Every finding on record at Hayes Residence

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled a minimum of eight consecutive hours each day. This had the potential to affect all 36 residents who resided at the facility.Findings include:The Facility's Payroll Based Journal (PBJ) Staffing Data Report dated 9/4/26, submitted for Quarter 3 of 2026 (April 1 to June 30), identified no RN hours for the following dates: 5/10/26, 5/16/26, 5/17/26, 5/24/26, 5/25/26, 5/31/26, and 6/7/26.Staffing schedules, timecard data and/or payroll verification were requested for these dates but not provided.During an interview on 9/10/26 at 12:53 p.m., the administrator stated dates of no RN coverage, the former director of nursing (DON) or herself would come in until an RN was on-site to relieve. Administrator stated that there was possibly RN coverage by the former DON for some of the specified dates, but that the hours were not recorded. No other information was provided.Facility staffing policy was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure culinary staff adhered to safe hand hygiene practices while serving resident meals. The facility also failed to ensure a food refrigerator in the medication room was at the proper temperature for food storage. This had the potential to affect all 35 residents receiving meals served from the kitchen.Findings include:Handwashing:During a dining observation on 9/9/26 at 11:44 a.m., culinary aide (CA)-A cleared dirty plates and silverware from a table, rinsed and placed them in dishwasher racks, and returned to serving food to another resident without changing gloves or washing hands.During an interview on 9/9/26 at 11:46 a.m., CA-A confirmed they had not washed their hands or changed gloves before serving residents' food after handling dirty dishes. They stated they should have removed their gloves, washed their hands, and put on new gloves when going from dirty dishes to serving clean plates.During an interview on 9/9/26 at 3:15 p.m., culinary director (CD) stated they expect kitchen staff to consistently wash their hands when preparing and serving food. They expect staff to change gloves and wash hands when moving from a dirty task to a clean task. CD indicated a concern for contamination of food if proper hand hygiene was not performed.Storage:During an observation of the food refrigerator located in the medication room on 9/9/26 at 8:47 a.m., the thermometer read 46 degrees Fahrenheit (F). The refrigerator contained a gallon of milk.Nursing Refrigerator Log dated 8/2026, instructed staff to check the refrigerator temperature daily and report if it was greater than 41 degrees F. The refrigerator temperature was logged above 41 degrees F on 21 of 23 days recorded and no temperature were logged for 8 of 31 days.Nursing Refrigerator Log dated9/2026, instructed staff to check the refrigerator temperature daily and report if it was greater than 41 degrees F. The refrigerator temperature was logged above 41 degrees F for all days. No notification was noted until 9/9/26.During an interview on 9/9/26 at 8:49 a.m., the administrator stated they expect staff to notify environmental services or the dietary director if the refrigerator temperature was higher than 41 degrees F. They had concerns about the milk being stored above food code standards.During an interview on 9/10/26 at 3:15 p.m., CD stated milk and juice were stored in the medication room food refrigerator for use overnight. They expected staff to discard perishable items such as milk and notify environmental services if the refrigerator temp was above 40 degrees F. CD indicated a concern for the milk spoiling at temperature above 40 degrees F.A facility policy titled Handwashing/Hand Hygiene revised 6/25/26, instructed all staff to follow handwashing procedures to help prevent the spread of infections to staff, residents, and visitors. It instructed culinary staff to wash hands before engaging in food preparation, after handling soiled equipment or utensils, and after engaging in other activities that contaminate hands.A facility policy titled Glove Use no date, instructed all dietary staff to change gloves when changing tasks.A food storage policy was requested but not received.

Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene practices were followed during blood glucose testing and insulin administration for 4 of 4 residents (R7, R16, R9, and R6), reviewed for medication administration. Findings include:R7's quarterly MDS dated [DATE], indicated R7 was cognitively intact and independent with cares. Diagnoses included congestive heart failure (CHF) and DM-2.R7's order set reviewed on 9/9/26, indicated blood glucose levels were to be assessed four times a day. Orders included sixteen units of NovoLOG short-acting insulin to be administered three times a day before meals with the parameter to give an additional two units of insulin for blood glucose levels between 200 and 250 mg/dL.R16's quarterly MDS dated [DATE], indicated R16 was cognitively intact and independent with cares. Diagnoses included coronary artery disease (CAD), liver cirrhosis, and DM-2.R16's order set reviewed on 9/9/26, indicated blood glucose levels were to be assessed four times per day. R7 had orders for 0.5 milliliters (mL) of Trulicity to be administered every Monday and 24 units of Lantus long-acting insulin to be administered every evening.R9's comprehensive MDS dated [DATE], indicated R9 was cognitively intact and independent with cares. Diagnoses included obesity and DM-2.R9's order set reviewed on 9/9/26, indicated blood glucose levels were to be assessed four times a day. Orders included sixteen units of HumaLOG short-acting insulin to be administered before lunch with parameters to give additional units for blood glucose levels greater than 200 mg/dLR6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and required minimal assistance with cares. Diagnoses included severe obesity, hyperlipidemia (high cholesterol), and Type 2 diabetes mellitus (DM-2).R6's order set reviewed on 9/9/26, indicated blood glucose levels were to be assessed four times a day. Orders included ten units of NovoLOG short-acting insulin to be administered before lunch with the parameter to hold insulin if blood glucose levels were less than 150 milligrams(mg)/deciliter(dL).During a continuous observation and interview on 9/9/26 at 11:00 a.m., registered nurse (RN)-A stated all residents with orders for blood glucose testing and/or insulin administration were expected to come to the nursing station at the appropriate times. She said residents in the facility were expected to be as independent as possible and were encouraged to perform their own blood glucose testing and insulin administration. RN-A stated all blood glucose testing and insulin administration were done under the direct supervision of a nurse, which allowed the staff to continuously assess residents for competence and provide additional education as needed. A shelf on the nursing station was observed to contain multiple plastic boxes with lids, each measuring approximately eight inches by six inches x four inches. Each box was labeled with an individual resident name and contained that resident's lancing device, lancets, blood glucose meter, and insulin pen(s).At 11:03 a.m., R7 entered the nursing station for blood glucose testing and insulin administration. R7 did not perform hand hygiene and was not asked to do so by RN-A. RN-A was wearing gloves and R7's lancing device, lancets, glucose meter, and insulin pen were on the counter. RN-A inserted a lancet into R7's lancing device. She removed a test strip from a container sitting on a shelf above the counter and inserted it into R7's glucose meter. R7 rubbed his finger with an alcohol wipe, pricked his finger with the lancing device, and held it to the test strip. R7's blood glucose measured 200 mg/dL His orders indicated eighteen units of insulin should be given. RN-A dialed up seven units on one insulin pen and eleven units on a second insulin pen. RN-A handed R7 an alcohol wipe and he rubbed it over an area on his right lower abdomen. RN-A gave the insulin pens to R7 and he injected them, one at a time, into his abdomen. R7 exited the room without performing hand hygiene. RN-A placed the used needles into the sharps container and replaced the caps on the insulin pens. She put the lancing device, lancets, glucose meter, and one insulin pen back in R7's box and placed the box back on the shelf. RN-A removed her gloves and without performing hand hygiene, donned new gloves. At 11:09 a.m., R16 entered the nursing station for blood glucose testing. He did not perform hand hygiene and was not asked by RN-A to do so. R16 removed his blood glucose meter from the box labeled with his name. He then removed a test strip with his bare hands from the same container which RN-A had previously used for R7. R16 placed the test strip in his glucose meter and inserted a lancet into his lancing device. R16 removed an alcohol wipe and rubbed it on his finger. He pricked his finger with the lancing device and held his finger to the test strip. R7's blood glucose measured 131 mg/dL Per R7's orders, no insulin administration was required. R16 placed his lancing device, lancets, and glucose meter back in his box and left the nursing station without performing hand hygiene. RN-A placed R7's box back on the shelf, removed her gloves, and did not perform hand hygiene.At 11:16 a.m., R9 entered the nursing station for blood glucose testing and insulin administration. R9 did not perform hand hygiene and RN-A did not ask her to do so. RN-A donned gloves without performing hand hygiene. RN-A retrieved R9's box from the shelf and removed her lancing device, lancets, glucose meter, and insulin pen. RN-A inserted a lancet into the lancing device and then removed a test strip from the same bottle as the one previously used for R7 and R16. RN-A inserted the test strip into R9's glucose meter. She handed R9 an alcohol wipe and R9 rubbed her finger with it. R9 pricked her finger with the lancing device and held it to the test strip. R9's blood glucose measured 175 mg/dL. Per the parameters in R6's orders, she was to receive 16 units of insulin. RN-A placed a needle on R6's insulin pen and dialed up 16 units of insulin. RN-A handed R9 an alcohol wipe and R9 rubbed it on her left lower abdomen. RN-A gave the insulin pen to R9 who self-administered the insulin. RN-A disposed of the needle in the sharps container and placed the cap back on the insulin pen. She placed R9's lancing device, lancets, blood glucose meter, and insulin pen back in R9's box and placed the box back on the shelf. R9 left the room without performing hand hygiene. RN-A removed her gloves but did not perform hand hygiene.At 11:29 a.m., R6 entered the nursing station for blood glucose testing and insulin administration. RN-A asked R6 to wash his hands and stated she always asked R6 to do this because sometimes his hands are sticky. R6 washed his hands at the sink and returned to the nursing station. RN-A donned gloves but did not perform hand hygiene. RN-A retrieved R6's box from the shelf and removed his lancing device, lancets, glucose meter, and insulin pen. She inserted a lancet into the lancing device and then removed a test strip from the same container previously used for R7, R16 and R9. RN-A inserted the test strip into R6's glucose meter. RN-A wiped R6's finger with an alcohol wipe and pricked his finger with the lancing device. R6's blood glucose measured 173 mg/dL. Per R6's orders, he was to receive ten units of insulin. RN-A placed a needle onto R7's insulin pen and dialed up ten units of insulin. RN-A handed an alcohol wipe to R6 and he used this to rub an area on his lower abdomen. RN-A gave the insulin pen to R6 who self-administered the medication. RN-A placed the used needle in the sharps container and put the cap back on the insulin pen. She placed the lancing device, lancets, glucose meter, and insulin pen back in R6's box and placed the box back on the shelf. R6 left the room without performing hand hygiene. RN-A removed her gloves and performed hand hygiene.During an interview on 9/9/26 at 11:25 a.m., RN-A confirmed the test strips used for all residents came from the same container. When asked if there could be any issues with this, she stated, Yes, I can see the problem. When asked what the problem might be, she replied, Contamination. Each resident should probably have their own bottle of test strips. RN-A also stated hand hygiene should be completed between cares for different residents as well as before and after performing blood glucose testing or insulin administration. Hand hygiene includes either using an alcohol-based sanitizer or washing hands with soap and water.During an interview on 9/9/25 at 12:25 p.m., the Assistant Director of Nursing (ADON) stated that in the past, the facility's nurse set up all lancing devices and glucose meters for the residents which helped to ensure expected infection prevention and control measures were taken, but now that the residents in the facility were more independent, some of them removed their own test strips out of the container. She stated there was a heightened risk of infection associated with having a single container of test strips for all residents.During an interview on 9/10/26 at 12:15 p.m., the ADON stated nursing staff were expected to perform hand hygiene before and after administering any medications. This included setting up medications for self-administration such as lancing devices, point-of-care meters, and insulin pens. She said residents who self-administer medications should be encouraged by nursing staff to perform hand hygiene and supplies should be readily available.The Director of Nursing (DON) was unavailable for interview during survey.The facility's Infection Prevention and Control Program policy dated 6/17/26, indicated that all departments were to follow proper hand hygiene to reduce the risk of the spread of infection and communicable disease.

