Every finding on record at Hope Springs at Minnetonka

Based on interview and document review the facility failed to submit accurate data for staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 1 2026) to the centers for Medicare and Medicaid (CMS) according to specifications established by CMS. This had the potential to affect all 21 residents living in the facility.Findings include:Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D for quarter 1 2026 (October 1st through December 31st), identified the metric for excessively low weekend staffing, and failure to have licensed nursing coverage for 24/hours a day had been triggered for the facility on the following days: 10/1/25, 10/11/25, 11/28/25, 11/29/25, 12/28/25, 12/29/25.Review of the facility's schedule and nursing staff census sheets for quarter 1 2026, indicated the facility did in fact have appropriate coverage on the weekends and 24 hours licensed coverage, however, indicated incorrect data had been reported for the PBJ to CMS. On 6/4/26 at 1026 a.m., the bookkeeper (BK) confirmed they were responsible for reporting the PBJ data for the facility. BK stated they did not have access to the schedule, and they would use the bills from the agency staffing companies as the source for their data. Due to being unable to view/access the schedule they couldn't navigate the data and see when the agency staff had been scheduled or working and had therefore been entering incorrect data based on what they had available to them.On 6/3/26 at 2:30 p.m., the administrator confirmed the BK did not have access to the facility schedule and based the reporting data off of the payroll invoices and not the schedule.A policy for staff reporting was requested and none was provided.

Based on record review and interview the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis. This had the potential to affect all 21 residents residing at the facility.Findings include:On 6/3/26 at 9:17a.m., The last 3 meeting minutes for QAPI had been requested via email, one of the three requested was provided for April 6th. The other two meeting minutes requested were requested again on 6/3/26 at 12:30 p.m., 6/3/26 at 3:45 p.m., and 6/4/26 at 8:40a.m., Neither were provided.On 6/4/26 at 12:38 p.m., the Director of nursing (DON) stated the facility had not conducted their QAPI meeting in January, had planned to reschedule the meeting, however, were unable to. Furthermore, the DON stated they had met in the fall, however, were unable to open the notes. The opportunity was presented for them to resend them or send in another format. The document was never provided.The Quality Assurance and Performance Improvement Plan last updated 6/19/2024, indicated the QAPI concerns, updates, or changes are to be reviewed and discussed at the quarterly meetings.

Based on record review and interviews, the facility failed to obtain diagnostic testing related to recommendations from a speech language pathology (SLP) evaluation for 1 of 1 resident (R11) reviewed for SLP recommendations.Findings include:R11's quarterly minimum data set (MDS) dated [DATE], indicated R11 was admitted [DATE], was severely cognitively impaired and had the following diagnoses: Hyperlipidemia (HLD) (high levels of fat in the blood), Alzheimer's Disease, non-Alzheimer's Dementia, anxiety, and schizophrenia. The Speech Language Pathology Initial Evaluation and Treatment Telehealth visit dated 12/11/25, indicated a referral had been made by R11's primary care provider (PCP) to SLP for evaluation. The report indicated R11 had the diagnosis of dysphagia (difficulty swallowing) and the need for instrumental imaging of swallow and was required to provide intervention for decreased aspiration and choking risk, and improve the residents quality of life.The Speech Language Pathology discharge report dated 12-29-26, indicated the SLP's evaluation recommended swallowing imaging, either a modified barium swallow study, or flexible endoscopic evaluation of swallow to assess impaired structures or musculature, as well as to determine the safest, least restrictive diet. Furthermore, the document indicated R11 was being discharged from SLP and stated Nursing director (DON) and SLP agree to discharge the speech orders for ongoing treatment to obtain new orders if the swallowing imaging assessment indicated the need for further speech dysphagia intervention.R11's chart lacked any evidence of the above listed diagnostic testing ever being completed.On 6/3/26 at 11:10 a.m. the speech language pathologist (SLP)-A stated they remember evaluating R11 and diagnostic imaging was needed to assess the resident's further speech needs. SLP-A stated they spoke to the DON, and the DON would inform the provider and obtain the orders and imaging. SLP-A stated they never heard back from the DON regarding the diagnostic testing, and they typically don't follow up unless further evaluations are ordered.The Appointment referral dated 1/21/26, indicated the provider had signed an order to continue SLP treatment.On 6/3/26 at 11:42 a.m. DON confirmed R11 was discharged from SLP services to pursue diagnostic testing in December. The DON confirmed they were responsible for completing those updates to the provider, and ensuring the diagnostic testing was conducted. However, the DON confirmed the diagnostic testing was never performed, and speech was never continued as per provider orders. The DON stated the orders were missed and never passed on and spoke to the importance of completing referral orders because they should have been completed as ordered.A policy for following physician orders was requested and none was provided.

