uncovered.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the there were not any rodent bait stations in R62's room.During an interview on 5/6/26 at 12:55 p.m., trained medication aide (TMA)-B stated residents could bring food from meals to their rooms. TMA-B stated R62 hoarded food and when she was out of the room staff would go in and try to collect garbage.During an interview on 5/7/26 at 8:52 a.m., the infection preventionist (IP) stated she was not aware of concerns about mice in the building. The IP stated they had started Spring cleaning on 4/27/26, and said storing belongings in garbage bags was not a good way to store items. The IP stated they were trying to get R62 to move her belongings into bins. The IP verified the rooms were crowded.R9R9's comprehensive MDS dated [DATE], identified R9 had diagnoses which included post-traumatic stress disorder (PTSD). In addition, R9's MDS identified she was cognitively intact.During an observation on 5/6/26, R9's room had bins on the floor which were overflowing onto the floor.R56R56's quarterly MDS dated [DATE], identified R56 had diagnoses which included paranoid schizophrenia, anxiety, depression, and PTSD. In addition, R56's MDS identified she was cognitively intact.During an observation on 5/6/26, R56's room had bins on the floor which were overflowing onto the floor.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the following:R56's room was not checked during the month of 4/2026R56's room was checked during the month of 3/2026, with light activity notedR56's room was checked and serviced during the month of 2/2026, with light activity notedR56's room was not checked during the month of 1/2026R56's room was not checked during the month of 12/2025, with light activity notedR56's room was not checked during the month of 11/2025, with light activity notedR12R12's quarterly MDS dated [DATE], identified R12 had diagnoses which included depression and homelessness. In addition, R12's MDS identified he was cognitively intact.During an observation and interview on 5/6/26 at 12:36 p.m., R12 talked about Spring cleaning and said he was trying to organize his belongings and maybe throw some things out. R12 was using all of the available space in the first and second bed areas. R12 was using all of the open closet space and cupboards for his belongings.A review of the [NAME] service summary records dated 11/2025-4/2026, identified the there were not any rodent bait stations in R12's room.During an observation on 5/5/26 at 5:16 p.m., a resident left the dining room with two of the desserts (uncovered) and stated he was going to have them for breakfast.During an interview on 5/6/26 at 11:23 a.m., the owner stated it was bad if there was pie sitting uncovered in a resident room. The owner stated it was not okay for residents to bring food/desserts to their rooms, stated there was a concern with pest control.During an interview on 5/6/26 at 1:43 p.m., MD stated there were residents who would not allow housekeeping staff to come in and clean their room. MD stated he had talked with the owner about this concern. He stated R33, R62, R12, were some of the residents who would not allow cleaning. He stated they remove food from under the R24's bed daily.During an interview on 5/7/26 at 9:26 a.m., a representative from the pest control company stated they came to the facility monthly and would fill the bait stations in resident rooms only when management told them to do this. The representative stated poor sanitation and clutter were things that contributed to pest problemsDuring an interview on 5/7/26 at 12:51 p.m., the DON stated the hazard with the rooms being cluttered was that they could attract bugs, lead to pest problems, and were a concern for infection control.A policy on pest control was requested but not provided.

Based on interview and document review the facility failed to have the appropriate funds available for 2 of 3 (R41, R21) Medicare/Medicaid residents who wanted to withdraw funds outside of scheduled withdrawal hours set up by the facility. In addition, insignificant funds were available on the evening shift for any residents. This had the potential to affect all residents who kept funds with the facility. Findings include:R41's comprehensive MDS dated [DATE], identified R41 was cognitively intact.During an interview on 5/4/26 at 1:20 p.m., R41 stated they could get five dollars out on the weekends by going to the nurse's station. R41 stated Monday through Friday they could take their money out from 1:00 p.m. to 2:00 p.m R41 stated if you missed the time the business window was open you could not get your money.R21's comprehensive Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact.During an interview on 5/4/26 at 1:25 p.m., R21 stated the facility kept money for him and he could access this money five times per week, Monday through Friday from 8:00 a.m. to 9:00 a.m., and from 1:00 p.m. to 2:00 p.m R21 said he was not able to take money out on weekends.During an interview on 5/6/26 at 11:46 p.m., business office coordinator (BOC)-G stated the business office opened the window Monday through Friday, twice a day from 8:00 a.m. to 9:00 a.m., and then from 1:00 p.m. to 2:00 p.m BOC-G stated if residents wanted their money outside of these hours or for large amounts of money they could make a request. On a weekend the times they could get their money was posted. It was as follows:Business office banking hoursMonday-Friday 8-9am and 1-2pmWeekends and holidays available through the 1st floor nursing station 9-10am and 1-2pmPer request outside posted hoursBOC-G stated residents could come to her window or door anytime and knock. She stated if they knocked on her window at 9:30 a.m., she would re-direct them to the 1:00 p.m. time, unless they were leaving the building and needed the money right away. During an interview on 5/6/26 at 12:04 p.m., trained medication aide (TMA)-A verified he worked weekends. TMA-A stated if a resident asked him about getting money on the weekend he would direct them to the nurse.During an interview on 5/6/26 at 12:06 p.m., registered nurse (RN)-A verified she worked weekends. RN-A stated if residents requested money on the weekends, she would direct them to make the request during the times that were posted. RN-A stated on Friday evening the business office would deliver a box with a code to open it. Inside the box would be a sheet of paper with the resident's name and their balances. RN-A stated all they could give a resident would be five dollars a day. RN-A opened the insulin room, then opened the cart where the cash box would be stored. There was not a box with money in the cart. RN-A stated the box with cash would not be delivered until Friday evening. RN-A verified after the business office closed Monday through Thursday, residents would not be able to access their money.During an interview on 5/7/26 at 12:51 p.m., the director of nursing (DON) verified the funds were available during specific times of the day Monday through Friday and at specific times on the weekend. The DON verified residents should be able to access their money when they wanted it.Resident Trust Fund and Authorization Policy dated 10/6/22, identified the following: Resident banking hours are from 8:00AM to 9:00AM. Resident trust cash is available through the Charge Nurse on weekends and holidays from 9:00AM to 10:00AM and again from 4:00PM to 5:00PM. Resident funds are also available outside of banking hours in case of an emergency 24/7 through the Charge Nurse.

Based on interview and document review, the facility failed to ensure a pre-admission screening and resident review (PASARR) level two screening referral was acted upon for 1 of 1 resident (R2) reviewed for PASARR screening process. Findings include:R2's quarterly minimum data set (MDS) dated [DATE], identified diagnoses of disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy. R2's care plan dated 4/8/26, didn't identify PASARR level two recommendations.During an interview on 5/7/26 at 2:39 p.m., the director of nursing (DON) confirmed a level two screening was not in R2's electronic medical record. The DON stated it was important so they can identify what services were needed for them. A document, OBRA Level 1 screening dated 4/19/24, identified serious mental illness and referral to level two screening with Hennepin County preadmission screening team (PAS) Team.A policy regarding the PAS process was requested but not received.

Based on observation and interview, the facility failed to ensure survey results were available without an individual needing to ask to see the results. This deficient practice had the potential to impact on any person wishing to see, but not ask for, the survey results.Findings include:On 5/5/26 at 6:04 p.m., the administrator stated the survey book was at the front desk behind the desk in a holder, and there was notification of where it was. The book was not visible when facing the desk, a chest-high partition obstructed the book. A posted sign indicated annual state survey results were located at the front desk reception and were available and readily accessible for residents to view 24 hours daily. During an interview with the resident council on 5/6/26 at 2 p.m., an anonymous resident identified the survey results were there, but they had to ask for them.

Based on observation, interview, and document review, the facility failed to ensure shared resident' rooms had adequate floor space (i.e., at least 80 square feet [SF] per resident) for 23 of 23 rooms (101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, 317 ). This had potential to affect any resident who currently or potentially could occupy these shared room spaces.Findings include:A provided Room Assignment and Census Report (RACR), dated 4/13/26, indicated a facility census of 64 and identified current residents and their corresponding rooms at the care center and also identified rooms with open beds that would be occupied by three residents when full. These identified rooms 101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, 317 each either already had three residents present or accommodation to accept three residents within the same room. The RACR indicated three rooms currently housed three residents. The RACR indicated there were two rooms completely empty, with the ability to take two residents, and there were 5 rooms with only one resident in the room, with the ability to take a second resident. On 5/5/25 at 8:30 a.m., a tour of the care center was completed which verified the listed rooms either had three residents inhabiting the spaces or, if needed, could inhabit the space (i.e., new admission).During an interview on 5/6/26 at 9:12 a.m., the director of nursing (DON) stated there had been no conversations during the weekly bed management meetings to move resident around to be able to meet the at least 80 SF per resident requirement. The DON reviewed the RACR and confirmed there were currently two completely empty rooms and five rooms that only had one resident living in them.During an observation on 5/6/26 at 9:40 a.m., the maintenance supervisor (MS) measured room [ROOM NUMBER] and indicated a room size of 230 SF. This gives each resident 76.67 SF of individualized space.During an interview on 5/6/26 at 9:43 a.m., the MS stated all rooms had the same square footage.During an observation on 5/6/26 at 10:19 a.m., R25 had belongings on the floor from the back wall to the foot board of the bed and from the side of the bed to the curtain, which separated R25 from the roommate in the middle.During an interview on 5/6/26 at 10:21 am. R25 stated he was not sure why the facility had three residents to a room. R25 stated it would be nice to have more space to hold personnel belongings and get around but understood if the room was needed for a third resident.During an interview on 5/6/26 at 11:37 a.m., the administrator stated the facility had bed management meetings on a weekly basis. During the meeting the facility would discuss residents with behaviors, incident reports and the need to move residents due to the incidents, and possible admissions. The facility did not discuss moving residents when able to give each resident at least 80 SF of living space. The administrator stated new admissions were made aware the room size was less than 80 SF but did not tell current residents in three person rooms when a bed opened to allow for at least 80 SF of living space. The only time residents found out about that was if they noticed an open room with and requested a bed change. At that time the request would be evaluated.A facility policy titled Policy and Procedure Regarding Waivered Room Sizes, dated 5/2024, indicated potential residents who seek admission to the facility and/or current residents who request a room transfer will be informed of the rooms that do not meet the 80 square foot minimum requirement and facility staff will discuss room organization and assist residents to accommodate their needs and individual preferences as appropriate.

Based on observation, interview, and record review the facility failed to ensure staff posting included the current census and visible hours worked. This had the potential to impact all residents who resided at the facility.Findings include: During observations on 5/4/26, 5/5/26, and 5/6/26, staffing sheets were posted on all three floors of the facility. The name of the facility, staff names and disciplines were visible, but the hours scheduled, and current census were not visible.During an interview on 5/7/26 at 12:04 p.m., the director of nursing (DON) stated the scheduler posted the daily staffing on all three units. The DON confirmed the current census was not being included in the posting.During an interview on 5/5/26 at 6:04 p.m., the administrator stated we post the schedule each day on the unit and showed the location where the schedule was posted on the first floor. The schedule was in an acrylic stand behind a plexiglass window. The front page visible through the plexiglass was dated 5/5/26, and included names of staff, and titles sorted by shift. Hours worked were not visible. The administrator reached under a small opening in the plexiglass and spun the posting around. The total hours per shift were listed on the back of the sheet by shift. The administrator confirmed the data on the backside of the plexiglass holder reflected total hours for 5/4/26, not 5/5/26 because the 5/5/26, posting had been slid into the holder on top of the 5/4/26 posting (each printed posting was double sided, names on one side and hours on the flip side). The administrator stated the census was not printed on the daily staffing sheets, but it could be.

Based on interview and document review, the facility failed to implement written policies to prohibit and prevent abuse from contracted staff and failed to include protocols for providing abuse prohibition education or verification of abuse education for contracted staff. This had the potential to affect all current and future residents residing in the facility.Findings include:On 2/25/2026 at 2:49 p.m. video footage from 2/11/26 at approximately 2:00 p.m. was reviewed in the presence of assistant director of nursing (ADON). The video revealed R1 was sitting in a wheelchair by the elevator doors. Several other residents and staff members were in the area. A tall male (identified by director of nursing (DON) as a contracted laboratory technician (LT-A)) walked up to the elevator and used his hand to motion to R1 to move back away from the closed elevator door. LT-A's mouth was seen moving and his right arm was swinging up and down. LT-A stepped forward and slapped R1's face with his open right hand. R1 lifted his arms as assistant director of nursing (ADON) intervened. At the conclusion of the video ADON stated she intervened immediately and took LT-A to the administrator's office. LT-A told the ADON R1 said something derogatory about LT-A's mother and LT-A would slap anyone who said anything derogatory about his mother. ADON stated if LT-A was willing to slap a resident with so many people around and questioned what would he do in a resident room with a resident who couldn't speak up for themselves?.During an interview on 2/25/2026 at 11:39 a.m., contracted lab supervisor (LS) stated laboratory technicians did not receive VA abuse prevention training.During an interview on 2/25/2026 at 2:25 p.m., director of nursing (DON) stated residents were protected from abuse by contracted staff through VA abuse prevention training. DON further stated the facility did not provide VA abuse prevention training for contracted staff from the laboratory.During an interview on 2/26/2026 at 10:35 a.m., the administrator (admin) stated residents were protected from abuse by contracted staff through VA abuse prevention training. Admin also stated the facility did not verify VA abuse prevention training for laboratory technicians before they were allowed to work with residents. The VA Abuse Prevention policy revised 10/1 did not address protocols for assuring VA abuse prevention education verification for contracted staff. The policy instructed the facility does not tolerate any form of physical abuse, verbal abuse, sexual abuse, mental abuse, neglect, corporal punishment, exploitation, involuntary seclusion, or misappropriation of resident property by anyone. The following policy protects residents from facility staff, other residents, consultants, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.

Based on observation, interview and document review, the facility failed to protect residents from physical abuse by contracted staff for 1 of 3 residents (R1) reviewed for abuse.Findings include:R1's diagnoses list dated 2/25/26 included disorganized schizophrenia, dementia, history of traumatic brain injury and mild cognitive impairment.R1's annual Minimum Data Set, dated [DATE] indicated R1 was rarely understood and had moderately impaired cognition.R1's care plan dated 1/14/26 included a focus of potential for abuse neglect and/or exploitation related to vulnerable adult status with a goal of [R1] will not be abused. Interventions included but are not limited to staff will follow Vulnerable Adult (VA) policy to keep resident free from exploitation, abuse and/or neglect.R1's general condition note dated 2/11/26 indicated R1 was hit at 2:00 p.m. by an external vendor. R1 had slight redness to his left cheek.During an observation and interview on 2/25/2026 at 1:03 p.m., R1 was observed sitting in a wheelchair in the dining room. R1 declined an interview by shaking head side to side then self-propelled the wheelchair out of the room.On 2/25/2026 at 2:49 p.m. video footage from 2/11/26 at approximately 2:00 p.m. was reviewed in the presence of assistant director of nursing (ADON). The video revealed R1 was sitting in a wheelchair by the elevator doors. Several other residents and staff members were in the area. A tall male (identified by director of nursing (DON) as a contracted laboratory technician (LT-A)) walked up to the elevator and used his hand to motion to R1 to move back away from the closed elevator door. LT-A's mouth was seen moving and his right arm was swinging up and down. LT-A stepped forward and slapped R1's face with his open right hand. R1 lifted his arms as assistant director of nursing (ADON) intervened. At the conclusion of the video ADON stated she intervened immediately and took LT-A to the administrator's office. LT-A told the ADON R1 said something derogatory about LT-A's mother and LT-A would slap anyone who said anything derogatory about his mother. ADON stated if LT-A was willing to slap a resident with so many people around and questioned what would he do in a resident room with a resident who couldn't speak up for themselves?.During an interview on 2/25/2026 at 11:39 a.m., contracted lab supervisor (LS) stated LT-A had been to the facility many times and had been terminated as a result of an internal investigation of the incident at the facility. LS further stated laboratory technicians did not receive VA abuse prevention training and could not recall any training related to not slapping a resident at a facility. During an interview on 2/25/2026 at 2:25 p.m., director of nursing (DON) stated a slap on the face was considered abuse. DON further stated facility staff did not provide supervision of laboratory technicians in the facility. Residents were protected from abuse by contracted staff through VA abuse prevention training. DON stated the facility did not provide VA abuse prevention training for contracted staff from the laboratory.During an interview on 2/26/2026 at 10:35 a.m., the administrator (admin) stated residents were protected from abuse by contracted staff through VA abuse prevention training. Admin also stated the facility did not verify VA abuse prevention training for laboratory technicians before they were allowed to work with residents. The VA Abuse Prevention policy revised 10/1 instructed the facility does not tolerate any form of physical abuse, verbal abuse, sexual abuse, mental abuse, neglect, corporal punishment, exploitation, involuntary seclusion, or misappropriation of resident property by anyone. The following policy protects residents from facility staff, other residents, consultants, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. The policy did not address VA abuse prevention education for contracted staff.

Based on observation, interview, and document review, the facility failed to comprehensively assess and develop or implement interventions to reduce the risk of ongoing potential physical and/or mental abuse for 1 of 3 residents (R1) reviewed for resident-to-resident abuse allegations. R1 was repeatedly harassed and physically grabbed by another resident (R2) which contributed to ongoing emotional distress and hospitalization resulting in psychosocial harm.Findings include:R2's progress notes, dated 8/1/25 to 12/19/25, identified over 20 recorded entries of R2 having behaviors with a note reading, Was behavior observed? YES. However, the notes lacked any additional information on what the behavior was, nor what interventions were done to reduce it. R2's progress note dated 9/5/25, indicated R2 was recorded as being physically and verbally aggressive towards another resident. The note recorded R2 rolled her wheelchair over another resident's foot and needed to be re-directed several times. The note did not identify who the other resident was involved. R2's progress dated 9/9/25 indicated R2 called out for her roommate and various other names aloud. The note recorded, She also comes up behind [R1] and attempts to pull her hair. The note included a section labeled, Immediate Intervention(s), which outlined that each time the behaviors are observed, R2 was redirected. However, the redirection is not successful adding, She acts as if she did not understand the words spoken to her . The progress note(s) lacked evidence of what, if any, other interventions were considered or done to reduce the risk of R2 seeking R1 and pulling on her hair. R2's annual Minimum Data Set (MDS), dated [DATE], identified R2 had moderate cognitive impairment, demonstrated both delusional thinking and hallucinations, and had multiple medical conditions including anxiety disorder and schizophrenia. The MDS identified R2 demonstrated both physical symptoms (i.e., hitting, scratching) and verbal symptoms at others for 1 to 3 days of the review period; however, these behaviors did not place others at significant risk of injury or intrude on their privacy. R2's POC (Point of Care) Response History, dated 12/3 to 12/19/25, identified R2's recorded behaviors in the POC charting along with what interventions were done for them and whether those interventions were successful or not. The charting identified R2 as grabbing others and pushing others on 12/9/25 and 12/18/25. The only recorded interventions for this were on 12/6/25 and 12/9/25; with one intervention recorded as, Redirect, with the behavior being, Same (Unchanged). R2's progress note dated 12/7/25, indicated R2 was recorded as having multiple behaviors which included, . pulling on the hair and dress of [R1] as she passes her in the main hall. The note identified R2 would also pass the staff in the hallway and raise her top exposing her breasts to them telling the male staff she was pregnant with their child. The note added R2 was redirected to not say things which were not accurate. R2's Associated Clinic of Psychology (ACP) note dated 12/5/25 indicated R2 was seen in person diagnosis included schizoaffective disorder, bipolar type, anxiety, and personality disorders. Was last seen three months ago with no changes, continues to be disorganized, insight judgement, memory, and concentration were limited, R2 reports no concerns. Plan to continue stability within the facility, no does reductions with medications due to fears of decompensation. R2's ACP note dated 12/10/25 indicated R2 was seen in person. Facility reports client pulled hair of peer. An examination was recorded which identified R2 had to have statements and questions repeated to her often stating, What? R2 was asked about pulling R1's hair and denied recalling the event but stated she would ignore the individual and no longer talk to her. The note provided treatment recommendations which included allowing R2 to express her needs, directing her to things she can touch (i.e., purse), and staff giving her positive reinforcement when she behaves appropriately. R2's progress note dated 12/17/25 indicated the facility met with ACP to discuss any concerns or recommendations and none were provided. R2's progress noted dated 12/17/25 indicated the facility was working with the county guardianship worker to assist R2 with moving to a smaller environment. R2's care plan, dated 12/19/25, identified R2's current potential and/or actual problems along with interventions to be done to mitigate their impact. The care plan identified consumed psychotropic medications due to her schizoaffective disorder. However, the care plan lacked any identified behavioral focus or interventions to demonstrate what, if any, actions the facility takes with R2 and her behaviors towards other residents. On 12/19/25 at 9:53 a.m., R2 was observed seated in a wheelchair in the main hallway of the first floor wheeling herself towards the outdoor smoking patio. R2 had a purse on her lap and as she wheeled towards the area, a male resident stood up from against the wall and yelled to her, You can't smoke right now. Turn around! R2 was interviewed by the surveyor and was unable to recall how long she had lived at the care center and just expressed aloud, Terrible, when asked how things at the center were going for her. R2 was asked about her interactions with R1 and expressed she had no issues with her and felt they got along fine before abruptly stating aloud, Can I go now? R2 then wheeled away, and the interview was stopped. R1's annual MDS, dated [DATE], identified R1 had moderate cognitive impairment and demonstrated delusional thinking. The MDS outlined R1 had multiple medical conditions including non-traumatic brain dysfunction, dementia, anxiety disorder, depression, and psychotic disorder. R1's progress notes, dated 8/1/25 to 12/19/25, identified R1 had a history of being fearful of her peers, at times calling 911 for various things (i.e., AC not working), and talking about events not relative to the current time. The notes also outlined the following: -On 12/7/25, R1 came down to the breakfast meal and was noted to be crying and talking rapidly about all the things that had happened last evening that had upset her. R1 calmed down and ate her meal. The note then outlined, She feared coming back to 2nd [floor] in the elevator. The note lacked documentation on what events R1 voiced being upset about causing her to be fearful. -On 12/7/25, the police presented to the care center. R1 had called 911 and reported being afraid of being at the care center and wanting to go to the hospital. A behavioral health team was called and was enroute. A subsequent note on 12/7/25, identified the team responded and determined taking R1 to the hospital was not needed and R1 agreed to stay at the care center. -On 12/8/25, the police again presented to the care center to see R1 who had called 911. R1 complained about not feeling safe and still being anxious. R1's guardian was called and agreeable to hospitalization. R1 was taken via EMS to the local hospital. Registered nurse (RN)-A. authored this note. R1's care plan, dated 12/19/15, identified all R1's current potential and/or actual problems along with interventions to be done to mitigate their impact. The care plan identified R1 had a history of calling 911 for her basic needs and staff had encouraged her to call internal numbers instead. The care plan outlined R1 was a vulnerable adult (VA) and had previous reported incidents of being touched inappropriately by a male resident (11/2024), and reporting to MDH that her roommate was calling her names (4/2025). The care plan directed staff would follow the VA policy and monitor or report incidents of abuse. This section was last revised 4/2025. R1's care plan lacked any specific identified issues or interventions related to R2 and their interactions. When interviewed on 12/19/25 at 9:04 a.m., hospital social worker (HSW)-A stated R1 had reported the allegation of being physically assault by R2 which made her feel uncomfortable. HSW-A stated the stress of that incident with R2 likely contributed to R1 needing to be hospitalized on the psychiatric unit due to her anxiety and becoming increasingly paranoid. During interview and observation on 12/19/25 at 10:00 a.m., nursing assistant (NA)-A explained they had worked with R2 multiple times prior and R2 would often ask staff and other residents if she could touch them repeatedly. NA-A stated they had seen R2 ask R1 to touch her which bothered R1. NA-B joined the interview and stated R2 grabbing at R1 happened all the time. NA-B stated R2 often would pass by R1's room and open the door to look for her. NA-B stated they believed R2 was trying to target her [R1] as she knew R1 was bothered by the repeated grabbing and touching. NA-B stated they attempt to redirect R2, but it often did not work. NA-B stated R1 was currently hospitalized and R2 seemed to miss her since she left as now R2 has nobody to bully. At 10:06 a.m., R2 was observed wheeling past R1's room and stopped to open the room door. NA-B then pointed to R2 and expressed aloud, See! She is looking for her [R1]! NA-B reiterated they try to redirect R2 but added the facility needs to do more. NA-B stated staff had not been given any new interventions to attempt for R2's behaviors with R1 to their recall, and expressed R2 seeming to seek R1 out and continue with the behaviors of hair pulling and grabbing had been happening for several months. NA-B stated the management was very well aware of the concerns with R2 and R1. When interviewed on 12/19/25 at 10:11 a.m., trained medication aide (TMA)-A stated R2 and R1 used to be roommates but they were separated after the most recent health survey (exited 4/2025) as R2 was attacking R1 repeatedly. TMA-A stated despite R2 being moved to a different room on the same floor, R2 continued to seek R1 out and have behaviors with her adding she is still attacking her. TMA-A stated staff attempt to redirect R2, but it was not effective as R2 had dementia and could not remember things most of the time. TMA-A stated R1 was bothered a lot by R2's behaviors toward her and at times would start crying because of it and try to move positions in the hallway to avoid R2 when she saw her coming towards her. TMA-A stated they felt more interventions needed to be done to protect R1 from R2 and wondered if a room change to a different floor or closer to the elevator, which would make it so R2 didn't have to pass R1's room to get to her own, would help the situation. R2's medical record was reviewed and lacked evidence the facility had comprehensively assessed the repeated seeking out of R1 to determine what, if any, interventions were needed to ensure R1 remained safe from potential physical and mental harm from R2 despite repeated incidents being documented, direct care staff having knowledge of R1 being in distress about the interactions, and redirection for R2 not being consistently effective. During interview on 12/19/25 at 10:22 a.m., RN-A stated R1 had a history of anxiety and would easily become really anxious with interactions with other residents. RN-A reviewed R1's medical record and verified they were working when R1 was sent to the hospital on [DATE]. RN-A explained the staff had reported to them on 12/7/25, that R2 had pulled on R1's hair and caused her to get really agitated. RN-A stated on 12/8/25, R1 was again upset and reported not feeling safe at the care center, however, R1 did not express a specific reason. RN-A stated R2 would often touch other residents which could cause a reaction by them, however, felt it was never intended to hurt someone. RN-A stated they knew being grabbed and touched by R2 bothered R1 adding R1 had repeatedly expressed it while being really scared and using anxious words. RN-A stated staff needed to watch them both closely and intervene when they are close to each other, but it was not always possible. RN-A stated moving R2 to another room would likely help reduce the interactions between R2 and R1, and verified R2 was not on any one-to-one monitoring or safety checks relating to R1 despite the repeated altercations. On 12/19/25 at 10:46 a.m., a group interview was held with the director of nursing (DON), facility social worker (SW)-B, licensed practical nurse MDS coordinator (LPN)-A. DON explained they had worked at the campus for approximately four months now, and SW-B stated they were on their third week at the campus. DON verified R1 remained hospitalized since being taken there on 12/8/25. DON stated ACP was involved with R2 and staff were trying a lot of redirections to keep R2 from R1 and others she was known to bother. SW-B stated they had secured a discharge location for R2 which would happen within the next week or so. DON stated R2's interactions bothered more than one resident but added R1 seemed to notice it the most and have the biggest reaction to it. DON stated R1 did become upset when R2 was physically near her but added R1 is often scared of many things and people, too. LPN-A stated they felt it was more anxiety with R1 than fearful feelings. DON verified they were notified about R2 pulling on R1's hair back on 12/8/25, however, did not report or act on that as an allegation of potential abuse and reiterated R1 becomes easily upset with many things. SW-B stated they felt R2 was learning to refrain from touching others despite her cognitive impairment adding they believed R2 to retain 60 percent (%) of things told to her. DON stated a floor change for either R2 or R1 was not likely possible due to both needing some activities of daily living (ADL) help but acknowledged that had not been something the IDT had discussed or considered thus far, either. SW-B stated they had just that week been talking with R1's guardian to help decide how to make R1 feel safer at the center. However, the DON and SW-B both expressed none of the direct care staff had reported to them the ongoing seeking out of R1 that R2 was doing from their perspective. DON stated had that information been reported to them, they would have involved ACP and assessed it to develop a plan using their Behavioral Assessment Form. DON verified there were no recent 1:1 or 15-minute safety checks being done for R2 related to R1 and expressed the team would have considered more interventions when R1 returned from the hospital. SW-B reviewed R1's care plan and verified there were no specific goals or interventions listed to help R1 specifically with R2 despite R2 being a known agitator of them. DON attributed this to the previous social worker having poor job performance. At 11:26 a.m., the administrator joined the interview, and they explained an allegation of potential abuse should be reported and investigated. The administrator expressed they felt R2 was not willfully seeking anyone out, rather R1 was just more paranoid and anxious which caused her to believe R2 was after her. The administrator stated R2 needed a better care venue, and the facility was working on discharging her soon. LPN-A reiterated the main intervention for R2 had been redirection, and the administrator added such intervention happened daily with R2. DON and the administrator both acknowledged the lack of documentation in the medical record to demonstrate what, if any, other interventions, or actions the facility had considered or were doing to keep R1 safe from R2 aside from redirection and working on securing another placement. The administrator added, I think we're not taking credit for a lot of the redirection we are doing. SW-B stated the facility was still working on a process to determine if R1's reported fears are more general-based or specific to a single event or person which would help them determine in the future what is reportable or not. The facility Vulnerable Adult Abuse Prevention Policy, 2218, (revised 10/1[SIC]) identified abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy outlined mental abuse could happen with either verbal or nonverbal contact that caused fear, shame, agitation, or degradation. The policy directed the center would identify events, such as patterns and trends, which may constitute abuse and those would be investigated. The policy directed all allegations of potential abuse were to be immediately reported to the administrator and then investigated.

Based on interview and document review, the facility failed to ensure a resident-to-resident physical altercation which contributed to feelings of fear and mental anguish was reported to the State agency (SA) immediately, but not later than two hours after the allegation is made of abuse for 1 of 3 residents (R1) reviewed reporting. R1 was grabbed and had her hair pulled by R2 which caused R1 psychosocial harm. Findings include: R2's progress note, dated 9/9/25, identified R2 called out for her roommate and various other names aloud. The note recorded, She also comes up behind [R1] and attempts to pull her hair. The note included a section labeled, Immediate Intervention(s), which outlined that each time the behaviors are observed, R2 was redirected. However, the redirection is not successful adding, She acts as if she did not understand the words spoken to her . R2's progress note, dated 12/7/25, recorded her as having multiple behaviors which included, . pulling on the hair and dress of [R1] as she passes her in the main hall. The note identified R2 would also pass the staff in the hallway and raise her top exposing her breasts to them telling the male staff she was pregnant with their child. The note added R2 was redirected to not say things which were not accurate. R2's ACP note dated 12/10/25 indicated R2 was seen in person. Facility reports client pulled hair of peer. An examination was recorded which identified R2 had to have statements and questions repeated to her often stating, What? R2 was asked about pulling R1's hair and denied recalling the event but stated she would ignore the individual and no longer talk to her. The note provided treatment recommendations which included allowing R2 to express her needs, directing her to things she can touch (i.e., purse), and staff giving her positive reinforcement when she behaves appropriately. R1's annual MDS, dated [DATE], identified R1 had moderate cognitive impairment and demonstrated delusional thinking. The MDS outlined R1 had multiple medical conditions including non-traumatic brain dysfunction, dementia, anxiety disorder, depression, and psychotic disorder. R1's progress notes, dated 8/1/25 to 12/19/25, identified R1 had a history of being fearful of her peers, at times calling 911 for various things (i.e., AC not working), and talking about events not relative to the current time. The notes also outlined the following: -On 12/7/25, R1 came down to the breakfast meal and was noted to be crying and talking rapidly about all the things that had happened last evening that had upset her. R1 calmed down and ate her meal. The note then outlined, She feared coming back to 2nd [floor] in the elevator. The note lacked documentation on what events R1 voiced being upset about causing her to be fearful. -On 12/7/25, the police presented to the care center. R1 had called 911 and reported being afraid of being at the care center and wanting to go to the hospital. A behavioral health team was called and was enroute. A subsequent note on 12/7/25, identified the team responded and determined taking R1 to the hospital was not needed and R1 agreed to stay at the care center. -On 12/8/25, the police again presented to the care center to see R1 who had called 911. R1 complained about not feeling safe and still being anxious. R1's guardian was called and agreeable to hospitalization. R1 was taken via EMS to the local hospital. Registered nurse (RN)-A. authored this note. R1's care plan, dated 12/19/15, identified all R1's current potential and/or actual problems along with interventions to be done to mitigate their impact. The care plan identified R1 had a history of calling 911 for her basic needs and staff had encouraged her to call internal numbers instead. The care plan outlined R1 was a vulnerable adult (VA) and had previous reported incidents of being touched inappropriately by a male resident (11/2024), and reporting to MDH that her roommate was calling her names (4/2025). The care plan directed staff would follow the VA policy and monitor or report incidents of abuse. This section was last revised 4/2025. R1's care plan lacked any specific identified issues or interventions related to R2 and their interactions. When interviewed on 12/19/25 at 9:04 a.m., hospital social worker (HSW)-A stated R1 had reported the allegation of being physically assault by R2 which made her feel uncomfortable. HSW-A stated the stress of that incident with R2 likely contributed to R1 needing to be hospitalized on the psychiatric unit due to her anxiety and becoming increasingly paranoid. During interview and observation on 12/19/25 at 10:00 a.m., nursing assistant (NA)-A explained they had worked with R2 multiple times prior and R2 would often ask staff and other residents if she could touch them repeatedly. NA-A stated they had seen R2 ask R1 to touch her which bothered R1. NA-B joined the interview and stated R2 grabbing at R1 happened all the time. NA-B stated R2 often would pass by R1's room and open the door to look for her. NA-B stated they believed R2 was trying to target her [R1] as she knew R1 was bothered by the repeated grabbing and touching. NA-B stated they attempt to redirect R2, but it often did not work. NA-B stated R1 was currently hospitalized and R2 seemed to miss her since she left as now R2 has nobody to bully. At 10:06 a.m., R2 was observed wheeling past R1's room and stopped to open the room door. NA-B then pointed to R2 and expressed aloud, See! She is looking for her [R1]! NA-B reiterated they try to redirect R2 but added the facility needs to do more. NA-B stated staff had not been given any new interventions to attempt for R2's behaviors with R1 to their recall, and expressed R2 seeming to seek R1 out and continue with the behaviors of hair pulling and grabbing had been happening for several months. NA-B stated the management was very well aware of the concerns with R2 and R1. During interview on 12/19/25 at 10:22 a.m., RN-A stated R1 had a history of anxiety and would easily become really anxious with interactions with other residents. RN-A reviewed R1's medical record and verified they were working when R1 was sent to the hospital on [DATE]. RN-A explained the staff had reported to them on 12/7/25, that R2 had pulled on R1's hair and caused her to get really agitated. RN-A stated on 12/8/25, R1 was again upset and reported not feeling safe at the care center, however, R1 did not express a specific reason then. RN-A stated they knew R1 being grabbed and touched by R2 bothered her (R1) adding R1 had repeatedly expressed it while being really scared and using anxious words. On 12/19/25 at 10:46 a.m., a group interview was held with the director of nursing (DON), facility social worker (SW)-B, licensed practical nurse MDS coordinator (LPN)-A. DON explained they had worked at the campus for approximately four months now, and SW-B stated they were on their third week at the campus. DON verified R1 remained hospitalized since being taken there on 12/8/25. DON stated R2's interactions bothered more than one resident but added R1 seemed to notice it the most and have the biggest reaction to it. DON stated R1 did become upset when R2 was physically near her but added R1 is often scared of many things and people, too. DON verified they were notified about R2 pulling on R1's hair back on 12/8/25, however, staff did not report the reaction R1 had to it. DON stated it was hard to always determine what or why R1 is upset as she becomes easily upset with many things. DON and SW-B both expressed no staff had reported the ongoing issues between R1 and R2 to them or it would have been addressed using a Behavioral Assessment Form which helps the facility investigate those allegations. DON verified a report of the 12/7/25 incident was not reported to the SA as they did not think of it as a reportable physical altercation despite R1's reaction of agitation and potential fear to being grabbed by R2. At 11:26 a.m., the administrator joined the interview. They explained any allegation of abuse should be reported and investigated. The administrator denied thinking R2's actions were willful towards R1 but acknowledged R1's reaction to the event. The facility Vulnerable Adult Abuse Prevention Policy, 2218, (revised 10/1[SIC]) identified abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy outlined mental abuse could happen with either verbal or nonverbal contact that caused fear, shame, agitation, or degradation. The policy directed the center would identify events, such as patterns and trends, which may constitute abuse and those would be investigated. The policy directed all allegations of potential abuse were to be immediately reported to the administrator and, if needed in reference to the policy, to the SA and then investigated.