Based on observation, interview, and document review, the facility failed to provide a pressure injury prevention intervention for 1 of 1 resident (R3) reviewed for impaired skin integrity.Findings include:R3's Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment, requiring substantial physical assistance of up to 1 for toileting, transfers and repositioning, and diagnoses of paranoid schizophrenia, Type 2 diabetes, severe obesity, and post-traumatic stress disorder (PTSD).R3's quarterly nursing assessment dated [DATE], identified R3's repeated refusal to allow wound measurements and assessments of the buttocks.R3's provider order dated 9/16/20, indicated R3's weight should be shifted from side to side every 2 hours by alternating (memory foam) pillow placement between buttock sides.R3's care plan dated 7/10/26, identified R3 had variable physical ability in upper body, weakness, impaired mobility, behaviors, obesity, mental illness, inconsistently communicates needs and increasingly doing less for self. Skin intervention of applying protective barrier cream at each toileting.R3's nursing progress note dated 9/4/26 at 10:56 a.m., stated R3 had redness with peeling mid buttocks to both sides of the crease. R3 was educated about skin issues and the need to shift or change position every 2 hours.During continuous observation on 9/9/26 at 8:15 a.m., TMA-B entered R3's room after breakfast, removed brief, reddened areas noted approximately 1 cm x 2 cm on both sides of crease mid buttocks, barrier cream and new brief applied. At 8:30 a.m., R3 was centered on pillow and reclined back in chair. At 8:40 a.m., R3 was brought to an upright position in reclining chair and TMA-B provided water and administered am medications, R3 was not offered repositioning or changing pillow placement and resumed lying back in reclining chair. At 8:59 a.m., (RN)-A moved reclining chair forward to upright position, removed dressing on bottom of right foot and placed in foot bath. At 9:04 a.m., RN-A returned and set out wound care supplies, removed R3's foot from foot bath, dried foot, administered wound care and returned reclining chair back to a lying position. RN-A left without offering repositioning or changing pillow placement. At 9/9/26 at 10:23 a.m., R3 maintains lying position in reclining chair. At 9/9/26 at 10:59 a.m., R3 replied that he did not need a brief change at this time. TMA-B stated she would check again at lunchtime when she came to assist with transfer and ambulation to dining room. TMA-B did not offer repositioning or changing of pillow position. Continuous observation ended at 11:35 a.m. when TMA-B entered room and assisted R3 to a standing position with front-wheeled walker. Continuous observation duration: 3 hours and 5 minutes (8:30 a.m. to 11:35 a.m.).During an interview on 9/9/26 at 11:36 a.m., TMA-B confirmed they did not offer to change R3's pillow placement during the observation and stated R3 often refused. TMA-B acknowledged regardless of R3 behaviors or refusals, offering to adjust the pillow placement should have been offered every 2 hours as ordered.During an interview on 9/9/26 at 1:15 p.m., RN-A confirmed that NAs should be offer and reposition residents every 2-3 hours or what was ordered, perform cares in a timely manner to prevent R3 becoming agitated, and reapproach based on mood and behavior.During an interview on 9/9/26 at 2:52 p.m., (LPN)-B confirmed repositioning should be offered every 2-3 hours depending on resident's orders. If resident refused, should be documented as refused after 3 reapproach attempts.During an interview on 9/10/26 at 1:05 p.m., the administrator stated staff were expected to follow repositioning orders specific to each resident and attempt varying verbal and non-verbal prompting approaches and reapproaches.Facility policy on pressure injury prevention was requested but not received.

Based on interview and document review, the facility failed to ensure pharmacist recommendations were acted upon and transcribed for 1 of 6 residents (R8) reviewed for unnecessary medications.findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 was severely cognitively impaired.R8's diagnoses included schizophrenia, bipolar, anxiety, depression, and seizure disorder.R8's care plan revised 7/17/25, indicated R8 received psychotropic medications and instructed staff to administer medications as ordered by the physician.R8's medication regimen review (MRR) dated 5/21/26, pharmacist (PH)-A recommended Latuda be taken with at least 350 calories to work effectively. This recommendation was not signed off by staff.R8's physician orders reviewed 9/10/26, lacked indication this recommendation was transcribed.During an interview on 9/10/26 at 1:14 p.m., the acting assistant director of nursing (ADON) stated they expect physician orders to be transcribed in 24 to 48 hours of receipt, and it was important to transcribe orders accurately and timely for medication safety and to reduce the resident's risk of adverse reactions. ADON confirmed the provider order, to change the instructions on R8's Latuda, was uploaded into electronic medical record by an unlicensed staff member, not signed off by licensed staff, and not entered on R8's medication administration record (MAR). ADON expected the order to be transcribed. During an interview on 9/10/26 at 2:30 p.m., PH-A stated their recommendation was for Latuda to be taken with food because food makes the medication more effective. They stated the medication would be absorbed less without food.Medication Orders policy, last reviewed 3/4/26, instructed nursing staff to review new orders received from providers to determine if order changes have occurred and enter medication order onto the current MAR in PCC.

Based on interview and document review, the facility failed to ensure adequate monitoring was in place for 1 of 1 resident (R2) on high-risk, psychotropic (i.e., anti-anxiety, anti-depressant, and anti-psychotic) medications, reviewed for unnecessary medications. Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], included diagnoses of schizophrenia, depression, generalized anxiety disorder, and post-traumatic stress disorder (PTSD).A review of R2's order set dated 9/9/26, listed the following provider orders:50 milligrams (mg) of hydroxyzine, an anti-anxiety medication, to be given by mouth once per day40 mg of duloxetine, an anti-depressant medication, to be given by mouth once per day50 mg of quetiapine, an anti-psychotic medication, to be given by mouth once per day4/1/26: Orthostatic blood pressure assessment to be completed on the first day of every month for psychotropic medication monitoringR2's care plan dated 8/28/26, indicated she was at risk for falls due to the use of psychotropic medications. Interventions listed included: monitoring for changes in mental status, observing for changes in gait/steadiness, and taking orthostatic blood pressure readings on the first day of every month.R2's progress notes indicated:6/1/26 at 9:06 a.m.: Resident was out of the building and on leave of absence (LOA).7/1/26 at 10:03 p.m.: Resident has not returned from LOA.8/1/26 at 11:43 p.m.: Resident is out on LOA until 8/3/26.R2's Treatment Administration Record (TAR) for the months of June, July, and August lacked evidence of orthostatic blood pressure assessments being completed on 6/1/26, 7/1/26, and 8/1/26, or after her return from LOA. During interview on 9/10/26 at 8:23 a.m., trained medical assistant (TMA)-A confirmed that orthostatic blood pressure assessments were not completed during the months of June, July and August for R2. She stated nursing staff were responsible for following provider orders related to tasks, including obtaining blood pressure readings. She stated if a resident was not in the facility or was on an LOA when a task was supposed to be completed, she would document that in the chart and write a progress note. She stated she would also convey that information to the next shift during report so the task could be completed. She stated nursing staff were responsible for reading any progress notes from previous shifts.During interview on 9/10/26 at 8:30 a.m., registered nurse (RN)-A stated all tasks were to be completed as ordered by the provider. If a task was not completed, that information should be documented in the chart and communicated to the next shift. RN-A stated if a resident was on a LOA, it was expected the task would be completed when the resident returned to the facility.During interview on 9/10/26 at 12:58 p.m., the Assistant Director of Nursing (ADON) stated nursing staff were expected to follow provider orders for all tasks and document appropriately. She said if a task was not completed on the shift for which it was ordered, nursing staff were expected to document that information in the chart and notify the next shift so the task could be done.The Director of Nursing (DON) was unavailable for interview during survey.The facility's Unnecessary Medications and Psychotropic Drug Use policy dated 8/1/26, directed nursing staff to routinely monitor and document side effects of psychotropic medications.The facility's Bed Hold and Leave Days policy dated 8/28/26, indicated residents are encouraged to notify staff and complete the facility sign-in process upon return. The policy directed staff to follow up on identified medical, medication, behavioral, or safety concerns related to the absence and initiate reassessment or care-plan review when indicated.

Based on observation, interview, and document review, the facility failed to ensure the plan of correction (POC) for the most recent survey of the facility was readily accessible and that the POC for the two preceding years was available upon request. This had the potential to affect all 36 residents residing in the facility as well as family, visitors, and staff.Findings include:During observation and record review on 9/9/26 at 7:18 a.m., a review of the survey results folder located on a bulletin board near the first-floor entrance to the facility was completed. Although the folder included the survey results from the past three years, the results did not include the facility's plan of correction (POC) or indicate that this could be requested from facility staff.During an interview on 9/9/26 at 11:49 a.m., the administrator stated she was responsible for maintaining the survey results folder. The administrator confirmed the POCs for all surveys occurring from 2023 to current were missing from the folder. She said she was unaware of the requirement for the POC associated with the most recent survey to be readily accessible, and for the POC for the two preceding years to be available upon request. She stated she had not included this information in the folder because it contained private resident information. Methods to ensure resident confidentiality when including the POC with survey results were discussed.A request was made for the facility policy regarding the posting of survey results, but this was not provided.

Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if necessary, place interventions for increased supervision to promote safety while outside of the care center for 1 of 3 residents (R1) reviewed. R1 enjoyed going outside and walking to nearby areas (i.e., Walgreens, the park); however, he had repeated incidents outside of falling and/or becoming unable to return to the care center without assistance which were not assessed in the medical record to determine if additional interventions were needed to ensure safety while outside. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment and several medical conditions including anxiety, psychiatric disorder, and Wernicke's encephalopathy (brain disorder caused by a lack of vitamin B1). Further, R1 demonstrated no wandering behavior during the review period.R1's Life Skills Inventory Independent Living Skills Assessment Tool, dated 7/17/23, identified multiple categories which reviewed various aspects of R1 functioning on their own. These categories included R1's money management skills, food management skills, personal appearance and hygiene, and emergency and safety skills. The evaluation recorded R1 as knowing the function of the police and fire department and being able to reach them at the appropriate number. An attached Community Goals Questionnaire, dated 7/17, identified R1's goals was walking to the park, going shopping, going out to meet new people and be helpful when I can. [NAME] Park, Walgreens, and the gas station were all listed as areas he felt comfortable going to. R1 did not have a desire to be on LOA overnight and would usually walk to places of distance with peers (i.e., other residents). The form recorded R1 as feeling he always let staff know when he left. R1 considered his strengths to be independent as, [I] always have a plan to get around [and] get home safe, I know the area well and have my friends, like [initials] help navigate the bus. R1's Elopement Risk Evaluation V 2.0, dated 5/15/26, identified R1 had moderate cognitive impairment and scored a 1.0 on the evaluation which meant, At Risk. The evaluation identified R1 had a history of attempting to leave the building without informing the staff and wandered. R1's progress notes, dated 7/12/26 to 8/12/26, identified R1 had sustained multiple incidents or events while outside the care center and behaviors. These included: On 7/18/26, R1 was non-compliant with staying inside despite the elevated humidity. The note recorded, . returned after 10 minutes leaning on another resident. Appeared confused, diaphoretic, face and arms flushed. R1 was given some water, and a cool towel was placed on his face. R1 returned to baseline within an hour and denied any more dizziness. On 8/4/26, R1 was away from the care center on a walk. R1 tripped on the curb and sustained a fall which left him with abrasions on his forehead and a skin tear on his nose. The skin abrasions were cleaned and dressed. Later, on 8/4/26, R1 was recorded as alert and oriented X2 with text, Does not know day, date or season. R1 was independent in all areas of mobility and had sustained a fall that evening while away from the care center. On 8/5/26, R1 had an Elopement Evaluation completed which identified a score of 1.0 which meant, At Risk. The note identified R1 had a history of attempting to leave the facility without telling staff which caused the resulting score. However, the note lacked any dictation of what, if any, interventions for supervision or safety outside were now considered despite the events recorded on 7/18/26 and 8/4/26. On 8/7/26, R1 was seen leaving the care center at 4:15 p.m. and was stopped by the trained medication aide (TMA) who attempted to have him stay at the care center by reminding him the supper meal would be served soon. R1 asked if he was in prison and left the care center. Following, at 5:00 p.m., a private vehicle pulled up with R1. The person reported seeing R1 outside of Walgreens and offered to take him home. The note recorded, Fortunately, he [R1] told her that he was going to [care center] nearby, and she brought him home. He appeared confused, wabbly and complained of unable to see well. The director of nursing (DON) was notified. Later, on 8/7/26, R1 remained confused and incoherent. R1 was sent to the hospital for evaluation. He returned the same evening. On 8/10/26, R1 left the care center and headed [NAME] down [NAME] Avenue. A peer was outside and observed R1 walking in the grass next to the sidewalk when R1 stumbled and fell forward on all fours. He did not hit his head. The peer assisted R1 to stand and walked him back inside the care center. R1 did not sustain any injury, and his vital signs were within normal limits. The provider was updated and R1 remained his own responsible party. R1's progress note, dated 8/11/26, identified a meeting was held and R1's recent falls were discussed. R1 had decreased meal intakes noted, and a recommendation was made to start a supplement and have the dietitian review R1. R1's weight was 141.4 pounds (lbs.) which was a downward trend. Boost nutritional supplements were started. A subsequent note, dated 8/11/26, identified R1 was evaluated by the nurse practitioner for his increased falls. New lab orders were placed. However, the progress notes lacked any further evidence of what, if any, review or interventions the interdisciplinary team (IDT) had reviewed or considered to ensure safety while outside despite the repeated incidents. R1's elopement care plan, last revised 2/23/26, identified R1 was at risk for elopement due to alcohol-induced dementia and impaired short-term memory and decreased insight. R1 frequently sought outdoor activities and had a history of walking beyond familiar routes and becoming disoriented. The risk increased with public transportation use and the interventions of the plan would focus more on structured safety planning, staff-directed oversight when needed, environmental safeguards, and a prompt response if his whereabouts became unknown. The plan listed multiple interventions including having him on the elopement risk list, staff confirming with him his destinations and routes when he left the building and reinforcing with him to follow the leave (LOA) policies and procedures. However, the care plan lacked any new interventions for elopement or safety in the community since 2/23/26, despite the incidents documented in the medical record.On 8/12/26 at 8:35 a.m., a tour of the care center main level was completed. This identified a main entrance with glass doors which opened to stairs and the sidewalk facing [NAME] Avenue (St. [NAME], MN). The door had a black-colored device mounted on the frame which had an illuminated light pattern. There was not visible wanderguard system attached to the door. The hallways off the main corridor each had a brown-colored door at the end, with an exterior opening door just beyond. These exterior doors were alarmed with signage posted saying an audible alarm would sound if pushed open. There were no wanderguard systems attached to those doors. The back corridor contained the kitchen and some office spaces with a single door opening to the exterior. This door also had a black-colored device mounted with a lighted pattern. At 8:53 a.m., the director of nutrition (DN) used her mobile phone to touch the black device which then illuminated green and DN walked through the door outside. No alarm sounded. DN returned a few minutes later and was interviewed. DN explained the device is how the doors unlocked so the alarm won't sound when passed through. The staff had passkeys on their phone which deactivated it, but the residents did not have that. If a resident passed through the door, then an alarm would sound at the nursing station to alert them to someone was leaving the building. The nurse could then check the cameras to see who it was and respond, if needed. At 10:38 a.m., R1 was observed in his room lying on his bed. R1 had a pair of eyeglasses on with tape around one lens but no visible wanderguard device on his person. R1 stated he was unsure how long he had lived at the care center but thought it was pretty good. R1 stated he liked to go outside often and added, You're lucky you caught me here [inside]. R1 liked to go to the park as there was a woman there who gave him marijuana. R1 reiterated repeatedly that it was legal now, so it was not an issue he was doing that. R1 stated he was free to come and go from the building to his understanding and that he should sign out at the desk when he leaves. R1 denied ever falling outside or having issues with getting back to the campus on his own. R1's Release of Responsibility for Leave of Absence (LOA) form, undated, was located at the main station in a binder labeled, [NAME] Residence Sign Out Book. The last time R1 had written on the form was 7/15/26 where he just wrote, Out?[,] and did not sign back in. When interviewed on 8/12/26 at 10:47 a.m., TMA-D stated residents were free to leave and go as they please just having to sign out in the LOA book prior. Most of the residents did that and only R1 frequently did not adding, He doesn't remember [to]. R1 had poor cognition and staff would always try to get him to stay in the building when he wanted to leave, to which R1 would often ask then if he was in prison. TMA-D stated staff can't really stop him from leaving and he enjoyed going for walks and over to Walgreens. TMA-D stated they had seen R1 leave before and he would just cross the street without using the crosswalk. TMA-D stated they didn't think it was safe for R1 to be outside unsupervised given his cognition. TMA-D stated that ideally a staff member could go with him when he left on LOA, but that was only possible if they had time to do that which would be rare as R1 was constantly wandering and hyperactive. TMA-D verified R1 was not on any safety checks, including when outside, and stated he never had been prior to their recall. R1's medical record was reviewed and lacked evidence the IDT had comprehensively reassessed R1's repeated incidents while outside to determine what, if any, additional interventions for supervision or safety were needed while he was outside the care center (i.e., safety checks, direct supervision, planned outside walks) despite R1 not consistently following the sign in/out process and staff having concerns he should not be outside unsupervised. When interviewed on 8/12/26 at 11:43 a.m., registered nurse (RN)-B explained they had just completed orientation and were the nurse on-duty that day. RN-B stated each resident was able to come and go from the campus as they desired but they always try to remind people to sign in and out when leaving. R1 liked to leave without signing in and out and management was aware he did that. RN-B stated they had raised some concerns to leadership about R1 leaving the building alone to which the response was, He has the right [to do it]. RN-D questioned R1 being outside alone and felt it was maybe unsafe adding, I honestly don't think he should be walking outside by himself. R1 likely needed more direct supervision when outside but there just were not enough staff to do that consistently. The staff would always try to convince R1 to stay inside the building and offer activities or cigarettes to persuade him, however, it did not always work. If a resident, including R1, left through the main door then it would alarm the station and that is how they attempted to better watch R1 for when he left and returned. RN-B stated it could happen that R1 would leave without staff seeing him on camera or knowing about it but felt this would be rare given the number of staff who are at the medication carts in the corridor next to the main door. RN-B stated if R1 was unable to be located in the building, they would check the sign out book then start a search for him. If he was not located within a reasonable amount of time, then they could involve 911 response to check the community for him. RN-B stated there was no specific timeframe ever told to them for when to active that response, rather it was just their assessment to wait 30 minutes or so to see if R1 returned on his own as he typically did. On 8/12/26 at 12:48 p.m., a group interviewed was held with the administrator, director of nursing (DON), social services director (SSD) and nurse consultant (NC). SSD explained that elopement risk was evaluated upon admission and quarterly thereafter using the formal assessment (Elopement Risk Evaluation) but also reviewing the resident's history, ability to solve problems, and their goals for care. The specific action plan for each resident, including what to do when they leave the campus, would then be built into the care plan. SSD stated they didn't consider R1 leaving the campus as an elopement as R1 had a destination in mind and was goal-oriented when he left. It was not just a wander-away without a plan or goal. The administrator stated they also repeatedly do in the moment re-direction and education with R1 when he does leave or states he is leaving. The facility did not have a wanderguard system, either. NC stated they continued to seek guardianship for R1, but he remained his own decision-maker as of that time. It was hard to make a blanket statement on R1's cognition as he would wax and wane with it; however, the administrator stated they felt R1 had enough insight to ask for help if he was in the community and was unable to find his way back to the campus on his own. The group expressed that the IDT was always reviewing R1 and his incidents both within the building and outside; however, acknowledged the lack of follow-up for the events recorded in the medical record. NC stated this was something they had identified as an area to improve and were working on a new template within the record to help ensure it showed the IDT reviewed each incident and what their plan or decision-making for it was. NC stated they felt the IDT was doing a review but just not taking credit for it. They explained, for example, on the 8/7/26 incident where R1 had to be brought back from Walgreens by a person in the public, that they identified R1's eyesight as a contributing factor, so they got him a temporary pair of eyeglasses to use which seemed to help. They had also started a supplement to help him have some additional calories and better prevent falls from happening. NC stated an incident report had been completed for the fall which happened outside (on 8/4/26) but not for the other events when R1 had left and then was unable to return on his own power. NC stated that may be another good educational moment for the staff to complete a report for those to ensure better follow-up on them. SSD verified the Life Skills Inventory Independent Living Skills Assessment Tool (dated 2023) was the last one completed for R1 and expressed the events, when reviewed, seemed to show a good opportunity to re-evaluate R1 using that tool to help ensure safety support needs were in place.On 8/12/26 at 2:07 p.m., a telephone call was held with the person who helped R1 return to the care center on 8/7/26. They were at Walgreens and noticed R1 to be staggering and using the shelves to help support himself. R1 stated he had started a psychiatric medication and that was causing him difficulty with walking. R1 reported living in a very long building down the street which the person figured had to be the care center after seeing it. R1 was returned to the center and a nurse who came to help R1 seemed to be unaware R1 had even been gone and asked him, Where did you go?! The person stated R1 was clearly a fall risk and questioned why he wasn't being supervised outside adding the situation seemed, Very scary. The facility Medically Related Social Services Assessment policy, dated 9/2025, identified assessments would be completed by trained staff and could include their elopement risk and community goals. The policy directed staff would interview the resident concerning goals for time spent in the community and complete a life skills inventory assessment prior to/upon admission, quarterly and when needed. This would review the resident specific goals and interventions for safe community time, and the care plan would be updated as scheduled/needed.

Based on interview and document review, the facility failed to ensure a resident's wishes for resuscitation were accurately documented in all areas of the medical record for 1 of 36 residents (R24) reviewed for advanced directives. This resulted in an IJ for R24 who would have received CPR against his wishes in the absence of a pulse or respirations. The IJ began on [DATE], when the facility failed to accurately document a resident's code status in the EMR. The facility administrator and owner were notified of the IJ on [DATE] at 5:20 p.m. The IJ was removed on [DATE] at 3:44 p.m. but non-compliance remained at the lower scope and severity of a level D, no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: R24's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of delusional disorders and chronic obstructive pulmonary disease (COPD). It further indicated R24 was independent with activities of daily living (ADL) and mobility. R24's face sheet/banner in point click care (PCC) indicated advanced directives: Cardiopulmonary Resuscitation (CPR). R24's physician's orders dated [DATE] as transcribed by the health unit coordinator (HUC), indicated Do Not Resuscitate (DNR). No directions specified for order. Pending confirmation. R24's Physician's Orders for Life Sustaining Treatment (POLST) dated [DATE], located in the paper chart, indicated CPR. R24's POLST dated [DATE], indicated DNR and was signed by R24, but was located in the physician folder awaiting signature from the physician. R24's care plan dated [DATE], indicated Advanced Directive (AD): POLST CPR/Full code with the following interventions: -document changes in AD as needed -ensure R24's health care providers and case manager (CM)/family are aware of current directive and any changes made. -respect R24's wishes around his AD for CPR R24's progress notes dated [DATE], entered by the HUC, indicated hospital preference and code status updated. Upon updating code status resident informed writer that he does not want to have CPR. Code status changed to DNR. However, the electronic medical record (EMR) did not reflect the new code status change, as R24 remained a full code on the face sheet/banner in the EMR. During interview on [DATE] at 2:55 p.m., R24 stated the HUC recently asked him if he wanted to have life saving measures in the event of an emergency and he decided he didn't want to be resuscitated stating if I'm going to die, I'm going to die. During interview on [DATE] at 1:00 p.m., the HUC verified interviewing R24 and completing a new POLST and placed the POLST in the physician folder to await a signature. Further, HUC stated the process for when a resident requested to change their code status (and they don't have a guardian), was to update it in PCC first and then the paper chart. The provider had to sign off on it so it takes awhile to get it in the actual chart (paper). The resident's code status would remain the same until the physician signs off on it (POLST), and once it was signed, the facility would change the AD to the new code status. The HUC further stated the provider was notified by mail or by leaving it in their file at the facility to review and sign the next time they came in. The doctor comes to the facility once a month and the nurse practitioner (NP) comes twice a month. The nurse (facility) can also reach out to the provider directly to get a verbal order for more serious concerns but they don't reach out to them for a change in code status. The HUC stated she does not reach out to the nurse directly to report a resident's change in code status but put's in a progress note which would then populate to the 24-hour report. The nurse was supposed to read the 24-hour report before the start of each shift. The HUC further stated she had explained the POLST to R24 (specifically the difference between CPR and DNR) but the Social Worker (SW) was also able to explain it. During interview on [DATE] at 1:26 p.m., licensed practical nurse (LPN)-A stated if a resident was found unresponsive, they would look in the hard chart under the AD tab (POLST) first for their code status or if they couldn't find it there, then on the face sheet/banner in PCC. LPN-A further stated if a resident wanted to change their code status, they would contact the provider right away and get a verbal order. During a follow up interview at 2:49 p.m., LPN-A stated the HUC was responsible for verbally letting the nurse know if a resident wanted to change their code status and then the nurse should put in a progress note. LPN-A further stated what if a resident was DNR and I'm sitting here doing compressions, that would be a problem. If LPN-A were to see the resident wanted to change their code status in PCC, they would call the provider immediately and get a verbal order to change it. LPN-A was aware R24 changed his AD because they saw the pending order in PCC but LPN-A did not notify the doctor. LPN-A further stated, no one had notified the doctor to her knowledge. LPN-A verified R24's POLST in his paper chart and the face sheet/banner in PCC both indicated to perform CPR and therefore would've performed CPR on R24 in the event of an emergency. During interview on [DATE] at 3:07 p.m., LPN-B stated if a resident was found unresponsive, they would look in the hard chart under the AD tab (POLST) first for their code status or if they were closer to the computer, then on the face sheet/banner in PCC. LPN-B further stated if a resident wanted to change their AD (and they are their own guardian) they would call the provider and get a verbal order to change it. It should be done as soon as possible during the shift. The resident shouldn't have to wait until the next time the provider or NP visits the facility. LPN-B was unaware R24 wanted to change his AD. LPN-B verified R24's POLST in his paper chart and the face sheet/banner in PCC both indicated to perform CPR and therefore would've performed CPR on R24 in the event of an emergency. During interview on [DATE] at 4:36 p.m., the director of nursing (DON) stated if a resident was found unresponsive, the first place nursing staff should look for their code status was on the outside of their hard/paper chart which had a red or blue tab. The red tab meant the resident was DNR and the blue tab meant CPR. The staff could also check the resident's code status on the face sheet/banner in PCC if they were closer to the computer. The DON further stated if a resident requested to change their code status the nurse should notify the provider right away to get a verbal order to do so, stating it shouldn't take a lot of time to do, since we have 24 access to our providers. This is important because if a person wanted a code status of DNR/Do Not Resuscitate and we assist in CPR, they made a choice and we are taking that choice always from them and the dignity and autonomy to make that choice themselves. A facility policy regarding AD last updated [DATE], indicated during the quarterly RAI process and with any significant changes of condition, facility staff will: i. Identify, clarify and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive ii. Define and clarify medical issue, review the resident's condition and existing choices and present information regarding relevant health care issues to the resident or resident representative as appropriate to determine continuation or modification of choices of care iii. Assess the resident for decision-making capacity and based on assessment, if the resident is determined not to have decision-making capacity, facility staff will invoke the health care agent or legal representative iv. Identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition v. Changes to the resident choices for advance directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care through resident care plan. vi. Staff must verify the legal authority of the resident's health care proxy, power of attorney, or legal representative before implementing changes to the resident's care preferences, particularly when the resident lacks decision-making capacity. vii. Updates or overrides to previously documented advance directives must be clearly documented in the resident's medical record, with confirmation of capacity or legal authority to make such changes. viii. Informed consent, including documentation of risks, benefits, and alternatives, must be obtained and documented before initiating or increasing any medications or life-sustaining treatments, consistent with the resident's advance directive. ix. Identify the process in which the facility and/or physician do not believe they can provide care in accordance with the resident's advance directives or other wishes on the basis of conscience x. Facility staff shall review, upon admission, the resident's verbal or written CPR/code status wishes; if a resident verbally declines CPR and no written order exists, two staff members shall witness and document the conversation. Staff shall immediately notify the physician and document discussions and actions taken while awaiting a written order. The resident's verbal refusal shall be honored as the care plan unless or until a written physician order is received. XI. In cases where a verbal refusal is not yet ordered but clearly expressed by the resident or representative and appropriately witnessed, staff must honor the resident's wishes regarding CPR. The IJ was removed on [DATE] at 3:44 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review, which included an audit of all resident's medical records (physical and virtual) in order to determine any discrepancies in the orders and the residents wishes. If a current advance directive wasn't available, the resident was immediately interviewed to determine their wishes. The facility also reviewed and updated their Advanced Directive and CPR policy and procedure. Education on CPR and Advanced Directive policy and procedure were provided to nursing staff and social services on [DATE], (in person for staff present, and electronically for staff who were not present).