Based on record review and interview, the facility failed to report a COVID-19 outbreak in their facility. This had the potential to affect all 21 residents in the facility, staff, and visitors.Findings include:According to the Minnesota Department of Health website (MDH) https://www.health.state.mn.us/diseases/coronavirus/hcp/report.html, SARS-CoV-2 Infection (COVID-19) must be reported to MDH within one working day.The Quarterly infection Control Log undated, indicated one staff member (LPN-A) tested positive for COVID-19 on 5/2/25 and one resident R7 tested positive for COVID-19 on 5/3/26. The facility provided evidence that the staff was sent home and R7 was put on precautions. However, no evidence was provided to show the outbreak was reported to state officials per regulations.On 6/3/26 at 2:28 p.m., the Director of Nursing (DON) confirmed the facility had a COVID-19 outbreak of one staff and 1 resident, and furthermore, it was never reported to MDH. The DON stated the task of reporting was previously done by a recently retired staff member, and the task of reporting had not been passed on to anyone else. The DON stated the importance of reporting outbreaks to aid tracking of the disease.The facility Public Health and Reportable Disease Reporting procedure reviewed 6/4/26, indicated when urgent reporting is required, make the initial public-health notification as soon as practicable and supplement additional information when it becomes available.

Based on record review and interviews, the facility failed to obtain informed consents including risk and benefit for 1 of 5 residents (R11) reviewed for psychotropic medications.Findings include:R11's quarterly minimum data set (MDS) dated [DATE], indicated R11 was admitted [DATE], was severely cognitively impaired and had the following diagnoses: Hyperlipidemia (HLD) (high levels of fat in the blood), Alzheimer's Disease, non-Alzheimer's Dementia, anxiety, and schizophrenia. R11's Order Summary Report dated 6/3/26, indicated R11 was currently prescribed Clozaril (anti-psychotic) start date 10/20/25, Lexapro (anti-depressant) start date 5/7/2018, lorazepam (antianxiety) start date 8/19/2026, and Olanzapine (anti-psychotic) start date 10/20/25.R11's medical record lacked evidence of informed consents regarding risk and benefits for any of the above listed medications being completed.On 6/3/26 at 11:42 a.m., the director of nursing (DON) stated they were responsible for completing the consents for psychotropics. The DON stated they did not have R11 sign the consent because they felt that R11 was unable to do so cognitively. The DON stated R11 has windows of lucidity, and confusion, and was their own decision maker. The DON stated they had been working to get R11 guardianship in place, however, had been thus far unsuccessful. The DON confirmed they made the decision for R11 to not sign themselves without speaking to R11 and did not include any other interdisciplinary members in the decision and could have included other interdisciplinary members of the care team however, they did not.The facility Psychotropic Medications policy last reviewed 7/2023, indicated nursing will document discussion with the resident and/or responsible party regarding the risk versus benefits of the use of these medications including in the discussion and written consent will be obtained.