Based on interview and document review the facility failed to provide a resident's prescribed therapeutic diet when on 11/17/25, a registered nurse (RN)-A assisted R3 to purchase a sticky bun from the vending machine at the facility because he was unable to do so himself for 1 of 3 residents (R3) reviewed for food and drink. While eating the sticky bun R3 started to choke and went unresponsive, cardiopulmonary resuscitation (CPR) was started and R3 was transferred to the hospital where he subsequently died on [DATE].The immediate jeopardy began on 11/17/25 when RN-A purchased a non-pureed item out of a vending machine for R3, R3 choked on the item resulting in his death was identified on 11/17/25. The chief financial officer (CFO)-A, a director of nursing (DON) was notified of the immediate jeopardy at 3:19 p.m. on 12/15/25. The immediate jeopardy was removed on 12/4/25, and the deficient practice corrected on 12/4/25, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R3's Minimum Data Set (MDS) dated [DATE], indicated he had mild cognitive impairment and no behaviors or depression during the seven days look back. He needed moderate assistance from staff to eat food during mealtimes. His medical history included Schizophrenia, diabetes, major depression, obsessive-compulsive personality disorder, and lung disease. R3's care plan dated 5/26/20, indicated he could independently move around the building in his wheelchair. In addition, he needed assistance from staff to eat. R3's care plan dated 6/5/25, indicated he required a pureed diet. R3's diet order dated 6/19/25, indicated he required a Level 1 Dysphagia (smooth, pudding like texture, no lumps, chunks to allow minimal chewing) food to prevent choking. R3's nutrition assessment dated [DATE], indicated he received a pureed diet and required help from staff to eat. There were no issues with choking while on the pureed diet. R3's incident report dated 11/17/25 indicated earlier in the day, R3 requested assistance from staff to purchase a sticky bun snack from the vending machine and was assisted to retrieve the snack. R3 was in the dining room having trouble breathing, stopped breathing, and fell from his chair. R3 was observed to have food in his mouth, which was removed. R3 had no pulse, CPR was started, AED was initiated, and EMS arrived taking over CPR. R3's progress note dated 11/17/25 at 3:45 p.m., indicated at 2:45 p.m., the camera showed R3 having trouble breathing. He stopped breathing and fell to the floor. Staff started CPR and placed the AED on the resident. EMS arrived and regained a pulse at 3:13 p.m. R3's hospital discharge note dated 11/23/25, indicated on 11/17/25, R3 experienced a witnessed aspiration event followed by an out-of-hospital cardiac arrest, CPR was started with return of spontaneous circulation. During the event he developed a cervical (neck spine bone) fracture, multiple rib fractures, anoxic brain injury (severe lack of oxygen leading to massive brain damage), and seizure activity. On 11/23/25, he was placed on comfort care and pronounced brain dead. On 12/11/25 at 1:20 p.m., registered nurse (RN)-A stated R3 asked her to purchase a sticky bun from the vending machine for him. She knew he sat at the feeding assistance table in the dining room, but she did not think about his ordered diet when she made the purchase. Once she gave him the item she went back to her office. Five minutes later the DON ran into the office and said they had a medical emergency in the dining room. She found staff providing CPR and was shocked to see it was R3. Once the paramedics arrived on scene, she started to ask what happened. She was told he choked. After R3 left for the hospital, she told the DON she purchased a sticky bun from the vending machine for him. On 12/11/25 at 1:45 p.m., the DON stated she was the first nursing staff to arrive at the scene. R3 was on the ground, and he did not have a pulse, and she started CPR. She looked in his mouth and found food lodged in his throat. She removed what she could see and continued CPR until more staff arrived. On 12/11/25 at 2:20 p.m., administrator stated after the incident the facility vending machines were moved to the third floor in a locked room. Residents are allowed access once staff confirmed their diet. The past noncompliance immediate jeopardy began on 11/17/25 was removed and the deficient practice corrected by 12/4/25 after the facility implemented a systemic plan that included the following actions: -The facility staff announcement memo dated 12/4/25, indicating vending machines were locked on the third-floor in the conference room. Staff expectations included: (1) no staff would assist a resident to get food out of the vending machine, (2) if a resident requested an item against his prescribed diet orders, staff would notify the charge nurse, offer a safe snack, and always verify the diet before offering food or drink, and (3) all snacks for residents must be approved by the dietician and come from dietary services. -The facility memo to residents 12/4/25, indicated the vending machines were relocated to the third-floor conference room. Several residents have special diets, and the move would ensure their safety. -The facility policy Cardiopulmonary Resuscitation dated 12/4/25, indicated staff would first check resident's code status prior to performing CPR. If full code, CPR would be initiated. In addition, staff would call 911. During every pulse check staff would look in the resident's mouth and remove visible obstruction. Staff are re-educated on choking procedures annually. Nursing and dietary staff receive additional training regarding the different types of mechanical soft diets, where to find a resident's diet type, and feeding assistance/aspiration prevention techniques.-Facility audits dated 12/4/25 through 12/19/25, indicated the DON completed random diet order checks for ten residents twice a week. No discrepancies were noted during her audits.

Based on observation, interview, and document review, the facility failed to provide trauma informed care including failure to complete a comprehensive assessment that identified triggers in order to eliminate or mitigate the risk of re-traumatization for 1 of 1 resident (R2) who had a known history of trauma prior to admission. The facility's failures resulted in actual psychosocial harm for R2 when R2 was involved in two resident to resident abuse incidents that caused R2 ongoing fear and aggressive reactions that were uncharacteristic of R2. Findings includeR2's hospital functional assessment dated [DATE] indicated R2 reported significant history of trauma including abuse which have led to intrusive memories/thoughts, nightmares, dissociative reactions, and significant psychological stress.R2's admission Minimum Data Set (MDS) dated [DATE] identified R2 did not have cognitive impairment, did not have behaviors, and was independent with activities of daily living (ADL). R2 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, depression, bipolar disorder, and schizophrenia. Only CAA triggered was psychotropic drug use. Review of R2's clinical record identified that although she was admitted to the facility with a documented history of trauma, including abuse and associated maladaptive psychological responses, there was no indication that the facility had conducted a comprehensive trauma-informed care assessment. Specifically, the record lacked documentation identifying environmental and interpersonal triggers that could elicit a PTSD response, as well as personalized therapeutic goals, targeted trauma-informed interventions, and preventive practices designed to minimize re-traumatization and promote psychological safety.R2's care plan dated 8/4/25 indicated R2 was a vulnerable adult related to mental illness with a goal of R2 will be provided with a safe environment and minimize risk of abuse. This focus area indicated on 6/6/25 R2 was in a verbal altercation on the back smoking patio; R2 threw water in other resident's face during altercation. Remind resident to walk away from disagreements with others and go sit in a quiet place and deescalate and notify staff. R2's care plan did not address and/or include a focus for management and treatment of PTSD that identified target behaviors/triggers with individualized goals of care and interventions to prevent and/or manage re-traumatization.R2's Associated Clinic of Psychiatry (ACP) notes dated 9/10/25, 9/17/25, and 10/01/25 identified diagnosis of PTSD; although the notes included supportive behavioral interventions there was no indication R2's care plan was updated to include the recommendations; however, the notes did not address potentially distressing stimuli or individualized strategies to manage or prevent re-traumatization. The notes included: -R2's ACP visit note dated 9/10/25 included R2 has experienced extensive emotional, physical and verbal abuse throughout her life. R2 was a bleeding heart for other people. Treatment recommendations: R2 may benefit from emotional validation and normalization of grief symptoms. Benefits from spending time with friend in facility, sleeping and walking outdoors.-R2's ACP visit note dated 9/17/25 included R2 was able to articulate that a structured daily routine with group meetings was helpful to her. She values connections with others in a similar situation. Treatment recommendations: R2 was encouraged to care for herself by separating from the constant responsibility she feels with other peers in the building. R2 will continue to benefit from staff support, kindness, patience, and reminders that she is well-liked, appreciated and respected.-R2's ACP visit note dated 10/1/25 included R2 presents as spiraling into manic phase with increased irritability, pacing and impatience. The treatment recommendations included utilize de-escalation strategies including anticipate trigger events.R2's quarterly MDS dated [DATE] indicated intact cognition with diagnoses including PTSD and schizoaffective disorder, bipolar type. R2 had verbal behavioral symptoms directed towards others 4-6 days and rejection of care 1-3 days. Despite the increase in verbal behaviors since the previous assessment dated [DATE], there was no indication a comprehensive assessment was completed. Facility resident to resident incident reports and surveillance videos identified two altercations involving R2; one on 10/25/25 and the other on 10/26/25. Video on 10/25/25 at 2:46 p.m. identified R1 exited his room as R2 walked toward him, speaking. R1 began waving his hand near R2's face in a rigid, vertical motion. It was unclear if contact was made. R2 swatted his hand away, and R1 moved toward TMA-A while continuing to gesture and speak. R2 then slapped R1 in the face, and both backed away. Moments later, R2 pushed R1, prompting TMA-A to intervene. R3 appeared and was reportedly asking R1 to leave R2 alone. R1 then pushed R3 into another room, out of view. R2 ran after R1, pulling his shirt and kicking at him. The situation escalated as R1 and R3 locked arms and moved down the hallway. R1 fell to his knees, and R3 began punching him. R2 appeared to yell and then jumped on R1's back, hitting him. R3 disengaged and moved away. R1 walked away from R2 and R3. TMA-A kept the residents separated.Video of the 10/26/25 altercation, R2 was observed assisting a resident off the elevator. R1 was observed walking past R2 several times. No staff members were observed in the hallway. A resident was observed in the doorway of the elevator when R1 walked behind him and started pushing him into the elevator. R2 walked to the elevator, shoves R1 against the side of the elevator door then R1 punches R2 on the left side of her head. Staff ran into the elevator and separated R1 and R2. R2 swung her arms at R1. R1 walked out of the elevator and down the hall. Director of nursing (DON) confirmed R2 was struck in the head by R1.R2's Behavioral Assessment for Physical Altercation dated 10/27/25 that was located in the download section of the electronic medical record on 10/28/25 at 2:05 p.m. was blank with no documentation. However, a subsequent assessment dated [DATE] that was completed with a notation This report was re-written due to error in saving the original written on 10/27/25 and was electronically signed on 10/30/25. This assessment summarized the abuse events, indicated no environmental triggers, the care plan was followed and was modified to prevent reoccurrence. The assessment identified the elements of the care plan that were not followed included Staff should encourage [R2] to remember that she is the more mature and bigger person. [R2] is vulnerable to [sic] Section 2: Behavioral Triggers and Context- included No prior triggers identified and R2 identifies as a survivor of domestic abuse and may be triggered by behavior that reminds her of past trauma. Males that suddenly invade personal space, provoke her verbally and when she cannot find her phone may trigger her react impulsively. Trigger identification checked was Personal space violation, Verbal provocation, and unable to locate phone. R2's record was reviewed between 10/25/25 through 10/30/25 at 2:05 p.m., although R2 had been involved in two resident-to-resident altercations, there was no indication a trauma assessment had completed. R2's care plan was revised on 10/27/25 to include a behavior focus but did not include a focus for PTSD with associated triggers. The behavior care plan indicated R2 had physically abusive behavior symptoms directed toward others. Associated interventions included house psychologist will visit with resident as needed, medications her MD order, encourage R2 to stay away from R1, if altercation occurs staff to intervene and separate residents.During an interview on 10/30/25 at 10:26 a.m., licensed social worker (LSW)-A indicated after the physical altercations he reviewed the videos and interviewed R2. LSW-A explained a behavioral assessment was supposed to be completed after a physical altercation and with any new admissions with a history of physical violence. The behavioral assessment includes asking about potential triggers; LSW-A stated he completed R2's assessment after the altercation but did not identify the date and time it was completed. LSW-A did not know if there was a formal trauma assessment the facility utilized, and he was not completing a trauma assessment on paper. Any information obtained by ACP would be entered into the care plan by interdisciplinary (IDT) team. LSW-A was surprised R2 lashed out at R1. She had never attacked anyone before. LSW-A did not know what triggered R2 to respond with aggression but thought R2 might have seen R1 waving his hands in her face as an attack or a precursor to an attack. LSW-A stated PTSD was caused by a serious event and domestic assault could be considered a PTSD event.During an interview on 10/28/25 at 2:09 p.m. R2 explained she had been abused most of her life by men and as a result I have PTSD. So, because of her experiences R2 exclaimed I deserve to feel safe! I will go after anyone who gets in my face! R2 explained what happened when R1 kept pointing his fingers inches from her face (R2 demonstrated R1's proximity to her and the hand gestures he made) and made contact with her face. R2 pushed R1's hand out of her face and started to walk away, but R1 followed her and continued with the pointing and yelling. When R1 went after R3, R2 felt she needed to protect R3 so she ran after R1 to pull him off of R3. Now R2 looked out her window before leaving her room to see if R1's vehicle was parked outside because she did not want to take a chance of running into him. If she were to see his car, her plan was to just stay in her room. If she did run into him in the halls, she would try to ignore him. R2 stated she feels like a mouse in a cage with a snake. She is the mouse just waiting for the snake (R1) get her.During an interview on 10/29/25 at 9:38 a.m., R3 stated he heard yelling outside his door. When he came out, he saw R2 with her back against the wall and R1 right in her face. R1 came at R3, grabbed his shirt and pushed him into another resident's room.During an interview on 10/29/25 at 12:47 p.m., licensed mental health therapist (Th)-A stated she was familiar with R2; R2 would only participate in sessions when she was struggling with depression. Since the incidents on 10/25/25 and 10/26/25, R2 had been offered an evaluation however, R2 had declined so Th-A was not aware of the impact to R2's mental health. Th-A indicated someone who had PTSD is not always aware of what their real triggers are and their response to those triggers would also be very individualized. It was important to address a person's triggers to offer sensitivity and to know how a person might respond in a certain situation, however R2's triggers had not been evaluated or establishedOn 10/31/25 at 11:21 a.m., the medical director (MD) was interviewed and stated people with a past trauma often do not feel safe or secure. They might be less likely to trust anyone. Each person reacts to a traumatic event differently. Staff should attempt to address specific triggers especially if there was a chronic trauma. MD could not confirm if trauma assessments were being completed. MD stated even a person without PTSD might be triggered by someone yelling and waving fingers close to the face. Asking the person being yelled at to move away from the situation would be a reasonable request in that situation.During an interview on 10/30/25 at 1:45 p.m., director of nursing (DON) stated the facility did not have a formal trauma assessment nor an official care plan focus for trauma informed care. Any behaviors, trauma, or triggers would be in the psychosocial or vulnerable adult care plan focus. Behavior interventions were put in the care plan LSW-A. DON stated the root cause of the altercation was R1 escalated R2. DON indicated after the incidents R2 informed her she had PTSD which is why she reacted so fast to R1. DON had previously indicated he did not like anyone talking in the hallway. After the incident staff were provided education to move residents away from R1's doorway however, that was not in his care plan and to keep R1 and R2 separated.During an interview on 10/30/25 at 4:42 p.m., administrator confirmed trauma assessments were not being completed on the residents.The Quality of Care and Trauma Informed Care policy dated 9/2022 instructed residents who are diagnosed with a mental disorder, psychosocial adjustment difficulty and/or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial well-being. Residents will be screened and assessed upon admission, quarterly and/or significant change by our social service department in order to identify any history of trauma and/or PTSD. The interdisciplinary team will document and care plan for any areas of trauma. This will include potential or actual triggers that may cause re-traumatization of the resident, experiences, preferences and/or other interventions that eliminate or mitigate triggers that cause re-traumatization of the resident, and identification of the stressor or past life trauma.

Based on observation, interview, and document review the facility failed to prevent and protect 3 of 3 residents (R1, R2, and R3) from physical and verbal abuse when staff failed to remove R2 and bystanders after R1 demonstrated aggression toward R2 which led to physical altercation between R1, R2, and R3. In addition, facility failed to comprehensively assess for triggering behavior patterns and implement interventions that could decrease the risk and/or prevent for recurrent incidences of resident-to-resident abuse. Findings include:R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated intact cognition with diagnoses including type 2 diabetes, depression, and psychoactive substance abuse. R1 was independent with all activities of daily living (ADL). R1 had verbal behavioral symptoms directed at others 1-3 days and rejection of care 4-6 days during the assessment period.R1's care plan dated 8/28/25 indicated R1 had potential for behavior concerns related to verbal and physical aggression towards residents. Interventions included encourage R1 to remove himself from altercations before they escalate, encourage R1 to notify a staff member before verbal altercations escalate, try to find a resolution to R1's concerns rather than arguing, and when R1 is aggressive, give him space, attempt to redirect and notify Police. The care plan also indicated R1 had potential for abuse related to vulnerable adult status with goal of R1 will note be abused. Interventions included staff will follow facility vulnerable adult policy to keep resident safe from abuse.On 10/28/25, a video of a resident-to-resident altercation was reviewed in which the director of nursing (DON) stated R1 was the verbal aggressor and R2 was the physical aggressor. The video identified on 10/25/25 at 2:40 p.m. R2 and another resident were in the hallway outside R2's room talking (no audio on the video)-At 2:46 p.m. R1 opened the door to his room said something then closed door.-At 2:46:44 p.m. R2 walked to nurse's station where trained medication assistant (TMA)-A was standing; the two were facing each other with mouths moving.-At 2:46:53 p.m. R1 came out of his room. R2 walked towards R1, R2's mouth was moving, and her arms were at her side. R1 started waving his hands near R2's face. His fingers were observed pointing straight with his thumb tucked in. His hand was perpendicular with the floor, and he was shaking it up and down. It was unclear whether R1 contacted R2's face.-At 2:47:04 p.m. R2 swatted R1's hand out of her face. R1 walked towards TMA-A. R1 and R2's mouths continued to move. R1 continued to wave his hand in her face.-At 2:47:27 p.m. R2 slapped R1 in the face. The two backed away from each other as R1 looked towards TMA-A.-At 2:47:41 p.m. R2 pushed R1. He stepped back and TMA-A positioned herself between R1 and R2. TMA-A put her up arms in front of R2. R3 was standing in his doorway; DON stated R3 was asking R1 to leave R2 alone. R1 crossed the hallway to R3 and pushed him into another resident's room. They went out of video view. R2 went around TMA-A and ran towards R1. R2 then pulled on R1's shirt and kicked her leg towards R1.-At 2:48 p.m. fight continued. R3 and R1 had their arms locked together moving down the hallway. R1 went down on his knees then R3 started punching R1. R2's mouth was moving and appeared to be yelling. R1 and R3 were on the ground wrestling. R2 jumps on R1's back and starts hitting R1. R3 got to his feet and moved away from R1.-At 2:49:38 p.m. R1 walked away from R2 and R3. TMA-A kept them separate. R1 walked past TMA-A, R2 and R3 and went into his room. TMA-A was talking to R2. R1 came out of his room then walked to the stairway. R2 and R3 went to their respective rooms.R2's admission MDS dated [DATE] indicated R2 did not have cognitive impairment and had diagnoses of post-traumatic stress disorder (PTSD) anxiety, depression, bipolar disorder, and schizophrenia. R2 was independent with all ADLsReview of R2's clinical record identified that although she was admitted to the facility with a documented history of trauma, including abuse and associated maladaptive psychological responses, there was no indication that the facility had conducted a comprehensive trauma-informed care assessment.R2's care plan dated 8/4/25 indicated R2 was a vulnerable adult related to mental illness with a goal of R2 will be provided with a safe environment and minimize risk of abuse. This focus area indicated on 6/6/25 R2 was in a verbal altercation on the back smoking patio; R2 threw water in other resident's face during altercation. Remind resident to walk away from disagreements with others and go sit in a quiet place and deescalate and notify staff. R2's care plan did not address and/or include a focus for management and treatment of PTSD that identified target behaviors/triggers with individualized goals of care and interventions to prevent and/or manage re-traumatization.R3's quarterly MDS dated [DATE] indicated intact cognition with diagnoses including schizoaffective disorder, bipolar type, depression and anxiety. R3 was independent with all ADL's R3 demonstrated physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 4-6 days, Verbal behavioral symptoms directed towards others 1-3 days, reject evaluation or care 4-6 days. R3's care plan dated 7/30/25 indicated R3 had potential for abuse related to vulnerable adult status with goal of R3 will not be abused. Interventions included staff will follow facility vulnerable adult policy to keep resident safe from abuse.Review of R1's, R2's, and R3's records R1, R2 and R3's care plans were updated on 10/27/25. The focus was physically abusive behavior symptoms directed at others with interventions including house psychologist will visit with residents as needed, medications per doctor order, and resident was in physical altercation with peer. Encourage resident to stay away from peer. If altercation occurs staff to intervene and separate residents if able. Each care plan identified the peer the resident had the altercation with.During an interview on 10/29/25 at 9:38 a.m., R3 stated the afternoon of 10/25/25 he heard yelling outside his door. When he came out, he saw R2 with her back against the wall and R1 right in her face. R1 came at R3, grabbed his shirt and pushed him into another resident's room. During an interview on 10/28/25 at 2:09 p.m. R2 explained she had been abused most of her life by men and as a result I have PTSD. So, because of her experiences R2 exclaimed I deserve to feel safe! I will go after anyone who gets in my face!!!. R2 explained what happened when R1 kept pointing his fingers inches from her face (R2 demonstrated R1's proximity to her and the hand gestures he made) and made contact with her face. R2 pushed R1's hand out of her face and started to walk away, but R1 followed her and continued with the pointing and yelling. When R1 went after R3, R2 felt she needed to protect R3, so she ran after R1 to pull him off R3. R2 explained after the incident she looks out her window before leaving her room to see if R1's vehicle is parked outside because she doesn't want to take a chance of running into him. If she sees his car, her plan was to stay in her room. If she does run into him in the halls, she would try to ignore him. R2 stated she feels like a mouse in a cage with a snake. She is the mouse just waiting for the snake (R1) to up out and get her. During an interview on 10/28/25 at 2:51pm, TMA-A stated on 10/25/25 she heard shouting and saw R1 in the doorway to his room. R1 asked TMA-A to tell R2 to be quiet. TMA-A told R1 that R2 was speaking at a reasonable level and was allowed to have a conversation in the hallway. R1 went back into his room but came out again yelling and swearing. R1 was waving 4 fingers in R2's face and yelling at her. TMA-A asked R1 to stop and go back to his room, but he continued to shake his fingers near her face and yell. TMA-A did not ask R2 to go to her room or move away from the situation as R2's care plan directed. TMA-A stepped between R1 and R2 but R2 was still able to reach out and slap R1. TMA-A's explained R3's involvement as per the video. During the interactions TMA-A continued to try to de-escalate by asking the three residents to return to their rooms. The residents finally separated and went separate directions. I don't know what got into her [R2]. I've never seen her [R2] like that. TMA-A stated she has observed R2 yelling at other residents but had never seen R2 engage in a physical altercation. TMA-A did not know if R1 or R2 had any specific triggers for their behaviors. She would look in the care plan for any information related to the resident.A facility incident report for R1 dated 10/26/25 identified another physical altercation between R1 and R2 on 10/26/25. The report included- R2 continued to strike R1 while R2 shouted He hit me, He took my phone. R1's description of the incident included R2 came after him in the elevator and started punching him. R1 tried to hold R2's arms so she could not hurt him. A facility incident report for R2 dated 10/26/25 indicated a physical altercation occurred between R1 and R2. R2 continued to strike R1 while R2 shouted He hit me; He took my phone. R2's description of the incident included R1 put his hands on R2 and took her phone, so she had to defend herself.During review of the video of the 10/26/25 altercation, R2 was observed assisting a resident off the elevator. R1 was observed walking past R2 several times. No staff members were observed in the hallway. A resident was observed in the doorway of the elevator when R1 walked behind him and started pushing him into the elevator. R2 walked to the elevator, shoves R1 against the side of the elevator door then R1 punches R2 on the left side of her head. Staff ran into the elevator and separated R1 and R2. R2 swung her arms at R1. R1 walked out of the elevator and down the hall. Director of nursing (DON) confirmed R2 was struck in the head by R1.R2's general condition note dated 10/27/25 indicated R2 stated her face hurts where she was punched by R1 but there is no sign of swelling or bruising.R2's care plan was revised on 10/27/25 to include a behavior focus but did not include a focus for PTSD with associated triggers. The behavior care plan indicated R2 had physically abusive behavior symptoms directed toward others. Associated interventions included house psychologist will visit with resident as needed, medications her MD order, encourage R2 to stay away from R1, if altercation occurs staff to intervene and separate residents.R1 was not available for interview.During an interview on 10/28/2025 at 2:09 p.m. R2 stated on 10/26/25 she saw R1 shoving another resident's wheelchair into the elevator. When R2 went to intervene, R1 punched her in the head. R2 stated she shoved R1 to get to the other resident because she thought R1 was hurting the other resident. R2 had a bad headache after R1 had punched her in the side of her head on 10/26/25 and she was still experiencing some pain on the left side of her face.During an interview on 10/29/25 at 10:41 a.m., TMA-B stated if 2 residents were in a verbal altercation she would ask the agitated resident to go to their room or outside. After they have calmed down, she would talk to them to figure out what had upset them and try to fix it. Following the 2 incidents, R1 and R2 could not be in the same place without supervision. TMA-B would remind them not to be in the same room together without supervision.During an interview on 10/29/25 at 4:30 p.m., licensed practical nurse (LPN)-A stated behavior interventions were in each resident's care plan. R1 and R2 need to be kept separate. LPN-A would make sure she knew where R2 was because she would not want R1 and R2 to meet in the hallway. R2 listens to LPN-A so R2 would be easier to redirect to a different location.During an interview on 10/29/25 at 4:49 p.m., TMA-C stated if she heard a resident yelling at another resident, she would use the walkie-talkie to call for assistance then try to separate the residents by talking with them. She would ask the residents to go to their rooms or wherever they wanted to go that was away from each other.During an interview on 10/29/25 at 5:05 p.m., LPN-B stated if residents were fighting, staff need to try to separate them by trying to redirect them with words. R1 and R2 need to be kept separate from each other. R1 usually stays in his room and doesn't associate with the other residents. If R1 and R2 were in the same place, LPN-B would talk to them to keep them distracted. LPN-B thought triggers for R1 and R2 might be on the TAR but did not find any.On 10/30/25 at 1:45 p.m., director of nursing (DON) was interviewed and stated the facility needed to keep the residents safe by following the care plan. Staff should talk to the residents, ask them to go to their room or somewhere away from the situation and/or follow mental health clinic's recommendations. DON stated the root cause of the altercation was R1 escalated R2. DON indicated after the incidents R2 informed her she had PTSD which is why she reacted so fast to R1. Staff were educated on 10/27/25 to encourage the 3 residents in the altercation to give space to each other and stay away from each other. Staff were to immediately intervene and separate if signs of verbal or physical altercation occurred. Staff were to encourage all residents to keep distance from peers and remind residents not to touch others. If a physical altercation happens, call the police.The facility Vulnerable Adult Abuse Prevention Policy revised 10/1 indicated the facility does not tolerate any forms of physical abuse by anyone. Physical abuse includes but is not limited to hitting, slapping, pinching and kicking.

Based on interview and document review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was completed in a thorough and timely manner to reflect actual resident' status and ensure appropriate care-planning for 1 of 3 residents (R2) reviewed for MDS accuracy.Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified the RAI was used to help identify problems for a resident and address them using an individualized care plan. The manual outlined a section labeled, SECTION C: COGNITIVE PATTERNS, which directed the section would be used to help determine the resident's attention, orientation and ability to register or recall information adding, These items are crucial factors in many care-planning decisions; with provided methods and instructions to ensure accurate, thorough coding of the MDS. Further, the manual included another section labeled, SECTION D: MOOD, which outlined the section would be used to help address mood distress and social isolation adding, Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity, and again, the manual provided methods and instructions to ensure the comprehensive evaluation of these conditions.R2's annual MDS, dated [DATE], identified R2 admitted to the care center in 2022 and had several medical conditions including osteoporosis, anxiety disorder, alcohol dependence- in remission, and insomnia. The MDS section labeled, Section C - Cognitive Patterns, identified the interview should be attempted with R2, however, the remainder of the information was recorded as a dashed line (i.e., - ). In total, sections C0200 to C1310 were dashed and not completed. The MDS section labeled, Section D - Mood, identified the mood-related interview should be attempted with R2; however, the remainder of the information was recorded also with a dashed line. In total, sections D0150 to D0600 were dashed and not completed. The MDS section labeled, Section J - Health Condition, identified a pain assessment interview with R2 should be attempted; however, again, the interview and staff assessment sections were dashed and not completed. In total, sections J0300 to J0850 were dashed and not completed. The MDS section labeled, Section V - Care Area Assessment (CAA) Summary, identified which CAA(s) triggered from the completed MDS data. This outlined the Cognitive Loss/Dementia CAA, the Mood State CAA, and the Pain CAA all did not trigger on the completed MDS. The MDS was signed as completed by the director of nursing (DON) on 10/10/25. R2's medical record was reviewed and lacked evidence these sections had any corresponding assessments completed during the assessment reference date (ARD) to demonstrate the respective areas had been evaluated (e.g. BIMS, PHQ-9). Further, R2's care plan, printed 10/23/25, identified all R2's current or potential problems with corresponding interventions to help reduce their impact on him. The care plan identified R2 had a significant history of behavioral issues including verbal and physical aggression towards peers and staff members. Further, the plan outlined R2 had, . a potential/actual alteration in pain ., which was initiated in 10/2022; however, the care plan interventions had not been revised since 2/2024. On 10/23/25 at 11:53 a.m., the DON was interviewed and verified they had reviewed R2's medical record and MDS. DON stated they had signed the MDS as completed, however, did not review it prior to ensure it was done with all sections having the correct data adding, I wasn't looking at them. DON stated they had just that day (10/23/25) started a PIP (Performance Improvement Plan) for the MDS' to ensure they were being completed. DON verified the corresponding assessments, such as the BIMS and PHQ-9, should be completed within the ARD so they can be recorded on the MDS. DON stated the campus had just recently hired a new MDS coordinator and felt the situation would improve shortly with them on the team. DON acknowledged the importance of completing the MDS thoroughly and not just dashing areas adding such was important, so staff were aware of changing resident' conditions. Further, DON verified R2 was at risk for pain due to an ankle wound and expressed that entered data which was not correct or having items dashed could impact what, if any, CAAs triggered to be completed adding aloud, Correct, 100 percent [%]. A facility provided Interdepartmental MDS Review policy, undated, identified the facility would ensure the MDS was completed using, . current, accurate documentation and assessments specific to that resident. The policy outlined multiple assessments to be completed by various departments which were to be used to complete the MDS. The social services department was listed as responsible for, Documentation concerning Cognition, Behavior, Mood and adjustment with outcome.