Based on observation, interview and record review the facility failed to ensure resident snack refrigerator temperatures were maintained to prevent food and drink items from spoiling and items in the snack refrigerator were labeled and dated. Furthermore, the facility failed to ensure the dishwasher was reaching temperatures required for proper sanitization and expired milk was removed from the main kitchen refrigerator. This had the potential to affect all residents who reside in the facility. Findings include: A facility document titled Nursing Refrigerator Log (bottom fridge) dated 6/2025, directed staff to notify maintenance if the temperature was greater than 41 degrees F. The document indicated temperatures were monitored on the following dates: 6/19/25, for 40 degrees Fahrenheit (F) -6/20/25, no temperature recorded -6/21/25, no temperature recorded -6/22/25, no temperature recorded -6/23/25 50 degrees F. -6/24/25 48 degrees F. A facility document titled Dish machine Temperature Log dated 6/2025, indicated temperatures were monitored twice daily and were within range for washing and rinsing. The document instructed staff to notify the supervisor if temperatures were not adequate. Wash temperatures were to be 150 degrees F. and rinse temperatures 180 degrees F. An observation on 6/23/35 at 6:27 p.m., the resident snack refrigerator was reviewed. On the outside of the refrigerator was a temperature log. The last temperature recorded was on 6/19/25 and the temperature was 40 degrees F. The refrigerator had two unlabeled, open half empty cups of vanilla snack pudding cups in the door. There was also an unlabeled take-out container. The fridge also contained two pitchers of juice and an open gallon of 2 percent milk. The items in the refrigerator felt warm. A round temperature gauge read 50 degrees F and was in the red zone. When interviewed on 6/23/25 at 6:32 p.m., trained medication assistant (TMA)- A verified the open items in the refrigerator. TMA-A stated the pudding was likely from medication passes and stated they should not be left in there open and unlabeled. TMA-A further stated the take-out container also should have been labeled. The items were removed. When interviewed on 6/23/25 at 6:35 p.m., licensed practical nurse (LPN)-B verified the temperature of 50 degrees F. and stated the items were a little warm. LPN-B was not aware of any temperature issues with the snack refrigerator and would need to let the maintenance team know. LPN-B further stated the night shift was responsible for monitoring the temperatures and writing it down on the log. An observation on 6/23/25 at 7:39 p.m., the snack refrigerator temperature was reviewed. The temperature now read 48 degrees F and was still in the red zone on the thermometer. This was verified by LPN-B. An observation on 6/24/25 at 8:35 a.m., the refrigerator in the main kitchen was reviewed. Inside was a half-gallon of Dairy Star lactose free milk had a best by date of 6/18/25. When interviewed on 6/24/25, at 8:40 p.m., cook-A verified the expired milk and further stated on Mondays, the cook would go through and check items and removed anything that was old or out of date. Cook-A further stated this must have been missed. An observation on 6/24/25 at 8:52 p.m., the snack refrigerator was reviewed. The log on the outside of the refrigerator was updated for 6/23/25 and a temperature of 50 degrees F was recorded. The temperature read 46 degrees F and was still in the red zone on the thermometer. The refrigerator still contained the opened gallon of 2 percent milk. When interviewed on 6/24/25 at 9:00 a.m., LPN-A verified the temperature. LPN-A was not aware of any concerns about the refrigerator temperatures and verified it was unknown when the last time it was in range. LPN-A verified residents had not had milk out of there today and stated it needed to be thrown out and maintenance would need to be notified. An observation on 6/25/25 at 10:38 a.m., the Eco lab high temperature sanitization dishwasher was observed. Two temperature dials were noted on the top of the machine. The wash temperature dial stated needed tor reach 150 degrees F. The rise temperature dial stated needed to reach 180 degrees F. During a wash cycle, the wash temp reached 160 degrees F on the dial and the rinse temp reached 115 degrees F. Cook-A ran the load again and the wash temperature was 160 and the rinse temperature was 120. Cook-A stated there had been some problems with the rinse gauge and wasn't sure what was wrong with it, and further stated it was working this morning. Cook-A further stated would need to let the owner know as he knows how to reset it. At 10:48 a.m., Cook-A was setting up tables for lunch. The owner walked by and cook-A did not report the low dishwasher temperatures. At 11:19 a.m., cook-A ran another dishwasher load, and the wash temperature was 160 degrees F, and the rinse was 120 degrees F. An observation on 6/25/25, at 1:13 p.m., cook-A was finishing the last load of dishes from lunch. The wash temperature was 155 degrees F, and the rinse temperature was 120 degrees F. Cook-A verified it still was not showing the correct temperature. Cook-A stated they weren't sure about the temperatures, but the dishes coming out were hot. Cook-A further stated the owner, maintenance and Ecolab were all aware and wasn't sure when it would get fixed or how to ensure the temperatures were in range. When interviewed on 6/25/25 at 1:45 p.m., the Environmental Service Director (ESD) stated he was aware of an issue with the temperature gauge not working correctly and stated he had checked it sometimes but had not been told about it today. ESD further stated the machine was rented from Ecolab and they should be notified and fix it. ESD was aware of the snack refrigerator not being at the correct temperature on 6/24/25. ESD further stated staff often adjust the dials when they should not be and verified it takes a while to get the temperature back to where it should be. When interviewed on 6/25/25 at 2:37 p.m., the clinical dietician (CD) was told the dishwasher hadn't been getting to the correct temperature when checking in with staff. CD stated the facility had recently obtained a 180-degree testing strip and a surface temp plate that could be used to verify if temperatures were not reading correctly. CD stated these were new and there training had not been completed with any staff until today after hearing the temperatures were not reading accurately. When interviewed on 6/26/25 at 8:20 a.m., the Director of Nursing (DON) expected nursing staff to monitor the refrigerator temperatures were too warm, maintenance should be notified and items should be removed and placed in the kitchen refrigerators. When interviewed on 6/26/25 at 11:50 p.m., the owner stated the dishwasher gauge had not been working and it was first noticed on 6/21/25. The owner stated he had turned it off and then back on a few times to reset the machine and then it would read properly. On 6/21/25, Ecolab had been called and a message left, however had not come out. On 6/25/25, they did come out in the evening and everything was working correctly now. A facility policy titled Dish Machine Temperature revised 6/25/25, directed staff to ensure wash temperatures were 150 degrees F, rise temperatures were 180 degrees F, and surface temperatures were 160 degrees F. Staff were to notify supervisor when temperatures were not adequate and describe corrective action taken in the log. If maintenance staff were not ale to resolve, staff will notify Ecolab for emergent repair. A facility policy for food storage was requested however was not received.

Based on observation, interview, and document review, the facility failed to ensure a comfortable environment, having hot water available for 4 of 4 residents (R36, R34, R31, R15) who were received for concerns with cold showers. Findings include: R36's admission Minimum Data Set (MDS) assessment dated , 4/10/25 indicated cognition moderately impaired and independent for personal hygiene cares including bathing/shower. R36's care plan indicated independent with set up, it was very important showering early in the morning assist as needed. If declines offer at another time and day. R34' s admission MDS assessment dated , 3/26/25 indicated cognitively intact and set up or clean up assistance for personal hygiene cares including bathing/shower. R34's care plan indicated independent with set up assist as needed. If declines shower on assigned date offer another time or day. R31's quarterly MDS assessment dated [DATE] indicated cognitively intact and independent with set up for personal hygiene cares including bathing/shower. R31's care plan indicated prefers tub bath, requires set up assist and assist in/out of whirlpool tub. Independent with shower with set up assist. During observation on 6/25/25 at 8:08 a.m., R15 complained of cold water in the shower to another resident in the main hallway. Stated they took a shower on Monday, and it was ice cold. Observed another resident stated they took a shower, too cold on Monday and today. During interview on 6/23/25 at 6:41 p.m., R36 reported that they requested to take shower at approximately 5:00 a.m., always had been an early riser. Asked staff to open shower, staff won't. R36 stated it was a simple request, benefits staff for starting showers early, but they acted like its an inconvenience. R36 discussed situation with director of nursing (DON-D), the answer R36 reported was, shower rooms were under the staff's care, it was their rules. The showers were usually cold, R36 washed and rinsed off very quickly. During interview on 6/23/25 at 7:39 p.m., R 31 reported the water for showers were cold, like really cold. The shower rooms were locked, staff won't open shower rooms without being rude. They acted like it was a big deal, and R31 was being a bother. During interview on 6/24/25 at 8:45 a.m., R34 reported there wasn't hot water in the shower and the towels and wash cloths were locked up, talked with staff, was told to go ask housekeeping for towels, staff were not going to get them for me. During interview on 6/25/25 at 8:08 a.m., with environmental services director (EVS-A) stated maintenance checked the boiler temperature, documentation not observed. Requested temperature for water coming out of shower head fixture, unable to temp, the facility had a broken water thermometer, did not report, did not know when facility would get a new one. Re-confirmed that the temperature from the shower head fixture could not be assessed, EVS-A verified unable to obtain water temperature from the shower. Obtained boiler temperature in the basement, the thermometer read almost 100 degrees Fahrenheit. EVS-A stated boiler temperature for warm showers was 120 degrees F. The boiler system was more than [AGE] years old, multiple repairs requested, had a quote for a new system for building. During interview on 6/25/25 at 8:21 a.m., R15 reported liked taking warm showers in the morning. Their days are Wednesday and Saturday, the water had been cold. Stated told nurses, they say not to take a shower if the water is cold. They need to wait until there was hot water, can wait over a day to get hot water. R15 stated not seen staff temp water, they ran hand under the shower water. Sometimes staff go downstairs and check. Sometimes the nurse will come and inform me when there was hot water, and then R31 was able to shower During interview on 6/26/25 at 12:07 p.m., with DON-D stated was aware of cold water in the showers the boiler will overheat, tripping off a safety switch, not send the warm water upstairs, only the cold water. Maintenance was responsible for the monitoring of safety switch, and water temperature with the boiler. The showers were locked in safety and monitoring of residents, the showers needed to clean and sanitized between each use. The towels and linen were held for residents until use for infection prevention. The shower hours were in place, so the medication passes and meals were not interrupted. Staff made accommodations for requests when able. During interview on 6/26/25 12:22 p.m., with the administrator-C, stated was aware of cold water in the showers, repair company worked on water heater, it kept tripping, a reset was needed. Called service company had maintenance staff trained on how to perform the task. Additionally, had parts replaced, the boiler system was old. The facility also received quote for replacing heater. The expectations for the residents regarding showers was to choose day and time, one to two times a week, a shower or a tub, if able. The staff was to be flexible with resident's requests. The temperatures were obtained in tub with a gauge, was unaware the facility had a broken water thermometer. Administrator stated they had their own water thermometer. They will investigate it; they temped water in the past. The times for the shower were flexible if it did not interrupt medication passes, mealtimes, or quiet nighttime hours. The showers are locked in safety of the residents and ability to clean and sanitize between residents' usage. The Hot Water Policy: Purpose: To ensure adequate hot water in building. Procedure: *Hot water temperature. Hot water supplied to sinks and bathing fixtures must be maintained with a within a temperature range of 105 degrees Fahrenheit to 115 degrees Fahrenheit at the fixtures. *The Environmental services staff shall maintain a quarterly temperature log *If the temperature is outside of above temperature range, staff will call Environmental Services Director or Designee to inform; if unable, staff to call Administration inform. If EVS or Designee is unable to detect and resolve failure, staff will call St. [NAME] Boiler Repair (651) [PHONE NUMBER], Cities 1 (651) [PHONE NUMBER] (or similar HVAC company) and request emergency repair.