Based on interview and document review, the facility failed to ensure the Quality Assurance (QA) committee identified and implement performance improvement projects to address any identified concerns. These findings had potential to affect all 21 residents residing within the facility. Findings include: During an interview on 2/13/25 at 2:49 the director of nursing (DON) stated the QA committee, consisting of herself, the administrator and the medical director, met quarterly to review adverse events. However, the committee did not have a system to identify, collect and use data from all departments and had not identified any opportunities for improvement or performance improvement projects to implement. A facility policy titled Quality Assurance and Performance Improvement (QAPI), dated 6/19/24, indicated, a Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day. This deficient practice had the potential to affect all 21 residents who resided in the facility. Findings include: The PBJ (Payroll Based Journal) Staffing Data Report triggered for no continuous 8-hour RN coverage in 24-hour period for four or more days within 4th quarter. Infraction dates were 7/17/24, 7/18/24, 7/24/24, 7/26/24, 9/21/24 and 9/22/24. Document review of the schedule from 10/1/24 - 2/9/25, identified the facility failed to have RN coverage for the dates of: 11/9/24, 11/10/24, 11/28/24, 11/29/24, 12/21/24, 12/25/24, 1/1/25, 1/18/25 and 1/20/25. During interview on 2/10/25 at 9:37 a.m., R12 stated no concerns were reported in resident council. R12 stated the facility was staffed very well with knowledgeable and well-established staff. During interview on 2/13/25 at 1:03 p.m., director of nursing (DON) indicated they were responsible for staffing the facility and submitting the PBJ reports. They confirmed the facility did not have eight hours of continuous RN coverage daily, however, stated there was proper coverage with regularly scheduled competent staff, and stressed the importance of continuity of care of licensed staff for the residents outweighing the title of RN over LPN (licensed practical nurse), and the skill set to care for these residents was met with an LPN. The focus of individual care plans for residents was important, as important to survey to individual care of facilities. A facility' policy on staffing was requested, not received.

Based on observation, interview, and document review, the facility failed to ensure cups were completely dry before storing and stacked bowls stayed dry to prevent bacterial growth. In addition, the facility failed to ensure food items were properly labeled and dated, failed to ensure staff covered their hair, assess food temperature during food prep, and to ensure staff followed appropriate infection control technique during food service. This had potential to affect all 21 residents who were served food from the kitchen. Findings include: During the initial kitchen tour on [DATE] at 12:26 p.m., a refrigerator in the main kitchen had sliced cheese with no opened date or expiration date and half of Smithfield boneless ham wrapped in plastic with expiration date of February 26, 2025 and no opened date. The freezer in the main kitchen area had a few packages of bratwurst unlabeled and not dated, multiple packaged tortillas with no label or date, and a packaged cheese omelet with white flakes with no date on them. The clean dish area had four stacks of clean cups, and multiple cups had condensation between them. Clean bowls were stacked upright, and condensation was observed in the first, second, and third bowl. During an interview on [DATE] at 12:45 p.m., dietary aid (DA)-A, who also cooked, confirmed the observations and stated the ham was used on Saturday, two days prior, and was not sure how long the brats, omelet, or tortillas were in the freezer. DA-A stated dishes needed to be dry before stacking. During observation on [DATE] at 11:51 a.m., DA-A wore a headband with two long loose braids halfway down their back and no hair net. DA-A had gloves on and used a knife to cut celery on a cutting board. DA-A removed gloves and stirred the beef in a pan on the stove. DA-A applied gloves and placed the celery in the pan with the beef. DA-A placed the cutting board and knife in the dirty area of the dish machine area, removed gloves, did not perform hand hygiene, and applied new gloves. DA-A prepped one plate with spaghetti and broccoli and gave to staff to serve. DA-A removed gloves, did not perform hand hygiene, applied new gloves, and placed cooked spaghetti noodles in the pan with the beef. DA-A plated multiple plates of the noodles and beef and broccoli and some plates with small pizza circles using tongs and utensils. One pizza circle fell on to the table, and DA-A used utensil to throw the pizza away. DA-A placed broccoli onto the plates of pizza, removed gloves, did not perform hand hygiene, and applied new gloves. DA-A gave plates of food to staff to serve in the dining area, cut pizza in half, continued meal service, removed gloves, did not perform hand hygiene, and applied new gloves. DA-A placed dish soap onto dishes and scrubbed some dishes, rinsed, and placed in dish machine. DA-A removed gloves and placed dirty pan into the dirty area of the dish machine area. DA-A grabbed a package of a small pizza circle from the freezer and placed on the counter by the microwave. DA-A did not perform hand hygiene, applied gloves, put the pizza in the microwave, grabbed a blender from the dish machine, blended and plated the food, placed the blender into the dirty area of the dish room, removed gloves, did