Based on observation, intervention and document review the facility failed to ensure a safe environment and prevent fire hazards for 2 of 2 residents (R5 and R6) when residents were found to be smoking in resident rooms with staff awareness. This resulted in an immediate jeopardy (IJ) for R5 and R6 and could lead to serious harm for all residents, staff, and visitors at the facility. The IJ began on [DATE] at. 4:54 p.m., when a strong smell of cigarette smoke was noted on the third floor near the elevator and trained medication aide (TMA)-A and TMA-B stated the odor was coming from room [ROOM NUMBER] (R6's room). R5 was observed in room [ROOM NUMBER] and was asked to leave by staff. During interview, R5 stated he was in the room and had just been smoking. The nightstand next to bed two was observed to be covered in cigarette ashes and there were multiple cigarettes burns on the floor. The window was also wide open in the room. TMA-A indicated staff often smelled smoke when R5 was in the room. Interview with R6 also revealed he smoked in his room, kept an ashtray in his nightstand and flushed the cigarette butts down the toilet when the ashtray got full. The director of Nursing (DON) and quality assurance nurse (QA) were notified of the IJ at 3:45 p.m. on [DATE]. The IJ was removed at 4:25 p.m. on [DATE], but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The National Fire Protection Association (NFPA) regulations regarding smoking inside healthcare facilities are designed to ensure the safety of both patients and staff. Here are the key points:Smoking Regulations - the BasicsAt a minimum, smoking regulations need to address the following points:1. Smoking must be prohibited in any location where oxygen, flammable or combustible liquids or gases, or combustible materials are stored or used. Please note that the Authority Having Jurisdiction (AHJ) may designate other hazardous locations where smoking must be prohibited.-No one using oxygen should be allowed to smoke. NFPA 99(12), Sec. 11.5.1.1.1 requires that smoking materials (e.g. matches, cigarettes, lighters, lighter fluid, tobacco in any form) be removed from patients receiving respiratory therapy.-Smokers must remain at least 5 feet away from oxygen in use [see also: NFPA 99(12), Sec. 11.5.2.3.1].-NFPA 99(12), Sec. 11.5.1.1.2 prohibits all sources of open flame in the area of administration. Area of administration is defined in NFPA 99(12), Sec. 3.3.13 as follows: Any point within a room within 15 ft of oxygen equipment or an enclosure containing or intended to contain an oxygen-enriched atmosphere.2. Smoking by residents/patients deemed unsafe to smoke independently must be prohibited, unless thosepersons are under direct supervision (a number of Minnesota nursing home residents have died or been very seriously injured over the years as a result of fires related to misuse of smoking materials). -Your policy should require an assessment of persons allowed to smoke to include the person's ability to light a cigarette, smoke it safely, handle the ashes and put the cigarette out safely. It is also important that the policy include provisions for proper and safe storage of smoking materials for those persons deemed unsafe to smoke independently without staff supervision.-Where nursing home residents are allowed to smoke, your policy should include procedures for extinguishing clothing fires. You will want to make sure that, whatever procedure is chosen for your facility - e.g. Stop, Drop & Roll; fire blanket; or pressurized water or water mist type portable fire extinguishers(dry powder type extinguishers are not recommended as the powder can be easily inhaled and potentially cause immediate breathing and/or long term lung problems), the proper equipment, if any, is immediately available in smoking area(s) and staff are properly trained on an on-going basis on how to extinguish clothing fires.3. A suitable number of noncombustible ashtrays must be provided in areas where smoking is allowed. Note: These ashtrays must be of a safe design, which has been interpreted to mean ashtrays designed so that cigarettes cannot be placed on the outer edge of the ashtray (as it burns down, a cigarette placed on the outer edge of an ashtray can fall out of the ashtray, potentially falling on something combustible and resulting in a fire).4. Smoking areas must be provided with metal containers equipped with self-closing covers for the disposal of cigarette butts and ashes. These containers should not have combustible (e.g. plastic or paper) liners in them. R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 had non-traumatic brain dysfunction, and was alert and oriented. R5's Care Plan (CP) dated [DATE], indicated R5 had been assessed as a safe smoker in designated areas, was to smoke only in designated areas and had a history of smoking in unauthorized areas of the facility. Staff were instructed to direct R5 to his own floor/room when he was found in a room that was not his and educate R5 on smoking policies and expectations. R5 had history of smoking in other resident rooms and refused to allow facility to store smoking materials. R5's Smoking assessment dated [DATE], indicated R5 was safe to smoke in designated areas, but had history of smoking in non-designated areas. Facility was to store smoking materials; however, resident refused and acquired smoking materials independently. Staff was to give reminders. R6's annual MDS dated [DATE], indicated R6 had non-traumatic brain dysfunction, short term and long-term memory problems and had disorganized thinking. R6's CP dated [DATE], indicated R6 had a history of being non-compliant with smoking plan and was to receive one cigarette per hour from the first-floor nurses' station due to smoking in the stairwell. R6 was given notice further violation could result in further smoking restrictions. R6's Smoking assessment dated [DATE], indicated he was assessed to be a safe smoker, had history of smoking in non-designated areas and facility was to hold smoking materials, however resident refused. Staff were to educate R6 on smoking policy after caught smoking in non-designated areas. During observation and interview on [DATE] at 4:54 p.m., a strong odor of cigarette smoke was noted on the third floor by the elevator. TMA-A and TMA-B stated the odor was coming from room [ROOM NUMBER]. Upon entering room [ROOM NUMBER], R5 was sitting on bed two, when TMA-A stated that this was not his room and told R5 he needed to leave. During observation and interview on [DATE] at. 5:00 p.m., R5 stated he was in room [ROOM NUMBER] and had just been smoking. The nightstand next to bed two was covered in cigarette ashes and there were multiple cigarettes burns on the floor; the window was also wide open. R6, who lived in 301, was not observed to be in the room at the time. TMA-A stated R5 was always in that room, staff must constantly direct him to leave that room and staff constantly smelled smoke when he is was in there. TMA-A also indicated there were always ashes on the nightstand and on the floor. A follow up interview with TMA-A revealed the nurses document when residents are smoking but she had forgotten to tell them, so it had not been documented. During interview on [DATE] at 5:15 p.m., R6 was walking back to his room and stated R5 spent time in his room. R6 stated he also smoked in his room when it was cold outside or when it was raining out and kept an ashtray in the top drawer of his nightstand, which was locked. R6 further stated when the ashtray was full, he flushed the cigarette butts down the toilet. During observation and interview on [DATE] at 11:15 a.m., TMA-C, who was a new staff, stated she smelt heavy smoke in room [ROOM NUMBER], had seen R5 in that room yesterday, lying on bed two and thought it was his room. While entering room [ROOM NUMBER] with TMA-C, she confirmed cigarette butts were on the nightstand next to bed two and said it also looked like cigarettes were being put out on the floor. During interview on [DATE], at 11:30 a.m., registered nurse (RN)-A stated R5 constantly goes into room [ROOM NUMBER] to smoke and we must tell him to leave the room. RN-A stated it is in his treatment sheet to document if we find him smoking in undesignated smoking areas and we are to redirect him, but it never improves, and we keep reporting this. RN-A stated the facility used to have a smoking program and the residents would have to come to first floor and get their cigarettes every 30 minutes or hour from the nurse or receptionist, but the facility decided to stop this because the residents had several violent behaviors with the staff. During observation and interview on [DATE] at 11:47 a.m., the quality assurance nurse (QA) stated the facility had a smoking program they stopped about a year ago due to resident behaviors, and now most of the residents have their own cigarettes and lighters including R5 and R6. The QA nurse stated she was not aware of any residents who were currently smoking in their rooms, but did state R5 had limited funds and had been known to pick up cigarette butts in the smoking patio area and smoke them. Upon entering room [ROOM NUMBER], QA nurse stated she could smell smoke in the room and confirmed there were cigarette butts on the nightstand and the floor. QA stated those are probably cigarette butts he had been taking from the smoking patio area. In addition, the QA nurse stated they removed the smoking program, due to the residents having behaviors and demanding cigarettes and a residents attacked the receptionist. The previous DON and Administrator stopped the program and allowed the residents to have their own cigarettes and lighters for the safety of the staff and that it was too much to deal with. During observation and interview on [DATE] at 1:00 p.m., maintenance director (MD) stated housekeeping noticed cigarette butts and ashes in room [ROOM NUMBER] every day when they came in the room around 2:30 p.m. to clean. There are burns all over the floor from what he expects are from cigarettes being put out on the floor, and in addition, there were burns on the nightstand next to bed two. MD indicated he had redirected R5 out of room [ROOM NUMBER]often and stated, now that they have a new person in the administrator's office, he was hoping things would get better and more attention would be paid to the situation. During interview on [DATE] at 5:05 p.m., TMA-A stated she does not have access to document on the treatment sheets and forgot to inform the nurse working on the evening shift of [DATE], that R5 was observed in room [ROOM NUMBER] and there was an odor of smoke in the room. TMA-A stated the nurse works on the first floor and only comes up to the third floor to complete treatments and insulins, and she often forgot to report this to the nurse. Review of R5's treatment record for the month of [DATE] indicated no incident of R5 smoking in non-designated areas from [DATE]st through [DATE]st, 2025. Facility Smoking Policy and Contract undated, indicated It is the policy of Bywood East Health Care to provide all residents with a safe environment in which to live. Smoking is a privilege and not a right. The safety of our facility supersedes the individual residents' right to smoke unsafely. At any time, a staff member observes and/or has reason to believe that a resident is/was smoking anywhere inside the facility, smoking materials will be extinguished immediately. The incident will also be reported to Social Services, Charge Nurse/Nurse Supervisor, and/or Administrator. All residents who smoke will be given this policy regarding the responsibility of the smoker to follow the facility policies regarding smoking. Should a resident be in jeopardy because of the irresponsible smoking behavior or put others in jeopardy because of such behavior, Bywood East administration will take appropriate action which may include loss of smoking privileges up to discharge from the facility. The IJ that was issued on [DATE] at 3:45 p.m., was removed on [DATE] at 4:25 p.m. when it was verified, the facility had implemented the following: -Revised policies and procedures related to smoking to ensure smoking is prohibited inside the facility and developed an all-systems approach for enforcing the policy. (including staff immediately reporting concerns related to resident smoking). -Ensured all resident's smoking assessments are accurate and revised care plans with new identified interventions and educated all employees on policy and procedures and revised resident care plans prior to next shift worked.

Based on observation, interview and document review the facility failed to ensure residents were protected from resident-to-resident abuse for 2 of 2 residents (R3 and R4) who were in a verbal and physical altercation which resulted a thoracic (T9) fracture with facial injuries for R4 and a swollen, bruised hand for R3. This resulted in an Immediate Jeopardy (IJ) for both R3 and R4.The IJ began on 8/14/25 at 10:45 p.m., when R3 and R4 had a verbal altercation, were separated by staff with one verbal redirection towards R3, but no other behavioral interventions were implemented despite a significant history of physical altercations for both residents, leading to R3 seeking R4 out again, re-engaging in the verbal altercation before starting a physical altercation which resulted in R4 needing emergency medical treatment for facial lacerations and a T9 fracture. The director of Nursing (DON) and quality assurance nurse (QA) were notified of the IJ at 3:45 p.m. on 8/22/25. The IJ was removed at 4:25 p.m. on 8/26/25, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had bipolar disorder, alcohol dependence, post-traumatic stress disorder (PTSD), was cognitively intact, and had physical and verbal behaviors towards others. The MDS indicated R3 was independent in activities in daily living (ADL)'s. R3's Care Plan (CP) revised 8/20/25, indicated a history of verbal and physical altercations (8 physical and 2 verbal since) since 9/2024 with care planning interventions focusing on staff encouragement and redirection.-9/14/24 verbal altercation with another resident. Encourage to de-escalate.-9/28/24 resident to resident altercation. Encourage R3 to not stand in front of door in lounge and let other residents pass with adequate space.-9/29/24 resident to resident altercation. Encourage R3 to walk away from potential altercations and inform staff member.-9/30/24 resident to resident altercation. Staff to supervise in smoking area and resident lounge daily to reduce the risk of altercations.-10/11/24 verbal altercation, staff directed to remove himself from altercations before they escalate.-12/11/24 resident to resident physical altercation, arguing over a lost item and incident escalated. Staff directed to inform nurse of missing items so situation can be resolved appropriately.-5/1/25 resident to resident physical altercation, R3 wanted to change the TV channel in the resident lounge. Staff to remind R3 the TV is in a shared space for all residents.-5/08/25 resident to resident altercation over TV in lounge. Staff to remind R3 the remote is to be shared with other residents.-5/16/25 resident to resident altercation, R3 approached another resident for payment for a shirt. Staff to encourage R3 to inform facility staff of any missing items and not to approach other residents.-8/14/25 resident to resident altercation, always identify and remain aware of location of resident, keep R3 arm's length away from R4. R4's quarterly MDS dated [DATE], indicated R4 had alcohol dependence and adjustment disorder with depressed mood. The MDS indicated R4 was cognitively intact with disorganized thinking, had no behaviors and was independent with ADLs. R4's CP indicated a history of verbal and physical altercations (4 physical, 2 verbal) since 6/2024 with care plan interventions focusing on staff encouragement and redirection for R4. -6/28/24 resident to resident verbal altercation. Staff directed to encourage R4 to notify staff member when witnessed other residents in an altercation and let staff members intervene with incident. -7/24/24 resident to resident verbal altercation in the dining room, throwing food at another resident. Staff to remind R4 it was not appropriate to throw food or yell at other residents, encourage to remove himself from other altercations. -12/08/24-resident to resident physical altercation. Staff were to encourage resident to report altercations to staff and move away before they escalate.-12/11/24 resident to resident physical altercation, arguing over a lost item. Staff to encourage R4 to inform nurse of missing items so situation can be resolved appropriately.-3/16/25 resident to resident altercation, R4 pushed another resident from his chair. Staff to encourage R4 to notify staff member when he witnessed other residents in an altercation and let staff members intervene. -7/08/25 resident to resident altercation, R4 kicked the back of another resident's wheelchair. Staff to encourage R4 to notify staff if another resident was in his wheelchair path so staff can assist the other resident to move out. R4's CP further indicated Associated Clinic of Psychology (ACP) started working with R4 on 2/2024, assisting with insomnia and behavioral elements to his care. CP interventions listed from ACP included, encourage R4 to choose his own battles to avoid altercations, listen to R4's concerns to assist in deescalating, validate his emotions in relationship to challenging peer interactions, encourage R4 to move away and breath, read a book, or talk with others, accept what he cannot control and direct to watch television (TV).A Facility Reported Incident dated 8/14/25 at 10:45 p.m., indicated R3 and R4 engaged in a verbal altercation on the smoking patio. Staff were able to separate them and R3 went back into the building to his room on the third floor. Several minutes later R3 returned to the smoking patio where R4 was seen on the ground hitting R3 in the face. R4 was sent to the hospital for his injuries and returned the next day. The Investigation Report dated 8/20/25, indicated the Care Plan was updated to include intervention to keep R3 and R4 in eye's view and to intervene if they are within arm's length. R4 was diagnosed with a fracture to his T9, and R3 refused to speak with writer. In addition, the investigation indicated the police were involved and did not take R3 in, and all staff were educated on what to do if a fight would occur between R3 and R4. In addition, the smoking patio will be locked at 10:00 p.m. instead of being open 24hours/7days a week. The Facility Report Incident lacked evidence on how staff would maintain an eyes view of either resident, what measures staff would take to ensure the residents were an arm's length away from each other and failed to identify the staff's failure to follow the care plan interventions during the initial incident, de-escalate the situation or addressed training to prevent an altercation between residents in the future. During interview on 8/21/25 at 4:09 p.m., R1 stated he observed the fight between R3 and R4 and now the smoking patio out back was locked at 10:00 p.m. R1 stated that has not changed anything because now everyone just smoked out front of the building after 10:00 p.m. During interview on 8/25/25 at 3:11 p.m., the facility security guard (SG) stated when he was informed R3 and R4 were physically fighting outside in the smoking patio area and with their history he did not want to get involved so he immediately called 911 to intervene for his safety and the staff safety. The SG further stated he had not been trained to deal with the resident specific behaviors. During observation and interview on 8/20/25 at 2:27 p.m , R3 stated he was out back in the smoking area around 10:30 p.m. when R4 started arguing with him. R3 stated he was sitting by the door where you enter from the back lobby area, and another resident was trying to go in when R4 was right behind the other resident who was in a wheelchair, R4 was drunk and started to yell at him, hurry up you mother fucker or I am going to piss on you. R3 told him, No you are not and R4's response was, Fuck you and I will piss on you too and your sister too. R3's sister recently hung herself and that, hit a spot on me, and then R4 came yelling at him and called him a fat ass. R3 stated, why would he care what I looked like. R3 indicated the nurse came out and he agreed to go back to his room on the third floor. R3 then stated when R4 gets drunk, he gets angry so R3 went back outside and that is when R4 started to call him a pussy and saying things like, you want to fight. R3 indicated the two residents had a history and that R4 went on for about five more minutes before he stood up from his wheelchair stating, I just lost it, thinking about him calling me a fat ass, I hate that word and speaking of my sister. it's like my eyes changed, he disrespected me. R3 indicated he was a championship wrestler in high school and just took R4 to the ground and started to wail him in the face until he said he had enough. At that point, R3 got up, went inside and the facility called the police. R3 stated he spoke to the police, and they were cool with him. During observation R3's right hand was swollen and bruised despite the incident having occurred six days prior.During observation and interview on 8/21/25 at 5:11 p.m., R4 stated during the incident with R3, he was mouthing off at R3, R4 went to get out of his chair when R3 started to attack him and beat the piss out of him. R4 stated he couldn't exactly remember what was said but he did remember calling R3 a fat sun of a bitch and they were arguing. R4 stated he did not start anything during the fight and did not know anything about his sister's death. Multiple scratches were observed on R4's face and no bruising. R4 was observed to be in a wheelchair and was able to wheel independently. During interview on 8/21/25 at 5:11 p.m., licensed practical nurse (LPN)-A stated he worked the first floor on the evening of 8/14/25, when R3 and R4 had a verbal and physical altercation. LPN-A stated he went out to the smoking patio when he heard R3 and R4 swearing at each other but could not hear what they were saying. LPN-A stated he immediately separated them and had R3 go back to his room on the third floor. LPN-A indicated he did not smell alcohol on either of the residents. LPN-A stated he informed the security guard who was working at the front desk, by the front entrance, that he had directed R3 to his room on the third floor, so he was aware. Shortly after, LPN-A heard another resident yelling R3 and R4 were fighting outside on the patio area. LPN-A ran out to the patio and observed R4 on the ground and instructed the security guard to immediately called 911. LPN-A indicated after the first verbal altercation between R3 and R4 he put R3 on 15-minute checks but was unable to recall any other care planned interventions for the residents. After the physical altercation, R3 was sent to the hospital and was diagnosed with a T9 fracture. An After Visit Emergency Department Summary indicated R4 arrived on 8/14/25 at 11:53 p.m. and seen for assault. Diagnoses were facial laceration, closed head injury, laceration of right hand and closed fracture of ninth thoracic vertebrae. The report further indicated X-rays and cat scans (CT scans) showed no broken bones or bleeding in the brain. A fracture was noted of the thoracic spine at the T9 level, and the neurosurgery team evaluated and felt it was safe for return home with the fracture with outpatient in six weeks to follow up with this finding. The report indicated R4 was given Tylenol, ibuprofen, and oxycodone (narcotic) for pain while in the Emergency Department (ED). The ED report indicated R4 was discharged on 8/15/25 at 9:43 a.m., with orders to continue to take ibuprofen 600 milligrams (mg) by mouth every 6 hours as needed for pain.During interview on 8/21/25 at 4:09 p.m., R1 stated he was outside when R3 and R4 were arguing. R1 stated he observed R3 dive at R4 and felt it was all R3's fault. R1 stated the staff sent R3 to his room after the argument and he came right back out to the smoking patio and began fighting with R4. R1 stated R3 put R4 on the ground and began hitting him, and he heard R4 tell him to stop and that was when the staff came out and stopped the fight. During interview on 8/22/25 at 12:13 p.m., interim director of nursing (DON) stated the security guard had not been trained in specific interventions for the residents' behaviors. The DON stated they have been looking for alternative placement for R3, although they have had difficulty with other facilities accepting him due to his behaviors. Vulnerable Adult Abuse Prevention Policy revised 2/22, indicated the facility shall establish and enforce an on-going abuse prevention plan which includes policies and procedures to design and maintain the physical plan that promotes the resident well-being and safety, on-going updating and review of the resident care policies, personnel policies, staffing ratio and pattern policies, and volunteer policy to minimize the risk of abuse. In addition, the policy indicated during the pre-admission process the nurse and social worker screens for a known history of potentially dangerous behavior patterns or behavior that tends to disrupt or annoy others such as constant verbalizations, taking item's that don't belong to them etc. In cases where these concerns are in this setting is appropriate. If so, then care planning and interdisciplinary including developing individual abuse prevention care plan. The plan includes measures to be taking to minimize risk that the resident might reasonably be expected to pose to others or that another might pose to them. The IJ that was issued on 8/22/25 at 3:45 p.m., was removed on 8/26/25 at 4:25 p.m. when it was verified the facility had implemented the following:-The facility reviewed and revised current policies and procedures related to resident-to-resident altercations.-R3 and R4 care plans were revised to include assessed behavioral interventions to reduce resident to resident altercations based on the comprehensive assessment.-Staff educated on policy and procedures.-Staff educated on R3 and R4's updated care plan interventions.

Based on interview and document review the facility failed to thoroughly investigate a resident-to-resident abuse allegation for 2 of 2 residents (R3 and R4) and a resident-to-resident sexual assault allegation for 2 of 2 residents (R1, R2) to determine incident details, interview all parties involved, appropriately assess and identify interventions to reduce likelihood of future abuse. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had bipolar disorder, alcohol dependance, post-traumatic stress disorder (PTSD) and was cognitively intact. R4's quarterly MDS dated [DATE], indicated R4 was cognitively intact with disorganized thinking and had no behaviors. A Facility Reported Incident dated 8/14/25 at 10:45 p.m., indicated R3 and R4 engaged in a verbal altercation on the smoking patio. Staff were able to separate them and R3 went back into the building to his room on the third floor. Several minutes later R3 returned to the smoking patio and R4 was seen on the ground where R3 was hitting him in the face. R4 was sent to the hospital for his injuries and returned the next day. The Investigation Report dated 8/20/25, indicated the Care Plan was updated to include intervention to keep R3 and R4 in eye's view and to intervene if they are within arm's length. R4 was diagnosed with a fracture to his T9, and R3 refused to speak with writer. In addition, the investigation indicated the police were involved and did not take R3, and all staff were educated on what to do if a fight would occur between R3 and R4. In addition, the smoking patio will be locked at 10:00 p.m. instead of being open 24hours/7days a week. During interview on 8/22/25 at 12:13 p.m., interim director of nursing (DON) stated staff attempted to interview R3 once and he refused and staff should have attempted to interview him again to find out more information for their investigation, R4 was interviewed. The Nursing Home Incident Report dated 8/20/25 lacked evidence the facility interviewed other resident witnesses, staff or the security guard during the investigation process to gain an understanding of what was observed, heard and what action staff took during the incident. R2's admission minimum data set (MDS) dated [DATE], indicated R2 was cognitive impaired. R1's admission MDS dated [DATE], indicated R1 was cognitively intact. A Facility Reported Incident (FRI) dated 8/14/25 at 1:40 p.m., indicated on 8/13/25 at 7:31 p.m., writer received a call that R2 and R1 were found to be engaging in a sexual act. Writer was told R1 offered R2 a cigarette in exchange for sex. This morning at approximately 11:30 a.m. writer went to go speak with resident (R2) and she stated nothing happed and she was okay and had no memory of the incident, she was her normal routine, had a BIMs of 5 (cognitively impaired), with no complaints of pain noted. The facility's investigation lacked evidence of interviews with staff involved in the incident, including details such as R2 smoking an actual cigarette when found and her demeanor. Additionally, the facility failed to interview R2's family to get historical significance to best determine possible consent and to determine appropriate interventions to reduce the likelihood R2 would seek out further trades for cigarettes, such as increasing how many cigarettes she gets or how often. During interview on 8/20/25 at 12:03 p.m., director of nursing (DON) stated when she received the call on 8/13/25, there was a mix up and they thought it was a different resident with the same name and the resident they thought was with R1 was alert and orientated and was able to consent. The DON stated when she went to interview the wrong resident at 8:00 a.m. she was sleeping and when she did talk to her at 11:30 a.m. she realized it was the incorrect resident. The DON stated once she realized it was R2 who was cognitively impaired she immediate informed the social worker and the staff. The DON further stated she also called the police and informed R2's case manager and responsible party. In a follow up interview on 8/20/25 at 12:20 p.m., the DON stated R1 was placed on 15-minute checks on 8/13/25, after the incident and when she found out it was R2, R1 was placed on a 1:1 for the safety of the other residents in the facility. During interview on 8/20/25 at 3:08 p.m. R2 stated she has been here a couple of months and stated she could not stand it here. R2 stated she did not recall having sex with anyone, but did recall be sent to the hospital because the facility though she was raped and does not believe she was raped. During interview on 8/20/25 at 4:19 p.m., R1 stated he was outside on the smoking patio next to R2 when she turned around and said do you want to f**k me. R1 described how R2 continued to persuade him and eventually they went to his room where he performed oral sex on her. R1 stated he felt like he was sexually harassed due to R2 wanting to have sex with him and that he does not see her anymore in the facility but knows she still lives there. He went on to say, now he has staff that sit with him all of the time and it has been pissing him off. During interview on 8/20/25 at 7:45 p.m., licensed practical nurse (LPN)-D stated she went into R1's room to give him his medication when he observed him naked from the waist down and R2 was completely naked lying in his bed. LPN-D stated R2 was observed to be relaxed and smoking a cigarette while he was sitting in-between her knees. LPN-D stated at first, she was so shocked she had to walk out of the room, and then return due to not expecting what she had seen. LPN-D then stated she opened the door and told R1, what are you doing, this is wrong and he was already standing next to the bed covering himself. He said in a slow voice and softly something about sex. LPN-D stated she immediately contacted the other nurse working and had that nurse come back to the room and by then, they were both dressed. LP-D stated R2 did not seem distressed, and stated she had not been trained for something like that so she called the on-call nurse. Then they were confused on what resident I was reporting about, which was strange to me since I told them it was the new resident who asked for cigarettes all the time and the on-call staff could have read my progress notes in the computer. LPN-D stated she immediately put R2 on 15-minute checks to make sure nothing more would happen. During interview on 8/22/25 at 10:00 a.m., DON further stated R2's family was not interviewed and probably should have been. Facilities Vulnerable Adult Abuse Prevention Policy revised 2/22, indicated upon receiving a report of an incident, the resident will be assessed and an investigation initiated. The Administrator, the director of Nursing, the Director of Social Services, or designees, shall conduct all VA investigations immediately. The investigation shall include interviews of the involved resident, family member (s) if appropriate and any others who may have pertinent information about the event.

Based on interview and document review, the facility failed to immediately report an allegation of sexual abuse to the state agency (SA) for 1 of 1 resident (R1, R2) when R2 was found engaged in a sexual act with R1 without staff's knowledge of R2's consent. Findings include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was cognitive impaired. R2's Care Plan dated 8/19/25, indicated R2 had potential for abuse, neglect and/or exploitation related to vulnerable adult status. R1's admission MDS dated [DATE], indicated R1 was cognitively intact. A Facility Reported Incident (FRI) dated 8/14/25 at 1:40 p.m., indicated on 8/13/25 at 7:31 p.m., writer received a call that R2 and R1 were found to be engaging in a sexual act. Writer was told R1 offered R2 a cigarette in exchange for sex. This morning at approximately 11:30 a.m. writer went to go speak with resident (R2) and she stated nothing happed and she was okay and had no memory of the incident, she was her normal routine, had a BIMs of 5 (cognitively impaired), with no complaints of pain noted. During interview on 8/20/25 at 12:03 p.m., director of nursing (DON) stated when she received the call on 8/13/25, there was a mix up and they thought it was a different resident with the same name and the resident they thought was with R1 was alert and orientated and was able to consent. The DON stated when she went to interview the wrong resident at 8:00 a.m. she was sleeping and when she did talk to her at 11:30 a.m. she realized it was the incorrect resident. The DON stated once she realized it was R2 who was cognitively impaired she immediate informed the social worker and the staff. The DON further stated she also called the police and informed R2's case manager and responsible party. The DON stated she was aware the report made to the SA was late and should have been reported sooner. During interview on 8/22/25 at 10:00 a.m., DON stated the incident should have been immediately reported to the SA, and due to the confusion of which resident it was, the report was filed the next day. In addition, the DON stated she had only been at the facility for less than a week and she was just getting to know the residents at the facility. Facilities Vulnerable Adult Abuse Prevention Policy revised 2/22, indicated a mandated reporter who has reason to believe that a vulnerable adult is being or has been mistreated, or how has knowledge that a VA has sustained a physical injury that is not reasonably explained shall immediately report that information internally to the Administrator, Director of Nursing, Director of Social Services or designee immediately.

Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 1 residents (R1) who was assessed to be unsafe in the community and at risk of elopement. This failure resulted in an immediate jeopardy (IJ) when on R1 left the facility without supervision for appointments, got lost, and was gone for over 5 hours before staff were aware. R1 was found 7 hours later by family member (FM)-A. The IJ began on 9/18/24, at 1:15 p.m. when R1 was sent to his 2:00 p.m. appointment without an escort and subsequently missed a 3:00 p.m. appointment when he became lost. R1 was later found by his family member (FM)-A outside of a highly trafficked area hospital at 10:00 p.m. director of nursing (DON) and administrator were notified of the IJ on 10/10/24, at 12:52 p.m. The facility had implemented corrective action prior to the start of the survey, therefore the deficiency is being issued at past-non-compliance. Findings include: In a Wandering and Elopement Risk Assessment, dated 9/17/24, R1 was identified to be at risk for elopement, resident is not safe in the community and cannot leave the facility without an escort. R1 has a recent diagnosis of traumatic brain injury, diabetes, schizoaffective disorder (serious mental disorder), seizure disorder, psychoactive (illicit drug) substance abuse, and opioid abuse. R1 ambulated independently and scored a 99 on his brief interview for mental status (BIM)s, dated 9/17/24, indicating unable to complete. R1's Significant Change Minimum Data Set (MDS) dated [DATE], indicated R1 had a non-traumatic brain dysfunction, diabetes, asthma, anxiety, and Schizophrenia. R1's MDS further indicated independent with Activities of Daily Living, ambulate independently, and had acute on-set mental status change with disorganized thinking. R1's Care Plan, dated 9/18/24, indicated R1 had cognitive impairment, was not safe in the community, and could not leave the facility without an escort. R1 was at risk for falls due to impaired cognition, received psychotropic medication, and had a history of substance abuse. R1's progress notes identified on: 1) 9/18/24 at 7:30 p.m.: The resident did not return from his appointments. The police, DON, administrator, and social services notified of the missing person. The staff also searched the whole facility inside per policy and did not find the resident. Missing person report was filed. 3) 9/18/24 at 9:21 p.m.: Resident left for appointment at 1:15 p.m. and has not returned. Missing person's report filled with police. No case number given. 4) 9/18/24 at 10:30 p.m.: The Guardian called writer that the resident was found in downtown Minneapolis and the police were called and said to call them back when he gets to the facility. During an interview on 10/8/24, at 5:55 p.m. family member (FM)-A stated the facility did not call to notify her R1 was missing on 9/18/24 until 9:30 p.m A family member drove to downtown Minneapolis and found R1 at 10:00 p.m. on Chicago Avenue (A highly trafficked [NAME] area). R1 had been walking around since 3:00 p.m. R1 was confused, saying he was looking for his room and reported R1 was upset and thirsty. During an interview on 10/9/24, at 11:00 a.m. FM-A stated R1's mental state is like a child FM-A and had concern for his history of substance abuse. FM-A felt considering the area [R1] was lost in, he had possible access to substances [illicit drugs]. During an interview on 10/09/24 at, 11:30 a.m. the facility social worker (SW) stated R1's wandering assessment completed 9/17/24, indicated it was not safe for him to be in the community alone and needed an escort. On 9/18/24, R1 went on an appointment with the transportation company without an escort. SW stated she verbally informed the Medical Records staff (MR) that R1 needed an escort, but indicated she might not have heard? and that MR staff was no longer employed at facility. During an interview with MR on 10/09/24, at 2:01 p.m. stated she asked the SW a week prior to R1's appointment and did not receive a clear answer if R1 needed an escort for his appointment on 9/18/24. MR-A stated she was not made aware R1 required an escort for his appointment and allowed R1 to attend his appointments on 9/18/24 unsupervised. He was to attend a 2:00 p.m. physical therapy and 3:00 p.m. occupational therapy appointment at the hospital. During interview on 10/09/24, at 2:45 p.m. director of nursing (DON) stated he received a call from the facility on 9/18/24 after 8:00 p.m. and was notified that R1 was not at the facility. He instructed staff to search the building for R1 and then to call the police. The DON reported he went to look for R1 at the hospital and was unable to locate him. During interview on 10/09/24, at 3:00 p.m. trained medical assistant (TMA)-B, stated she works at the front desk and on 9/18/24, was also working as a TMA. During her shift at 7:30 p.m., she noticed she had not seen R1, and immediately notified management. The SW notified the police. During interview on 10/14/24, at 11:42 a.m. licensed practical nurse (LPN)-B stated she is the quality assurance nurse at the facility. She indicated that although R1 was to receive medications at 5:00 p.m. on 9/18/24, staff did not realize he was missing until 7:30 p.m LPN-B stated staff thought R1 was still at an appointment and did not realize his return time. The staff did sign out and provide R1 his medications when he returned around 10:30 p.m. since it was just a vitamin and Senna for his bowels. During interview on 10/14/24, at 1:00 p.m. the facility administrator stated the staff should not have allowed R1 to attend his appointment without an escort, and they now have systems in place to prevent this from happening again. During interview on 10/17/24, at 11:30 a.m. the facility medical director stated he was unaware of the incident of R1. The medical director further stated after R1's traumatic brain injury (TBI) from his fall in August of 2024, he should not have been sent to appointments alone. The facility Wandering/Elopement Prevention Plan Policy and Procedure Revised 02/2024, indicated It is the policy of the facility to provide a safe environment for all residents. 1. Assess the resident's needs prior to and after admission to determine his/her ability to leave the facility safely. A wander assessment will be completed on admission day and quarterly by social services. 2. Discuss the facility policies on admission with the resident and/or responsible parties regarding wandering prevention program. 3 If assessment indicates wandering risk to be appropriate, update orders, elopement/wandering list (located at front reception desk) and care plan. The past non-compliance immediate jeopardy began on 9/18/24. The immediate jeopardy was removed and the deficient practice corrected by 10/1/24, after the facility implemented a systemic plan that included the following actions by ensuring R1 was care planned to require an escort while in the community. All residents were re-assessed for need for an escort while in the community and care plans were updated accordingly. All nursing staff were educated regarding appointment/escort procedures. All residents with any significant change in condition had elopement risk assessments completed. Any resident deemed for elopement risk had interventions in place and care planned for elopement. A list of residents requiring escorts was newly posted at each nurse's station. The facility social worker was educated to immediately update the list of residents requiring escorts when changes requiring supervision by an escort were required.