Based on observation interview and record review the facility failed to ensure call lights were accessible to 1 of 1 resident (R3). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of paranoid schizophrenia and post traumatic stress disorders (PTSD). It further included R3 had upper extremity impairment on one side, required staff assistance with most activities of daily living (ADL) and mobility, and was frequently incontinent of bladder and occasionally incontinent of bowel. During observation on 6/25/25 at 8:00 a.m., R3 was sitting in his recliner/lift chair in his room. His call light was stuck inside the bottom of his chair and not within reach. During observation and interview on 6/25/25 at 10:13 a.m., nursing assistant (NA)-A entered the room and assisted R3 to reposition in his chair. NA-A verified his call light was stuck in the chair and that it should be within reach. NA-A attempted to remove the call light from being stuck but was unable to do so and stated they would fix it when he got up for lunch. During interview on 6/26/25 at 8:17 a.m., licensed practical nurse (LPN)-A stated all residents should have their call lights within reach when they are in their room. During interview on 6/26/25 at 11:45 a.m., the director of nursing (DON) stated resident call lights should be placed within reach of the resident in order for them to have access to safety. A facility policy regarding call lights was asked for but not received.

Based on observation, interview and document review, the facility failed to provide quality of care for 1 of 1, resident (R34) to ensure bruises were adequately assessed, monitored and documented. Findings include: R34's Minimum Data Set (MDS) dated [DATE], indicated Brief Interview for Mental Status (BIMS) cognition score 13, cognitively intact. R34's Care Area Assessment (CAA) for mood dated 3/26/25, indicated mood severity score 12. Risk for change in mood due to mental illness and needed to adjust to new environment. Staff to observe for change in mood, offer support and reassurance, and update doctor/Psych as needed. Functional abilities: R34 is new admit to [NAME] from home for ongoing support services for mental health and diabetes management. R34 was living in family home with brother until home sold. He was alert and oriented with forgetfulness, mental illness had diagnosis of schizoaffective disorder with baseline delusion about Satan and how he tried to control him. Had challenges of coping with his anxiety and become overwhelmed, with racing paranoid thoughts causing R34 to become fearful about trying new things, causing low energy and lack of motivation affecting his ability to complete activities of daily living (ADL). R34 had delusions since admit self-reporting to writer that when he was watching TV downstairs Satan told him to stop watching TV and then tells him to hit himself. R34 benefited from validation and reassurance. Had been followed by ACT team and will continue to be routinely seen by psychiatry. PHQ-2-9 assessment completed with score 12 indicating moderate depression. R34 stated was lonely often due to being shy and difficult being in crowds. Nurse to do foot/skin checks weekly any abnormalities document in progress note. Skin risk assessment on 6/24/25, identified risk for bruising due to daily use of aspirin. R34 was independent with all activities of daily living and mobility with no assistive devices used. Continent of bowel and bladder. The nurse was to check feet/skin for changes weekly. Currently has bruise under left eye stated the devil told him to hit himself. R34's current physician orders included the following: Shower/bath during week, assist as needed, start date 3/22/25 Monthly weight, start date 3/22/25 Monitor change in mental status and progress note the changes, if any. Start date 3/20/25 Clozapine oral tablet 100 mg, 2 tablets by mouth daily, start date 4/11/25 Clozapine oral tablet 50 mg, ½ tablet by mouth at bedtime, start date 4/30/25 Standing orders for Skin and Wound management: -Assess all wounds and dressings daily -Complete wound measurements weekly if not a higher frequency by ordering provider -Moisture barrier cream or ointment two times a day as indicated to keep irritants or moisture from skin surface -Moisturizing cream two times a day as needed for dry skin -Cleanse minor skin tear, abrasions, pressure injury, and minor injuries with normal saline or non-cytotoxic wound cleanser. Cover with non-adherent dressing and secure appropriate cover dressing avoiding tape to the skin. -Change all dressings every 3 days and as needed -May initiate pressure reduction mattress and/or occupational therapy wheelchair positioning eval and treat as clinically indicated for patients with, or at high risk for skin breakdowns. -Discontinue dressings and other treatments when wound resolved. For localized reaction apply cold compress 15 minutes every two hours as needed. Notify provider if worsening or no improvement in 24 hours. R34's Treatment Administration Record (TAR) dated June 2025 reflected the following: Nurse to do, monitor change in mental status and progress note the changes, if any. Every day and evening shift, start date 3/20/25. Shower/bath every Saturday start date 3/22/25 Skin check, nurse to do, one time a day every Saturday document abnormal finding in progress note, start date 3/22/25 Self-injury related to command hallucinations, repetitive questions. Repetitive questions. Anxiety and obsession surrounding medical conditions: excessive blood sugar monitoring and repeated testing, rumination, redundant outreach to providers, etc. Offer non-pharmacologic intervention and document response: 1) Massage 2) Redirection 3) Music Therapy 4) Change of surrounding 5) Validation Therapy 6) Warm Blanket 7) Doll therapy 8) Pet therapy 9) Family visit 10) Spiritual Care every shift for Behavior Monitoring related to SCHIZOAFFECTIVE DISORDER, BIPOLAR Document if target behavior was observed and interventions provided, start date 3/22/25 Monitor change in mental status and progress note the changes, if any, start date 3/22/25 R34's care plan dated (6/26/25): Focus: R34 experienced chronic auditory hallucinations, included derogatory and command voices, which have previously led to self-injurious behavior. Recently, R34 reported hitting himself under the influence of these voices, resulted in a bruise under his left eye. Although he currently denies active self-harm urges, he acknowledged that symptoms could intensify with increased anxiety, paranoia, or change in routine. R34 was aware of his symptoms, receptive to support, and agreed to engage with staff and clinical supports to manage internal stimuli and prevent harm. Start day 4/22/25 Goals: Remain free from self-injurious behavior or risk of harm to self/others through the review period. Start date 4/22/25 Report any negative internal stimuli or urges to self-harm to staff upon on onset for intervention and support. Start date 4/22/25 Demonstrate use of at least one positive coping strategy when distressed by hallucinations. Start date 4/22/25 Work with staff and providers to explore distress tolerance and cognitive strategies to challenge hallucinations and associated behaviors. Start date 4/22/25 Interventions: Collaborate with clinical providers to support R34 participation in distress tolerance training, cognitive behavioral therapy, or similar interventions aimed at challenging hallucinations and associated thoughts/behaviors. Start date 4/22/25 Collaborate with clinical providers to update and review safety plans and coping strategies regularly with R34. Start date 4/22/25 Conduct frequent check-ins to assess mental state, especially signs of increased anxiety, paranoia, or preoccupation with hallucinations. Start date 4/22/25 Encourage and facilitate the use of positive coping strategies. Start date 4/22/25 Encourage open and nonjudgemental communication. Document and report any signs of distress, changes in routine, or signs of self-injurious behavior immediately. 4/22/25 If at any point R34 poses imminent threat of harm to himself or others, staff are to contact emergency medical services (EMS)/authorities, inform clinical management, update providers and emergency contacts, and document accordingly. Start date 4/22/25 If R34 reports that he has self-injured, assess for signs of injury, report to clinical management, and utilize EMS when necessary. Offer hospital evaluation and/or connection with [NAME] County Crisis. Start date 4/22/25 R34's electronic health record (EHR) was reviewed on 6/24/25 R34's Medical Medication Review on 6/24/25 reported no changes. Provider notes: R34 provider note dated 6/5/25 presented for review of systems, hypertension, schizoaffective disorder. Physical examination: psychiatric, orientated to person, place and time, anxious. Skin: warm and dry. No rashes or lesions on exposed skin. R34 denied any blood pressure issues or mood concerns. He thinks he is otherwise doing ok. Plan: continue Clozaril, following with psych. R34 provider note dated 5/13/25 presented for follow up. R34 told me doing well but concerned of feeling tired easily. No concerns per nursing staff. Physical examination: psychiatric: orientated to person, place and time, judgement appropriate, mood and affect appropriate. Skin: warm, dry. No rashes or lesions on exposed skin. Plan: continue Clozaril, following with psych, monthly CBC. R34 provider note dated 4/9/25 presented for follow up, no complaints, other than oral sores, no bleeding appointment for dentist. No concerns per nursing staff. Skin: Warm and dry. No rashes or lesions on exposed skin Psychiatric: Oriented to person, place and time. Judgment appropriate, mood, and affect appropriate. Plan: Continue Clozaril, following with psych, monthly CBC. R34 provider note dated 3/27/25 presented for long term care admission, schizoaffective disorder. Skin: Warm and dry. No rashes or lesions on exposed skin. Psychiatric: Oriented to person, place and time. Judgment appropriate, mood, and affect appropriate. Plan: continue Clozaril, following with psych. Ordered CBC, CMP, TSH, hba1c. Progress notes: R34 progress note dated 6/24/25 social services followed up with resident again regarding preoccupation with roommate's fan use and belief that he cannot be exposed to dry air medically. Writer explained options were being discussed with clinical management to decide on best rooming option and inquired if he would be open to moving to an open double room contingent on all parties agreeing and clinical indications. Resident was receptive to this and will follow-up with writer once other residents have been addressed. Writer updated DON and administrator. R34 progress note dated 4/22/25 Writer followed up on nursing note that resident had purple bruise under his left eye that he reports was a result of Satan telling me to hit myself. Per skin/wound note resident was assessed to have no open wounds/swelling, reported pain, and agreement to communicate regarding these thoughts and actions in the future. R34 confirmed that he had tapped hard on my temple, pointing to left side of face where centimeter long purple bruise was noted. He did not have any residual pain, however, agreed to allow staff to monitor with report made to doctor, psychiatry, and ACT team. R34 endorsed chronic auditory hallucinations of the devil making derogatory statements about his character and command hallucinations instructed himself to hit himself: A couple years ago I gave myself two black eyes. Resident noted that he generally manages these voices and urges well, however, when he is anxious or paranoid they tend to escalate. Resident acknowledged that changes in his medication i.e. Metformin discontinuation had elevated his anxiety, however, he understood clinical rationale given by (nurse practitioner) NP. Writer assessed for safety and resident denied any current urges to self-harm or presence of unsafe thoughts or internal stimuli. Resident declined need to be evaluated in the hospital setting, however, was made aware that if he is at risk of harm to self in future evaluation may be recommended. Encouraged resident to communicate openly if experiencing these symptoms and utilize staff as support to devise safety plan, discussed ability to reach out to ACT team, brother, or crisis team as coping skill alongside spending time outside of his room and reading the Bible. Resident was receptive and in agreement to expand care plan to include the above and explore onboarding with therapist to practice distress tolerance and challenging voices. Staff will continue to monitor and update providers ongoing. R34 progress note dated 4/21/25 The resident was seen a with purple bruise under his left eye. He stated, Satan makes him hit himself. There were no open wounds, nor swelling. Asked him to speak with staff when he is having these thoughts or conversations. he said he would. During observation on 6/24/25 at 8:45 a.m., left eye red bruise underneath it. During interview on 6/24/25 at 8:45 a.m., R34 stated he did it to himself and refused to elaborate. During interview on 6/24/25 at 9:49 a.m., nursing assistant (NA-A) stated R34 had a bruise under left eye, inquired what happened, R 34 stated, Satan beats his ass. R34 reported a way to calm down was to pray. NA-A documented findings in progress note, and updated charge nurse. During interview on 6/26/25 at 11:38 a.m., with licensed practical nurse (LPN-A) the process for a non-pressure injury was assess it, implement standing orders, notify doctor, measure and describe it in progress note and skin and wound, continue to monitor and document assessment until healed. Also, fill out an incident report. Additionally, report to director of nursing (DON). If the injury is of unknown origin do investigation, research, and evaluate, and document findings. It was an expectation for staff to follow doctor's orders. LPN-A reviewed point click care (PCC) electronic health records (EHR), hard chart that contained paper documentation, stated there was a bruise documented in progress notes by NA-A, however, no follow up of nurse initial evaluation of injury. Furthermore, documentation lacked any additional assessments for monitoring of injury. R34 skin assessment checks on 6/7/25, 6/14/25 and 6/21/25 documented skin assessment was completed, no bruises observed. During interview on 6/26/25 at 12:03 p.m., with director of nursing (DON-D) the expectation of staff if a skin injury was observed, contact the lead nurse, release standing house orders for wound care and observation treat injury accordingly. Monitor and assess skin injury daily, document in PCC under skin assessment and progress note. Additionally, fill out an incident report and if its behavioral, notify behavior team. The expectations for all staff to was follow doctor's orders. A facility policy for Skin Assessment updated on 6/26/25 reflected: Purpose: To assure skin impairment was identified, assessed and treated in a timely manner. Guidelines: Completes a head-to-toe skin assessment/skin check by nursing staff to observe for skin changes and address wound care needs. Procedure: 1. Provide for resident privacy and explain procedure to the resident. Maintain dignity during skin assessment by exposing only one area at a time 2. Assessment was conducted from head to toe in systematic order. The nurse conducting the assessment does not have to remove dressing-only confirms a wound exists and the documentation and treatments have been established. 3. Assess skin surfaces for *Reddened areas *Heat *Tenderness *Excoriations *Rashes *Spongy areas *Bruises *Breaks in skin integrity, including new skin tears or abrasions *Areas of dry, scaly, or cracked skin 4. Document skin condition. NAs to communicate to nurse on duty for any observed skin conditions for further nursing assessment. 5. If the skin assessment reveals a change requiring treatment, orders, and/or interventions, the nurse will initiate the appropriate action. 6. Nursing staff to utilize standing house orders for general wound care management and treatment. Additional orders for treatment/management of wounds requiring care beyond standing house orders to be received from provider.