not perform hand hygiene, and applied new gloves. DA-A removed the pizza from the microwave, plated the pizza and broccoli, and served. During interview on [DATE] at 12:23 p.m., DA-A stated they checked the broccoli temperature but did not take the temperature of the beef served with the meal or the one pizza circle cooked in the microwave. DA-A stated they cooked the pizza in the microwave based on the time frames listed on the package and had prepped the beef for a long enough time for it to be cooked. DA-A verified they had not worn a hair net today or the day prior and did not know where the hair nets were until the previous day. DA-A verified they had not washed their hands and were supposed to wash their hands with every glove change, but indicated they did not unless they touched a food item or had dirty hands for time management purposes. During observation on [DATE] at 11:45 a.m., DA-B, who also cooked, temped the food, washed their hand, applied gloves, and dished up salad and barbeque pork. DA-B wore a stocking cap and had a beard. A longer loose hair dangled from DA-B's chin as they scooped salad onto plates. DA-B continued plating food and gave to staff to serve without a beard net. During interview on [DATE] at 12:23 p.m., DA-B stated they took the temperature of food before they served. DA-B stated they labeled food when opened and when taken out of its original package, and food was rotated daily so new food was towards the back and older stock would be used first. DA-B stated they changed gloves and wash hands when changing tasks or anytime there was a chance of cross contamination. DA-B stated they had hairnets and needed to wear them, or a hat, when in the kitchen to keep their hair covered. DA-B stated a quarter inch of hair was okay without a beard net and thought the hair on their chin and sides of face was an okay length, but agreed their mustache needed to be covered. During interview on [DATE] at 2:27 p.m., the administrator expected staff to check the temperature of served food to ensure the food was at appropriate to prevent sickness for those who consumed the food. The administrator expected items to be thrown when expired and products to be labeled when opened and taken out of the original box. Staff was expected to cover their hair in the kitchen, including facial hair. It was also expected dishes would air dry before stacking to ensure no contamination. The administrator expected staff to wash their hands between gloves changes, especially after completion of dirty tasks and before clean tasks with food. The facility policy Food Receiving and Storage dated ,d+[DATE], indicated all food stored in the refrigerator or freezer would be covered, labeled, and dated with use by date. The policy indicated all dishes, silverware, pots, and pans were air-dried. The facility policy Dietary Areas- Cleanliness, Safety, Organization, and Regulations dated 2023, directed staff with significant facial beard and/or mustache to wear facial beard nets and hairnets or hats were to be used by all dietary personnel or hair pulled back into secure pony. The policy directed staff to label food with the date it was opened. The facility policy Dietary Gloves and Handwashing dated ,d+[DATE], directed staff to remove gloves, wash hands, and apply new gloves after contact with items such as refrigerator, stove, freezer, and dirty dishes.

Based on interview and document review the facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven quality assurance and performance improvement (QAPI) program. These findings had potential to affect all 21 residents residing within the facility. Findings include: During an interview on 2/13/25 at 2:49 the director of nursing (DON) stated the QA committee, consisting of herself, the administrator and the medical director, met quarterly to review adverse events. However, the committee did not have a system to identify, collect and use data from all departments and had not identified any opportunities for improvement or performance improvement projects to implement. The DON further stated the facility did not record any meeting minutes or documentation of their ongoing QA meetings. A facility policy titled Quality Assurance and Performance Improvement (QAPI), dated 6/19/24, indicated, QA [quality assurance] and PI [performance improvement] combine to form QAPI, a comprehensive approach to ensuring high quality care. QAPI concerns, updates, or changes are reviewed and discussed at the quarterly QAA meeting.

Based on interview and document review the facility failed to ensure the Quality Assurance (QA) committee consisted of the minimum required members. These findings had potential to affect all 21 residents residing within the facility. Findings include: During an interview on 2/13/25 at 2:49 p.m., the director of nursing (DON) stated the committee, consisting of herself (also the infection preventionist), the administrator and the medical director, met quarterly to review adverse events. The DON confirmed the QA did not consist of at least two additional staff members to meet the required members however, they had discussed having a nursing assistant join the committee. A facility policy titled Quality Assurance and Performance Improvement (QAPI), dated 6/19/24, indicated, members of the team will include the Administrator and Director of Nursing (DON), the medical director and other key staff members from other departments, along with a designated resident as designated by the Resident Council if they wish to participate, and family or guardians if they wish to participate.