Based on interview and document review, the facility failed to comprehensively assess to determine cause of falls and implement interventions to prevent further falls for 3 of 3 residents (R1, R5, R6) reviewed for falls. This resulted in an immediate jeopardy (IJ) for R1 when he had a fall that resulted in a diagnoses of traumatic brain injury with loss of consciousness and subarachnoid hemorrhage, brain bleed (bleeding in the space between the brain and the tissue covering the brain). R1 remained hospitalized . The IJ began on 8/13/24 at 1:30 a.m., when R1 had a second unwitnessed fall and hit his head. R1 was sent to the hospital and was diagnosed with a subarachnoid hemorrhage. R1 had another unwitnessed fall on 8/18/24 at 12:45 p.m., and returned to the hospital. The administrator and director of nursing were notified of the IJ on 9/5/24 at 4:34 p.m. The IJ was removed on 9/6/24 at 4:01 p.m., but noncompliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 Diagnoses List undated, indicated R1's diagnoses included orthostatic hypotension (a sudden drop in blood pressure when standing from a seated or lying position with feelings of dizziness or feeling faint). R1's annual Minimum Data Set, dated dated dated [DATE] indicated R1 moderately impaired cognition, and required supervision with set-up assistance for bed mobility, transfers, toileting and reamined independent with ambulation. The MDS indicated R1 had no falls since admission. R1's care plan dated 4/12/22 indicated R1 had a potential risk for falls related to impaired cognition and the use of psychotropic medications (medications used to treat mental illnesses). R1 was independent with mobility and ambulation with no assistive devices. The care plan also indicated R1 was independent with activities of daily living (ADLs), with some assistance required for personal hygiene and bathing. R1's Fall Risk assessment dated [DATE] indicated R1 was at risk for falls, had no falls in the prior six months, and was independent with ambulation and transfers. On 8/12/24 at 10:48 p.m., a progress note indicated R1 fell near the elevator. R1 could not state how he fell , but reported hitting his head, with a reddened area noted on the left side of the forehead. R1's provider was updated and ordered neurological checks (neuro checks, a series of questions and tests to check brain, spinal cord, and nerve function). 911 was called, but R1 refused to go to the hospital. R1's medical records lacked documentation neuro checks were completed. R1's Risk Management Assessment (a post fall assessment completed by the facility) dated 8/12/24 lacked new interventions to prevent further falls. On 8/13/24 at 2:06 a.m. a progress note indicated R1 fell at 1:30 a.m. going to the bathroom and hit his head. 911 was called and R1 was transferred to the hospital. On 8/13/24 at 6:47 a.m., a progress note indicated R1 was admitted to the hospital with a brain bleed (subarachnoid hemorrhage). On 8/16/24 at 7:32 p.m., a progress notes indicated R1 returned from the hospital at 7:15 pm. R1's hospital After Visit Summary (AVS) dated 8/16 24 indicated R1 was hospitalized [DATE] through 8/16/24 for subarachnoid hemorrhage, and staff should monitor for signs and symptoms of stroke and brain injury. R1's medical record lacked a post fall assessment following the 8/13/24 fall, and the facility did not complete a falls risk assessment upon his return from the hospital. On 8/18/24 at 1:49 pm., a progress note indicated R1 fell at 12:45 p.m., could not recall what happened, had involuntary bodily movements, and walked to this bed. 911 was called and R1 was transferred to the hospital. An emergency department (ED) progress note dated 8/18/24 at 2:15 p.m., indicated R1 arrived to the ED following an unwitnessed fall. He was confused, nonverbal, and not responding to commands appropriately. A CT scan indicated R1 had stable multifocal subarachnoid hemorrhages. The note further indicated R1 had a traumatic brain injury with loss of consciousness, subarachnoid hemorrhage, hypoxia (enough oxygen in the tissues to sustain bodily functions) and fall. On 9/4/24 at 9:20 a.m., family member (FM)-A stated R1 had no prior history of falls, could walk independently and perform some ADLs independently, but since the falls he could not walk alone, and could not perform ADLs independently. FM-A stated R1 was still hospitalized . On 9/4/24 at 11:33 a.m., licensed practical nurse (LPN)-A stated she saw R1 on 8/8/24 at 6:00 a.m. and noticed blood on the floor from an unknown source. R1 was seated, and he would not allow her to assess him. She tried to talk to R1, but he refused to talk, and he left the area. She noticed R1 was walking with an unstable gait. When she left her shift, she reported the blood to the oncoming nurse. She knew R1 was unstable, and when she returned for her shift the next night, she learned R1 had fallen again. She did not notify the provider about R1's condition. On 9/4/24 at 11:47 a.m., registered nurse (RN)-A stated after paramedics left on 8/12/24, staff was checking on R1, but she didn't know the frequency of the checks. Neuro checks and vital signs (VS) were typically performed the first four hours after a head strike when residents were awake. R1 had been asleep for a while after the fall, so neuro checks were not done while R1 was asleep. She observed R1 talking and walking after the fall, and he walked to his room after having a cigarette outside. She had performed neuro assessments and documented them on the neuro assessment sheet for R1; however, there were no documented neuro checks in R1's medical record. On 9/4/24 at 12:31 p.m. RN-B stated on night shift (8/13/24 at 1:30 a.m.) she was doing rounds and a nursing assistant was checking on residents. About midnight, R1 was sleeping in his bed. RN-B stated a trained medication aide (TMA) found R1 on the floor at 1:30 a.m., so RN-B performed vital signs on R1. His vital signs were low. He wasn't speaking or responding much. She called 911 and sent R1 to the hospital. R1's medical record lacked evidence of VS taken on 8/13/24. On 9/5/24 at 9:39 a.m., the director of nursing (DON) stated the nurses should follow the instructions in a hospital after visit summary, and acknowledged R1 was not monitored for stroke or traumatic brain injury after his falls. There was no evidence neurological assessments were completed for R1 after his fall on 8/12/24. There was not a facility protocol for neuro checks. On 9/5/24 at 1:14 p.m., nurse practitioner (NP)-A stated R1 should have been kept awake after the fall on 8/12/24, and vital signs and neurological assessments should have been performed per facility protocol. The care plan should have been updated as indicated by the AVS forms to monitor for signs of traumatic brain injury and stroke to prevent death, stroke, or a delay in care for a medical issue that required immediate care. If the neurological assessments were not recorded, they were not done, but should have been performed. NP-A stated they were supposed to be completing neuro checks on the 12th (8/12/24) and that may have made a difference for R1. Most facilities do them for 48 hours, and based on what they are seeing, they are supposed to report. If they looked different, they should let me know. She stated her office was not notified of R1's fall on 8/13/24. R5's Diagnoses List undated indicated R5's diagnoses included osteoporosis, dementia, and abnormal gait. R5's admission MDS dated [DATE] indicated R5 was cognitively intact, required assistance of one staff for transfers, and had no history of falls since admission. R5's care plan dated 6/24/24, indicated R5 had a potential risk for falls related to impaired cognition and use of psychotropic medications. R5's fall interventions included encourage R5 to rise slowly and stand for a few seconds prior to ambulating, wear non-skid shoes, and remind R5 when and how to use the call light as needed. R5's Fall Risk assessment dated [DATE], indicated R5 had no history of falls in the previous six months, required assistance of one staff for transfers and ambulation, used a walker and wheelchair for locomotion, and was at high risk for falls. On 8/28/24 at 1:33 p.m., a progress note indicated R5 was found lying on the floor by the resident's phone on second floor. R5 indicated she laid down on the floor because she was weak. R5 was assisted off the floor by two staff. She denied hitting her head, neurological assessments were completed, and NP-A was notified. R5's Risk Management Form dated 8/28/24 indicated R5 was found lying on the floor, and stated she laid down because she was weak. R5 was assisted off the floor by two staff, VS were completed, she denied hitting her head, but neurological checks were done. R5's medical record lacked documentation neurological assessments were completed. R6 Diagnoses List undated indicated diagnoses included epilepsy, and a history head injury with loss of consciousness. R6's quarterly MDS dated [DATE] indicated R6 was cognitively intact, and no history of falls since admission. R6's care plan dated 3/8/19, indicated R6 was a potential risk for falls related to use of psychotropic medication. Interventions included encourage R6 to wear non-skid, properly fitted shoes during transfers and ambulation, and maintain a clutter free environment. The care plan indicated R6 had a fall in the community on 8/8/24, and staff should encourage R6 to use a scooter to move throughout the store if available to prevent falls. R6's Fall Risk assessment dated [DATE], indicated R6 had no history of falls, and was independent with ambulation. On 8/8/24 at 11:38 p.m., a progress note indicated R6 fell in a store in the community, was transferred by ambulance to the hospital, and required a follow-up visit with his primary care provider in two weeks for repeat labs and assessment of lightheadedness. The progress note lacked indication R6's primary provider was notified. R6's AVS from the hospital emergency room dated 8/8/24, indicated R1 fell in a store in the community, the hospital performed lab work, and indicated R6 should see his primary provider and have repeat lab work in two weeks. On 9/4/24 at 3:57 p.m., the administrator stated staff did not implement fall prevention interventions for R1 after either fall on 8/12/24 and 8/13/24. If we don't do [neurological assessments] like we should, we could be in a life-or-death situation. The administrator acknowledged the facility did not have a neuro assessment policy, or any other policy related to falls. On 9/5/24 at 9:39 a.m., the director of nursing (DON) stated there was no evidence R5 had neuro checks after her fall on 8/28/24, but the facility nurses would be expected to complete a neurological assessment after an unwitnessed fall. There was no facility protocol for neurological assessments, and the facility Fall Procedure did not include neurological assessments for a fall with a head strike or unwitnessed fall. When R6 fell , it was unknown if he hit his head, so R6 should have had neurological assessments when he returned to the facility but had not. After each fall, the Falls Risk Assessment should have been updated for R1, R5, and R6 by the nurses, and had not been. On 9/5/24 at 1:14 p.m., NP-A stated she tried to see R6 after he fell , but he was out of the building and not available. NP-A stated she was told R6 was fine. NP-A stated she was not told R6 needed labs after his fall, or they would have been done. NP-A further stated she saw R6 on 9/4/24, but not in the requested time frame as indicated on the hospital discharge form. NP-A looked in R6's medical record and acknowledged the hospital wanted follow-up labs, and acknowledged they were not done. The facility Fall Assessment Policy and Procedure dated 9/23 directed falls were assessed using the Fall Risk Assessment with each fall, and care plans would have interventions to prevent falls. The procedure lacked information about staff protocols for head strikes, assessment requirements, and neurological checks. The immediate jeopardy that began on 8/12/24 at 10:48 p.m., was removed on 9/6/24 at 4:01 p.m., when the facility updated the Fall Risk Assessment Policy and Procedure, updated protocol for neurological assessments, and updated the neurological assessment form. Additionally, nursing staff was trained about the new neurological assessments and post-fall procedures. The facility reviewed falls for all residents who fell in the previous 90 days, and updated the care plans, performed post-fall assessments, and completed a Falls Risk Assessment for each of the residents identified. This was verified through observation, interview and document review.

Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 3 residents (R1) who was unsafe in the community and at risk of leaving without supervision. This failure resulted in an immediate jeopardy (IJ) when R1 left the faciity on [DATE], and was gone for seven hours before staff were aware. R1 had not been found at the time of the survey, five days later. The facility had implemented corrective action prior to the start of the survey, therefore the deficient practice is being issued at past non-compliance. The IJ began on 8/20/22, at 9:00 p.m. when the facility staff noted R1 left the facility without supervision. The director of nursing (DON) was notified of the IJ on 8/25/22, at 5:11 p.m. The facility implemented immediate corrective action on 8/22/22, prior to the start of the survey and was issued as past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], included moderately cognitively impaired with a diagnoses of paranoid [CONDITION(S)], [CONDITION(S)], and drug abuse. R1 was independent with activities of daily living (ADLs). R1's 3/28/22, Tribal Court Order commitment indicated R1 was not to leave the facility unescorted or unsupervised. [R1] was to remain at the facility he was placed until the guardian determined he should be discharged . R1's Wandering Risk Assessment completed on 8/3/22, indicated a score of 1 (low risk for elopement) but did not take into account previous history, tribal court order and guardian's concerns about family coming to get the resident or leaving the facility unattended. R1's Safety In The Community Evaluation completed on 8/4/22, indicated R1 showed a lack of understanding of safety in the community and recommended R1 have an escort when leaving the facility. R1's care plan dated 8/4/22 indicated R1 was not safe to go into the community unescorted; there were no interventions to prevent this from occurring. Notes in the facility's investigation file indicated R1 was missing on 8/20/22, at 9:00 p.m. during medication pass. R1 was last seen at on 8/20/22, at 2:00 p.m.when the nurse administered him an as needed (PRN) pain medication. Through investigation the facility identified R1 left the facility by jumping the fence and walking down the alley outside the smoking area sometime between 2:00 p.m. and supper time (starts at 4:45 p.m.). A female resident (not identified) saw R1 climb over the fence and walk down the alley between lunch and supper on Saturday 8/20/22. However, this resident did not inform the facility until 8/22/22. When the facility realized R1 was missing they notified police, the guardian, local jails, local hospitals, local detox centers, casinos, and the Lower Sioux reservation were called and notified of the elopement; as R1 may have returned to areas he had previously lived. R1 had not been located to date and continued to be missing for five days. During interview on 8/25/22, at 10:41 a.m. R1's guardian expressed concern R1's family would come to the facility and remove him without permission. R1's guardian wasn't surprised R1 left the facility unsupervised and stated I believe this won't be a single episode so I will be looking for a more secure facility when he's located. During interview on 8/25/22, at 11:36 a.m. trained medication aide (TMA)-A stated typically during meal times each resident would come to a staff person assigned as host and obtain a meal ticket with the resident's name and then get their meal tray. Further, stated it is the expectation, the usual practice, of the host to review all unclaimed meal tickets and follow up with the corresponding resident to make sure they recieved a meal. During interview on 8/25/22, at 11:42 a.m. the director of nursing (DON) stated she was aware of R1's commitment and not being able to leave the facility unsupervised. Although R1's commitment started 3/28, he was not admitted to the facility until 8/3/22.The DON also stated R1 was independent throughout the facility and only got checked on by staff during shift change and medication times. During interview on 8/25/22, at 1:15 p.m. the social service director (SSD) stated the social service assistant (SSA) should have used R1's history to make the determination regarding his potential to leave the facility unsupervised. During interview on 8/25/22, at 1:53 p. m. the SSA stated R1 was at risk based on the Safety In The Community evaluation and verified R1 was unsafe to go into the community without an escort or supervision. Further, SSA explained the Safety In The Community evaluation determined elopement status since there isn't a separate elopement assessment. During interview on 8/25/22, at 2:05 p.m. TMA-B stated R1's meal ticket on 8/20/22 wasn't picked up by R1during supper time; however TMA-B did not check on R1 and wasn't able to verify if R1 was still in the facility. Further, TMA-B stated due to the time of day it was too busy to go check on R1. The wandering/elopement prevention plan policy and procedure dated 7/2022, included, The facility will assess the resident's needs prior to and after admission to determine his/her ability to leave the facility safely. Further included, the facility would update orders, wander book, and care plans as appropriate. The past noncompliance immediate jeopardy began on 8/20/22. The immediate jeopardy was removed, and the deficient practice corrected by 8/22/22, after the facility implemented a systemic plan that included the following actions, which all verified by record review on 8/25/22: On 8/20/22, at 10:00 p.m. the staff called 911 and R1's guardian and reported R1 missing. On 8/21/22, at 9:30 a.m. the SSD called the Jackpot Junction Casino to locate R1 with no success and drove to Shakopee Wacipi, the American Indian Center and detox center to locate R1 with no success. On 8/21/22, at 10:50 a.m. the administrator called the local hospitals to locate R1 with no success. On 8/21/22, at 2:24 p.m. the staff searched all closets, unoccupied rooms, the business office, boiler room, and north stairwell to locate R1 with no success. On 8/22/22, at 10:34 a.m. audits were completed on all other residents at risk for elopement or who can't leave the facility unsupervised. Further, the elopement book and care plans were updated. On 8/22/22, the DON reviewed the wandering/elopement and the missing resident policies, and no changes were needed. On 8/22/22, and 8/23/22, the facility staff were educated on the wandering/elopement and missing resident policies. The staff that were not present on 8/22/22 and 8/23/22, were educated prior to their next shift. This was verified by sign in sheets and interviews with staff on 8/25/22.

Based on interview and record review, the facility failed to ensure all 86 residents and 87 staff were tested for COVID-19 folowing an outbreak regardless, immediately and, if negative, again 5-7 days later. This deficient practice had the potential to affect all 82 non-COVID-19 positive residents, as well as staff, and visitors in the facility. The IJ began on 12/15/21, when a staff member tested positive for COVID-19 and the facility failed to offer or conduct tests for COVID-19 for all residents, according to Center for Disease (CDC) guidelines. The Administrator and director of nursing (DON) were notified of the IJ on 2/4/22, at 1:19 p.m. The IJ was removed on 2/7/22, at 12:39 p.m. when the facility implemented interventions to ensure all residents were offered or given tests for COVID-19 however, noncompliance remained at the lesser level of F which indicated no actual harm with potential for more than minimal harm that was not an IJ. Findings Include: Review of the 9/10/21, Centers for Medicare and Medicaid (CMS) QSO-20-38-NH memo identified facilities were to conduct testing in a manner that was consistent with current standards of practice for COVID-19 testing. For each instance of testing: Document that testing was completed and the results of each staff test; and document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test. The memo identified an outbreak as any new case of COVID-19 in the facility. Upon identification of a single new case of COVID-19 infection in any staff or resident, testing should have begun immediately. Facilities had the option to perform outbreak testing through two approaches, contact tracing or broad-based (facility-wide) testing (when contact tracing was not possible). Interview on 2/1/22 at 10:30 a.m., with the infection preventionist (IP) identified there were 4 residents in the facility that tested positive for COVID-19 (R47, R49, R51, and R9). They all lived on the locked unit with 34 other residents. Review of R47's progress notes identified although the facility had been in outbreak status since 12/15/21, R47 was only tested for COVID-19 at a clinic, prior to her appointment, on 1/26/22. The facility was notified of R47's positive results on 1/27/22. Review of R25's progress notes identified although R25's roommate, R47, had tested positive for COVID-19, and the facility was in outbreak status, R25 had not been offered or tested for COVID-19. Interview on 2/3/22, at 2:49 p.m.with the Infection Preventionist (IP) identified 2 staff members (registered nurse (RN)-D and dietary aide (DA)-A tested positive for COVID-19 on or around 12/15/21. There were approximately 9 more staff since that time who also tested positive, including the administrator. The IP kept no documentation to show what staff or the dates they tested positive as she shreds all documents after Quality Assurance Performance Improvement (QAPI) committee meetings. She stated the last meeting was held on 1/31/22. The facility had not performed outbreak testing on any resident after any positive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Roommates of positive COVID residents were not tested for COVID because they were isolated with their positive roommate. The IP was unfamiliar with the CMS QSO-20-38-NH memo that instructed facilities to begin outbreak testing for residents and staff immediately after 1 positive case of COVID was identified through broad-based testing. The facility was unable to conduct contact tracing of the residents due to residents high mobility and movement throughout the building and staff not having set unit assignments. The staff were to be tested twice a week through routine testing due to high COVID county transmission levels; however, if staff were not working on Mondays and/or Thursdays when the IP or DON conducted the COVID tests, or if staff did not choose to be tested , the IP stated she was not going to chase people down,. Some will fall through the cracks. Review of the QAPI meeting minute notes for January 2022, identified per our protocols, QAPI investigation materials and records are destroyed once QAPI committee has review . The minutes also made no mention of any staff having been found positive for COVID. Interviews on 2/1/22 at 2:00 p.m., through 2/4/22 at 11:00 a.m., with R10, R52, and R53, identified none of those residents had received any outbreak testing according to CDC outbreak testing guidelines after staff first tested positive in December 2021. Interview on 2/4/22 at 8:26 a.m., with the administrator identified he was unaware how many staff or residents had been diagnosed with COVID. He himself had been diagnosed with COVID recently and had just returned to work. He was unaware how the IP was performing testing or surveillance. He agreed the facility needed to follow CMS and CDC guidance for COVID to prevent further outbreak. Interview on 2/4/22 at 12:58 p.m., the medical director (MD) identified resident and staff testing for COVID-19 should have been conducted according to the CMS guidelines and offered, if not conducted, regularly. Surveillance was also to be performed to track, trend and analyze data to attempt to contain or minimize transmission of COVID throughout the building. Interview on 2/7/22, at 10:12 a.m., RN-D stated residents were only tested prior to going to a clinic appointment even though the facility was in outbreak status. Review of the May 2021, COVID Testing Policy indicated in the event of a COVID-19 outbreak, staff who refused to be tested twice a week would be excluded from work, and residents would be tested every three to seven days. Residents had the right to refuse COVID-19 testing and refusals would be documented in their medical record. The IJ was removed on 2/7/22, at 12:39 p.m. when it could be verified by interview and record review that the facility reviewed and revised policies and procedures, educated licensed nursing staff on the revised policies and procedures and on how to administer COVID-19 tests, and offered testing to all residents in the facility. The immediacy was removed, and noncompliance remained at the scope and severity of F which indicated no actual harm with potential for more than minimal harm that was not an IJ.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19 to prevent or minimize the transmission of COVID-19 related to use of personal protective equipment (PPE) and the disinfection of multi-resident use equipment from a known COVID-19 positive residents' (R47 and R25) room (room [ROOM NUMBER]) to a non-COVID-19 positive residents' (R7 and R46) room (room [ROOM NUMBER]). The facility's failure resulted in an Immediate Jeopardy (IJ) situation for all 38 residents who resided on the locked housing unit. In addition, the facility also failed to perform active, ongoing surveillance to track and trend all infections, in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guideline for COVID-19. This had the potential to affect all 86 residents in the facility. The IJ began on 2/1/22 at 2:50 p.m., when nursing assistant (NA)-A entered room [ROOM NUMBER] with a cart containing multi-resident use equipment (blood pressure cuffs, thermometer, and pulse oximeter). NA-A entered the room without putting on appropriate PPE. NA-A wore a surgical mask, gloves, and eyewear. NA-A took vital signs then exited the room without removing her PPE, or performing any hand hygiene, and failed to disinfect the multi-use equipment. NA-A then went into room [ROOM NUMBER], wearing the same PPE and performed vitals on those residents, with the contaminated equipment. The facility administrator and director of nursing (DON) were notified of the IJ on 2/1/22 at 6:43 p.m The IJ was removed on 2/2/22 at 2:34 p.m., but non-compliance remained at the lower scope and severity level of E, pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: PPE/DISINFECTION OF SHARED EQUIPMENT Review of the current CDC guidelines for COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated February 2. 2022, recommends health care staff who enter a room of a patient with suspected or confirmed COVID-19 infection should adhere to transmission-based precautions (TBP) and wear not only a facemask, but gown, gloves, and eye protection. Also, dedicated medical equipment should be used when caring for a patient with suspected or confirmed COVID-19 infection. Interview on 2/1/22 at 10:30 a.m., with the infection preventionist (IP) identified there were 4 residents in the facility that tested positive for COVID-19 (R47, R49, R51, and R9). They all lived on the locked unit with 34 other residents. During observation on 2/1/22 at 2:50 p.m., NA-A entered room [ROOM NUMBER] with a cart containing multi-resident use equipment (blood pressure cuffs, thermometer, and pulse oximeter). NA-A entered the room without putting on appropriate PPE and only wore a surgical mask, gloves, and eyewear. NA-A took vital signs on both residents, then exited the room without removing her PPE, without performing any hand hygiene, and failed to disinfect the multi-use equipment. NA-A then went into room [ROOM NUMBER] wearing the same PPE and performed vitals with the contaminated equipment. Review of the progress notes for the below COVID positive room residents identified on: 1) 1/27/22, R47 was identified as having been tested at the clinic on 1/26/22. R47 tested positive for COVID-19 and was placed on isolation precautions on 1/27/22 after notification from the clinic. R47 was without symptoms (asymptomatic) of COVID-19. R47 was not tested at the facility, even though there was an outbreak. 2) 1/27/22, staff noted R25 was notified her roommate (R47) was positive for COVID-19. R25 was noted to also be asymptomatic that day, and therefore R25 was never tested for COVID-19 as the facility was not performing outbreak testing and only tested residents when symptomatic. Interview on 2/1/22 at 3:05 p.m., with NA-A stated she did not see the COVID-19 isolation information sign posted on the door of room [ROOM NUMBER] before she entered it with the multi-resident use cart to take vital signs. NA-A stated she did not perform hand hygiene or change gloves when exiting the room and did not wear a PPE gown prior to entering the room. NA-A also stated she did not disinfect the multi-resident use equipment after obtaining vitals and before leaving room [ROOM NUMBER] entering room [ROOM NUMBER]. During interview on 2/1/22 at 3:18 p.m., the DON identified expectation that staff were expected to wear appropriate PPE. Shared resident equipment was expected to be disinfected following each resident use, and NA-A should not have entered the shared COVID-19 positive room with the equipment cart. NA-A entering room [ROOM NUMBER] was a breach in infection control practices. During interview on 2/4/22 at 12:58 p.m., the medical director identified his expectation was facility staff were expected to follow recommended CDC guidance to prevent and limit the spread of infection. He agreed the above observation was a breach in IC practice and could lead to spread of infection. Review of the May 2021, Disinfection of Multi-Resident Use Equipment policy identified nursing equipment items such as blood pressure devices and pulse oximeters that were used by more than one resident were to be appropriately cleaned and disinfected before and after use. Hand hygiene was to be performed prior to donning gloves and after cleaning and disinfecting the item. Review of the August 2021, Pandemic Illness Plan policy identified staff were to use gowns, gloves, masks and eye protection for any emerging pandemic illness. PPE USE DURING COVID TESTING Review of the 9/10/21, Center for Medicaid and Medicare Services (CMS) QSO-20-38-NH memo indicated facilities must maintain proper infection control including wearing a NIOSH-approved N95 or equivalent mask, gloves, and gown when collecting COVID-19 specimens. During an observation and interview on 2/3/22, at 1:20 p.m. the IP was administering COVID-19 rapid tests to nursing assistant (NA)-E in her office. NA-E sat at the IP's desk, approximately two to three feet from the IP, while a swab was inserted into NA-E's nostrils. The IP did not wear an N95 mask or gown, according to CMS guidelines, while administering the tests. The specimen was then paired with a timer on a three-tiered cart, with multiple other specimens and timers. When a timer alerted at 15 minutes, the IP turned off the timer and placed the specimen on her desk to read the results. The IP did not wear gloves to handle the specimen. The IP verified that she always administered the COVID-19 tests to staff in her office and did not wear a gown or N95 mask during the process or wear gloves when handling specimens. During an interview on 2/4/22, at 8:02 a.m. licensed practical nurse (LPN)-D stated the IP administered the COVID-19 tests in her office and LPN-D had never seen the IP wear a gown or N95 mask when conducting the tests. The facility COVID Testing policy revised May 2021, did not indicate the need for appropriate use of PPE during the administration of the COVID-19 tests. No other policy on proper PPE wear and use during COVID-19 testing was provided. SURVEILLANCE During an interview on 2/3/22, at 2:49 p.m. the infection preventionist (IP) stated the facility resident population had a high incidence of chronic obstructive pulmonary disease ([CONDITION(S)]) (often caused from smoking and could result in chronic coughing) and therefore, it was too difficult to track residents' signs and symptoms of COVID-19. The IP stated R9 had fallen and was found to have a low oxygen levels. The IP stated sniffles was not a symptom of COVID-19 and therefore, although their tests were positive, they were considered asymptomatic. The IP was unable to provide the exact date when the first two staff members tested positive for Covid-19 in December 2021, putting the facility into outbreak status, but documented they would be able to retest on 3/15/22, which was 90 days after their initial positive test. The IP was not performing appropriate outbreak testing and failed to test any residents for COVID according to CMS and CDC. Review of the facility infection surveillance log for 2021 revealed it contained only copies of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility infection surveillance log for 2022 indicated only 3 residents were positive for Covid-19 although there were four. The log only indicated quarantine start dates for two positive residents, no end dates, signs or symptoms, or their onset were listed. The facility Antibiotic Stewardship policy dated 2/1/22, indicated the IP should track and monitor all infections as they occur. No other policy related to IC surveillance was provided by end of the survey. The IJ was removed on 2/2/22 at 2:34 p.m., when it could be verified by observation, interview, and document review, the facility took steps to ensure all nursing staff were educated on appropriate PPE use, performing hand hygiene, appropriately disinfecting multi-resident use equipment, and we re-educated to policies and procedures, and designated multi-use equipment for each resident on COVID-19 isolation. The facility also immediately tested all residents for COVID-19.