Based on interview and document review the facility failed to ensure weekly monitoring and measurement of pressure ulcers were completed for 1 of 1 resident (R3). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, delusions, and diagnoses of paranoid schizophrenia and Post Traumatic Stress Disorder (PTSD). It further included upper extremity impairment on one side, required supervision with bed mobility, substantial assistance with toileting hygiene and transfers, was frequently incontinent of bladder and occasionally incontinent of bowel. R3's physician's orders dated 6/17/25, indicated nursing staff to measure wounds on right and left buttocks weekly and document in the nursing progress notes, in the evening every 3 days for wound care. It further included an order dated 1/19/24, which indicated weekly skin checks (to be done on shower day) every night shift, (Friday) for skin monitoring and to document any skin abnormalities in the progress notes. R3's care plan dated 6/20/25, indicated on 6/10 during morning (a.m.) cares night staff found a pressure ulcer (open area) on both buttocks. The right side measured about 2.5 centimeters (c.m.) by 2 cm while the left side measured 0.3 c.m. by 0.5 cm. Report was passed to next shift to follow-up with the order for wound care. It further included the following interventions: -Administer treatments as ordered and monitor for effectiveness. -Educate the resident/family/caregivers as to causes of skin breakdown: including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Monitor dressing Allevyn and Optiview dressing to right and left buttock to ensure it is intact and adhering. Report lose dressing to treatment nurse. - Monitor nutritional status. Administer 8 ounces (oz.) Boost glucose control one time a day for healing. Document amount consumed and discontinue if develops loose stool. Ok for equivalent brand. diet as ordered, monitor intake and record. -Nursing: Allevyn and Optiview dressing to right and left buttock. Change every 3 days until healed. -Nursing: measure wounds on right and left buttocks weekly and document in nursing progress notes. -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. -The resident requires : pressure relieving/reducing device on chair and bed. -Treat pain per orders prior to treatment/turning etc. to ensure resident comfort. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. R3's skin and wound notes for the months of May and June of 2025 indicated the following: -6/24/2025 R3's bottom was looking good, no drainage, no odor. Dressing changed today and measured. Right buttocks was 2 c.m. in width and 2 c.m. in length, left buttock was 3 c.m. in width and 4 c.m. in length. No complaints of pain to the area. Will continue to monitor healing process. -6/17/2025 R3's progress note lacked documentation the wounds had been measured. -6/10/25 during morning care, open area was noted on both buttocks, the right side measured 2.2 c.m. by 2 c.m. while the left side measure 0.3 by 0.5 c.m. Report passed to next shift to follow up with the order of wound care. -6/3/25 R3's medical record lacked documentation the wounds had been monitored or measured. -5/28/25 R3's medical record lacked documentation the wounds had been monitored or measured. -5/22/25 R3's medical record lacked documentation the wounds had been monitored or measured. -5/16/25-The gluteus maximus of the resident was observed. It appears to be purple and blue in color 4 inch by 4 inch across bilateral aspect. There seems to be some openings bilaterally. Left side 1 inch long, 0.5 c.m. wide, the area is blanchable. Staff will continue to monitor and document that resident continues to offload his weight. -5/8/25 R3's medical record lacked documentation the wounds had been monitored or measured. -5/1/25 late entry: During the brief change noted R3 had purple and blue bruising to his buttock. The resident was up and cream applied. R3's progress note lacked documentation to continue to monitor and/or measure the area. During interview on 6/26/25 at 8:17 a.m., licensed practical nurse (LPN)-A stated the nurse was responsible for completing weekly skin checks. R3 had a pressure ulcer on his buttocks and he was supposed to have his wounds measured, dressing changed, and documentation every 3 days. They don't have an official wound doctor but if the wound get's worse they should inform the provider. During interview on 6/26/25 at 11:45 a.m. the director of nursing (DON) stated the nurses were responsible for performing weekly skin checks and if the resident refused, the nurse was still expected to document what they could see and/or document the refusal. If a resident developed a new pressure ulcer, it should be measured, document the description, provide basic wound care, continue to monitor, and then get a wound care order from the provider. They do not have formal wound rounds but they monitor all residents on a weekly basis. The DON further stated on 5/1/25, she noticed R3 had bruising on his buttocks and put in a progress note regarding it. She didn't measure it because he was firing everyone. The TMA (unknown) said it had been there for awhile so she asked staff to keep an eye on it. The DON verified she hadn't put in a note to monitor the area and R3's medical record lacked documentation of consistently monitoring and measuring his pressure wounds weekly and it should have been. The facility policy regarding treatment and services to prevent/heal pressure ulcers dated 5/1/25, indicated if a pressure ulcer was present, appropriate staff within proper scope and practice will provide treatment and services to heal it and to prevent infection and the development of additional pressure ulcers.

Based on observation, interview and record review the facility failed to ensure a root cause analysis and ensure interventions were implemented for 1 of 1 residents (R5) reviewed for falls. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderately impaired cognition and diagnoses of paranoid schizophrenia. R5 required substantial assistance for toileting and partial assistance to transfer from bed to chair. R5 was at risk of falls and had 2 or more falls since the prior assessment. R5's fall risk assessment dated [DATE], indicated R5 was at high risk for falls due to intermittent confusion, 1-2 falls in the past 3 months, chair bound and need for assistance with elimination. R5's nursing progress note dated 6/13/25 at 8:15 a.m., indicated R5 was found on the floor at 7:50 a.m., R5 was sitting upright with her back against the bed reaching for their shoes. Apparently, R5 had slid out of bed. No injury was noted. R5 was assisted back to bed. The TMA staff remained with R5 for morning cares. A facility document titled Fall assessment dated [DATE], indicated R5 had an unwitnessed fall. The document indicated R5 was transferring in their room and had glasses in place. There was no indication if R5 had appropriate footwear. The form indicated R5 used a wheelchair and was unsteady. The form lacked indicate of a root cause for the fall or what may have contributed to the fall. The form also lacked indication R5's care plan and treatment sheet were reviewed, or interventions implemented. R5's nursing progress note dated 6/23/25 at 12:03 a.m., R5 was found lying on the floor next to their bed. R5 told staff wanted to use the bathroom. R5's legs were extended with socks on. R5 was assisted back to bed with an assist of 2. A facility document titled Fall assessment dated [DATE], indicated R5 had an unwitnessed fall. The document indicated R5 was transferring in their room and had glasses in place. R5 did not have appropriate footwear in place, used a wheelchair and was unsteady. The form lacked indicate of a root cause for the fall or what may have contributed to the fall. The form also lacked indication R5's care plan and treatment sheet were reviewed, or interventions implemented. R5's care plan revised 5/12/25, indicated R5 was at risk for falls due to food drop, a shuffling gait, and walking on tip toes when in pain. Interventions included encourage use of cane or rolling walker, monitor gait and keep provider up to date of changes, and provide skin checks weekly. R5's care plan lacked indication falls interventions had been revised after the 6/13/25 or 6/23/25 fall. An observation on 6/25/25 at 7:26 a.m., R5 was in bed sleeping. R5 was laying curled up and was lying sideways in their bed. R45's wheelchair was folded and had been placed next to the bed. Nursing assistant (NA)-A entered the room. NA-A moved the wheelchair out of the way to see if R5 wanted to get up. R5 was agreeable and the folded wheelchair was further moved out of the way to the end of the bed. NA-A assisted R5 to get straightened out in bed. R5 had regular socks on. NA-A and NA-B then assisted R5 with shoes and then unfolded the wheelchair and transferred R5 to the chair. Supplies were gathered and R5 was brought to the bathroom. When interviewed on 6/25/25 at 7:54 a.m., NA-A stated R5 was a fall risk and had been falling more lately and had fallen over the weekend. NA-A was not aware of any interventions R5 needed to help prevent falls and stated staff round every hour or so to check on residents. NA-A verified the care plan was used to determine what interventions were in place and verified the interventions were not related to the resident self-transferring to use the bathroom. When interviewed on 6/258/25 at 8:10 a.m., licensed practical nurse (LPN)-A stated when a resident falls, the nurse needs to assess them to see if there was any injury. If no injury was noted, the resident would be assisted up and monitored for the next 24 hours. Monitoring would include skin check, vitals, neuro checks if they hit their head. The family and provider would be notified. Then a progress note would be written. LPN-A stated a paper form would be filled out that described the situation around the fall. Then that form would be filed in the chart. LPN-A stated there was a new risk management form in the electronic medical record, however, that wasn't in use yet and paper forms were still used for risk management. LPN-A verified R5 had recent falls and didn't have a paper risk management form that was in use. LPN-A stated it must have been completed and placed in the chart. LPN-A further stated the DON or Administrator would update the care plan for any new interventions. When interviewed on 6/26/25 at 8:32 a.m., the Director of Nursing (DON) expected nurses to complete a risk management form and monitor for 24 hours. The nurses were expected to complete the details and determine the root cause of the fall. After that, the DON signed off on the form. Any new interventions would be entered by the nurse or MDS nurse. DON verified R4 was at risk of falls and had become weaker over the past several months. DON verified R5 had a fall from bed on 6/13/25 and 6/23/25. DON stated nurses were supposed to be switching to the risk management forms in the EMR, however they were not found. DON stated when the falls risk managements were requested, she completed it with what she knew about the fall from the progress notes and the resident. DON was not aware if a root cause analysis was completed or if new interventions were determined due to not being able to get to the electronic risk management report. A facility policy titled Fall Assessment Policy revised 6/2025, directed staff to re-assess residents with any fall, complete an incident report, and notify the provider and family. Any incident involving a resident will be reviewed by the DON to assure the resident's safety plan was appropriate.