Based on interview and document review, the facility failed to ensure completed Minimum Data Set (MDS) assessments were accurately coded to reflect correct medication use for 5 of 5 residents (R1, R3, R6, R9, and R15). Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), dated 10/2024, indicated medications are to be indicated as taken by a resident based on pharmacological classification, not how it is used. The RAI Manual further indicated herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug Administration (FDA). These products are not regulated by the FDA (e.g., they are not reviewed for safety and effectiveness like medications) and their composition is not standardized (e.g., the composition varies among manufacturers). Therefore, they should not be counted as medications (e.g., melatonin). R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the care facility 7/24/23 and was cognitively intact. The MDS further indicated R1 had taken a hypnotic medication during the look back period despite not being prescribed a hypnotic medication and lacked mention of R1 receiving a anticonvulsant medication despite receiving two different anticonvulsant medications during the look back period. R1's Diagnoses list, printed 2/13/25, indicated R1 had several medical and mental health diagnoses including major depressive disorder, anxiety disorder, dementia, and bipolar disorder. R1's Orders indicated R1 was on several medications including Melatonin (a dietary supplement) 6 milligrams (mg) by mouth one time a day at bedtime, dated 7/24/23; Gabapentin (an anticonvulsant medication) 200 mg by mouth three times a day, dated 7/24/23; and Lamotrigine (an anticonvulsant medication) 25 mg by mouth one time a day, dated 7/25/23. R3 R3's quarterly MDS, dated [DATE], indicated R3 was admitted to the care facility on 9/21/09 and was cognitively intact. The MDS lacked mention of R3 receiving anticoagulant and anticonvulsant medication despite being prescribed both medications. R3's Diagnoses list, printed 2/13/25, indicated R3 had several medical and mental health diagnoses including bipolar disorder, major depressive disorder, anxiety disorder. R3's Orders indicated R3 was several medications including Lamotrigine (an anticonvulsant medication) 75 mg by mouth one time a day at bedtime, dated 5/22/24 and Eliquis (an anticoagulant medication) 5 mg by mouth two times a day, dated 2/25/22. During an interview on 2/13/25 at 12:59 p.m., the director of nursing (DON) stated she was also responsible for completing the MDS. The DON confirmed both R1 and R3 had inaccuracies coded on their MDS, stating it would be expected that each medication is coded as the medication drug class and not what the medication is given for. The DON stated she believed Melatonin should have been classified as a hypnotic, despite the RAI manual stating otherwise. 48299 R6 R6's significant change MDS dated [DATE], indicated R6 was admitted to the care facility on 10/28/24 and was cognitively intact. The MDS indicated R6 had taken a hypnotic medication during the look back period despite not being prescribed a hypnotic medication, and lacked identification of R6 receiving an anticoagulant medication despite receiving an anticoagulant during the look back period. R6's Diagnoses list, printed 2/11/25, indicated R6 had several medical diagnoses including chronic embolism (blockage in a blood vessel) and thrombosis (occurs when blood clots block blood vessels) of other specified veins and other specified veins, peripheral vascular disease (slow and progressive circulation disorder cause by narrowing, blockage, or spasms in a blood vessel), and insomnia. R6's Medication Administration record dated 11/1/24 to 11/30/24, indicated R6 received Eliquis (an anticoagulant medication) 2.5 mg by mouth two times a day and Melatonin (a dietary supplement to promote sleep) 5 mg by mouth at bedtime. R9 R9's quarterly MDS dated [DATE], indicated R9 had a reentry to the care facility on 11/4/24, and moderately impaired cognition. The MDS indicated R9 had taken a hypnotic medication during the look back period despite not being prescribed a hypnotic medication. R9's Admission Record, printed 2/11/25, indicated R9 had diagnoses including insomnia, schizoaffective disorder (chronic mental health condition characterized by symptoms such as hallucinations, delusions, mania, and depression), catatonic schizophrenia (type of schizophrenia which involves a syndrome where the brain does not manage muscle movement signals as it should), and generalized anxiety disorder. R9's Orders indicated R9 was on medications which included Melatonin 6 mg by mouth at bedtime, dated 5/22/24. R15 R15's annual MDS dated [DATE], indicated R15 was cognitively intact, and lacked identification of R6 receiving an anticonvulsant medication despite receiving an anticoagulant during the look back period. R15's Diagnoses list, printed 2/14/25, indicated R15's diagnoses included major depressive disorder, anxiety disorder, and attention-deficit hyperactivity disorder. R15's Orders indicated R15 was on several medications including Gabapentin (an anticonvulsant medication) 100 mg by mouth two times a day and 300 mg by mouth at bedtime, dated 6/13/24. During an interview on 2/13/25 at 3:09 p.m., the DON confirmed R6, R9, and R15 had inaccuracies coded on their MDS. The facility provided MDS policy dated 10/23, indicated staff chart in the electronic medical record on resident's care, behaviors, needs, eating, and activities. A licensed practical nurse assisted the DON with interviewing residents and floor staff completed assessments for annual and quarterly MDS. The DON completed significant change and discharge MDS.