Based on interview and document review, the facility failed to ensure a resident did not have access to, and did not consume unprescribed medications for 1 of 2 residents (R1) reviewed for substance abuse. In addition, the facility failed to implement interventions, including monitoring for impairment and withdrawal symptoms, physical safety, and conduct a Suspected Substance Abuse Assessment. In addition, the facility failed to ensure to behavioral health services for chemical dependency were offered for R1. This resulted in an immediate jeopardy for R1 who consumed unprescribed benzodiazepine medication (depressant medication used to treat anxiety, [CONDITION(S)] and prevent seizures), sustained two falls, and required hospitalization . The IJ began on 8/28/21, at 9:57 a.m. when R1 had over 40 unprescribed [MEDICATION(S)] (benzodiazepine), and refused to give them to staff. On 8/29/21, R1 had two falls in his room, and was noted to have been self-administering [MEDICATION(S)]. R1 was sent to the hospital where he tested positive for benzodiazepines and was diagnosed with benzodiazepine overdose. The administrator and the director of nursing (DON) were notified of the IJ on 9/3/21, at 2:35 p.m. The IJ was removed on 9/7/21, at 12:44 p.m. but non-compliance remained at the lower scope and severity of a D, no actual harm with potential for more than minimal harm. Findings include: R1's Face Sheet printed 9/3/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a short-term memory problem, and was independent in cognitive skills for daily decision making. The MDS also indicated R1 was on a scheduled pain regimen, indicated pain was experienced frequently, and R1 did not have history of falls. The MDS indicated R1 did not receive antianxiety medications. R1's Self Administration of Medication assessment dated [DATE], indicated R1 could not self-administer medications. R1's care plan dated 7/6/21, indicated R1 was at risk for abuse, neglect and/or exploitation related to Vulnerable Adult Status and opioid abuse. R1's care plan lacked interventions related to opioid abuse. R1's hospital discharge orders dated 6/28/21, included an order to evaluate and treat R1 for medication help. The discharge orders lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/28/21, at 9:57 a.m. a progress note indicated trained medication aide (TMA)-A informed registered nurse (RN)-A that R1 had medication on him. RN-A asked R1 what medication he had in his pocket. R1 stated, It's my medication. I don't want to show you my meds. RN-A continued to talk to R1 who stated, It's in my drawer and agreed to show RN-A. R1 attempted to search in his drawer, but the medication was in R1's pocket. R1 took the pills out of his pocket and showed RN-A. RN-A estimated their were more than 40 tablets. RN-A determined the medication was [MEDICATION(S)]. R1 stated he would give the pills to his sister, but not to RN-A. R1 stated he had been taking one tablet three times a day for over [AGE] years. When R1 refused to give up the [MEDICATION(S)], RN-A notified the DON. RN-A did not notify R1's physician. R1's Fall Report dated 8/29/21, at 6:10 a.m. indicated R1 was found on his back on the floor, and was calling for help after trying to reach for a clean shirt from the closet. No injuries were noted and R1 was helped back to bed. The fall report indicated R1 had been self-medicating with [MEDICATION(S)], the pills were seen yesterday by the day nurse and counted. On 8/29/21, at 6:40 a.m. a progress note indicated RN-C was called to R1's room and found R1 on the floor. R1 stated he was attempting to grab a shirt when he fell . R1 had no injuries were sustained. R1 was helped back to bed. RN-C did not notify anyone of R1's fall. Twenty minutes later, RN-C was called to R1's room as he had fallen again. R1 was found sprawled on the floor with head under the bed. RN-C emphasized the importance of staying in bed and using the call light to R1, who was noted to have very unstable gait, uncoordinated movement, and had been self-administering [MEDICATION(S)] which could be the contributing factor to the falls. R1 was assisted back to bed. R1's nurse practitioner (NP) and guardian were notified. The DON was called and agreed R1 should be sent to the ER. On 8/29/21, at 7:22 a.m. a progress note indicated, Late entry: Resident wouldn't allow writer to search his pockets or personal items for the suspected pills. The progress note lacked a date or time for when the late entry was referring to. R1's Suspected Substance Abuse assessment dated [DATE], at 7:42 a.m. indicated R1 was suspected of using [MEDICATION(S)] and displayed a lack of muscle coordination and falls. R1's person, personal belongings, or room were not searched because, Resident wouldn't allow Writer to search him. On 8/29/21, at 9:00 a.m. a progress note indicated R1 was sleeping and breathing normally. Staff asked to search R1's room and R1 declined. Staff asked to search R1's pockets and he declined. Staff asked if R1 wanted to go to the hospital and R1 stated, Ok. On 8/29/21, at 9:05 a.m. a progress note indicated R1 was sent to the hospital at 9:07 a.m. On 8/30/21, at 9:36 a.m. a progress notes indicated RN-C searched R1's room and found 37 whole tablets and four half-tablets of [MEDICATION(S)] 10 milligrams loose in R1's top bedside table drawer. The medication was destroyed. R1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/30/21, at 12:09 p.m. a progress note indicated a toxicology screening was ordered for R1 at the hospital, who tested positive for benzodiazepines ([MEDICATION(S)]). On 9/3/21, at 10:39 a.m. social service director (SSD)-A was interviewed and stated assessment of residents for substance abuse upon admission was dependent whether they were active users. SSD-A stated this was defined as having more recent use of alcohol or illicit drugs. SSD-A stated if a resident was an active user, they would be referred to an in-site chemical dependency counselor to conduct an assessment and would be asked if they want to be in the program. If the resident refused, they would be referred to psychiatry services to follow up. SSD-A stated R1 was not assessed for substance abuse upon admission because he had come in sober. SSD-A verified R1's care plan indicated history of opioid use, but R1 had no red-flags and had no history of use within the facility prior to the incidents on 8/28/21, and 8/29/21. SSD-A stated no one even knew R1 was taking [MEDICATION(S)] or had an active recent history of substance use. SSD-A verified R1's hospital admission record reflected substance use, but stated it was not current, and, The hospital didn't even know he was using. SSD-A further stated if R1 had recent drug use, she would absolutely have offered a chemical dependency assessment, and she always knew when residents were admitted and needing treatment. SSD-A stated she knew nothing about R1's daughter or guardian being involved. On 9/3/21, at 11:40 a.m. RN-A was interviewed and stated the facility contraband policy directed to complete a suspected substance abuse document, search the resident, and confiscate any contraband. RN-A stated if the resident refused, staff needed to call the provider, the DON, and the family. RN-A stated when R1 refused to surrender the [MEDICATION(S)], he had contacted the DON, as R1 could not have medications without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated he did not complete the suspected substance abuse assessment as R1 did not exhibit any signs of intoxication at the time, and the DON did not direct him to do so. RN-A stated he did not contact R1's provider as he did not see signs of intoxication, and the DON did not direct him to do so, however, the following day the DON had asked RN-A if he had called the provider. RN-A also stated he did not call the police as he was not directed to do so. RN-A further stated, I think I should have called and notified the MD that he had the medication, but I was awaiting the direction from DON. On 9/3/21, at 11:58 a.m. TMA-A was interviewed and stated she observed the [MEDICATION(S)] tablets on R1's dresser when she went to administer R1's morning medications. TMA-A asked R1 what the pills were, he stated they were allergy medications, and placed them in his pocket. TMA-A stated she told R1 she needed to take the pills, but R1 would not allow it. TMA-A notified RN-A and continued with her medication pass. TMA-A stated she did not search R1's room for more pills, as R1 would not allow the search, and she expected RN-A to conduct the search. TMA-A stated she overheard R1 tell RN-A the pills were [MEDICATION(S)] his sister had given him. TMA-A stated she and RN-A attempted to remove the pills from R1 several times throughout the shift and R1 would not allow them to. TMA-A stated R1 was in his room lying down the entire day, however, she did not notice signs or symptoms of intoxication. TMA-A stated she was not aware of any substance use history with R1. On 9/3/21, at 12:05 p.m. RN-B was interviewed and stated if staff believed a resident was intoxicated, they were to complete the suspected substance use assessment, contact the resident's provider, take vitals, and conduct a room search. RN-B stated R1's [MEDICATION(S)] was not confiscated as it was on his person and, We cannot restrain them and take it from them. RN-B stated R1 was not assessed for suspected substance use as staff did not think R1 was intoxicated. RN-B stated she expected staff to continue to attempt to find an opportunity to confiscate the medication. RN-B stated she expected staff to call R1's provider, as R1 stated that he was taking three pills a day for [AGE] years, to ensure safety and no potential drug interactions. RN-B stated the police were not usually called in these situations. On 9/3/21, at 12:33 p.m. the DON was interviewed and stated the facility process with substance use began with reviewing the resident's history, and all things that may pertain to substances. The DON stated residents signed an agreement upon admission they cannot have non-prescribed substances. The DON stated she did not know if social services completed a chemical dependency assessment with R1 upon admission, and R1 was not on any substance monitoring protocol. The DON stated the facility contraband policy directed for the removal of contraband if possible, and this included medications. The DON verified the [MEDICATION(S)] was not removed from R1's possession, and when R1 refused to surrender the medications, We could have called the police, we could have called the doctor. The DON stated she was not aware R1 tested positive for benzodiazepines prior to admission, and staff should have assessed him and developed a plan of care. The DON verified R1's care plan indicated a history of opioid abuse and lacked interventions around this. The DON stated she did not think to direct RN-A to call contact R1's provider, emergency contact, or the police when R1 refused to surrender the [MEDICATION(S)], but directed RN-A to continue to try to remove them from the R1. The DON further stated, We always call the provider for change of condition, I don't know. I missed a step too, we could have called the police. On 9/7/21, at 12:20 p.m. RN-C was interviewed and stated on 8/28/21, she was called to R1's room as R1 had fallen. RN-C initiated neuro checks on R1 for the unwitnessed fall, noticed R1 had an unsteady gait and put him back to bed. RN-C stated she immediately went to the 2nd floor to continue medications for other residents, and 20 minutes later was called back to R1's room for another fall. RN-C stated she had not gotten the chance to notify anyone of R1's first fall before she was called back to his room for the second fall. RN-C stated she wondered what was wrong with R1, then remembered RN-A reported to her during shift change that R1 had been seen with [MEDICATION(S)] the day before, and RN-A could not get the pills from R1. RN-C stated she had not looked for the [MEDICATION(S)] or attempted to confiscate the medications from R1 during her shift as she had forgotten. RN-C asked R1 to empty his pockets, R1 refused and stated he did not have anything and became aggressive. RN-C stated R1 looked like he was on something at which time she contacted R1's provider, R1's emergency contact, and the DON who directed RN-C to send R1 to the ER. The immediate jeopardy that began on 8/28/21, was removed on 9/7/21, when the facility updated their policies, reviewed all residents with substance abuse disorders and updated their care plans, assessments were completed, and staff were educated. This was verified through interview and document review. The facility document When Residents Bring Contraband into the Facility undated, directed staff to call the provider/ Don/on call provider. Search their room and person as able, remove contraband, document, and destroy. Do a suspected substance abuse assessment (this includes vitals, increased monitoring, and room searches). Call the family, caseworkers, and others who may offer assistance. Reapproach with a different staff person if the resident is uncooperative. Contraband includes medications they do not have for or should not have on them, alcohol, and illicit drugs. If you believe other residents or staff are in danger, call 911. The facility policy Suspected Substance Abuse assessment dated ,d+[DATE], directed staff will perform an assessment on residents suspected of substance abuse based on their experienced nursing judgment in the following circumstances: The resident returns from a leave of absence and is suspected of intoxication or alteration The resident's demeanor is consistent with having consumed alcohol or illicit drugs The resident is found with alcohol, illicit drugs or medications not prescribed to them The resident confirms using alcohol, illicit drugs or medications not prescribed to them The resident is suspected to have misused prescribed controlled medications After performing this assessment, based on findings the nurse will: Call EMS for transport to the nearest emergency facility as needed Search the residence person and belongings in confiscate any substances not allowed by facility policy Notify the residents provider and discuss which medication they may want withheld Notify the residents family or guardian Notify the administrator and director of nursing

Based on interview and document review, the facility failed to provide high blood pressure medications as ordered and notify the physician when held, for 1 of 3 residents (R1), reviewed who had hypertension ([CONDITION(S)]). This resulted in actual harm for R1 when he had a hypertensive (high blood pressure) crisis and was treated in the emergency room . Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], included, cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was independent with most activities of daily living. R1's care plan dated 3/3/21, included, alteration in medication administration with a goal of, Resident will receive all prescribed mediations per MD/NP [medical doctor/nurse practitioner] orders. Staff were directed to, give the medications as ordered. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)]-HCTZ (an ACE inhibitor used for hypertension) 20-12.5 milligrams (mg), 2 tabs by mouth per day for hypertension ([CONDITION(S)]). The order did not give any directions on holding the medication based upon blood pressure. [MEDICATION(S)] (beta blocker used for [CONDITION(S)]) 25 mg, 2 tabs by mouth every evening for [CONDITION(S)]. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the American Heart Association, a normal blood pressure reading for an adult is a systolic (top number) reading that is below 120 and a diastolic (bottom number) reading that is below 80. A blood pressure would be considered low if under 90/60. An emergency elevated blood pressure would be over 180 systolic or 120 diastolic. A normal pulse is between 60-100. R1's Weights and Vitals Signs form dated 3/1/21 through 3/17/21, identified a blood pressure range of 117/91 to 205/118. R1's blood pressure on 3/18/21, at 7:39 a.m. was listed as 99/64. The blood pressure had not been recorded as being rechecked until 12:23 p.m. and was 147/89. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no rational identified for R1 not receiving the medications. R1's treatment administration record (TAR) dated March 2021, identified a new order on 3/15/21, to monitor blood pressure twice a day for three days and report any out of ranges 120/80 to nurse. The blood pressure recorded on 3/18/21, for 7:39 a.m. was 99/64 and the one documented in the 8:00 a.m. spot was 147/89. R1's progress note dated 3/18/21, at 1:25 p.m. included, R1 had come to TMA-A and asked for his blood pressure medications. TMA wrote, I went to the nurse and she said it was too late. His BP [blood pressure]could drop. R1 complained of a headache and TMA-A offered Tylenol, which he stated he was allergic to. I asked if there was anything we could do and he said you all want to kill me off. R1's blood pressure was recorded again at 1:55 p.m. as 147/89. R1's progress note dated 3/18/21, at 2:01 p.m. included, LPN-A had contacted a nurse practitioner in, regards to res [resident] high b/p [blood pressure], LPN-A had left a message and was waiting for a call back. R1's progress note dated 3/18/21, at 2:09 p.m. identified some new orders from R1's physician which was to add another blood pressure medication of [MEDICATION(S)] daily, change in insulin, and some lab work was to be done. However, there were no new orders on how to manage R1's currently held blood pressure medications from the morning, or how to manage his current headache. R1's progress note dated 3/18/21, at 10:39 p.m. included, The writer checked the resident's BP and it was 172/106. P [pulse] 109. The writer called extended care and talked with NP. The NP ordered [MEDICATION(S)] 25 mg now and to update the primary provider about his blood pressure and pulse. The note indicated R1 was administered [MEDICATION(S)] 25 mg. R1's progress note dated 3/19/21, at 12:44 a.m. included, R1 was walking unsteady and did not feel well. R1's blood pressure was 191/125 and 191/122. LPN-B had indicated in the note he had called the NP, but called 911 as was waiting for a return call from the NP. The paramedics came and resident refused to go with them and said he will take a cab to the hospital. The paramedics left and resident later came downstairs and told writer his cab was here and needs staff to open the door. Resident refused to tell staff which hospital he was going to and kept saying, 'they refused to give me my meds.' Resident stepped outside and got in his truck and drove off. R1's North Memorial Health Hospital Emergency Department notes dated 3/19/21, identified R1 had arrived at the emergency roiagnom on [DATE], at 1:28 a.m. with, Hypertensive urgency and hypertensive crisis. Blood pressures were: 3/19/21, at 1:33 a.m. 186/104, 5:30 a.m. 168/104, and 5:45 a.m. 153/102. R1 was given blood pressure medications and discharged at 5:45 a.m. with new orders to follow up with primary care physician, and to take the [MEDICATION(S)] at night and the [MEDICATION(S)] in the morning. The instructions sent with R1 identified an emergency hypertensive crisis is a systolic blood pressure over 180 or diastolic over 120. When interviewed on 3/23/21, at 10:42 a.m. R1 stated, trained medication aide (TMA)-A had woken him up early in the morning on 3/18/21, and took his blood pressure and his blood pressure was low, the TMA said she consulted with the nurse and they would hold his blood pressure medications and recheck his blood pressure in an hour. R1 stated, TMA-A returned 2 hours later and checked his blood pressure, which was up, but stated she could no longer give him his scheduled blood pressure medications because it was outside of the one hour window of the scheduled time. R1 stated he had developed a headache and requested his blood pressure be rechecked later in the afternoon, but the afternoon nurse was too busy. On 3/18/21, around 10:00 p.m. he was told the doctor said to give him a smaller dose of his [MEDICATION(S)], at 25 mg. R1 stated his headache was worse and he was dizzy and LPN-B had rechecked his blood pressure about 11:40 p.m. and it was 191/111. R1 stated LPN-B was unable to reach the provider. LPN-B called 911, but R1 insisted he drive him self to the hospital. When interviewed on 3/25/21, at 11:16 a.m. registered nurse (RN)-C stated, she had checked R1's blood pressure the evening of 3/18/2. R1 had told her he had not received his blood pressure medications all day. RN-C had called the on call NP and the NP had ordered [MEDICATION(S)] 25 mg. The [MEDICATION(S)] was given to R1. About 2 hours later, R1 stated he did not feel well and his blood pressure was elevated at, 192 over something, 911 was called, but R1 refused to go with paramedics, R1 went left on his own. When interviewed on 3/24/21, at 2:45 p.m. RN-B stated, she had been made aware of R1's blood pressure medication being initially held in the morning of 3/18/21 due to low blood pressure and how R1's blood pressure medication was not then administered until 10:39 p.m. RN-B stated, staff should have rechecked the blood pressure in a different position and notify the provider before holding the medication. If it had been held, but the blood pressure came up, the medication should have been given. When interviewed on 3/25/21, at 9:01 a.m. NP-B stated she was not notified of R1's blood pressure on the morning of 3/18/21. If she had been she would have instructed the staff to recheck the blood pressure right away with R1 in another position as low readings were not consistent with R1's history. If the original blood pressure was accurate, holding the medication may have been appropriate as long as it was rechecked again in one hour. If an abnormal blood pressure is noted, a nurse would be expected to perform a nursing assessment to identify symptoms such as lightheadedness, dizziness and for the nurse to push fluids. NP-B stated she did not understand why they held the medications until it was too late. Facility policy titled, Significant Change Policy, last revised 6/2017, indicated staff notify the provider of a change in condition. If staff are unable to reach the provider or are unsatisfied with the response from the provider then staff should notify the medical director of the significant change in condition. Further, staff should assess residents condition and chart the assessment throughout the change in condition. Facility staff to call 911 at any time in the above process if the residents condition requires the intervention of emergency personnel.

Based on interview and document review, the facility failed to comprehensively assess/reassess and develop interventions to minimize the risk of harm for 2 of 2 residents (R1,R2) who were consuming alcohol in an unsafe manner. This resulted in an immediate jeopardy (IJ) situation for R1 and R2 who remained at risk of serious injury, impairment or death related to unsafe alcohol use in the community. In addition, the facility failed to implement immediate interventions to locate 1 of 1 residents (R1) who had a history of unsafe drinking behavior and did not return to the facility as anticipated. This also resulted in an (IJ) situation for R1 when the facility let three days pass before starting an investigation to located R1. The unsafe alcohol use IJ began on 1/8/21, when R1 returned to the facility from the community intoxicated, with no shoes on his feet and continued a pattern of unsafe alcohol use while in the community. On 1/13/21, R2 was found on the floor intoxicated, soaking wet and with a wound on their knee, between the double entrance doors with their wheelchair was folded up outside the facility. The facility had knowledge of R1 and R2's unsafe behaviors in the community related to alcohol consumption but did not comprehensively assess their alcohol use or develop interventions to minimize the risk of injury to R1 and R2 who continued unsafe alcohol use while in the community. The director of nursing (DON) and social services director (SSD) were notified of the IJ on 1/27/21, at 5:52 p.m. The IJ was removed on 1/29/21, at 9:22 a.m. however, noncompliance remained at a lower scope and severity of isolated with no actual harm with potential for more than minimal harm (Level D). The missing resident IJ began on 1/19/21, when R1 did not return to the facility after being gone over night and the facility failed to make attempts to locate R1 until 1/20/21. The DON and SSD were notified of the IJ on 1/27/21, at 5:52 p.m. The IJ was removed on 1/29/21, at 9:22 a.m. however, noncompliance remained at a lower scope and severity of isolated with no actual harm with potential for more than minimal harm (Level D). Findings include: UNSAFE ALCOHOL USE: R1's admission Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and was independent with all activities of daily living. Diagnoses included Wernicke's [CONDITION(S)] (acute neurological disorder which could affect mental activity or consciousness) anxiety disorder and depression. R1's discharge MDS identified R1 had an unplanned discharge from the facility on 1/21/21. R1's Wandering Risk assessment dated [DATE], indicated he was not a wandering risk and was able to leave the facility unsupervised. However, the medical record lacked evidence an assessment was completed to determine safety in the community. R1's care plan dated 11/5/20, indicated R1 admitted to the facility to complete a chemical dependency program and indicated he was assessed as safe to leave the facility safely without an escort and was not a wandering risk. The care plan identified a substance abuse disorder related to alcohol use. R1's Associated Clinic of Psychology (ACP) Psychiatric Progress Note dated 12/23/20, indicated R1's insight and judgement seemed below average; memory and concentration seemed limited. R1's progress note(s) identified the following: - 1/2/21, R1 returned to the building right before lunch. Staff noticed a glazed look in his eye suggesting he may be high and smelled alcohol on his breath. R1 ate lunch and slept and left the building again at 3:00 p.m. - 1/7/21, R1 returned to the facility at 10:22 p.m. R1's eyes were red and when asked, R1 stated he was high. R1 was re-oriented to facility rules. - 1/8/21, R1 arrived at the facility at 8:22 p.m. very intoxicated. R1 had no shoes on his feet and his pants were dragging on the floor. R1 was noted to be unsteady. [The weather channel identified the temperature on 1/8/21, ranged from 16 degrees Fahrenheit (F) to 23 degrees F. The maximum wind speed was identified as 9 miles per hour (mph).] - 1/9/21, R1 was assaulted downtown. A nurse from hospital called and reported R1 had been found on the street with a cut on his lower lip and told paramedics he had been punched. Hospital nurse stated R1 was intoxicated. R1 had left the facility at 3:10 p.m. that day and was already intoxicated. - 1/10/21, a hospital nurse called to say R1 would be returning to the facility and had refused to get sutures in his lip and was prescribed an antibiotic. R1 returned wearing a bloody orange sweatshirt and had an unsteady gait. R1 arrived at the facility at 2:00 a.m. - 1/10/21, at 8:10 a.m. R1 left the facility. - 1/10/21, R1 returned to the facility at 5:30 p.m. He was intoxicated and had impaired balance. - 1/11/21, interdisciplinary team (IDT) discussed R1 having increased vulnerability due to intoxication in the community. SSD and chemical dependency counselor (CDC) to follow up with R1. An undated IDT document indicated on 1/8/21, R1 arrived at the facility with no shoes on and was very intoxicated. Interventions were identified as, will continue to monitor and best practice for those returning intoxicated: vitals, intervene if in any altercations, offer food and beverage and escort to room to sleep it off. 1/9/21, R1 was assaulted downtown, Intervention: prescribed [MEDICATION(S)] (antibiotic), ACP and chemical dependency program. The document lacked evidence the IDT discussed safety concerns related to R1's alcohol use in the community or interventions to promote safety. R1's medical record lacked evidence any follow up was completed by SSD and the CDC as indicated by progress note dated 1/11/21. In addition, R1's medical record lacked any assessment related to unsafe drinking behaviors and interventions to reduce the risk of harm related to drinking unsafely in the community. On 1/26/21, at 12:05 p.m. nursing assistant (NA)-A stated R1 would come and go from the facility. NA-A stated R1 left on his own and would drink alcohol. The staff would offer to help R1 and he would agree then the next day he would leave and go drink. At 12:18 p.m. family member (FM)-A stated she felt the facility was too lenient. FM-A stated R1 was not safe to leave the facility and did not have the ability to make good decisions and the facility made no effort to stop R1 from leaving. FM-A stated when R1 admitted to the facility she had been given the impression they were more structured. At 12:34 p.m. registered nurse (RN)-A stated R1 was supposed to be in the chemical dependency program. RN-A stated R1 would come and go from the facility and was not predictable. RN-A said the IDT discussed R1 most days. On admission the nurses completed a wander assessment to determine if a resident had the cognition to go out into the community alone. Regarding leaving the facility, drinking and returning, RN-A stated the chemical dependency counselor was at the facility by 9:00 a.m. and tried to get the residents to go to group and said he walked around and encouraged them to attend. At 12:45 p.m. SSD stated the IDT discussed on 1/6/21, R1 needing a higher level of treatment but there was no where else to send him. They were going to give R1 until Monday 1/11/21, to start attending group therapy. And when he did not start attending group therapy they started the revocation of his commitment. She was not aware of of the 1/9/21, hospitalization until after the fact. The SSD did not identify any interventions the facility had implemented to limit the risk of harm and injury for R1 while drinking unsafely in the community. On 1/27/21, at 9:03 a.m. medical doctor (MD)-A stated she had not been aware R1 had been drinking since he admitted to the facility but was aware, he had been out of the building a lot in December. MD-A was not aware R1 had been injured while out drinking in the community and stated the facility should have told her. The facility did not have a good plan for residents who drank. MD-A stated the residents thought Oh, I can go to [facility] and drink. R2's annual MDS dated [DATE], identified R2 had moderately impaired cognition and required assistance from one staff for dressing, toileting and bathing and was frequently incontinent of bladder. The MDS indicated R2 did not ambulate and used a wheelchair. R2's undated Admission Record identified the following diagnoses: Alcohol abuse, major depressive disorder, altered mental status and failure to thrive. R2's Wandering Risk assessment dated [DATE], indicated he could follow directions, displayed impaired judgement and was deemed safe to leave the facility and return on his own. The medical record lacked evidence R2's safety in the community had been assessed. R2's care plan dated 10/26/20, indicated he was his own decision maker, however lacked insight into health, well-being and safety. The care plan indicated R2 was impulsive with decision making but had been assessed as safe to leave the facility on his own accord per assessment. The care plan further identified areas of vulnerability due to cognitive deficits and mental illness and identified alcohol abuse and indicated he drank frequently while out in the community; however, no interventions were provided to limit the risk of harm for drinking while out in the community. R2's progress note(s) identified the following: - 1/13/21, R2 was seen on the floor of the front door by another resident who notified the nurse. R2 was found between the double doors of the facility and his wheelchair was folded up outside the facility. R2 was intoxicated and soaking wet and had a small wound on his knee. [The Weather Channel identified the temperature on 1/13/21, ranged from 28 degrees F to 39 degrees F. with a maximum wind speed of 9 mph] - 1/15/21, at 11:49 a.m. IDT discussed R2 returning to the facility intoxicated and apparently having fallen out of his wheelchair in the community. Staff followed protocol related to intoxication. The progress note lacked evidence the IDT discussed R2's safety concerns related to drinking and falling. - 1/15/21, at 9:11 p.m. the facility received a call from an unknown person who stated R2 was passed out on his property at 25th and Nicollet Avenue downtown. Another nurse called 911 and gave them the address. Staff was still awaiting R2's return at the time of the note. [The Weather Channel identified the temperature on 1/15/21, ranged from 33 degrees F to 35 degrees F with maximum wind speed of 21 mph.] - 1/15/21, R2 arrived back at the facility at 10:33 p.m. R2 was intoxicated. - 1/18/21, IDT discussed R2 returning to the facility intoxicated, staff followed protocol. There was no evidence the IDT reviewed safety concerns or implemented interventions for R2's safety. - 1/18/21, R2 returned to facility intoxicated at 5:00 p.m. R2's medical record lacked any assessment related to unsafe drinking behaviors and interventions to reduce the risk of harm related to drinking unsafely in the community. R2 was unavailable for observation during the survey as he was out of the facility. On 1/27/21, at approximately 9:30 a.m. licensed practical nurse (LPN)-A stated R2 would leave the facility and drink alcohol. LPN-A stated they were supposed to search him for alcohol when he returned and hold his medications if he had been drinking. LPN-A stated she had not received any further direction related to R2's alcohol use. LPN-A added He's [R2] probably on his way now to go drinking. At 10:33 a.m. SSD stated R2 went out into the community and when he went out, he got intoxicated. The SSD stated that was R2's baseline. The facility had attempted a chemical dependency program, but it didn't work out. She was not aware of the incident on 1/15/21, when R2 was found passed out in the community. The SSD stated the facility did not complete a community safety assessment and said they used the wandering assessment to determine if a resident was safe to leave the facility. Upon admission the social services department went over the policies with R2 including the leave of absence (LOA) policy, alcohol and drug policy and smoking policy. The SSD stated if risks were identified they had a verbal conversation with the resident. At 1:25 p.m. DON stated when a resident admitted to the facility a wandering assessment was completed. The DON stated if a resident was their own decision maker, unless there is something to lead us to believe they are not safe, we let them go into the community. The DON said criteria for being considered not safe would include a low cognition score, any documentation of being unsafe, any type of commitment or if a guardian said so. The DON stated, Unless I have something that says they can't go out, they can go out, and stated she could not block a resident's ability to leave the building. The DON further stated the only assessment used to determine a resident's ability to safely go out into the community was the Wander assessment. The IJ for unsafe alcohol use was removed on 1/29/21, at 9:22 a.m. when it could be verified through document review and staff interviews: the facility comprehensively assessed R2's alcohol use in the community and implemented interventions to reduce the risk of harm. In addition, the facility discussed the risks of continued alcohol use in the community to R2 and updated the medical director and implemented polices and procedures to assess for safety in the community and unsafe alcohol use. A comprehensive assessment was not completed for R1 as he had been discharged from the facility and did not anticipate readmissions back to the facility. MISSING RESIDENT: R1's admission Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and was independent with all activities of daily living. Diagnoses included Wernicke's [CONDITION(S)] anxiety disorder and depression. R1's discharge MDS identified R1 had an unplanned discharge from the facility on 1/21/21. An incident report submitted to the SA on 1/21/20. indicated R1 had not been in the facility since 1/18/21, and staff had not been able to locate him. The corresponding investigation report summary submitted to the state agency on 1/22/21, indicated R1 admitted to the facility and was required to attend the substance abuse treatment program within the facility. The report indicated R1 avoided admission to the program and would leave the facility often for periods of time (days). The facility failed to notify the police when R1 did not return to the facility after leaving on 1/18/21. The facility left a voicemail with R1's county case manager on 1/20/21; but made no further attempts to locate R1 until 1/21/21. The facility Resident Sign Out sheets for January of 2020, indicated on 1/17/21, R1 signed out of the facility at 9:00 a.m., Destination indicated out. Time in was not identified. The records indicated R1 did not sign out or back in again. R1 did not sign out of the facility on 1/18/21. R1's progress note(s) identified the following: - 1/18/21, R1 was absent for breakfast. - 1/18/21, R1 refused lunch. - 1/20/21, Voice mail was left for R1's county case worker (CCW) regarding his whereabouts, awaiting a call back. - 1/21/21, indicated R1 had not been in the facility since 1/18/21. Writer received a voicemail from county case worker that she did not know where R1 was. - 1/21/21, R1 had not been in the facility since 1/18/21. Writer placed call to R1's family member (FM)-A, identified as R1's emergency contact and power of attorney, and asked if she knew of his whereabouts. FM-A stated she had not spoken to R1 since 1/16/21 and believed he may be at a friend's house. -1/22/21, R1's FM-A called the facility and explained she believed R1 was at a friend's house and gave the address to staff. - 1/22/21, FM-A called facility and reported she had called the police to do a welfare check on R1. - 1/22/21, Received a call from the police department stating R1 had been found. R1's medical record lacked evidence R1 left the facility against medical advice. There was no evidence in the medical record R1 did not have any intention of returning to the facility. On 1/26/21, at 12:18 a.m. FM-A stated the facility did not tell her when R1 left on 1/18/21 and did not return for several days. FM-A stated she heard R1 had not been in the facility since 1/18/21, from R1's CCW. At 12:45 p.m. SSD stated each day R1 would leave the facility and come back. R1 began spending longer amounts of time in the community. When R1 left the facility and did not return they were not concerned until three days passed without seeing R1. SSD stated, We didn't feel his safety was at risk until several days had passed. At 1:25 p.m. DON stated when a resident admitted to the facility a wandering assessment was completed. The DON stated if a resident was their own decision maker, unless there is something to lead us to believe they are not safe, we let them go into the community. The DON said criteria for being considered not safe would include a low cognition score, any documentation of being unsafe, any type of commitment or if a guardian said so. The DON stated, Unless I have something that says they can't go out, they can go out, and stated she could not block a resident's ability to leave the building. The DON did not identify if a resident did not return from an outing what steps the facility would take. On 1/27/21, at 3:45 p.m. NA-B stated most of the residents in the facility were able to leave and come back. NA-B stated if a resident was okay to leave they would pass on to the next shift if the resident had not returned by midnight attendance. NA-B stated a resident was not considered missing unless they had a wanderguard (and could not be found) or staff were told they could not leave. On 1/27/21, at 4:00 p.m. RN-B stated if a resident was assessed to be safe to leave the facility they could leave. When a resident left the building and did not return the staff would pass it on from shift to shift until the resident returned unless the resident had a wanderguard or was not allowed to leave for some other reason. On 1/27/21, at approximately 4:15 p.m. the DON stated the facility did not have a missing persons policy and/or procedure. On 1/29/21, at 9:30 a.m. RN-A stated staff should report to the DON or on-call nurse, falls, incidents of aggression, elopements, and any other things they were not sure about. Regarding R1, RN-A stated if he left on a Monday and Tuesday came, she didn't expect staff to call her. RN-A stated R1 could leave the building and she didn't feel staff should call. RN-A stated if a resident was a wandering risk and was considered missing, a report would be made to the state agency within 24 hours. But if a resident was not a wander risk, they were not considered missing if they did not return to the fancily. A missing resident policy was requested and was not received. The missing person IJ was removed on 1/29/21, at 9:22 a.m. when it could be verified through document review and staff interviews the facility had developed a policy with procedures to implement if a resident had not returned from an outing by midnight.

Based on observation, interview and record review, the facility failed to ensure medications were secured, allowing a resident (R1) to have access to medication that was ingested for a suicide attempt. These practices resulted in an immediate jeopardy (IJ) for R1, whom was hospitalized and then intubated (insertion of a tube into the airway) as a result of the adverse effects of the medication overdose. The immediate jeopardy began on 12/15/20, when trained medication aid (TMA)-A failed to secure medication that was left unattended. The facility administrator and Licensed Practical Nurse (LPN)-B were notified of the immediate jeopardy on 12/17/20, at 2:45 p.m. The facility had implemented corrective action, ending the immediate jeopardy on 12/16/20, prior to the start of the survey, so the deficient practice is being issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further indicated R1 was independent with bed mobility and transfers, needed limited assistance for dressing and activities of daily living (ADL's), and ambulated without assistive devices. R1's annual MDS dated [DATE], indicated R1 had thoughts of self-harm or thought she would be better off dead on several days. R1's care plan last reviewed 11/18/20, indicated R1 had daily auditory hallucinations of voices telling her to kill herself. R1's care plan further indicated R1 used a computer communication device as needed to communicate with caregivers. A progress note written by LPN-A on 12/15/20, at 11:47 p.m. indicated TMA-A reported R1 ingested 14 pills from a [MEDICATION(S)] (an anti-psychotic medication) pill card. The progress note further indicated R1 informed LPN-A I took the pills from the cart and I took them. and The voices in my head told me to kill myself. I want to die. When interviewed on 12/17/20, at 11:36 a.m., registered nurse (RN)-A stated she reviewed camera footage from 12/15/20, that showed the following: -6:07 p.m. TMA-A removed medication from the cart, and was interrupted by another resident. TMA-A set the medication down on top of the cart. -at 6:09 p.m. TMA-A walked away from the cart, leaving a medication card on top of the cart. -at 6:15 p.m. R1 was seen standing at the medication cart, taking a card off the medication cart, then returned to her room next to the cart. -at 6:25 p.m. TMA-A returned to the medication cart and continued her medication pass. -at 6:40 p.m. R1 approached TMA-A, and handed a medication card and her computer communication device to TMA-A. RN-A further stated TMA-A told her R1's computer communication device indicated R1 ingested the medication and that she wanted to die. A document titled Medicine Intensive Care Unit (ICU) Admission, dated 12/15/20, indicated R1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medicine ICU Admission further indicated R1 had acute [CONDITION(S)] and was intubated for airway protection. A urine drug screen report dated 12/16/20, at 5:02 a.m., indicated [MEDICATION(S)] and [MEDICATION(S)] metabolites were present in R1's urine. The facility policy titled Policy And Procedure For Storage Of Medications, revised 12/20, indicated all medications in the facility would be stored in a safe, secure, and orderly manner. The policy further indicated medications were to be stored in locked medication carts that would be locked whenever the medication [NAME] is not in attendance. The immediate jeopardy (IJ) that began on 12/15/20, was removed on 12/16/20, when the facility implemented the following immediate action and corrected the deficient practice: Immediate safety and investigation -In an e-mail sent 12/15/20, at 7:54 p.m., the Director of Nursing (DON) indicated R1 had been sent to the hospital, TMA-A was sent home on suspension pending investigation, and the incident would be investigated including video review by RN-A. -In a behavior report dated 12/15/20, LPN-A indicated R1 was assessed and placed on 1:1 monitoring until emergency medical services took R1 to the hospital at 7:10 p.m. The report further indicated TMA-A was suspended from duty on 12/15/20, at 8:00 p.m., pending the facility investigation. The report further indicated LPN-A searched R1's room and bathroom for medication and found no medication. -When interviewed on 12/17/20, at 11:36 a.m., RN-A stated she reviewed video footage which indicated the resident accessed the medication while TMA-A left a medication card on top of the medication cart and left the cart unattended. Medication audits -In an e-mail sent 12/15/20, at 7:54 p.m., the DON indicated audits of the medication [MEDICATION(S)] would be done to ensure accurate counts. The DON further indicated audits of medication passes would be done on all shifts to ensure that medications were secured and medication carts were locked at all times. -When interviewed on 12/17/20, at 11:36 a.m., RN-A stated [MEDICATION(S)] medication counts were audited and random audits of all narcotic medications would be increased to weekly going forward. -A document titled [MEDICATION(S)] Audit, signed 12/16/20, indicated audits of [MEDICATION(S)] counts on all medication carts was completed by LPN-B on 12/16/20. Policy review -In an e-mail sent 12/15/20, at 7:54 p.m., the DON indicated LPN-B and the DON would review the medication administration and storage policies for needed changes. Policy and procedure for administration and storage of medications were reviewed and no changes were needed. Education -In an e-mail sent 12/15/20, at 7:54 p.m., the DON indicated re-education of all TMA's and nurses on the medication administration and storage policy and procedure must be completed prior to the next worked shift. -When interviewed on 12/17/20, at 11:36 a.m., RN-A stated LPN-B had been re-educating every nurse and TMA on policies and procedures concerning med storage and safety prior to their scheduled shift. -When interviewed on 12/17/20, at 9:15 a.m., TMA-B stated she has had training on medication passing and storage policy and indicated she would never leave the medications unattended. TMA-B further stated if she needed to leave cart, she would put meds into a labeled paper pouch, and lock the cart before leaving. -When interviewed on 12/17/20, 12:21 p.m., TMA-C stated she received verbal education on med storage, reinforcement to keep keys with her, and to lock the medication cart. TMA-C further stated she was shown and offered a paper copy of the policy and signed off on receiving the education. -When interviewed on 12/17/20, 12:28 p.m., TMA-D stated he recently had education regarding locking the medication cart and received the policy on medication storage. TMA-D further stated he signed a paper that education was received. -A document titled Education 12/2020, undated, indicated signatures of TMA's and Nurses that received re-education. Interdisciplinary team review and interventions -A progress note dated 12/16/20, at 11:20 a.m., indicated the interdisciplinary team reviewed the incident investigation and response and plan to reassess the resident upon return to the facility. -When interviewed on 12/17/20, at 11:36 a.m., RN-A stated R1 would have new care planned interventions upon return to the facility, after recommendations from the psychologist and further discussion with the interdisciplinary team.