Based on observation, interview and record review the facility failed to ensure separately purchased bed rails and bed frame were compatible for 1 of 1 resident who was reviewed for bed rail use. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had moderate cognitive impairment and diagnoses of schizophrenia. R8 had grab bars in place and was independent with sitting to standing and bed mobility. R8's care plan revised 3/17/24, indicated R8 was at risk for falls related to gait instability and used a grab bar on the bed to assist with independent bed mobility and transfer. The manufactures recommendations for R8's bed rails installed at the time of entrance was requested however was not received. An observation on 6/23/25 at 6:40 p.m., R8 was lying in their bed. R8's bed was placed against a wall and had a bed rail placed on the other side. The bed rail mounted in the middle of R8's bed in a sleeve like bar. R8 grabbed the rail to assist themselves up to the edge of the bed. The rail did not appear to be tight and had movement back and forth. R8 stated he wouldn't be able to get up by himself without the bar. R8 stated it always moved some and showed it slid in that sleeve up and down some as well as back and forth. When interviewed on 6/24/25 at 1:50 p.m., licensed practical nurse (LPN)- A stated residents were assessed quarterly for use of bed rails or grab bars. When a resident wanted one or could use one, nursing completed an assessment and then maintenance was notified to install them. LPN-A was aware R8 had a bed rail in place to help with mobility and wasn't aware of any problems with it. LPN- A verified R8's bedrail moved back and forth and slid up and down. LPN-A stated maintenance would need to be notified. When interviewed on 6/24/25 at 1:59 p.m., the Environmental Service Director (ESD) stated bed rails applied when there was a provider orders. Quarterly checks were completed to ensure the rails were secure. ESD reviewed the completed logs. Maintenance-A was already in R8's room attempting to tighten the railing and told ESD the bar would not tighten any further and R8 didn't want the bar to be moved up towards the top of the bed. ESD verified R8's bed rail was loose and further stated the rail was not made for that bed. Some of the beds need to be updated, but there were budget constraints. Maintenance-A and ESD attempted to determine the manufacturer of the bed rail, and the bed were, however, were unable to. ESD stated the bed and rail had numbers on them, but there was no manufacture name. ESD stated he had put the bar in place and had put some extra screws in it to ensure it was secure. ESD acknowledged this could be a safety issue and further stated some of the beds and rails were old and there was no way to determine compatibility. ESD had been trying to make it work for R8 how he wanted it. A follow up interview on 6/25/25 at 1:45 p.m., ESD verified R8's bed rail had not been addressed yet. ESD stated R8's room would need a deep clean next week, and it would have to have another screw placed to be more secure. When interviewed on 6/25/25 at 3:04 p.m., the Administrator expected nursing to notify maintenance when a side rail assessment was completed, and one could be installed. Bed rails were expected to be installed per manufacturer's guidelines. The Administrator further stated the only rails ordered were universal rails that were compatible with all kinds of beds as there are different beds in use. R8's loose bed rail was confirmed by the Administrator stated this was a safety risk and would be changed out right away. A facility policy titled Bedrails revised 6/26/25, directed staff to ensure the bed was appropriate for the resident and the bed rails were properly installed per manufacturers guidelines.

Based on observation, interview, and document review the facility failed to ensure food items were properly labeled and dated and disposed of. Furthermore, the facility failed to maintain clean cooking equipment. This had the potential to affect all residents who ate food from the kitchen. Findings include: During the initial tour with cook (C)-A on 9/22/24 at 10:28 a.m., observed the following: Refrigerator: A tray of juices and milks uncovered in the refrigerator. C-A stated it would be tossed out. Lettuce that had yellowish brown discoloration and was undated. C-A stated it would be tossed out and verified it was undated. A 16 ounce bottle of barbeque sauce with barbeque sauce located around the outside of the lid. C-A took it out of the refrigerator and stated it would get wiped down. Freezers: A package of 10 beef patties in a bag that was twisted shut with no date. C-A stated they were beef patties and verified they were undated. A blue bag of fish that was undated. Equipment: A KitchenAid contained yellow particles along the top where the attachments connect and a powdery substance was located on the handle. C-A stated the KitchenAid was used for icing or for making cakes and further stated she did not use the KitchenAid on 9/22/24, and stated the KitchenAid was supposed to be cleaned after use and did not know what the yellow particles were, and stated there was cake mix on the handle and stated it should have already been cleaned by whoever used it last. During interview on 9/23/24, the certified dietary manager (CDM)-A stated foods should be dated and labeled and further stated she placed the dates on there the morning of 9/23/24. A policy, Dating and Labeling Opened Foods and Juices, dated 10/16/23, indicated all employees will date and label each food and juice item opened with the date in which it was opened and the name of the product. Foods that need to be stored in airtight container will also have date in which it was contained. All perishable items with out expiration date will be discarded after 3 days of opening. A policy, Equipment Cleaning, dated 8/1/22, indicated all equipment shall be cleaned and sanitized after each use or following any interruption of operation during which contamination may have occurred. This begins by removing any physical contaminants from the equipment, then cleaning it with an appropriate solution, then rinsing this solution from the equipment, and then sanitizing the equipment to finish.

Based on observation, interview, and document review the facility failed to ensure clean linen was transported and stored in a manner to prevent the spread of infection. This had the potential to impact all 31 residents who reside in the facility. Findings include: An observation on 9/23/24 at 8:25 a.m., housekeeper (HSK)-A had brought up a cart of linens from downstairs. The cart contained fitted sheets, flat sheets, pillowcases, and fabric incontinent protector/pads. The linens were not covered during transport. The cart was transported down past residents and resident rooms and stored on the far end of the east hallway. An observation on 9/23/24 at 12:07 p.m., the same linen cart was now halfway down the west hallway. The cart contained less linens than earlier. The linens remained uncovered. At 12:10 p.m., HSK-B pushed the uncovered linen cart to the middle hallway just outside of the dining room. Residents were coming and going from the dining room for lunch and moving past the uncovered cart. When interviewed on 9/23/24 at 12:12 p.m., HSK-B was not sure if the linen cart needed to be covered when transported or when on the resident hallways. When interviewed on 9/23/24 at 12:17 p.m., HSK-A stated every Monday they changed the sheets and blankets on resident beds and usually it would be completed by now, but it was just taking longer today. HSK-A verified there was a lot of resident traffic on the unit with lunch and stated usually they try to place the cart in a less busy area. HSK-A acknowledged the linen cart should be covered during transport and on the unit. When interviewed on 9/24/24 at 10:46 a.m., the infection preventionist (IP) expected staff to have linens covered when transported or when in the hallways. This was to help prevent infection. A facility policy titled Laundry for Soiled Linens and clothing revised 9/20/23, directed staff to fold linens into piles of like items and stock storage cabinets and bed making cart. The policy lacked direction of how staff were to transport clean linen or if linen was required to be covered when stored on resident units.

Based on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, and attempt alternatives prior to installation of grab bars for 1 of 1 residents (R31) who were observed to have grab bars affixed to their bed. Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 was cognitively intact and had diagnoses of alcohol use and neuropathy. R31 was independent with rolling side to side and moving from lying to sitting in bed. R31's physical device review dated 8/29/24, lacked indication R31 was assessed or had been educated on the risks of grab bars or had attempted alternatives prior to installation of grab bars. R31's care plan dated 9/8/24, indicated R31 was independent in bed mobility. R31's care plan lacked indication R31 used a grab bar for assistance. R31's provider and nursing orders lacked indication R31 required a grab bar. An observation on 9/22/24 at 11:05 a.m., R31 was sitting on their bed. R31's bed was placed close to the wall and on the left side of the bed was a circle grab bar. R31 stated the grab bar was on the bed since they arrived. R31 used the bar sometimes at night when the room was dark. When interviewed on 9/23/24 at 1:34 p.m., registered nurse (RN)-A stated grab bars were used to help residents turn in bed or get up out of bed. If a resident required a grab bars then maintenance was notified to place them. RN-A wasn't sure if there was any other assessment completed other than a mobility assessment. RN-A wasn't aware of R31 having a grab bar and verified with the resident there was one on the bed. RN-A verified R31's care plan did not identify R31 required a grab bar for mobility assistance. When interviewed on 9/24/24 at 11:29 a.m., the Director of Nursing (DON) stated the MDS nurse usually completed the assessments for grab bars or any assistance devices. The assessment would include the resident's mobility and a visual inspection to determine safe use of the bar. DON expected the assessment as well as a provider order to be completed with residents who have grab bars in place. A facility policy titled Use of Side Rail, Grab Bar on Resident Beds revised 9/22/23, directed staff to attempt alternatives prior to installation of grab bars and complete an assessment to determine the need for grab bars and risk of entrapment, and educate the resident of the risks and benefits of grab bars.

Based on interview and document review the facility failed to ensure 2 of 5 residents (R31, R1) were accurately assessed and offered the pneumococcal vaccination according to the Centers of Disease Control (CDC). Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 was [AGE] years old, was cognitively intact and had diagnoses of alcohol use and nicotine dependence. Furthermore R31's MDS indicated R31 was not offered the pneumococcal vaccination. R31's Minnesota Information Connection (MIIC) printed 9/24/24, indicated R31 had no prior pneumococcal vaccinations. The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, directed residents 19-[AGE] years of age who had no history of previous vaccination and a risk factor of smoking to give one dose of pneumococcal 15-valent Conjugate Vaccine (PCV15), pneumococcal 20-valent Conjugate Vaccine (PCV20), or pneumococcal 21-valent Conjugate Vaccine (PCV21). R31's paper and electronic medical record lacked evidence staff had assessed R31's pneumococcal status or offered the pneumococcal vaccination prior to survey entrance on 9/22/24. R1's quarterly MDS dated [DATE], indicated R1 was [AGE] years old, had moderate cognitive impairment and diagnoses of diabetes and lung disease. Furthermore, R31's MDS indicated R31 was up to date for the pneumococcal vaccination. R1's immunization record reviewed 9/23/24, indicated R1 had previously received Prevnar 13 on 9/8/16 and 10/31/18. R1 had received pneumococcal polysaccharide vaccine 23 (PPSV23) on 1/21/13 and on 10/24/17. The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, directed residents [AGE] years of age who had who had not previously received the PCV15, PCV20, or the PCV21, and had previously received the PCV13 and also the PPSV23 after the age of 65 required shared clinical decision making between the provider and resident on offering the PCV20 or PCV21. R31's paper and electronic medical record lacked evidence staff had accurately assessed R31's pneumococcal status or that shared clinical decision making had taken place to determine if R1 should receive the PCV20 or PCV21 prior to survey entrance on 9/22/24. When interviewed on 9/24/24 at 10:46 a.m., the Infection Preventionist (IP) who was also the Director of Nursing (DON) stated the vaccination status of residents was assessed and determined upon admission. This was by reviewing the hospital paperwork and obtaining a MIIC report. If the need for a pneumococcal vaccine was determined, the resident was educated and either consented or declined. Then usually each year all residents were reassessed to determine if they were not eligible for a vaccination or to education and offer again. The IP stated the assistant DON who reviewed the immunizations was no longer with the facility and it was currently up to the IP or the MDS nurse to complete. A follow up interview on 9/24/24 at 207 p.m., the IP verified R31 had not been assessed and due to the smoking status should have been offered the pneumococcal vaccine. R1 also could receive an additional dose if the resident and provider believed it was necessary. IP stated on R1's MIIC report, it stated the pneumococcal vaccinations were complete and so R1 was not further assessed for the additional dose. IP stated R31 and R1 were being followed up upon. A facility policy titled Influenza, Pneumococcal, COVID-19 vaccinations revised 7/31/24, directed staff to utilize the CDC vaccination guidance and definitions to determine eligibility and up to date status. Furthermore, upon admission staff were directed for pneumococcal vaccines to be given if applicable and all residents will be offered the pneumococcal immunization unless medically contraindicated or the resident had already been immunized during the appropriate time frame.