Based on observation, interview and document review the facility failed to ensure residents who self-administered topical medications creams were assessed for safe and appropriate use for 2 of 3 residents (R11 and R15) reviewed for self-administration of medications. Findings include: R11: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was admitted to the care facility on 4/6/23 and was cognitively intact. R11's Orders, indicated R11 had an order for Betamethasone Valerate External Cream 0.1% (a steroid cream used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions), apply to affected skin as needed for rash unsupervised self-administration. Apply to affected skin twice daily PRN [as needed] for rash up to five days a month and two times a day for rash for two weeks. R11's care plan, dated 6/26/24, indicated for staff to provide medications as ordered, including Betamethasone cream PRN for rash outbreaks. R11's electronic medical record (EMR) indicated R11's last skin observation by a licensed nurse was 11/8/24. R11's EMR lacked evidence that R11 had been assessed for safe self-administration of medication including how to use it, where, and how often. During an interview on 2/13/25 at 10:57 a.m., licensed practical nurse (LPN)-A stated that she did not believe R11 should be able to administer her own medicated cream as she had recently self-declared blindness. LPN-A stated nursing staff should be doing an assessment to ensure residents are visually and cognitively able to self-administer medications. LPN-A further stated it was questionable whether R11 had a [neck] rash and although R11 kept the cream in her room, she should be asking staff to assist her with applying the cream. During an interview on 2/13/25 at 11:09 a.m., R11 stated she kept the medicated cream in her bathroom. R11 stated she had been using the cream on her neck twice a day and the rash had cleared up but now she was using it for a rash on her right thigh. R11 stated nursing staff were not assessing her skin and were not offering, or asking, if she needed help applying the cream. She was doing it on her own. During an interview on 2/13/25 at 12:32 p.m., the consultant pharmacist (CP) stated Betamethasone Valerate External Cream 0.1% can cause thinning of the skin which is why it is generally prescribed with a time limit. The CP stated she would want to ensure R11 had the same rash on her thigh the cream was prescribed for on her neck before she used it on the rash on her thigh. During an interview on 2/13/25 at 12:59 p.m., the director of nursing (DON) confirmed R11 had not been assessed for self-administration of her medicated cream. The DON stated she believed R11 had been fine to self-administer medications when they were prescribed but was not as reliable now and was unsure if R11 could safely self-administer medications at this time. The DON stated she was unaware of a rash on R11's thigh and she should be assessed for safe and proper use. 48299 R15: R15's annual MDS dated [DATE], indicated R15 was admitted to the care facility on 12/17/20 and was cognitively intact. R15's Order Summary Report printed 2/14/25, indicated: -Hydrocortisone External Cream 1% (Hydrocortisone (Topical)) (topical corticosteroid which treats skin conditions). Apply to lower extremities and/or [abdomen] topically as needed for pruritus (itching) unsupervised self-administration apply to lower extremities bid prn (twice daily as needed) for leg rash- may keep at bedside. -Micotrin AP External Powder 2% (Miconazole Nitrate (Topical)) (antifungal medicine used to treat certain kinds of fungal or yeast infections of the skin). Apply to areas of irritation. Apply to under breasts and between skin fold when irritation is present as needed BID. -Terbinafine HCl External Cream 1% (Terbinafine HCl (Topical)) (an antifungal medication which treats fungal infections of the skin). Apply to rash on abdomen topically two times a day for rash unsupervised self-administration. Apply BID until clear. Ok to keep at bedside. -Voltaren Gel 1% (Diclofenac Sodium) (nonsteroidal anti-inflammatory drug which treats joint pain caused by arthritis). Apply to [bilateral] wrists and hands topically every six hours as needed for pain- moderate unsupervised