Based on observation, interview, and document review, the facility failed to place 4 of 4 residents (R1, R5, R14 and R6) on the required 14 day quarantine due to potential exposure to COVID-19, upon admission or return from a leave of absence (LOA) or hospitalization , which had the potential to spread COVID-19 to all 79 current residents, which could result in serious illness or death. The immediate jeopardy (IJ) began on 11/9/20, when R1 returned from an LOA and was not placed on the 14 day quarantine. The IJ was identified on 11/17/20, and the administrator and director of nursing (DON) were notified of the immediate jeopardy on 11/17/20, at 4:51 p.m. The immediate jeopardy was removed on 11/19/20, but noncompliance remained at the lower scope and severity of an F- widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified moderate cognitive impairment with a [DIAGNOSES REDACTED]. R1's progress note dated 11/9/20, identified R1 had eloped from the facility on 11/6/20, and had returned to the facility on [DATE], after spending 3 nights at, Higher Ground, a homeless shelter, receiving meals at Catholic Charities. R1's care plan dated 9/25/20, included, Resident may be subject to a 14 day isolation in their room if they are gone on LOA out into the community for more than 24 hours or cannot maintain COVID-19 guidelines. During observation on 11/16/20, at 9:56 a.m. R1 was laying in his bed, in his room he shared with R9 and R10. R1's bed was less than 6 feet away from his room mates beds. R1 was not wearing a face mask. R9's quarterly MDS dated [DATE], identified [DIAGNOSES REDACTED]. These comorbidities placed R9 at significant risk factors for complications if R9 were to contract COVID-19 per CDC guidelines. R10's quarterly MDS dated [DATE], identified he was [AGE] years old, placing him at significant risk of serious complications if he were to contract COVID-19. During observation on 11/16/20, at 12:20 p.m. R1 was on the first floor and asked registered nurse (RN)-Z for a cigarette. RN-Z went into the medication cart and handed him a cigarette. R1 lightly touched her arm and said, You're the best, and proceeded outside to smoke. R1 was not wearing a mask during this time. RN-Z did not direct R1 to quarantine, or put on a face mask. During observation on 11/17/20, at 8:00 a.m. R1 was on the first floor in the dining room. He was sitting at a table with R4 and they were both leaning towards each other looking at something on the table. Neither of them were wearing masks and they sat and talked for over 15 minutes. During observation on 11/17/20, at 10:00 a.m. R1 walked into the common area and sat down next to R11. R11 got up and stood directly in front of R1 and started to talk to him. Neither of the residents were wearing a mask. R11's quarterly MDS dated [DATE], identified a [DIAGNOSES REDACTED]. When interviewed on 11/17/20, at 12:30 p.m. R1 stated he had spent several nights at a homeless shelter. He had not been told to quarantine when he returned to the facility, he just went right back to his normal room with his room mates. He had no restrictions on visiting in the facility with other residents. R14's admission MDS dated [DATE], identified an admission date of [DATE], was independent with ADL's (activities of daily living) and had a [DIAGNOSES REDACTED]. R14's care plan dated 10/29/20, included, he may be subject to 14 day isolation in his room if he was on LOA in the community for more than 24 hours or couldn't maintain COVID 19 guidelines. It further indicated, R14 would be asked to remain in the facility and practice social distancing to prevent the spread of COVID 19, be asked to wear a cloth mask when in common areas of the facility, and be assessed at least daily (or more often if indicated) for signs and symptoms of COVID 19. If R14 was symptomatic and/or positive, he will be asked to isolate in his room and be cared for with contact precautions as the facility was able. R14's progress note dated 11/7/20, identified he went on an LOA. R14's progress note dated 11/12/20, identified he had returned to the facility on [DATE], five days later and he had a temperature of 101.4 degrees Fahrenheit, a pulse rate of 111 beats per minute, and oxygen saturation of 98 percent on two liters of oxygen via nasal cannula. R14 also reported body pain. R14, appeared to be shaky, fatigued with labored breathing, and had a respiration rate of 28. R14 was sent to the hospital. R14's progress note dated 11/13/20, identified R14 had a hospital [DIAGNOSES REDACTED]. R14 had a roommate (R12) when he came back to the facility on [DATE] with COVID symptoms. R12's admission MDS dated [DATE], identified [DIAGNOSES REDACTED]. R6's MDS's indicated an entry tracking date of 11/6/20, a discharge date of [DATE], and another entry date of 11/16/20. R6's admission MDS dated [DATE], identified [DIAGNOSES REDACTED]. R6's care plan dated 11/3/20, included, Resident may be subject to a 14 day isolation in their room if they are gone on LOA out into the community for more than 24 hours or cannot maintain COVID-19 guidelines. R6's hospital discharge orders dated 11/16/20, identified R6 had been hospitalized with shortness of breath related to increased fluid and was being discharged back to the nursing facility. R6's progress note dated 11/16/20, noted R6 had returned and had a room change while hospitalized and was, not happy about it. R6 was to be in a private room due to return from hospitalization . During observation on 11/17/20, at 9:09 a.m. R6 stated to the trained medication assistant (TMA)-B, I'm back. She was wearing a coat and pulling an oxygen tank. She had just returned from a [MEDICAL TREATMENT] appointment. She was not wearing a mask and the nurse did not tell or encourage her to put one on. During observation on 11/17/20, at 9:55 a.m. R7 was observed carrying bags from consumer value stores (CVS). R7 entered R6's room (previous room, not the private room) and gave her some items out of the bag he was carrying. RN-B was also in the room with R6. Neither of the residents had masks on. RN-B did not remind or encourage either resident to wear a mask or maintain a physical distance of six feet. R7's quarterly MDS identified him as [AGE] years old and with [DIAGNOSES REDACTED]. R6 had a room mate, R13, and their beds were less than 6 feet apart and they shared a bathroom. R13's quarterly MDS dated [DATE], identified she was [AGE] years old and had lung disease, which placed her at risk for significant complications should she contract COVID-19. R5's face sheet (undated) included [DIAGNOSES REDACTED]. R5's entry MDS indicated an admission date of [DATE], and the admission MDS dated [DATE], identified he was cognitively intact. The monthly census report for November 2020, indicated R5 was admitted to the facility on [DATE] to a private room. R5's care plan dated 11/5/20, indicated he may be subject to 14 day isolation in his room if he was on an (LOA) in the community for more than 24 hours or couldn't maintain COVID 19 guidelines. It further indicated, R5 would be asked to remain in the facility and practice social distancing to prevent the spread of COVID 19, be asked to wear a cloth mask when in common areas of the facility, and be assessed at least daily (or more often if indicated) for signs and symptoms of COVID 19. If R5 was symptomatic and/or positive, he would be asked to isolate in his room and be cared for with contact precautions as the facility was able. During observation on 11/17/20, at 9:35 a.m. R5 came out of his room and told the nurse he needed to leave for a, little bit. The nurse (RN)-C replied That's okay, they will save your lunch for you. R5 went back to his room and then walked down the hallway to R4's room. After a few minutes, he went back to his room. At 9:39 a.m. he came out of his room and stopped at the front desk and signed out on the log book. R5 was not wearing a mask and the staff sitting at the front desk did not encourage him to wear a mask or try to deter him from leaving the facility. He walked out of the facility and toward the bus stop. He waited at the bus stop until the bus picked him up. During observation on 11/18/20, at 3:10 p.m. R5 was standing in the hallway outside of his room and was not wearing a mask. R5 stated he was recently admitted to the facility, does have a private room but has no restrictions on leaving and returning to the facility or on visiting with other residents in the facility. When interviewed on 11/17/20, at 9:22 a.m. RN-B stated the resident's don't need to be quarantined unless they stay out of the facility over 24 hours. When they come back, the staff try to get them to quarantine but, we can't force them. We educate them and show them what they are supposed to do. We take their vitals and if anything is abnormal, we record and monitor. New admissions were given a private room but were not quarantined to their room, they could come and go as they wished. When interviewed on 11/17/20, at 10:04 a.m. trained medication assistant (TMA)-A stated, We can't stop residents who are quarantined from leaving the facility. If they refuse and leave, they should get a new COVID test and be re-quarantined when they come back, depending on what the DON says and her instructions. There wasn't a specific amount of time they need to be out of the facility in order for them to be re-quarantined and they should also be getting rescreened when they come back in the building. When interviewed on 11/16/20, at 2:49 p.m. the director of nursing (DON) stated they did not have the capacity to quarantine residents once they return from the hospital or from LOA. They only had 3 private rooms and they were reserved for new admissions (107, 108, and 109). R1 had returned from the homeless shelter on 11/9/20, and was not placed on the 14 day quarantine because they had no open private rooms to place him. R14 had returned from an LOA on 11/12/20, because he was sick. R14 was not placed in a private room or quarantined and was sent to the hospital shortly after returning. R5 was a new admit and had a private room, but was not on the required 14 day quarantine to his room. R6 had returned from the hospital on [DATE], was given a private room, but refused to stay there and R6 insisted on returning to her own room with a room mate. The CDC guidance entitled, People with Certain Medical Conditions, revised November 2, 2020, identified adults with certain underlying medical conditions such as kidney disease, diabetes, or lung disease, are at increased risk from [MEDICAL CONDITION] that causes COVID-19. The greatest risk is with advanced age. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. The CDC (Center for Disease Control) Nursing Home COVID-19 Infection Control Assessment and Response Tool Facilitator Guide 11/20, included the need to place all newly admitted residents and returning residents on a 14 day quarantine period. This included isolation to their room and use of PPE. The purpose was due to potential exposure to COVID-19 while hospitalized or in the community, and to monitor for signs and symptoms of illness, and to protect staff and other residents of the long term care facility. The CDC Responding to Coronavirus (COVID)-19 in Nursing Homes updated 4/30/20, identified a facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended personal protective equipment (PPE) should be worn during care of residents under observation and should include a facemask/respirator, eye protection, gloves and gown. Further, Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. The immediate jeopardy that began on 11/9/20, was removed on 11/19/20, when it was verified through observation, interview and document review, the facility rearranged resident rooms to accommodate extra private rooms to quarantine R1, R5, and R6. R14 was discharged . All staff were educated to quarantine residents who return from LOA or hospital and new admissions for the required 14 days. All residents were assessed for unnecessary leave, care plans were updated with quarantine guidelines, residents were educated on risk of leaving the facility and social distancing. Staff monitored sign out book to determine why residents were leaving to see if needs could be met without them having to leave. However, the noncompliance remained at the lower scope and severity of an F-widespread scope and severity level, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to test all staff for COVID-19 according to CDC/CMS (Center for Disease Control/Center for Medicare/Medicaid Services) directives, allowed 13 staff members (maintenance (M)-A, dietary aid (DA)-A, DA-B, DA-C, housekeeping (HSK)-A, HSK-B, nursing assistant (NA)-A, NA-B, NA-C, NA-D, licensed practical nurse (LPN)-A, LPN-B, registered nurse (RN)-D), to work with residents without being tested for COVID-19, and failed to test all 79 residents for COVID-19 despite the facility being in a COVID-19 outbreak due to 4 staff members (activities assistant (AA)-A, AA-B, social worker (SW)-A, and dietitian-C) testing positive for COVID-19. The facilities failure placed all 79 of 79 residents at risk of contracting COVID-19, which had to potential to cause serious illness or death. The immediate jeopardy began on 11/8/20, when the facility became aware of a staff member who had worked with symptoms of COVID-19 and subsequently tested positive for COVID-19. The facility failed to test all staff and residents for COVID-19. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 11/17/20, at 4:51 p.m. The immediate jeopardy was removed on 11/18/20, but noncompliance remained at the lower scope and severity of an F- widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: When interviewed on 11/17/20, at 10:19 a.m. the infection preventionist, registered nurse (RN)-A stated, there was a, small handful, of staff who refused to be tested for COVID-19, for religious reasons. RN-A added, We honor that. They have to wear their PPE (personal protective equipment). You have to be stellar with your PPE if you are not tested . When interviewed on 11/17/20, at 12:38 p.m. the director of nursing (DON) stated, they had a few staff members who had refused to be tested for COVID-19 citing religious reasons. Who am I to question someone's religious preferences? If staff refused to be tested , they are screened each day before work and can not work if they have a fever and they have to wear PPE. The DON stated, We don't track who refuse to be tested . The DON identified their county positivity rate was 11.3%, which meant they needed to be testing staff twice a week. The DON stated they had one resident, R14, who had returned from a leave of absence with symptoms of COVID-19 on 11/12/20. R14 had only been in the facility a couple hours before they sent him to the hospital where he was diagnosed with [REDACTED]. The facilities Staff Testing Log, dated 11/12/20, identified 76 current staff, however only 48 of those staff had been tested for COVID-19. When the DON and administrator were interviewed together on 11/17/20, at 2:54 p.m. the administrator stated they had one staff (dietician-C) test positive for COVID-19 on 11/6/20, and was tested outside of the facility. The facility was made aware of the test results on 11/8/20. The staff member last worked on 11/3/20, which is the day the employee identified as the onset of symptoms. This staff member was put on leave for 14 days. The administrator stated 3 of the 48 staff tested on [DATE], were positive for COVID-19 (AA-A, AA-B, and SW-A) and placed on leave for 14 days. The other 28 staff had either refused to be tested for COVID-19, or were not working on the testing dates. The director of nursing (DON) stated residents were not being tested for COVID-19, even though staff had tested positive. The DON stated they were not testing residents because they did not consider themselves to be in an outbreak status with just staff testing positive. Residents are tested per their request, if a doctor wants to rule something out, or if the resident is symptomatic. The DON reviewed the current CDC and CMS guidance for outbreak testing and agreed all staff should have been tested for COVID-19 and if refused, should have removed from the schedule and they should have begun testing residents once a positive case was identified on 11/8/20. The facility's COVID-19 testing log indicated the facility offered testing for all staff on 11/16/20. 49 of the 75 staff eligible for testing were tested for COVID-19. 26 staff members (NA-A, NA-B, NA-C, NA-D, NA-E, NA-F, NA-G, LPN-A, LPN-B, LPN-C, LPN-D, LPN-E, RN-D, TMA-C, TMA-D, TMA-E, DA-A, DA-B, DA-C, DA-D, DA-E, DA-F, HSK-A, HSK-B, M-A) remained untested . No additional positive tests were reported. R14's progress note dated 11/7/20, identified he went on an LOA. R14's progress note dated 11/12/20, identified he had returned to the facility on [DATE] and he had a temperature of 101.4 degrees Fahrenheit, a pulse rate of 111 beats per minute, and oxygen saturation of 98 percent on two liters of oxygen via nasal cannula. R14 also reported body pain. R14, appeared to be shaky, fatigued with labored breathing, and had a respiration rate of 28. R14 was sent to the hospital. R14's progress note dated 11/13/20, identified R14 had a hospital [DIAGNOSES REDACTED]. A total of 16 staff were not tested on either 11/12/20 or 11/16/20. Review of the employee time card from 11/8/20 through 11/17/20, showed 13 of these 16 staff members worked with residents since the facility's COVID-19 outbreak began on 11/8/20 (M-A, DA-A, DA-B, DA-C, HSK-A, HSK-B, NA-A, NA-B, NA-C, NA-D, LPN-A, LPN-B, RN-D). The facility's Refusal of Testing policy (undated) indicated, If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The CDC recommendations include, Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility. A single new case of [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection in any HCP (health care personnel) or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC (infection prevention and control) interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 (COVID-19) transmission. The immediate jeopardy began on 11/17/20, was removed on 11/18/20, when the facility reviewed and revised their staff testing policy to ensure all staff were tested for COVID-19 twice a week, or removed from the schedule. Staff were educated on the policy and consequences of refusal of testing. The facility implemented testing of all residents every 3-7 days. Residents were educated on the risk of refusal. This was verified by observation of testing, interview of staff and document review of testing and education provided to staff and residents and care plan review. However, the noncompliance remained at the lower scope and severity of an F-widespread scope and severity level, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to ensure the wanderguard was functioning to prevent an elopment for 1 of 3 residents (R1) reviewed for elopements. This resulted in an immediate jeopardy (IJ) when R1 eloped out of the building on 9/10/20 and was missing for 3.5 hours and was found by police unharmed. The facility immediately implemented interventions and corrected the deficient practice on 9/11/20. This is issued as past noncomplaince at Immediate Jeopardy (IJ). The IJ that began on 9/10/20 was corrected on 9/11/20 when the facilty implemented interventions to prevent reoccurance. The administrator and director of nursing (DON) were notified of the IJ past noncomplaince on 9/17/20, at 11:37 a.m., as a result of the immediate corrective action taken by the facility. Findings include: R1's admission Minimun Data Set ((MDS) dated [DATE], indicated R1 had [DIAGNOSES REDACTED]. The MDS further indicated R1 was independent for ambulation and surface to surface transfers. A Brief Interview for Mental Status (BIMS) was most recently completed on 8/21/20, that indicated R1 had severe cognitive impairment. A wander risk assessment completed on 8/19/20, indicated R1 exhibited behaviors of refusals, impaired judgement, impulsive behavior, and had wandered aimlessly within the facility or grounds within the past month. The assessment further indicated R1 was deemed unsafe to leave the facility unescorted. R1's care plan, last reviewed 8/18/20, indicated R1 was a wander risk, had a wanderguard alarm in place, and was deemed unsafe to leave the facility unescorted. A progress note dated 9/10/20, at 9:11 a.m. indicated R1 was persistently asking for cigarettes and would not wait for staff, setting off the door alarm. The progress note further indicated R1 was found walking down the alley, just off campus, and was redirected. A progress note dated 9/10/20, at 1:23 p.m. indicated R1exited the living room door with a cigarette in hand and the alarm did not sound. A progress note dated 9/10/20, at 1:41 p.m. indicated the maintenance director (MD)-A was notified via email to check the wanderguard on R1 to see if it was defective. An email from the food services director (FSD)-B to MD-A sent on 9/10/20, at 1:44 p.m., had a subject that indicated to please check, and further indicated R1 went out the living room door and the alarm did not sound. A progress note dated 9/10/20, at 8:34 p.m. noted R1 had not been seen by any staff member in or around the facility since 3:00 p.m. and no report was provided by previous shift about R1 leaving the facility. Staff searched for R1 around the vicinity but were unable to find R1. The DON, administrator, case manager, and police were notified. A progress note dated 9/10/20, at 10:53 p.m., indicated R1 was brought back by police at about 10:30 p.m. and R1 was noted to have no injuries. When interviewed on 9/16/20, at 12:09 p.m., FSD-B stated R1 exited through the living room door, and the alarm didn't sound. FSD-B further stated she charted the incident and emailed MD-A, asking him to check the door. FSD-B further stated she did not notify anyone else, but will copy the administrator or the DON in the future. FSD-B confirmed having received disciplinary action and re-education regarding elopement procedures. When interviewed on 9/16/20, at 11:45 a.m., MD-A stated when a wanderguard was not working he should be informed via text or phone call, anything but an email. MD-A further stated with an urgent issue, an email would be the last resort. When interviewed on 9/15/20, at 4:24 p.m., the facility administrator stated MD-A did not receive the email notification of the wanderguard alarm not sounding because MD-A had left for the day. The administrator further stated FSD-B did not inform anyone else the alarm was not working properly. The administrator contacted MD-A on 9/11/20, at approximately 6:00 a.m., at which time MD-A reported the wanderguard alarm system had already been checked that morning and was working properly. When interviewed on 9/16/20, at 11:45 a.m., MD-A stated there were no issues during an audit of the wanderguard alarm system on 9/11/20. MD-A further stated during an audit he ensures the key pads and unit power sensor works and that the magnet is on. MD-A further stated green lights indicate the door unit was in working order. On 9/16/20, at 12:07 p.m., licensed practical nurse (LPN)-A was observed to escort R1 from the smoking patio into the facility. When LPN-A and R1 passed through the door, the alarm sounded appropriately. When interviewed on 9/15/20, at 3:24 p.m., R1 stated a staff member goes with him outside to smoke. R1 further stated feeling safe at the facility. When interviewed on 9/15/20, at 3:31 p.m., trained medication aide (TMA)-A stated all residents' wanderguard placement was checked each shift and the evening supervisor tested each night to make sure their wanderguard works. When interviewed on 9/15/20, at 3:33p.m., nursing assistant (NA)-A stated staff recently received training on wanderguard and elopement procedures. NA-A further stated all staff respond to the wanderguard alarm and must locate the resident before deactivating the alarm. When interviewed on 9/16/20, at 10:07 a.m., NA-B stated all staff were recently re-educated regarding elopement procedures, including which residents were at risk and how to respond. When interviewed on 9/16/20, at 12:21 p.m., NA-C stated she recently received education on how to respond if someone with a wanderguard elopes from the facility. NA-C further stated the charge nurse would be immediately informed if a resident could not be located. When interviewed on 9/16/20, at 12:26 p.m., housekeeping staff (H)-A stated he received education on elopement and wanderguards when he first started working at the facility earlier in the year, and had recently read new education related to elopement and how to respond to the wanderguard alarm. When interviewed on 9/16/20, at 12:29 p.m. LPN-A stated R1 had a wanderguard and was cognitively impaired. LPN-A further stated appropriate interventions were currently followed and worked well for R1 over the past week. When interviewed on 9/16/20, at 2:49 p.m., the DON stated the facility checked wanderguard placement on residents every shift and wanderguard function every 24 hours for residents with wanderguards. The DON further stated if it were noted the wanderguard system was not working the expectation was to notify the DON, infection preventionist, administrator, or assistant administrator immediately. The DON further stated staff should monitor the door or have increased monitoring of the resident if there was an issue with a residents wanderguard. The DON also stated, in response to R1's elopement on 9/10, staff followed the policy when the wanderguard alarm went off around 3:30 p.m., and staff did not realize R1 had eloped when another resident set off the wanderguard alarm. The DON added when the facility realized R1 was missing they searched rooms, the building grounds, called the police and reported the incident to the State Agency (SA). Finally, the DON stated all staff had been re-educated on the elopement policy. When interviewed on 9/17/20, at 9:39 a.m., the administrator stated FSD-B should have notified the administrator and DON immediately about the wanderguard alarm not sounding on 9/10/20, versus writing an email to MD-A. The policy titled Wandering / Elopement Prevention Plan Policy and Procedure, updated 6/20, indicated it was the policy of the facility to provide a safe environment for all residents. The policy further indicated the safety care plan would be assessed as needed to ascertain appropriate wandering prevention. The policy further indicated staff would inform maintenance of any alarm maintenance or needed repair work. The document titled Wanderguard Protocol Refresher, dated 9/11/20, included images of residents with a wanderguard, and indicated when the wanderguard alarm sounds, staff should check for residents on a wanderguard outside the building and around corners. The protocol refresher further indicated staff should not turn off the wanderguard alarm unless they are 100% certain residents with a wanderguard are safe and accounted for. The immediate jeopardy (IJ) that began on 9/10/20, was removed on 9/11/20, when the facility took the following steps to remove the IJ and correct the deficient practice: On 9/11/20, an audit of the wanderguard system, including all wanderguard bracelets used, was completed to ensure they were in proper working order. On 9/11/20, disciplinary action and re-education regarding equipment malfunction was provided to maintenance staff and staff that observed the wanderguard malfunction. On 9/11/20, the elopement protocol was updated to indicate staff will check the grounds thoroughly and account for residents with a wanderguard in response to the door alarm. All staff were re-educated to the facility elopement policy and protocol beginning on 9/11/20. Verification of corrective action was confirmed by interview with a variety of nursing and non-nursing staff that verified education was provided and staff will notify maintenance and administrative staff of any possible malfunction of the wanderguard system and ensure the notification is received.