Based on observation, interview, and document review the facility failed to provide 1 of 3 residents (R1) adequate supervision to prevent elopement from the facility who had a history of elopement. This resulted in immediate jeopardy (IJ) when R1 eloped on 6/18/23 and was found an hour and a half later by a concerned citizen and the police returned R1 to the facility. The immediate jeopardy began on 6/18/23, at approximately 12:05 p.m. when R1 eloped from the facility. The immediate jeopardy was identified on 6/29/23, and the assistant administrator was notified on 6/29/23, at 3:45 p.m. The immediate jeopardy was removed on 6/30/23, at 2:50 p.m. but noncompliance remained a lower scope and severity of a D with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding include: During various observations from 9:00 a.m. to 3:00 p.m. on 6/27/23, there were seven exits to the building, two of which residents were exiting and entering multiple times a day, the front entrance, and a side porch where a smoking patio was. The smoking patio was attached to the dining room, and exits to the side of the building, there was a direct exit into the neighborhood, no barriers or fencing. The only exits that were noted to be alarmed were on east and west halls. R1's care plan initiated on 12/9/21 noted R1 was at risk for elopement due to increased confusion/disorientation, increased risk for elopement when R1 has exhibited wandering or has had more money. R1 had been observed leaving the building to go to the pharmacy down the street and returned with items he had purchased, R1 had eloped from the facility and been found by staff and returned by emergency medical staff (EMS). The care plan noted R1 required someone to attend appointments with him and for any community outings. A progress note dated 5/8/22, noted R1 eloped from the facility and returned later with a pack of cigarettes, there was no indication how long he was away from the facility. A progress note dated 9/14/22, noted R1 was not in his bed at 9:00 p.m. rounds, he was returned the next evening by law enforcement officers. A progress note dated 3/20/23, noted R1 was missing from the facility upon 3:00 p.m. rounds, and was returned to the facility that evening by law enforcement officers. R2's care plan was updated with the following interventions; staff to document increased periods of wandering and implement every 30 minute checks, staff to call police for missing persons report. A physician order in R1's electronic medical record dated 3/28/23, noted staff should initiate every 30-minute checks if they notice increased wandering. R1's quarterly Minimum Data Set (MDS) dated [DATE], noted R1 had severely impaired cognition, had diagnosis of unspecified psychosis, was hard of hearing and had difficulty understanding others as well as being understood due to unclear speech, he required supervision with ambulation and used a walker. A Nursing Home Incident Report (NHIR) dated 6/18/23, noted R1 was not present in the building after eating lunch, staff noted he ate lunch and then went into his bedroom, and that he was last seen approximately 15 minutes prior to him missing from the facility. A progress note dated 6/18/23, noted R1 had eaten his lunch and returned to his room at 12:10 p.m. and that he was noted to be gone from the facility at 12:40 p.m. staff searched building and grounds, called the assistant administrator at 12:58 p.m. and was instructed to call the police. The police arrived at approximately 1:15 p.m. and as the officer was obtaining information, police received a call that R1 had been found, he was returned to the facility by law enforcement at 1:40 p.m. and the facility began every 15-minute checks on R1. A later progress note dated 6/18/23, noted an NHIR had been submitted regarding R1's elopement, that R1's guardian had been updated along with his care provider. A Police Department Missing Persons Report dated 6/18/23, noted the initial phone call came in at 1:07 p.m. that R1 had been missing from the facility for about 40 minutes, it noted that R1 was extremely hard of hearing, disoriented and had diagnoses of mental illness like psychosis. The report noted a description of R1, he limped, ambulated with a walker, that it was unknown which direction he went and that there was a limited search of the neighborhood due to staffing. The report noted that another call came at 1:31 p.m. regarding an elderly male person that was wandering, seemed lost at an address that was 1.1 miles from the facility. The police returned R1 to the facility at 1:43 p.m. R1's care plan initiated after R1's elopement on 6/18/23, the facility implemented the following interventions: placement of stop signs at exits, bells on R1's bedroom door and his walker. The NHIR 5-day report dated 6/23/23, noted camera footage from the date of R1's elopement was reviewed by the assistant administrator, R1 exited the dining room at 12:03 p.m. and walked toward the front entrance of the building, he exited the building at 12:05 p.m. During an interview on 6/27/23, at 1:15 p.m. the trained medication aide (TMA)-A stated R1 was at risk for elopement and had eloped recently. The TMA-A identified three other residents that would need supervision in the community. TMA-A stated interventions included frequent checks, every 1-2 hours, she corrected to every 30 minutes after reading the intervention in R1's electronic medical record (EMR). During an interview on 6/27/23, at 1:20 p.m. registered nurse (RN)-A stated R1 was at risk for elopement as well as another resident but only after dark as he would likely get lost at night. RN-A stated they do not do room checks on day shift for R1 as there was enough staff around meals and medications to provide observations. RN-A stated the east and west door alarms were on all the time, other exits had alarms that were turned on at some point at night and that she has a view of the front door from the office, there is a door to the smoking patio that leads outside and cameras were throughout the building with a live feed however, no one is actively watching the cameras as they are in the other room. (The office is enclosed but has three windows with blinds on them, one window faces the front door). The RN-A stated they now have bells on R1's walker so that they may hear when he is ambulating around the facility. During an interview on 6/27/23, at 1:56 p.m. the assistant administrator (AA) stated there was not a list of residents that were at risk for elopement but R1 was identified as a risk for elopement and had a history of eloping. The AA stated another two residents required supervision in the community and that door alarms were typically turned on around 11-11:30 p.m. each night. During an interview on 6/27/23, at 2:30 p.m. the director of social services (SS) stated R1 was a high risk for elopement and identified three other residents that would need supervision in the community. During a follow up interview on 6/27/23, at 3:25 p.m. the AA stated the cameras do not save footage for very long but she was able to view the footage from the day R1 eloped. The AA stated he was seen on the camera dressed appropriately, with his walker ambulating to the front door, he turned and pushed the door with his hip and was able to continue to push the door and move his walker through without difficulty. The AA stated there was two staff and one resident in the camera footage, though no one noted R1 go out. During an interview on 6/28/23, at 9:38 a.m. TMA-B stated she was working the day that R1 eloped. She stated she last saw him in the dining room and he had finished eating lunch, she asked him if he wanted to go back to his room and he told her no. TMA-B stated she later noted he was not in his room after she passed by and thought maybe he was in the restroom, she completed another task and went back to his room and he still was not there, she checked the restroom and all the bedrooms of the facility and could not locate him. TMA-B stated she told the nurse on duty and searched the rest of the facility, he was not in the building. TMA-B stated she did not know what time it was that she last saw R1, she stated his lunch typically begins at 11:30 a.m. The TMA stated the nurse called the assistant administrator and then she called the police, while the police were onsite, they received a call that R1 was found and was brought back to the facility by law enforcement officers. On 6/28/23, at 11:35 a.m. a resident sign out book was at the nursing station, the book contained a resident roster that was printed on 6/28/23, it also had tabs with names of residents, some resident names on the tabs are not listed on the printed roster. During a follow up interview on 6/28/23, at 11:49 a.m. the SS stated she performs a wandering risk on residents along with the MDS nurse on residents, they are done at admission, quarterly and annually. The SS stated the wandering assessment indicates a residents cognition, orientation, mood and behavior, aggression, anxiety, mobility, diagnoses and history of wandering. The SS agreed that wandering and eloping are two different things and in the case of R1, his elopement was a direct product of his wandering, in confused state and he leaves. This did not occur in the last elopement (6/19/23). The SS stated there are two doors that are not alarmed, the front entrance and the side smoking patio door, during the day and residents are required to sign out prior to leaving the facility, however, no one is actively watching the doors or monitoring the sign out book. During a follow up interview on 6/28/23, at 1:03 p.m. the AA stated there were 4 doors that had alarms on at all times, the other 3 doors are not alarmed during the day, nursing staff have the ability to turn on the alarms and some have, if we see, R1 is increasing in his wandering. The AA stated they don't have the door under direct observation unless they start to see increase in behaviors. During an observation on 6/28/23, at 3:42 p.m. the front entrance door was alarming. The SS stated all the doors were alarmed that afternoon due to R1's increased wandering. During obseration and interview on 6/28/23, at 4:01 p.m. licensed practical nurse (LPN)-A stated R1 is at risk for eloping and noted two other residents at risk. The smoking patio door was alarmed during the interview, LPN-A pressed a button to silence the alarm. When asked if she was aware of who just exited the facility she stated kitchen staff were in the dining room, and were alert to residents that exited the smoking patio. She identified R1 was intentionally placed in the building so that he is in easy view, however LPN-A did not have a direct view of him and was not sure where he was. LPN-A also did not communicate with kitchen staff, exit the nursing office to look at the live feed camera view, nor did she call a kitchen staff to verify who the resident was that were exiting that sounded the alarm. LPN-A just turned the alarm off, without verifiying if it was R1 or other residents at risk for elopement. During an observation on 6/30/23, at 10:47 a.m. RN-A silenced the door alarm for the dock door, when asked how she confirmed a resident did not elope, RN-A did not respond. The AA was present, she left to check the dock door and let RN-A know that it was not a resident. A facility policy effective on 10/24/22, noted that each resident receives adequate supervision. The immediate jeopardy that began on 6/18/23, was removed on 6/30/23 and was verified through observation, interview and document review, when the facility implemented the following interventions: -created and established an Elopment Risk Assessment tool -posted elopment risk listings in all departments identifying residents at high risk and those that required supervision in the community -assured continuous visualization of R1 -armed alarms to all doors of the facility -reviewed elopement policy and educated all staff on all interventions

Based on record review and interviews, the facility failed to ensure that one of three residents (R1) reviewed for medication errors, received all ordered doses of physician prescribed medications. Findings are as follows: R1's medical record was reviewed and showed R1 was admitted to the facility on [DATE] from a hospital. R1 received treatment for [REDACTED]. Hospital discharge papers dated 10/01/2013 were reviewed, R1 was admitted to the hospital July 22, 2013 for suicidal ideation, underwent 12 electroshock treatments and medication adjustments. [MEDICATION NAME] 200 mg (milligram) at bedtime was added to R1's medication regimen at the hospital. [MEDICATION NAME] is a [MEDICAL CONDITION] medication used to treat symptoms of [MEDICAL CONDITION]. R1 did not have suicidal thinking when discharged from the hospital. Physicians discharge orders show [MEDICATION NAME] 200 mg every night to continue at the facility. R1's Care Plan was reviewed and revealed that R1 is at risk for impaired decision making, depression and suicidal thinking related to mental illness, interventions include taking medications as prescribed (medications not specified), encouraging R1 to interact with peers, relaxation techniques and staff checking with R1 regarding suicidal thinking. R1's Medication Administration Record [REDACTED]. The document reveals that R1 did not receive 30 doses of [MEDICATION NAME] 200 mg in October 2013. Review of the MAR indicated [REDACTED]. The facility titrated the medication according to a standard titration schedule until the full dose of 200 mg was received by R1 on 11/19/2013 at 8:00 p.m. A total of 35 doses of [MEDICATION NAME] were omitted from 10/2/2013 until 11/6/2013. Documents from the pharmacy that monitors patients blood and dispenses the [MEDICATION NAME] show that R1 was not enrolled in their system prior to 10/31/2013 when the facility contacted them to initiate [MEDICATION NAME] therapy for R1. R1 should have been enrolled with the pharmacy on 10/2/2013, the day R1 was admitted to the facility. Nursing Progress notes dated 11/5/2013 through 11/6/2013 reveal that in response to R1's increased symptoms of agitation and irritability, LPN-B obtained an order to have R1's blood drawn emergently to monitor for agranulocytosis, an acute condition of decreased white blood cells, and the [MEDICATION NAME] re-introduced via titration schedule. The Nursing Drug Handbook, Lippincott, Williams & Wilkins, 2012; directs that the white blood count of patients be monitored due to risk of agranulocytosis, an acute condition of decreased white blood cells. If therapy is reinstated, follow standard guidelines for dosage increases (titration). R1's case manager (CM) -D was interviewed and said that he drove R1 to the facility 10/2/2013 when R1 was discharged for m the hospital. CM-D stated he had seen R1 several times during month of October. On 11/5/2013 while running errands with R1 CM-D observed R1 to be nervous and breathing heavily. Upon return to the facility CM-D told licensed practical nurse (LPN)-B that R1 appeared to be decompensating mentally, LPN-B asked CM-D at that time if he thought R1 needed [MEDICATION NAME]. LPN-B was interviewed on 11/25/2013 at 12:50 p.m. and said as the day charge nurse, she follows up on issues such as the availability of medications and communication with providers but she did not get a note from the evening staff letting her know the medication wasn't being given. The director of nursing (DON) was interviewed on 11/25/2013 at 11:17 a.m. and said that the error occurred when staff did not question why the medication was on the MAR but not available. The circles indicating the medication was not given should have prompted the staff to question why and look into the matter instead of circling it and not questioning why the medication was not available.