Based on observation, interview and document review, the facility failed to thoroughly assess, investigate and implement interventions to minimize the risk of elopement for 1 of 4 residents (R13) reviewed for accidents. The facility's failures resulted in an immediate jeopardy (IJ) with potential for serious harm for R13. In addition, the facility failed to thoroughly investigative causative factors for falls in order to determine appropriate interventions to reduce the risk of falls for 2 of 4 residents (R103, R96) reviewed for falls. The immediate jeopardy began on 4/12/16, when R13 was determined to be unsafe to leave the facility unsupervised. The director of nursing (DON) was notified of the immediate jeopardy on 5/17/16, at 5:00 p.m. The IJ was removed on 5/18/16, at 12:50 p.m. however, non-compliance remained at a lower scope and severity of D, indicating an isolated issue with potential for more than minimal harm for R13. Findings include: R13's Admission Record Resident Information Sheet indicated he had [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE], indicated R13 had intact cognition and was independent with all activities of daily living. Although facility staff were aware R13 had displayed behaviors of elopement at his previous placement prior to the resident's admission, a Health Care Center Assessment For Resident's Ability To Leave Facility Safely dated 3/11/16, indicated R13 could leave the facility unescorted. The rationale for allowing R13 to continue to go into the community independently was documented as, went out independently at prior facility. R13's care plan dated 3/22/16, identified a potential for abuse to self and/or to/from others related to impulsive behaviors and borderline intellectual functioning. The care plan identified a history of unsafe behaviors. such as running out into the street without looking, approaching strangers in the community and going up to strangers' cars in traffic. Care planned interventions included: assessing and reviewing quarterly, documenting and reporting any incidents, educating staff, monitoring and intervening as needed. The care plan further identified use of a Wanderguard (bracelet system that activated selected doors when attempting exit) due to engaging in unsafe behaviors outside of the facility. The care plan also indicated R13 had displayed these behaviors at his previous facility. The facility's Health Care Progress Notes dated 3/11/16 through 5/18/16, revealed the following: 1) 3/13/16 R13 was described at restless, was wandering about the first floor of the facility and attempted to get out of the front door. 2) 3/14/16 Medical records staff reported as she was parking her car on Central Avenue (a busy metro street), R13 walked across the street and approached her car window. A subsequent note indicated another staff was parking her car and R13 also approached her car on the driver's side with cars coming in the same direction. 3) 3/16/16 Staff pulled up in front of the building and R13 approached the car on the drivers side in the lane of oncoming traffic. A subsequent note indicated R13 attempted to exit the facility seven times within one hour and indicated he walks up to the traffic light and the alley. Another note on the same day indicated R13 had been running in and out of the facility begging for money from visitors. 4) 3/18/16, Staff was walking by the first floor lobby and heard alarm sounding from the door leading to the outside. Staff turned off the alarm and upon returning outside observed R13 running across Central Avenue to the bus stop. 5) 3/26/16, At approximately 3:00 a.m. staff observed R13 outside the back door. R13 stated he did know when he went outside, but demonstrated how he exited. The note indicated R13 held his arms and hands at shoulder level and was able to exit through the door without sounding the alarm. 6) 4/2/16, R13 was knocking on the front door to be let in at 2:15 a.m. and again at 2:30 a.m. At 4:45 a.m. R13 was observed leaving via the south stairwell. 7) 4/3/16 At 5:15 a.m. R13 was observed going out the back door with another resident. When the other resident returned R13 was not with him. Staff went outside to look for R13 but did not find him. Staff got into a car to look for R13 and found him walking south from the local pharmacy several blocks away. R13 was crossing the street irregardless of any passing car. At 7:00 a.m. another staff was driving south to work and observed R13 to be walking haphazardly south on the sidewalk. 8) 4/5/16 Staff responded to the exit door alarming to find R13 crossing the street to the median and then crossing to the other side. A second note indicated later in the day another resident called out loudly reporting R13 had gone outside via the fire door. The alarm did not sound so staff thought the resident was mistaken. Somewhat later R13 appeared at the locked front door knocking to get in. 9) 4/6/16 R13 was heard pounding on the main lobby door at 1:00 a.m. and could not state how long he had been outside. 10) 4/7/16 At 3:00 a.m. R13 was knocking on the glass of the front lobby door to gain access. Staff on his floor was not aware he had eloped. 11) 4/9/16 R13 was brought back into the facility at least four times since 4:00 a.m. At 10:30 a.m. R13 went out the back patio door and into the alley. Staff could not see him until he reached Central Avenue and already several blocks away. He was escorted back to the facility. 12) 4/11/16 A note indicated despite the use of a Wanderguard, R13 left the building up to 15 times per day. The note further indicted staff was to complete a community safety awareness test to check for appropriateness of the Wanderguard. 13) 4/12/16 Life Skill/Life Safety evaluation performed. R13 was able to answer most questions without issue but was unable to demonstrate his actual ability to put what he could verbally state into practice. The Life Skill/Life Safety Pedestrian Safely (sic) evaluation dated 4/12/16, indicated the following: R13 does not understand the importance of signing in/out of the facility .20 seconds after reminder, he forgot what to do. R13 was not able to recite the facility address and phone number, did not have a cell phone, nor did he have a wallet or identification card. The assessment further identified R13 did not understand jay walking, did not cross the street appropriately, and did not demonstrate an ability to look both ways before walking across the street .writer had to hold resident back. Very impulsive. R13 was unable to demonstrate a need to wait for traffic to clear and had to be held back several times for safety reminders. The assessment indicated R13 did not hold his head up when walking, walked between parked cars, and is very impulsive, poor decision making skills. Walks into the street with no regard for safety. After the evaluation had been completed, there was still no indication the facility had implemented intervention to promote safety and reduce the risk of elopement which resulted in the following incidences: 1) 4/19/16, R13 left the building several times, setting off the fire alarm door twice but the sound was not loud enough to be heard from the 1st floor desk. He had gone out the front door and sometimes his wander guard sets off the alarm and sometimes not .At least once he has taken off down the side walk and when staff requested he return, he refuses. 2) 4/24/16, At 4:00 p.m. R13 was outside the facility pushing a local pharmacy shopping cart with a couple of bags of pop. 3) 4/27/16, Staff member reported that R13 was observed on the south side of Central Avenue at 6:45 a.m. R13 crossed Central Avenue without looking both ways. As he crossed into the northbound lane a car had to stop quickly to avoid hitting him. 4) 4/28/16, At 6:00 p.m. the assistant director of nursing saw R13 at 37th avenue and Central Avenue, approximately three blocks from the facility. 5) 5/3/16, A late entry note for 5/2/16, indicated R13 was observed walking across Central Avenue over the railroad tracks through traffic. He then went to the bank and was asking strangers for money. 6) 5/7/16, R13 eloped from the facility at approximately 1:35 a.m. through the south emergency exit and could not be seen in the dark. He did not return for approximately 20 minutes. At 4:45 a.m. R13 set off both the parking lot door alarm and the emergency exit alarm. R13 appeared to be panhandling on Central Avenue and refused to come back into the building. 7) 5/10/16, R13 went out the front door for the sixth time that evening. R13 walked north on Central Avenue, got to a corner and crossed during a red light without looking. A car narrowly missed him, he continued up the road. 8) 5/17/16, A late entry note for 5/16/16, indicated staff found R13 at 37th Avenue and Central Avenue. He appeared to be headed back toward the facility, and refused a ride offered by staff. During an observation on 5/17/16, at 12:34 p.m. R13 was lying in his bed and appeared to be asleep. A Wanderguard bracelet was observed on R13's right wrist. During an interview on 5/17/16, at 12:38 p.m. a nursing assistant (NA)-A stated no one on the third floor was considered an elopement risk at that time. She stated two residents on the unit wore Wanderguard bracelets, but was not aware R13 had one. NA-A stated if a resident with a Wanderguard attempted to go downstairs in the elevator the elevator would not work however, a resident could exit the unit via the stairs while wearing a Wanderguard bracelet. NA-B stated on 5/17/16, at 12:43 p.m. the Wanderguard bracelet would activate the elevator and the exit doors of the facility . She stated she was aware R13 wore a Wanderguard bracelet, but further stated he has left the facility while wearing the bracelet. NA-B explained the second floor residents with Wanderguard bracelets were to be checked every 30 minutes, but the whereabouts of third floor residents was not also routinely monitored. During an interview on 5/17/16, at 12:48 p.m. trained medication aide (TMA)-A stated, When a resident with a Wanderguard attempts to leave the facility the door will alarm. TMA-A also said staff are aware of who was at risk for elopement because they wear a Wanderguard bracelet. She stated the facility had a machine used to check the functioning of the Wanderguard bracelets but, but TMA-A was unsure whether there was documentation to that effect. A review of R13's May 2016, medication and treatment administration records did not reflect evidence of monitoring for placement or function of the Wanderguard. The director of nursing (DON) stated during an interview on 5/17/16, at 1:50 p.m. R13 was unsafe to be out of the facility unsupervised. She explained he wore a Wanderguard but was able to get out of the door before the alarm sounded off by lifting up the arm while wearing the bracelet. The DON also stated the facility had been working with R13's day program to find interventions to keep him from eloping from the facility. She added, The social worker developed a budget for him and the facility has purchased chewing tobacco in an effort to tide him over between cigarette breaks. During a subsequent interview with the DON at 3:50 p.m. on 5/17/16, the DON stated if R13 leaves the facility and would not return, staff would sometimes follow him and other times observed him from the building. However, she stated if he left and could not be seen, staff waited for him to return. The DON verified there had been times when R13 had been out of the facility and not within sight of staff. She stated on the night shift there were two TMA's, one nursing assistant, and one nurse on duty. Staff tried to re-direct R13, but he went out another door. She stated when the over night nurse started blood glucose checks and insulin administration, they were unable to watch him. The DON stated there had been no formal investigations regarding R13's elopements from the facility, and stated she was unsure whether his psychiatrist had been updated regarding the elopements. The DON stated the medical director would have been aware of R13's elopements, but would not have written any orders or notes since he was not the resident's primary physician. During an interview on 5/18/16, at 6:45 a.m. NA- C stated she was typically in the dining room in the morning. She stated she could sometimes hear the alarms. NA-C stated if an alarm sounded she would go to the door and follow R13. She stated if he wouldn't come back she would hope other staff would come and help. A registered nurse (RN)-A stated in an interview on 5/18/16, at 6:51 a.m. R13 had become quite talented at getting out of the facility. She stated he could go out the back door and get out into the alley. RN-A stated R13 would frequently go out of the building around 4:00 a.m. and would eventually return. She stated staff tried to spot where he was going but was not always able to and stated, He likes to go full speed across Central Avenue. She stated on the night shift she would try to get him to come back but could not abandon the building because there was not enough staff on duty. While R13 had left the faciity on multiple occasions and was assessed to be unsafe to leave the facility independently, there was no evidence the facility investigated the incidents nor was there evidence of care planned interventions to keep him from leaving the facility and wandering through high traffic areas. A facility policy titled .Health Care Wandering Prevention Plan Policy And Procedure dated 8/2010 was reviewed. The policy indicated the facility was to provide a safe environment for all residents and directed staff to assess the resident's needs prior to and after admission to determine his or her ability to leave the facility safely. The policy further directed staff to review the safety care plan quarterly and as needed. The immediate jeopardy that began on 4/12/16 was removed on 5/18/16 when the facility had taken measures including: moving the resident to a more secure living unit, initiating 15 minute checks to verify the resident's whereabouts, utilizing 1:1 staffing as needed, adding additional activities and cigarette breaks for the resident, developing a system to check the resident's Wanderguard each shift, updated the primary physician and psychiatrist, and began investigating alternate placement options which may be more appropriate for the resident. Surveyors verified the plan had been implemented by observation of the resident, interviews with staff, and through review of the facility's documented protocols, assessment and plans. R103's admission Minimum Data Set ((MDS) dated [DATE], indicated he was severely cognitively impaired, required extensive assist of two staff for toileting, transfers and ambulation and had a history of [REDACTED]. A Fall Risk Assessment - Admission/Annual dated 5/11/16, indicated R103 had been in the facility less than two months and had sustained multiple falls in the past six months. The assessment indicated R103 attempts to ambulate independently but is very unsteady which has led to several falls since admission. He had an alarm on in bed and wheelchair to alert staff when he is attempting to self transfer and has had 5 falls since admission. The assessment further indicated R103 was being monitored for elevated blood pressure, has had medication adjustment and is receiving physical and occupational therapy. R103's care plan dated 5/13/16, identified a risk for falls and directed staff to remove foot rests on wheel chair, encourage use of handrails or assistive devices, reinforce need to call for assistance and refer to physical and occupational therapy. During an observation on 5/18/19, at 1:41 p.m., R103 was lying in bed on his back with one foot hanging off of his bed. He had a pressure pad alarm under him. R103 was wide awake with the curtains pulled around his bed. A review of the Health Care Progress Notes dated 4/28/16, through 5/19/16, indicated the following: - 4/28/16, R103 admitted to the facility at approximately 12:00 p.m., At 4:15 p.m., R103 was ambulating in the dining room, tripped on his foot rest and fell , hitting his mouth on the table. A corresponding Health Care Resident Incident Report dated 4/28/16, indicated R103 had a bruise below his lower lip, alarms were placed on his wheel chair and his bed and a reminder to ambulate with staff assistance. - 4/30/16, At 8:00 p.m., staff heard R103's alarm sounding and responded due to NAR's, nurse and TMA all too busy. R103 was lying in bed with both feet on the floor. Staff directed R103 to stay in bed. At 8:20 p.m. R103 was found on the floor next to his bed. He had an abrasion on the left side of his head and he re-opened a scrape on his left knee. A corresponding Health Care Resident Incident Report dated 4/30/16, did not include any new interventions. - 5/2/16, At 12:00 a.m. R103 attempted stand up by himself, took a couple of steps, and fell backwards on to his buttocks. The note indicated he had been incontinent of urine. A corresponding Health Care Resident Incident Report dated 5/2/16, indicated R103 seems to be sleeping better at night and did not include any new interventions however, a subsequent progress note indicated staff called nurse practitioner to request an order for [REDACTED]. - 5/6/16, At 12:15 p.m. R103 had a fall in the dining room. He stood up and fell to his bottom. A corresponding Health Care Resident Incident Report dated 5/6/16, did not include any interventions. An IDT review of R103's fall indicated the physician adjusted his medication. The note further indicated R103 was left in the dining room after the meal and nursing assistants were directed to stay with him until he returns to the unit. - 5/10/16, R103 was found on the floor in another residents room 10:00 p.m. His chair alarm was turned off. A corresponding Health Care Resident Incident Report dated 5/10/16, did not identify any new interventions. - 5/11/16, R103 was found on the floor by his bed at 9:00 p.m. He was found on his left side almost on his stomach with his head next to a trash can. A corresponding Health Care Resident Incident Report dated 5/11/16, indicated a bruise beginning to appear behind R103's left ear. The incident report identified the need for a half side rail to assist in mobility, however, during an observation on 5/19/16, at 7:00 a.m., no side rail was present on R103's bed. A subsequent note indicate R103 had bruising to the side of his face. -5/18/16, R103 was found on the floor by his bed at 9:35 p.m. A corresponding Health Care Resident Incident Report was requested but not received. During an observation on 5/19/16, at 6:36 a.m., R103 ambulated independently out of his room and into hallway and fell on to his buttocks and side. R103's pants were soaked with urine. R103's wheel chair was in his room and the alarm was not sounding. At 7:13 a.m., NA-D and NA-E assisted R103 to the bathroom. R103 was wheeled to a grab bar in the bathroom where he stood while NA-D and NA-E pulled down his pants and lowered him to a shower chair. The shower chair was wheeled to the toilet. R103 was not wearing a transfer belt while staff assisted him. NA-D changed R103's pants and then wheeled the chair back to the grab bar. R103 was assisted to stand up from the shower chair, his feet were pressed against the wall while holding onto the bar with his body at an angle. R103 still did not have a transfer belt on and Both NA-D and NA-E were approximately 2 feet from him while hung hung on the grab bar. While NA-D and NA-E were applying a clean incontinent brief to R103, he was leaning against NA-E's left thigh for support. NA-D stated, We are supposed to use a transfer belt when assisting R103 to transfer. During an interview on 5/19/16, at 6:37 a.m., TMA-B state R103 was at risk for falls. She stated he is supposed to have an alarm in his wheel chair and in bed. TMA-B checked the alarm on R13's wheel chair and stated it had not been turned on. During an interview on 5/19/16, at 6:44 a.m., RN-B stated R103 is supposed to have an alarm on and stated he has had a lot of falls. She stated R103 is impulsive and tries to get up on his own. RN-B stated she was unaware of any fall interventions for R103 aside from the alarm. RN-B walked away stating, I don't understand, why was he in the room by himself? During an interview on 5/19/16, at 6:53 a.m., NA-D stated R103 likes to stand by himself. She stated we keep eyes on him. NA-D stated she usually works the PM shift and staff toilet R103 before and after supper. She was unable to locate a care sheet to direct her when to toilet R103 or what fall interventions had been implemented. During an interview on 5/19/16, at 11:03 a.m. licensed practical nurse (LPN)-A stated a transfer belt should be used for all resident who require assistance. LPN-A was unable to locate a care sheet for R103 that directed staff regarding cares and safety interventions. During an interview on 5/19/16, at 11:03 a.m., the DON stated R103 required a two staff transfer and stated a transfer belt should be used for all residents unless they were independent. The DON stated when a resident in the facility falls the nurse on the floor starts an incident form. She stated the IDT reviews falls every Monday, Wednesday and Friday and looks to see what can be done differently. An undated facility document titled 2nd floor, directed staff to transfer R103 with assist but did not identify how much assistance was required. The document further directed staff to assist with toileting, but did not direct staff on level of assistance required. Further, while the document had a category for safety, there were no safety interventions listed for R103. While R103 had sustained eight falls in the facility since his recent admission, including some with minor injuries, and while the facility did attempt to put some interventions in place, there was no evidence the facility thoroughly investigated the falls in an effort to determine the underlying cause of the falls. nor was there evidence that staff had been educated regarding fall interventions for R103. A facility policy titled Health Care Fall Risk Assessment Policy And Procedure, dated 1/9/14 indicated: It is the policy of Health Care Center to provide protective and preventive care for the problems identified from the assessments. The policy directed staff to identify specific underlying causes for falls and develop a treatment plan and record it in the care plan. R96's falls were not adequately investigated for root cause, in order for appropriate interventions to be developed. R96's annual Minimum Data Set ((MDS) dated [DATE], indicated the resident was cognitively intact but required extensive physical assist of two staff for toileting and transferring. A Fall Risk assessment dated [DATE], indicated R96 had sustained multiple falls in the past six months. The assessment indicated R96 Is refusing to ambulate at this time, not because she is 'lazy' but because of the pain in her legs. She is using a wheelchair for primary mode of locomotion. She can propel herself, but moves at a very slow pace and staff assist to bring her to destinations prn (as needed). She is very unsteady/shaky when she stands, and moves her feet very slowly. Staff provide assistance w (with)/bed mobility (lifting legs into bed prn) and with transfers as she is unsteady and needs staff to assist to steady self. No longer is able to transfer independently. Unknown cause for functional decline. Has been seen in the hospital and labs/testing were wnl (within normal limits)/negative. Requires up to three staff members depending on how she is feeling at the time. Often shaky and very stiff. Is discouraged form (sic) attempting self transfers due to the high numbers of falls (5 past quarter, one with minor injury). History of falls prior to admission, last noted June 2014. The assessment further indicated R96 displayed wandering, verbal and physical behaviors, and socially inappropriate behaviors in the previous seven days. R96's care plan printed 4/21/16, indicated a high risk for falls and instructed staff to encourage resident to ask for assistance with mobility needs/transfers when needed, ensure environment was free of clutter, evaluate effectiveness and side effects of medications with providers prn, orthostatic blood pressures weekly and reinforce need to call for assistance prn. An undated Nursing Assistant Sheet (care instructions) directed staff to provide R96 with assistance in transferring and toileting and indicated R96 had a colostomy, used a wheelchair and smoked. The instructions did not identify R96 as being at risk for falls, nor any reminders to prevent falls such as: reminders to ask for assistance, use the wheelchair brakes, or to call for assistance from staff. A review of Progress notes and the facility's Health Care Resident Incident Reports 10/1/15 through 5/18/16, indicated the following: 1) 10/23/15, R96 told staff she had rolled out of bed bed the previous night at 10:30 p.m. but was able to get up independently and was 'fine.' A corresponding Health Care Resident Incident Report dated 10/24/15, indicated R96 had sustained a fall next to her bed on 10/22/16, at 10:30 p.m. The resident had reported falling/rolling out of bed, but later said she was transferring from her wheelchair and fell to her knees. Under the prevention section, it indicated it was an isolated incident, therefore the new intervention section was left blank. Under interdisciplinary team (IDT) meeting notes, staff were to encourage R96 to ask for staff assistance as needed. 2) 11/18/15, at 8:15 p.m. R96 fell in her room next to her closet. When staff asked R96 what had happened, she explained the wheelchair flipped over. The resident complained she had hit her head, shoulder and back, but denied pain. A corresponding Health Care Resident Incident Report dated 11/18/15, indicated R96 was going through a drawer in her closet when the wheelchair flipped over. The prevention and new intervention sections were left blank. The IDT notes section (also dated 11/18/15) indicated staff was to remind the resident to ask for assistant to reach times in closet and not to reach past core balance. 3) 11/21/15, at 6:10 p.m. R96 was found sitting on the bathroom floor. The resident reported she had deliberately sat on the floor. Staff had assisted her onto the toilet and went on break. The incident report was requested, but was not provided. 4) 11/21/15, at 9:42 p.m. R96 was found on the bathroom floor crying. R96 told staff she had fallen again while transferring from the wheelchair to the toilet. A corresponding Health Care Resident Incident Report dated 11/21/15, indicated the resident slipped and hit the left side of her head while attempting to independently stand. The prevention and new intervention sections were blank. the IDT notes dated 11/25/15, noted staff was to encourage R96 to follow through with physical and occupational therapy recommendations for strengthening and to use call light to summon staff as needed with toileting. 5) 12/18/15, at 8:46 p.m. R96 was found on floor in front of her bed. R 96 told staff she had forgotten to lock her wheelchair brakes. A corresponding Health Care Resident Incident Report dated 12/18/15, indicated R96 was found on the floor at 6:00 p.m. when the wheelchair rolled away from her when she forgot to lock her brakes. On the incident report, under the prevention section, nothing had been filled in and the new intervention section was also blank. Interdisciplinary Team meeting notes dated 12/21/15, instructed staff to encourage and remind R96 to lock wheelchair brakes before all transfers. 6) 1/10/16, at 1215 a.m. R96 was on floor in room lying on right side in front of bed. R96 stated she had missed a step while transferring herself from bed to wheelchair. The resident was reminded to use call light for staff assistance with transfers. A corresponding Health Care Resident Incident Report dated 1/10/16, indicated R96 was found on the floor at 12:15 a.m. On the incident report, under the prevention section, documentation indicated R96 required assist of one to transfer but forgets to put her call light on for staff assist. The new intervention section indicated the call light should be used by R96 during the day and suggested staff should offer assist with rounds . 7) Subsequent notes from 1/11/16, at 3:37 p.m. indicated R96 was very difficult to transfer, was leaning forward and was hunched over. The doctor was updated. On 1/11/16, at 8:01 p.m. R96 was sent to a local emergency room (ER) for evaluation. The Emergency Center Visit Note dated 1/12/16, identified the resident's [DIAGNOSES REDACTED]. Documentation indicated R96 had returned from the ER at 3:24 a.m. on 1/12/16. 8) 1/12/16, documentation from 4:10 p.m. indicated R96 had been found on floor at 2:40 p.m. Resident stated she had been reaching for a pop, fell , and hit her head on a waste can. The note indicated R96 had sustained a one inch laceration to her forehead. A corresponding Health Care Resident Incident Report dated 1/12/16, indicated R96 was found on the floor at 2:30 p.m. On the incident report, under the prevention section, documentation indicated R96 had difficulty transferring and was suppose to use call light to have staff assist. However, the notes indicated R96 had not called for help. The section for new interventions was left blank. 9) 1/16/16, at 3:36 p.m. NA-C charted, I think she would benefit a lot if she could transfer down to second floor, where there are more staff available to help with cares. 10) 3/2/16, at 12:18 a.m. R96 was lying on the floor. R96 stated she had fallen, and had hit her head against the bathroom door. A corresponding Health Care Resident Incident Report dated 3/2/16, indicated R96 had been found on the floor in the bathroom. The section for prevention on the incident report had been left blank. The new intervention section included instruction for staff to assist the resident to toilet and encourage resident to use call light. Documentation in the progress notes from 3/14/16, at 2:42 p.m. indicated R96 was being moved to the second floor the following day. During interview on 5/18/16, at 2:24 p.m. R96 said, I transferred myself to bed and walked a few steps today. R96 also stated, Quite a few times when I use the call light they come right away. I try to remember to use the call light but do not always. I do not know why I fall. The falls started at Anoka Regional Treatment Center. NA-F stated on 5/18/16, at 3:00 p.m. R96 does most of the work. (R96) grabs the the grab bar. I just stand by. During interview on 5/19/16, at 1:07 p.m. the director of nursing (DON) verified the interventions identified for R96 post incidents included: encouraging R96 to use call light and not go to the bathroom by herself, to encourage R96 to not reach past center of balance, and to encourage R96 to lock her wheelchair brakes. The DON said, we are developing a new incident report. We know the incident reports could be filled out more completely. I think the IDT team has a good grasp of root cause analysis, we are working with the nurses. As we start using the new form we will be identifying true root cause analysis. The DON said when encouraging a resident to use a call light is part of the interventions it is ok, but if it is the only intervention it would probably not be adequate. When asked how new interventions were communicated to the NAs, the DON stated we make sure the nurse on the floor knows the interventions so they can tell the nursing assistants. We also use a communication page in Point Click Care (electronic medical record) and all staff can see it. A copy

Based on observation, interview and document review, the facility failed to provide assessment and interventions to prevent accidents for 3 of 7 residents (R93, R100, R58) related to safety in the community and who regularly left the facility unescorted and without supervision. This resulted in an immediate jeopardy (IJ) for R93, R100 and R58 who were known to leave the facility and sustained injuries and/or fracture. Findings include: R93 was known to not obey traffic rules, drove his motorized scooter without wearing glasses, without wearing shoes and in an unsafe manner (in the street). R93 had sustained falls from his motorized scooter after drinking alcohol and was transported from a county jail in an unsafe manner without a scooter or canes resulting in falls. R100 was known to leave the facility to drink alcohol at a nearby bar, return to the facility and sustained three separate falls resulting in serious injury (fractures) in his room. R58 was known to not obey traffic and pedestrian rules, had a known history of being hit by motorized vehicles, had a known history of being robbed outside the facility, had a known history of not wearing safety equipment (a helmet and reflective vest/smock) and who had sustained 42 falls in and outside of the facility within an eight month period. In addition, the facility failed to comprehensively assess 2 of 3 residents (R93, R94) who used a motorized scooter for safe use of the scooter; failed to re-assess 3 of 7 residents (R93, R100, R58) after incidents of falls. The IJ began [DATE], after observations on [DATE], at 11:30 a.m. when R93 was observed leaving the facility unescorted through the front door via a motorized scooter. R93 was observed to be barefoot, had no glasses on and the scooter had several scuff marks on the front left below the handle bars. The outside temperature at the time was 50 degrees Fahrenheit (F). R93 was observed to head north on Central Avenue Northeast (a busy four lane street) driving in the street. On [DATE], at 11:15 a.m. R93 was observed to leave the facility via a motorized scooter. R93 was barefoot, the temperature outside was 54 degrees F and he was not wearing glasses. R93 was observe to drive the scooter north on Central Avenue. Although there was a side walk on the facility side of the street, R93 was observed to drive the scooter on the shoulder and in the street on the traffic side of the parked cars. R93 was observed to motorize near the heavy traffic on Central Avenue, drive over railroad tracks and proceed to 37th Avenue Northeast where he drove east for approximately two miles (still in the shoulder of the road and not on the sidewalks) and headed north on Stinson Boulevard. R93's scooter was observed to be nearly hit by a pick-up truck, the truck driver slammed on the brakes and swerved to the left to avoid R93. Review of incident/accident reports determined R100 and R58 also were in IJ situation due to unsafe conditions and potential accident hazards. On [DATE], at 3:47 p.m. the administrator, the director of nursing (DON) and the director of social services (DSS) were notified of the IJ. The IJ was removed on [DATE], at 1:54 p.m. but non-compliance remained at the lower scope and severity level of a G (actual harm). The IJ that began on [DATE], ended on [DATE], when the assessments for resident fall risk, resident outdoor safety, and resident ability to leave the facility safely were completed; safety equipment was added as appropriate, the care plans for the identified residents were updated, policies were developed and revised, the residents and the staff were educated on the IJ removal plan. Monitoring visits were conducted on [DATE], and [DATE]. R93 was admitted on [DATE], with [DIAGNOSES REDACTED]. R93 was not assessed for safety and falls upon admission ("469 days overdue" per the clinical record) and following each accident/fall. R93 lacked the care and services to prevent and/or minimize injury from the potential falls or from being hit for oncoming traffic. R93 continued to fall and was not re-assessed for falls nor was safety re-assessed after each incident which involved the scooter. R93 continued to maneuver the scooter in the community without a comprehensive assessment. On [DATE], at 11:30 a.m. R93 was observed leaving the facility through the front door via a scooter. R93 was observed to be barefoot, had no glasses on and the scooter was observed to have several scuff marks on the front left aspect of the scooter, below the handle bars. The outside temperature at the time of the observation was 50 degrees F. R93 was observed to head north on Central Avenue Northeast (a busy four lane street) in the street. On [DATE], at 11:15 a.m. R93 was observed to leave the facility via a motorized scooter. R93 was barefoot, the temperature outside was 54 degrees F and he was not wearing glasses. R93 was observe to drive the scooter north on Central Avenue. Although there was a side walk on the facility side of the street, R93 was observed to drive the scooter on the shoulder and in the street on the traffic side of the parked cars. R93 was observed to motorize near the heavy traffic on Central Avenue, drive over railroad tracks and proceed to 37th Avenue Northeast where he drove east for approximately two miles (still in the shoulder of the road and not on the sidewalks) and headed north on Stinson Boulevard. R93's scooter was observed to be nearly hit by a pick-up truck, the truck driver slammed on the brakes and swerved to the left to avoid R93. The nursing assessment for pre-admitted d [DATE], listed R93 as forgetful, delusional, impatient, and identified R93 required glasses. The assessment of R93's ability to leave the facility safely dated [DATE], identified R93 as quadriplegic with physical devices of a motorized scooter and two canes. The most recent care plan dated [DATE], indicated R93 had been deemed safe to leave the facility unescorted, but needed reminders to follow traffic rules and to ensure R93 wore glasses. The care plan indicated R93 had been reported as causing problems on the city bus and met with the customer advocate from Metro Transit on [DATE], to try to resolve complaints. The care plan also indicated on [DATE], R93 was observed driving his scooter "in the street," that he drove the scooter "really fast" and did not always pay attention to others. The care plan further identified, "Does not always obey the traffic rules when out." The care plan goals indicated: "will comply with metro transit regulations," "will obey traffic rules when out in the community," and "will wear appropriate footwear at all times when up." The care plan interventions directed staff to: remind R93 of agreement to abide by metro transit rules and regulations; resident should not ride scooter on the street and should stay on the sidewalk. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R93 had a brief interview for mental status (BIMS) score of 15 (no impairment). The Care Area Assessment (CAA) dated [DATE], noted a history of falls and that R93 was not steady, but able to stabilize without staff assistance. The CAA also indicated R93 was at further risk for falls related to bilateral lower extremity impairment secondary to [DIAGNOSES REDACTED]. R93 could steady himself with the use assistive devices. Review of care conference notes dated [DATE], revealed the team listed R93's vulnerabilities as, "Due to mental deficits related to mental illness, would need assistance to cope with a potentially harmful situation. Staff follow care plan interventions and guards for safety." Review of R93's clinical record indicated the following: - A progress note dated [DATE], at 9:56 p.m. indicated the facility was notified by police R93 was in the middle of the street with his scooter and stranded. The note indicated the scooter battery had died and R93 was trying to push it up a hill. The note indicated the police told R93 to get out of the middle of the street, it was getting to be dusk outside and the people in cars would not see R93. The note further indicated the police had come to the facility to alert the staff R93 should not be outside on the road on his scooter at night. - The police report dated [DATE], revealed the officers came to the facility and informed the charge nurse (LPN-B) a motorist had called the police and stated R93 was barefoot and trying to make his way back to the facility by pushing his scooter on foot. The report indicated the officers expressed their concern with LPN-B, that R93 could be seriously hurt if he kept driving his scooter on the streets in oncoming traffic. When requested, no incident report was provided to the surveyor by the facility for this incident. - A facility incident report dated [DATE], indicated R93 sustained a fall in his room while trying to "steam clean" the carpeting. The report indicated R93 hit his head on the scooter when he fell and R93 expressed concern of a neck injury and requested an x-ray. The clinical record lacked evidence an x-ray was obtained. The new intervention listed to prevent future incidents was, "Resident should have help when using steam cleaner, need to ask staff for help." The incident report was signed by LPN-B. - A facility incident report dated on [DATE], indicated R93 sustained a laceration from bumping his left fourth toe on the front door while exiting the building. The new intervention was "continue to encourage resident to wear proper footwear." The clinical record lacked evidence R93's ability to drive the scooter safely was evaluated or a monitoring system was implemented to ensure R93 wore proper footwear. - A facility incident report dated on [DATE], indicated a head injury occurred when R93 drove the scooter down the stairs, instead of the ramp, after drinking alcohol at a bar down the street from the facility. R93 went to the emergency room (ER) and was diagnosed with [REDACTED]. The new immediate intervention was, "Should not attempt to drive scooter down steps - use ramp." The clinical record lacked evidence a root cause analysis was completed to determine causal factors of the fall, such as alcohol intoxication or ongoing non-compliance, to determine interventions to potentially reduce fall risk and prevent future falls. In addition, the clinical record lacked evidence R93 was provided with risk information regarding drinking and operation of a motorized scooter, community safety or evaluation of R93's ability to safely operate a motorized scooter in the community. - A facility incident report dated on [DATE], indicated R93 sustained additional head trauma when R93 backed the scooter up onto a curb and flipped backwards in the scooter and hit his head when he fell . In addition, R93 was sent to the ER for evaluation and x-ray. R93's left foot was bandaged from mid foot to toes, the left elbow was dressed, he sustained a swollen left thumb and swelling to the left side of the head. The incident report indicated R93 had thong sandals with him, but did not indicate if they were worn at time of the fall. Although the new intervention was, "Unable to avoid fall once scooter went backwards over the curb-isolated incident," The clinical record lacked evidence a root cause analysis was completed to determine causal factors of the fall, such as R93's ability to operate the scooter safely and adherence to pedestrian/street safety and ongoing non-compliance, to determine interventions to potentially reduce fall risk and prevent future falls. - A progress note signed by LPN-C dated on [DATE], at 10:20 p.m. indicated R93 was taken to jail at 10:20 p.m. and the scooter was impounded. - A progress note dated on [DATE], written at 8:48 p.m. indicated the facility received a call from the Ramsey County Adult Detention Center at 7:40 p.m. The note indicated R93 was being booked at the jail, had signed a release of medical information and requested the facility to fax R93's medical information to the jail. The note indicated R93's "MAR's/facesheet/ kardex" were faxed to the detention center. The clinical record lacked evidence of further communication with the detention center. - A progress note dated on [DATE], at 5:34 p.m. indicated LPN-D took a call from Metro Transit. The note indicated a Metro Transit dispatcher reported they had (R93's name) "on a South bound bus from Northtown" and R93 "would need assistance off the bus in about 15 min (fifteen minutes)." The note indicated LPN-D told dispatcher, "I can't guarantee anything because of our staffing and the staff that had talked to the Jailer told them res. (resident) needed to be sent back by medical transport due to residents physical needs, the dispatcher said that the driver had a hard time getting him on the bus." A progress note written at 6:20 p.m. indicated R93 was observed by facility staff "across the street holding onto something stable to prevent from falling." The note indicated R93 was assisted into her car and brought back to the facility parking lot where a wheelchair was used to return to the facility building. The clinical record lacked evidence the incident of unsafe transfer from an outside agency was reported to the State Agency (SA) and investigated to determine if neglect had occurred. The clinical record lacked evidence of ongoing communication with the outside agency, such as social service documentation to determine length of incarceration and anticipated discharge to arrange safe medical transport from the jail. - A facility incident report dated [DATE], indicated R93 fell twice while unescorted and transferring between city buses, during transport back to the facility from the county jail. The incident report indicated R93 was transported without the motorized scooter or two canes (as identified in the care plan). The incident report indicated R93 notified the facility he fell two times on two separate occasions, during transport back to the facility. The incident report also indicated, "Anoka county jail refused to get his scooter from Ramsey county jail and refused to provide canes to walk." R93 had to use a bag in each hand to balance while attempting to ambulate and transfer on and off the city bus. The new intervention was: "unable to anticipate as safe transport was not supplied after release from Anoka jail." The report indicated the doctor was not notified because no redness or scratches were noted on R93, but the assistant director of nursing (ADON) was informed. Review of interdisciplinary team notes reveal discussion of above incidents by the team, however no new interventions to ensure safety were implemented. In addition, the above incidents were never reported to the SA. On [DATE], at 8:30 a.m. R93 stated he did not sign out when he left the facility. When asked about the fall in his room, R93 stated he had gotten his own Shark Floor Cleaner because, "The facility vacuum cleaners don't pick nothing up. I had this room really clean. They kept taking the steamer out of my room." When asked about other accidents R93 stated, "I had two accidents in the scooter, if I fall I pick myself up. When I was at Regions I had therapy. This place does not have no therapy. When I fell in the room and I asked for an x-ray, they said no. The concern was if I pop that plate in my neck, I have 8 screws, I don't want that halo again." When asked how he got his scooter out of impound he implied his scooter company, Alliance, retrieved it for him. On [DATE], at 9:00 a.m. registered nurse (RN)-A stated R93 could "come and go as he pleases. He has had accidents outside the facility a couple of times." RN-A further stated, "I can't remember, he knows how to use scooter, he doesn't always obey safety rules in traffic. There might be another incident. We have a fall meeting, twice a week, we go over the falls, we review things, sometimes we change things." On [DATE], at 9:15 a.m. the maintenance director (DM) stated, "R93 goes out and comes back sometimes without his scooter, then we get a wheelchair, I've seen him pulled over by the police, they yell at him to get his flags, I've seen the sheriff yell at him to get up on the sidewalk." On [DATE], at 9:25 a.m. the administrator stated, "If they (residents) come in with a scooter, they (the facility) don't do an assessment for safe use of the scooter." The administrator confirmed he was aware of the recurrent scooter accidents and also acknowledged the incident of unsafe medical transport on [DATE], was never called in to the SA or investigated and stated he "would do that right away." On [DATE], at 10:15 a.m. the DON acknowledged the facility did not complete assessments for safe use of electric motorized scooters on admission. She stated, "We assume it's safe when they come in." She also stated R93 sometimes "makes choices that not are in his best interest." The DON stated she was only aware of two incidents of scooter accidents in the community. The DON also acknowledged there was no falls risk assessment completed for R93 since admission. When asked why the incident reports were not completely filled out, the DON stated they only fill the last two pages out "if they are calling it in." When asked why the incident of unsafe transfer was never called in to the SA, the DON stated, "Because it was part of the legal system." When asked about the police concerns regarding R93 safety she stated the police "communicated with social services" and communication "would be in the progress notes" if the police called the facility. The DON confirmed the incident of unsafe transport from jail was never called into the SA or county Common Entry Point. On [DATE], at 9:37 a.m. the DSS stated R93 was "not a vulnerable adult when out in the community" and confirmed R93 did not have a court appointed guardian. The DSS also stated R93 was "supposed to sign out when leaving the facility" and if some residents were gone at midnight, "they would call the police." R100 was admitted on [DATE], with [DIAGNOSES REDACTED]. R100 fell in his room after drinking alcohol and subsequently sustained fractures on [DATE], on [DATE] and on [DATE]. R100 was not re-evaluated for falls and safety after each fall, was not monitored for safety after alcohol consumption to prevent potential falls. As a result R100 sustained actual harm when he fell in his room after consuming alcohol and sustained a fracture of his left hip on [DATE], and sustained a fracture of his left arm above and below the elbow on [DATE], after a similar fall in his room after consuming alcohol. A review of the incident/fall progress note dated on [DATE], at 9:44 p.m. revealed a fall in the resident's room at 5:15 p.m. A general condition progress note dated on [DATE], at 12:28 a.m. indicated, "Called emergency room at 12:30 a.m. admitted with hip fracture, currently in emergency room ." A hospitalization progress note dated on [DATE], at 5:13 a.m. indicated, "Resident has been admitted to Hennepin County Medical Center (HCMC) for hip fracture." A hospital return progress note dated on [DATE], at 7:15 p.m. noted R100 to return to the facility. According to the note, later that evening, the nursing assistant (NA) brought a small 200 milliliter (ml) Vodka bottle to the nurse's desk. She indicated she found by the TV, not sure where that came from, because writer had set up the TV when he returned. There was only approximately 40 ml of the 200 content. The staff went back into R100's room and noted an odor of alcohol once. When the staff asked R100 about the bottle, he had adamantly denied it by saying that he had learned his lesson when he broke his arm, then back and now the femoral head. R100 stated drinking had been a problem since he was a young teenager and he hoped he could stop now. An interview was conducted with R100 on [DATE], at 10:30 a.m. R100 verbalized that drinking was his only passion in life. He purposely tried to get to his room after drinking alcohol without being seen as he felt the his drinking was not the facility's fault. When R100 was queried about the potential effects of alcohol with dialysis, R100 did not answer the question. Although, he confirmed the faciltiy and the primary doctor did explain the risks and benefits and offer treatment, the patient did not inform the nephrologist of the alcohol consumption. The annual MDS dated [DATE], indicated R100 was cognitively intact, he was independent with all activities of daily living (ADLs). Although R100 was admitted for a fracture related to a fall just prior to admission to the facility, the MDS incorrectly identified R100 had no falls. The MDS did not identify R100 had fallen within a period of up to six months prior to admission. The MDS further identified R100 had functional limitations in one side of the upper and lower extremities and he used a cane/crutch, walker and a wheelchair. The CAA for falls dated [DATE], identified R100's gait was "stable," and he had improved since physical therapy (PT) with the use of "various assistive devices." The CAA indicated R100 continued to "work with PT for gait training," and he was "steady with various devices." Although the CAA identified a fall in 2010 and carried over to ,[DATE], the CAA did identify alcohol abuse and prior falls as a risk factor in further falls for R100, but lacked a summary and root cause analysis of R100's risk factors for falls and supervision needs. The most recent care plan revised [DATE], indicated R100 had a history of [REDACTED]. The care plan goals indicated R100 would refrain from alcohol use and would be safe while in or out of the facility. The care plan interventions directed staff to confiscate any alcohol found on person or belongings, discourage the use of alcohol, and to notify the doctor, family and dialysis center if R100 was drinking. The quarterly MDS dated [DATE], indicated R100 had not changed in his cognition, the MDS identified R100 had declined and had developed a functional limitation in both sides of the upper extremities, and he no longer used mobility devices. The MDS lacked evidence that R100 had fallen within the last six months in which R100 had fallen on [DATE]. R100's Progress notes and Incident/Fall Reports were reviewed from [DATE], going forward. - On [DATE], at 12:45 a.m. the Incident/Fall Report indicated R100 had fallen on the floor next to his bedroom door. R100 reported his right shoulder hurts but refused to rate his pain level. "He admitted that his (sic) was drinking earlier. A cup with 100 ml of alcohol was found on the floor in resident room and taken away." - At 7:46 p.m. the note indicated, "resident complained of lower left hip pain due to fall sustained on [DATE] at 2:00 a.m., call physician (MD) at 4:30 p.m. returned call with okay to have x-ray done to rule out hip fracture, call with result in the a.m." - At 10:59 p.m. the note indicated, "result of x-ray; slightly displaced fracture through the superior aspect of greater trochanter. Doctor recommendation was to sent (sic) to hospital, ambulance came at 10:48 p.m. will update as information becomes available." - On [DATE], at 7:28 a.m. the note indicated, "Received a call from (R100's) brother. He wanted to know if (R100) was on Antibuse and circumstances of his fall. Related incident details per chart. Informed him that Antibuse was never ordered. Stated he had been in touch with the hospital and they would make a decision today on what they were going to do for his left hip. Thanked me for information." - At 11:23 a.m. the note indicated, "Surgery will not be done, will return with orders for home therapy." - On [DATE], at 10:57 p.m. the Progress note indicated, "Returned from hospital at 5:00 p.m. via wheelchair and attendant." - On [DATE], at 7:24 p.m. the physician progress notes [REDACTED]." - On [DATE], at 10:26 p.m. a Progress note indicated, "Staff reported to writer that they suspected (R100) had been drinking. At 9:45 p.m. he had asked the TMA for his medications, which were taken approximately 2 hours prior. His speech was slurred and he was a little unsteady while standing with his walker asking for the medications. Writer knocked and spoke to (R100) through the curtain, which he okayed to be opened to speak with him. Writer asked him about drinking, but he denied it. He okayed his area be searched. Writer glanced around the room, asked about the black bag hanging from the walker, reached in and pulled out a bottle of Vodka. 80% gone. He said that it was not his bottle, but did slightly less denying of his drinking from it as well. Told him that we feared the side effects from his medications and alcohol combined with the risk of falling. He says that he will be 'ok'. Nurse and on call physician notified that resident had already received his blood pressure lowering medications, will observe and if respiratory distress send to the hospital for treatment." - On [DATE], at 2:32 p.m. a Physician Visit Progress note indicated the right leg was now one inch shorter after the fracture, a custom made insert for the right shoe will be made. - On [DATE], at 7:30 p.m. a progress note indicated, "NA suspected resident of alcohol consumption, resident breath smell with alcohol , has unsteady gait, very chatty with slurred speech, resident eyes red and was alert and oriented times three, advised resident to lay in bed to prevent him from falling." Resident had already taken medications to lower blood pressure before alcohol was suspected, room was searched but no alcohol was found, writer called primary medical doctor (PMD) office at 8:57 p.m. and left a message regarding the incident. - On [DATE], at 9:14 a.m. the note indicated, "Resident stated that he had a really bad stomach ache and he cannot go sit in the chair for four hours for dialysis. Asked if it was from him drinking last night and he said he must have ate (sic) some bad food. Resident stated that he is fine until Friday to go to dialysis." The facility canceled the dialysis run. - On [DATE], at 9:23 p.m. a Behavior Progress note indicated R100 "came in from outside unable to walk on his own (another resident) had to hold him up and help him up to the third floor and out of (sic) elevator to his room. (R100) was cooperative and had vital sign done." "(R100) had unsteady gait slurred speech, muscular in coordination, red glossy eyes" PMD office was notified. "Received orders to send to hospital to evaluation and treatment." "Received phone call from hospital stating breathalyzer was double legal limit 1.9." - At 12:15 a.m. on [DATE], the note indicated R100 was sent to HCMC in around 5:30 p.m. - At 1:00 a.m. on [DATE], the note indicated R100 "returned from emergency room at 12:56 a.m., no new orders he's alert and oriented times 3, he denies pain and discomfort will continue to monitor." R100 had documented events of continued alcohol use on [DATE], [DATE], [DATE], [DATE] and [DATE]. - On [DATE], at 11:11 a.m. a Physician Visit Progress note indicated R100 was seen in clinic by PMD. The note read, "(R100) declines any consideration of alcohol treatment." - On [DATE], at 9:21 p.m. an Incident/Fall Progress note indicated R100 "was outside by the door to the backyard when he fell on his left side hitting the head on the pavement while he was walking towards the door. He developed a bruise on the left side above the eye. Redness also noted on the eyes. The left side of the face and on the left knee. Unable to reach contact on record or chart as the number on file was received by a wrong person. Patient asked to call there (sic) family member when able. PMD was left with a message with the answering system via a person on scheduling line." - On [DATE], at 1:51 a.m. an Incident/Fall Progress note indicated, "At 1:40 a.m. (R100) came to the first floor nursing office and requested to go to hospital to check if left arm is broken. (R100) had limited range of motion on left arm. Call placed to PMD office, but no answering service available. Writer called 911 and requested non-emergency transport to hospital. (R100) states usually goes to HCMC. Writer asked (R100) if would like pain pill and (R100) stated that the pain pill would not help this kind of pain. (R100) presently waiting patiently in lobby for emergency medical technician (EMT)." - At 2:03 a.m. indicated, "EMT arrived at 2:00 a.m. and asked (R100) what caused fall and (R100) stated that he had been drinking. When asked if blacked out, (R100) stated no. Left elbow noted to have moderate amount of swelling and (R100) moaned when EMT touched left arm. (R100) was able to ambulate to ambulance. (R100) left at 2:05 a.m. to be transported to HCMC hospital." - At 4:27 p.m. indicated R100, "Returned from emergency room at 11:00 a.m. Has two fractures on his left arm, one above the elbow and 1 below the elbow. Arm is wrapped in cotton batting and covered with ACE wrap. New order for Percocet called and faxed to pharmacy. Needs an appointment this week to go back to orthopedic clinic and have arm casted. Did not want lunch, they gave him intravenous Dilaudid (narcotic pain shot) in the hospital and he just wanted to sleep." - At 4:34 p.m. indicated, "Spoke with (R100's) brother and he was VERY ANGRY (sic), said we should be doing something to stop him from drinking; that we have way too much drinking going on here and that we don't do anything to stop it. Said he wanted to talk with (DSS) first thing Monday morning." - At 9:18 p.m. indicated, "Patient had a visit to emergency room and has fractures from the fall. Reports pain on the arm. Percocet requested to pharmacy and will be delivered tonight. Has some narcotics prior orders before fall that he has been using since falling. Has ACE wrap on his left upper extremity to support his fractured arm and will have other appointment with to get a cast placed per emergency direction. Reports pain relieved by pain medications." - On [DATE], at 12:33 p.m. a social services progress note indicated, "Received a call back from R100's brother. Upset that (R100) is being allowed to drink alcohol when we have a policy of no alcohol. He also went on about PMD not returning his calls for over 1 year. ....suggested brother seek legal council (sic) if he desires and also to discuss guardianship at that time. Brother feels if (R100) was on Antibuse none of his injuries over the past year would have taken place. Discussed (R100's) right to refuse medication. Brother plans to attend (R100's) care conference on [DATE] at 2:00 p.m. Brother rarely allowed me to talk but was able to remind of Bywood's policy is no alcohol on the premises. Police will not remove a resident from Byword (sic) and transport to Detox center (a supervised place to detoxify from alcohol or drugs) just because they have been consuming alcohol." - On [DATE], at 1:51 p.m. a Physician Visit note indicated, "Seen by PMD, (R100) refused alcohol treatment several times, can resume oxycodone 5 milligrams (mg) 1 tablet by mouth every six hours as needed. On [DATE], at 11:55 a.m. the director of nursing (DON) confirmed the falls with serious fracture injuries for R100 for [DATE] (causing a right hip fractu

Based on observation, interview, and document review, the facility failed to ensure freedom from neglect for 3 of 3 residents (R58, R93, R100) in the sample observed to leave the facility in an unsafe manner. Facility staff were aware R58 sustained multiple falls in the facility and in the community, had been hit by a motor vehicle, had been mugged and was non-compliant with wearing safety equipment while unescorted in the community; facility staff were aware R93 left the facility without wearing appropriate footwear or glasses, was transported in an unsafe manner on the city bus, that R93 did not obey traffic/pedestrian rules while in the community and R93 consumed alcohol and drove a motorized scooter in an unsafe manner while unescorted in the community; R100 was known to consume alcohol to the point of intoxication in and outside the facility, would return to the facility intoxicated and sustained three falls resulting in fractures while intoxicated in the facility. The neglect of supervision resulted in actual harm with R93 consumed alcohol and drove a motorized scooter down the steps and sustained a head contusion with a hematoma; R58 sustained multiple injuries as a result of falling 42 times in an eight month period; R100 sustained a right [MEDICAL CONDITION] from a fall on [DATE], sustained a left [MEDICAL CONDITION] from a fall on [DATE], and sustained a left arm fracture from a fall on [DATE]. Findings include: R58 had a known history of accidents and being robbed in the community, continued to have falls with injury in the community and in the facility, was known to dispose of safety equipment (a helmet and reflective vest), was not assessed for community safety following each incident and was allowed to continue to leave the facility unescorted. R58 was admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent Assessment of Resident's Ability to Leave Facility Safely dated [DATE], indicated R58 was safe to leave the facility unescorted. The Fall Risk Assessments dated [DATE], and [DATE], both identified R58 was at high risk for falls. Neither of the assessments indicated if R58 was safe to continue going into the community. The clinical record lacked evidence R58 was assessed for community safety after [DATE]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R58 was independent with ambulation, was cognitively intact and was frequently incontinent of urine. The Care Area Assessment (CAA) dated [DATE], indicated R58's falls happened with no predictable pattern and happened both inside and outside the facility. The CAA indicated R58 was noted to have thrown away or hidden his safety gear. The CAA did not address if R58 continued to be safe to go into the community unescorted and lacked interventions to ensure R58's safety in the community. An Internal Ethics Committee Consultation dated for [DATE], indicated a decision was to be made "whether to move R58 to a locked facility because he left the nursing home regularly and was considered unsafe to do so." The ethics committee identified "(R58) was very high functioning and had been going off on his own for years. About 2 ,[DATE] years ago he was hit by a car and suffered very serious injuries. He had a luminous jacket he usually wears but is not always good about following traffic rules." The ethics committee identified R58 was "falling both in and out of the facility and not following the rules established for him" in order to continue to go out into the community safely. The committee identified "(R58) is the type of guy who will agree to anything and not follow it." The committee identified R58 inconsistently used a cell phone to call the facility and "did not follow the other two rules (obey traffic rules and not take the bus)." Although the ethics committee identified R58 continued to have safety concerns in the community and was not following safety rules, there were no further reviews of R58's need for a locked facility. One of the ethics committee recommendations was to have a discussion to make R58 aware current placement at the facility was in jeopardy if the resident was not able to follow expectations. There was no documentation the discussion had been completed. R58's care plan dated as written on [DATE], and revised on [DATE], indicated R58 was safe to leave the facility unescorted with the following requests: R58 was to only go out during daylight hours, R58 was not to take the city bus, and R58 was to obey all traffic and pedestrian rules. The care plan identified R58 had potential for harm/abuse from others, was easily distracted at times, and did not always abide by pedestrian rules. The care plan further identified R58 had a habit of looking down when walking (looking for lost change). The care plan indicated R58 had been struck by a car while catching a bus on [DATE], resulting in multiple injuries including: left rib fractures, left pneumothorax, closed head injury, and a left coracoid fracture. The care plan further indicated R58 was mugged [DATE], and hit by a bicyclist in ,[DATE]. The care plan identified R58 had sustained numerous falls while out in the community. The behavior care plan dated as reviewed on [DATE], indicated, R58 "continues to go out into the community, occasionally goes to a local restaurant and does various odd jobs for money: however, he was caught stealing and has been banned from there. Has been noted to rummage through garbage at the gas station and other areas." The cognitive function care plan dated as reviewed on [DATE], indicated R58 was unable to make independent decisions and R58 had a guardian. The falls/incidents care plan dated as reviewed on [DATE], identified R58, "Doesn't pay attention to where he is going and bumps into things. Insists on going outside despite poor weather conditions etc., even though staff encourages him to stay inside." The clinical record indicated R58 sustained 42 falls both inside and outside the facility between [DATE], and [DATE], was not assessed for safety after each fall, continued to leave the facility unescorted and did not consistently wear safety equipment of a helmet and a reflective safety vest. Review of the clinical record (Interdisciplinary Team (IDT), Resident Incident Report (RIR)) revealed the following: In the month of [DATE], R58 had fallen three times. On [DATE], between 5:30 a.m. and 12:00 p.m. R58 fell while out of building and complained of back pain. The new interventions noted were: "no injuries when falls, to wear all safety equipment." On [DATE], R58 fell at 9:00 a.m. on the back patio while trying to open the door. The report indicated R58 hit his head and suffered a laceration to his back. The new intervention noted was: "encourage resident to pay close attention to what he is doing at all times." On [DATE], at 7:00 a.m. R58 went to sit in a chair and fell to the floor. The new interventions noted were: "resident needs to get more sleep at night and encourage to stay in bed and feel back of chair when getting up." Although the care plan indicated R58 removed his safety gear, there is no evidence staff monitored R58's use of safety gear. Although the care plan identified, "R58 does not pay attention", the new intervention for the fall [DATE], that R58 should pay close attention contradicted the care plan. In the month of [DATE], R58 had fallen fourteen times. On [DATE], indicated at 11:50 a.m. R58 "dozed off" and fell out of the chair, hit his head and bruised his elbow. The new intervention noted was: "assigned seat at dining room table." R58 then left the building unescorted, and fell again less than two hours later at 1:15 p.m. The IDT report indicated another resident and activity staff saw R58 approximately five blocks north of the facility with paramedics on the sidewalk, near the railroad tracks. The IDT report further indicated, R58 had an unsteady gait, had fallen earlier and refused to stay in bed; the new interventions noted were: "unsure how resident fell encourage to be careful when out." The clinical record lacked evidence of a thorough investigation regarding the causative factors to rule out neglect. On [DATE], R58 fell at 5:35 a.m. and at 9:00 p.m. the new interventions noted were: "assist with activities of daily living in morning or encourage resident to sleep when wandering or up at night" and " staff will assist back to room and assist resident into bed." R58 fell on [DATE], at 8:15 a.m. [DATE], at 1:15 a.m. and [DATE], at 10:35 p.m. interventions included, " resident should not be allowed to sleep in chair" and for staff to assist R58. Although the facility knew R58 had fallen outside the facility and left the facility unescorted, all the new interventions for the above falls required staff to be with R58 either to ensure safety or complete a task, but did not address R58's safety outside the facility. The new intervention for a fall on [DATE], at 2:30 p.m. was "orthostatic blood pressure checks for 48 hours and update nurse practitioner (NP)." The clinical record indicated the NP made no changes for R58. On [DATE], R58 fell at 6:55 a.m. and at 7:40 a.m. with new interventions of "remove rug by dining room" and "encourage resident to wait for elevator to clear out before entering." The new interventions did not direct how tripping hazards and crowds would be managed outside of the facility. R58 fell on [DATE], at 11:20 a.m. the new interventions were, "encourage not to pick up items from floor and scheduled toileting plan." After a fall on [DATE], at 6:30 a.m., the IDT report directed to "evaluate need for every 30 minute safety checks." The clinical record lacked evidence of safety checks being completed for R58. On [DATE], at 12:10 p.m. R58 fell at corner of road and got up and kept walking away from facility. New intervention noted was, "consider keeping R58 in facility for safety and safety checks added to team sheets." R58 fell again outside the facility on [DATE], at 6:00 p.m. and was taken to the hospital. New intervention noted was, "escort resident when out of building and continue to discourage resident from going out." The clinical record lacked evidence R58 was escorted at all times when out of the building or that a system was in place to discourage him from going out. In the month of [DATE], R58 had fallen three times. On [DATE], at 6:15 a.m. R58 tripped over rug in business office and fell . The new intervention noted was, "rug was removed." Although rug removal was the same intervention noted after a fall on [DATE], the facility did not ensure rugs in other locations of the facility were addressed to prevent tripping hazards. There was no indication as to how tripping hazards would be avoided while out of the building. A progress note dated [DATE], at 5:47 a.m. indicated R58 had been up wandering throughout the night trying to open both the front and back doors. R58 was encouraged to go back to sleep but did not. On [DATE] and [DATE], R58 had falls related to door operation. New interventions noted were, "encourage to pay attention and assist with doors" and "push smoke room door slowly and take time." R58 was known to go into restaurants and stores while out of the building. There was no indication how R58 was to be provided with assist with doors when out of the building. Although the care plan identified "R58 does not pay attention", the new intervention for the fall [DATE], that R58 should pay close attention again contradicted the care plan. In [DATE], R58 had fallen six times. A progress note dated [DATE], at 1:19 p.m. noted R58 was repeatedly trying to leave the facility without his helmet on and was swearing and angry. The note indicated R58 left the facility around 9:00 a.m. with the helmet on and "promised not to remove it." R58 was observed at 9:22 a.m. picking up garbage at a store and did not have the helmet on. Although the intervention elicited R58's cooperation with keeping the safety devices on, the intervention contradicted the Ethics Committee determination that "(R58) is the type of guy who will agree to anything and not follow it." R58 fell on [DATE], at 8:45 p.m. although the intervention to "pay attention" was identified as a problem in R58's care plan and it had been attempted as an intervention for three previous falls, the new intervention for the [DATE] fall was "continue to encourage resident to pay attention to surroundings and slow down." The only new intervention after R58 fell on [DATE], at 4:30 p.m. outside of building at store and received and elbow abrasion was, "resident should report incident immediately." The medical record lacked documentation any new interventions were identified related to the fall. On [DATE], at 10:30 a.m. R58 fell in driveway at a restaurant, was not wearing his safety gear (helmet and vest) and hit his head resulting in abrasions and hematomas. Although the facility had identified R58 had a history of [REDACTED]." The medical record lacked documentation of how R58 was to be kept on facility property and R58 was allowed to continue to leave the facility unescorted. R58 had falls on [DATE], at 12:00 p.m., [DATE], at 8:45 a.m., and [DATE], at 10:10 a.m. The new interventions; "remind and bring to (feeder) table for supervision with meals", "remind to sit slowly and use arm rests", and "give resident activities to do" all required staff supervision or assistance. The clinical record lacked evidence of a plan to assist/supervise R58 when he was out of the facility. In [DATE], R58 had fallen seven times. On [DATE], at 1:15 p.m. R58 fell in 3rd floor hallway receiving a laceration that needed stitches. R58 was seen in the emergency room (ER) following the fall. The new intervention noted was, "encourage to wear helmet and hold onto railing in hallway." A progress note dated [DATE], at 1:39 p.m. (documented after the fall at 1:15 p.m.) indicated staff was aware R58 was not wearing his helmet prior to the fall and the helmet was left off of R58 for a "shower." On [DATE], at 5:40 p.m. R58 fell outside of elevator and received a laceration to the elbow. Although the past fall history and clinical record indicated R58 did not follow direction, the new intervention noted was, "encourage to hold onto railing when standing or walking." The intervention for the falls on [DATE], [DATE], [DATE], and [DATE], directed R58 was to hold onto the railing. Although the facility had identified R58 was unsteady and required to hold onto a railing while ambulating/standing in the facility hallways or bathroom, the clinical record lacked direction as to what R58 was to hold onto when he left the facility unescorted. The falls on [DATE], and [DATE], both had interventions that directed to provide R58 with staff assist. On [DATE], at 9:15 a.m. R58 fell backward striking his head by the coffee machine. The new intervention noted was, "has MS unable to anticipate or prevent falls." The medical record lacked documentation of any new interventions related to the fall. R58 fell again on [DATE], at 12:40 p.m. when he slipped in water and fell to the floor in the elevator and received a laceration to the left hand. The new intervention noted was, "encourage to exit elevator slowly and new elbow pads." The IDT incident report review for ,[DATE] or [DATE], unknown time, indicated R58 reported he had been hit by a car, hit by another resident and fell on a rug resulting in a large swollen bruise to the left back. R58 was later found to have multiple rib fractures, closed [MEDICAL CONDITION] column, contusion of the abdominal wall and a lung hematoma after being admitted to the hospital on [DATE]. An investigation was completed and indicated R58 must have fallen because of the type of injuries sustained. The new interventions noted were, "encourage to report incidents and moved other resident." In [DATE], R58 had fallen two times. R58 fell on [DATE] with a new intervention of "supervise while in the bathroom and given elbow protectors." R58 was hospitalized with multiple injuries (noted above) from [DATE]-[DATE]. The hospital discharge planning note dated [DATE], indicated the hospital verified with the facility R58 could return under close obs. (observation) status." R58 returned from the hospital at 5:48 p.m. on [DATE]. On [DATE], at 11:32 a.m. R58 signed himself out of the building. A progress note dated [DATE] indicated staff was aware R58 had left the building to "buy cigarettes." The medical record lacked evidence how the facility maintained close observation status for R58 or decided close observation was no longer needed. On [DATE], at 12:00 a.m. R58 fell outside bathroom and hit head. Although the facility was aware of R58's history of removing his safety devices, the new intervention noted was, "check frequently on nights and remind nursing assistants that resident should always have helmet, elbow pads and braces on." In [DATE], R58 had fallen four times. On [DATE], at 4:00 a.m. R58 fell while running away from staff. Staff had been attempting to put R58's helmet on. The note further indicated R58 had "refused to wear his helmet all shift." The new intervention noted was, "encourage to wear protective gear." On [DATE], at 6:00 p.m. R58 fell outside on sidewalk and sustained scraped knees. The new intervention noted was, "call podiatrist and knee pads for safety." On [DATE], at 9:45 p.m. R58 fell in room and was found to have a laceration to knee. The new intervention noted was, "sit on bed or chair when removing shoes. " A progress note dated [DATE], at 3:20 p.m. noted R58 returned to the facility without his helmet. R58 reported he had thrown the helmet away. A progress note dated [DATE], indicated the helmet was replaced. On ,[DATE] or [DATE], unknown time, R58 reported he had slipped on coffee. The new intervention noted was, "resident should not pour himself coffee." A progress note dated [DATE], at 3:07 p.m. indicated R58 was difficult to understand and was falling asleep when asked about a prior fall. From [DATE]st through the 13th 2012, R58 had fallen two times. A progress note dated [DATE], at 4:11 a.m. noted R58 had been up all night and had returned from outside of the building when another resident came in. The note indicated staff was not sure how R58 had gotten outside. Although the facility had identified R58 left the building without the facility knowledge and past interventions indicated the facility was to encourage R58 to remain in the facility and the care plan directed R58 was not to leave the facility unescorted at night, the clinical record lacked evidence the incident was investigated to determine if potential neglect had occurred. On [DATE], at 6:50 a.m. R58 fell in the hallway. The new intervention noted was, "encourage resident to hold onto hand rail with both hands and not carry anything." A progress note dated [DATE], at 7:00 a.m. indicated R58 had been at the Fridley police station on [DATE], "asking for directions to the social workers house." Although the care plan directed R58 was not to take the city bus, the note indicated the social worker told police R58 was "knowledgeable of the bus system" and "could return to the facility independently." The officer gave R58 a ride back to the facility. A progress note dated [DATE], at 9:41 a.m. indicated R58 was outside and "not paying attention to where he was walking, was looking at the curb and what was in the street." R58 was not wearing a helmet when observed by facility staff. On [DATE], at 4:05 a.m. R58 reported he fell in the dining room and had pain to the rib area. The new intervention noted was, "alert staff as soon as falls and hold onto railing." The intervention again noted R58 to hold onto railing with no plan for what he should hold onto when he left the building. A progress note dated [DATE], at 7:17 a.m. indicated R58 had been observed by the director of social services (DSS) at 45th and Central Avenue on [DATE], at 8:20 p.m. R58 was not wearing the safety vest and was driven back to the facility by the DSS. A review of the resident sign out logs for July-[DATE] showed R58 signed out of the facility frequently and was often gone for hours. Many of the interventions listed on the IDT reports included staff supervision, assist and reminders, to be kept in the facility, or have an escort when out of the facility. The clinical record lacked evidence of how staff would implement the identified interventions when R58 was out of the building and how the facility would ensure an escort for him. In addition, the clinical record lacked evidence of when R58 did or did not need an escort outside of the facility and how that decision was made. Although the facility identified R58 required an escort while out of the building, had identified R58 had unsteady gait, did not wear his safety equipment consistently, did not pay attention to his surroundings, did not obey traffic/pedestrian rules, had fallen and sustained injuries in the facility and outside the facility, had a history of [REDACTED]. On [DATE], at 11:32 a.m. R58 reported going out into the community and riding the bus. In addition R58 stated the left side injury was possibly related to a fall. R58's speech became slurred and was unable to continue the interview. On [DATE], at 12:53 p.m. the director of nursing (DON) verified the assessment of resident's ability to leave the facility safely dated [DATE], was the most recent assessment. The DON stated the goal was to keep R58 in the facility but they were "not always able to do so." In addition, the DON stated a restaurant up the road was "paying" R58 to "pick up boxes" which encouraged R58 to go out. The DON further stated the care plan was reviewed quarterly and confirmed there was no documentation regarding a risk versus benefit evaluation for R58's falls or safety in the community. On [DATE], at 9:51 a.m. the DON was interviewed regarding the Internal Ethics Committee Consultation from Lutheran Social Service from [DATE]. The DON stated R58's family and guardian did not want R58 " locked up, " but was unable to provide documentation that had been discussed with them. On [DATE] at 8:37 a.m. R58's guardian confirmed R58 had a [DIAGNOSES REDACTED]." The guardian stated she was aware R58 fell "a lot" and "loved to be out in the community." The guardian also stated she was "trying not to restrict" R58 and R58 was not going "as far away anymore" or "out at night." When the guardian was informed by the surveyor R58 had been outside the facility at night and without the safety vest as recently as [DATE], the guardian confirmed she had not been informed by the facility. The guardian stated she was not aware R58 had been mugged in 2009, or that a neighbor who witnessed the mugging had returned the wallet and reported the incident to the facility and not R58. The guardian stated she would have to look at the notes and would call the surveyor back. At approximately 9:50 a.m. the guardian called the surveyor back and stated "only two dollars had been taken" from R58. Although the guardian was informed by the surveyor of R58's safety concerns in the community, the guardian further stated R58 would be allowed to take the bus again and would have money available to take a taxi. The guardian also stated R58 would need to be "reviewed again" by the Internal Ethics Committee regarding "safety." On [DATE], at 4:28 p.m. R58 was observed to be alone walking north on the sidewalk towards the corner of 35th and Central Avenue Northeast (a four lane divided road). R58 was looking down at the ground while walking, was wearing a black helmet and a bright yellow and orange reflective safety vest. The resident was not looking where he was going. Although R93 was known by the facility to not obey pedestrian rules, was known to drink alcohol while out in the community and operate a motorized scooter, was known to not obey traffic safety rules, was known to have recurrent accidents/falls in the community and in the facility, and was known to be incarcerated at the county jail, the facility did not implement systems to ensure R93 was safe while unescorted in the community. On [DATE], at 11:30 a.m. R93 was observed leaving the facility through the front door via a scooter. R93 was observed to be barefoot, had no glasses on and the scooter was observed to have several scuff marks on the front left aspect of the scooter, below the handle bars. The outside temperature at the time of the observation was 50 degrees Fahrenheit (F). R93 was observed to head north on Central Avenue Northeast in the street. On [DATE], at 11:15 a.m. R93 was observed to leave the facility via a motorized scooter. R93 was barefoot, the temperature outside was 54 degrees F and he was not wearing glasses. R93 was observe to drive the scooter north on Central Avenue. Although there was a side walk on the facility side of the street, R93 was observed to drive the scooter on the shoulder and in the street on the traffic side of the parked cars. R93 was observed to motorize near the heavy traffic on Central Avenue, drive over railroad tracks and proceed to 37th Avenue Northeast where he drove east for approximately two miles (still in the shoulder of the road and not on the sidewalks) and headed north on Stinson Boulevard. R93's scooter was observed to be nearly hit by a pick-up truck, the truck driver slammed on the brakes and swerved to the left to avoid R93. R93 was admitted on [DATE], with [DIAGNOSES REDACTED]. The nursing assessment for pre-admitted d [DATE], listed R93 as forgetful, delusional, impatient, and identified R93 required glasses. The assessment of R93's ability to leave the facility safely dated [DATE], identified R93 as quadriplegic with physical devices of a motorized scooter and two canes. The quarterly MDS dated [DATE], indicated R93 had a Brief Interview for Mental Status (BIMS) score of 15 (no impairment). The CAA dated [DATE], noted a history of falls and that R93 was not steady, but able to stabilize without staff assistance. The CAA also indicated R93 was at further risk for falls related to bilateral lower extremity impairment secondary to [DIAGNOSES REDACTED]. The most recent care plan dated [DATE], indicated R93 had been deemed safe to leave the facility unescorted, but needed reminders to follow traffic rules and to ensure R93 wore glasses. The care plan indicated R93 had been reported as causing problems on the city bus and met with the customer advocate from Metro Transit on [DATE], to try to resolve complaints. The care plan also indicated on [DATE], R93 was observed driving his scooter "in the street," that he drove the scooter "really fast" and did not always pay attention to others. The care plan further identified, "Does not always obey the traffic rules when out." The care plan goals indicated: "will comply with metro transit regulations," "will obey traffic rules when out in the community," and "will wear appropriate footwear at all times when up." The care plan interventions directed to: remind R93 of agreement to abide by metro transit rules and regulations; resident should not ride scooter on the street and should stay on the sidewalk. Review of care conference notes dated [DATE], indicated R93's vulnerabilities were, "Due to mental deficits related to mental illness, would need assistance to cope with a potentially harmful situation. Staff follow care plan interventions and guards for safety." Review of R93's clinical record indicated the following: - A progress note dated [DATE], at 9:56 p.m. indicated the facility was notified by police R93 was in the middle of the street with his scooter and stranded. The note indicated the scooter battery had died and R93 was trying to push it up a hill. The note indicated the police told R93 to get out of the middle of the street, it was getting to be dusk outside and the people in cars would not see R93. The note further indicated the police had come to the facility to alert the staff R93 should not be outside on the road on his scooter at night. - The police report dated [DATE], revealed the officers came to the facility and informed the charge nurse (LPN)-B a motorist had called the police and stated R93 was barefoot and trying to make his way back to the facility by pushing his scooter on foot. The report indicated the officers expressed their concern to LPN-B, that R93 could be "seriously hurt" if he kept driving his scooter on the streets in oncoming traffic. When requested, no incident report was provided to the surveyor by the facility for the incident. The progress note and police report indicated R93 was driving in an unsafe manner and the care plan was not followed (as R93 was barefoot at the time). In addition, the clinical record lacked evidence the facility acted upon the report, such as instituting a system to ensure the scooter battery was charged (to prevent the scooter from stalling in the street) or monitoring to ensure R93 wore appropriate footwear. - A facility incident report dated on [DATE], indicated R93 sustained a fall in his room while trying to "steam clean" the carpeting. The report indicated R93 hit his head on the scooter when he fell and R93 expressed concern of a neck injury and requested an x-ray. The clinical record lacked evidence an x-ray was obtained. The new intervention listed to prevent future incidents was, "Resident should have help when using steam cleaner, need to ask staff for help." The incident report was signed by LPN-B. In addition, the clinical record lacked evidence why the x-ray was not warranted and lacked evidence R93 was notified why the x-ray was not completed, such as risk benefit information or clinical rational from a physician. - A facility incident report dated on [DATE], indicated R93 sustained a laceration from bumping his left fourth toe on the front door while exiting the building. The new intervention was "continue to encourage resident to wear proper footwear." The clinical record lacked evidence R93's ability to drive the scooter safely was evaluated or a monitoring system was implemented to ensure R93 wore proper footwear. In addition, the clinical record lacked evidence the incident was thoroughly investigated to rule out neglect due to the care plan not being followed and R93 was barefoot on the scooter in the community. - A facility incident report dated on [DATE], indicated a head injury occurred when R93 drove the scooter down the stairs, instead of the ramp, after drinking alcohol at a bar down the street from the facility. R93 went to the ER and was diagnosed with [REDACTED]. Although the new immediate intervention was, "Should not attempt to drive scooter down steps - use ramp." The clinical record lacked evidence a root cause analysis was completed to determine causal factors of the fall, such as [MEDICAL CONDITION] or ongoing non-compliance, to determine interventions to potentially reduce fall risk and prevent future falls. In addition, the clinical record lacked evidence R93 was provided with risk information regarding drinking and operation of a motorized scooter, community safety or evaluation of R93's ability to safely operate a motorized scooter in the community. - A facility incident report dated on [DATE], indicated R93 sustained additional head trauma when R93 backed the scooter up onto a curb and flipped backwards in the scooter and hit his head when he fell . In addition, R93's was sent to the ER for