self-administration. Apply 4 grams every six hours prn. May keep at bedside. R15's care plan, indicated the following interventions: -1/29/21, administer analgesia (refers to the relief or absence of pain) as per orders. Give half hour before treatments or care. -8/29/24, R15 self-administered clotrimazole cream under abdominal fold for rash and has as needed for cortisone cream. R15's progress note dated 8/27/24 at 12:23 [12:23 p.m.], indicated R15's providers saw R15 for a continued rash around their abdomen and lower legs and ordered clotrimazole cream twice daily to waist area until rash healed and may keep clotrimazole and hydrocortisone at bedside to use until healed. R15's progress note dated 11/22/24 at 14:47 [2:47 p.m.], indicated R15's providers saw R15 and ordered micotin antifungal powder to apply under breasts and between skin folds when irritation was present as needed twice daily. R15's EMR lacked evidence that R15 had been assessed for safe self-administration of medication including how to use it, where, and how often. During an interview on 2/13/25 at 11:45 a.m., licensed practical nurse (LPN)-A stated they did not complete self-administration assessments since they were an LPN. LPN-A stated residents were assessed for self-administration when medications first ordered, and R15 cleaned their own skin folds and self-applied needed creams. LPN-A checked with R15 daily to ensure areas cleaned or if R15 had concerns. During observation and interview on 2/13/25 at 12:55 p.m., R15 stated the use voltaren gel once or twice a day for their knees, thumbs joints, and wrists and keep the gel in their room. R15 stated they kept hydrocortisone in their room and used when their skin folds were irritated. R15 stated they also had an antifungal powder in their bathroom which R15 used when they had a rash. R15 stated the doctor ordered the powder, and staff provided R15 the powder and knew about it too. R15 stated they asked the doctor to write they may keep the powder and other treatments at bedside. R15 went to the bathroom to grab their powder, and the powder was miconazole nitrate 2% antifungal powder with a pharmacy label. During an interview on 2/13/25 at 3:35 p.m., the director of nursing (DON), verified R15 did not have a self-administration assessment and needed an assessment rather than only the doctor's orders. A facility policy titled Self-Administration of Medications Assessments, dated 8/2023, indicated if a resident wished to self-administer medications the interdisciplinary team must assess the resident's cognitive, physical, visual ability to carry out/administer medications. If resident wishes to self-administer medications/treatments such as insulin's, eye drops, lotions and/or wish medications left for self-administration, resident will be instructed in proper technique and then monitored for 10 days for correct task completion. Staff will document on MAR.

Based on observation, interview, and document review, the facility failed to ensure food preferences were honored for 1 of 1 resident (R4) reviewed for choices related to food. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had intact cognition, disorganized thinking, verbal behavioral symptoms directed towards others, and did not reject cares. R4 required supervision or touching assistance with eating and was independent with most activities of daily living. R4 had diagnoses of orthostatic hypotension (condition where blood pressure drops when standing up from a sitting or lying position), dementia and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R4's oral intake care plan revised 12/13/24, indicated R4 had potential for inadequate oral intakes related to history of varying appetite secondary to mental health and had been hospitalized for not eating and weight loss. Care plan interventions indicated R4 liked Mexican food, soups, desserts, macaroni and cheese, carrot cake, chicken wrap, pizza, tuna, and hot cereal. R4 disliked Chinese food, liver, gizzards and hearts, and red met. R4's Kardex Report printed 2/14/25, indicated R4 was independent with eating, may need encouragement to come to meals, and offer strawberry ensure if R4 did not want to eat. R4's progress note dated 12/13/24 at 10:19 [10:19 a.m.], indicated R4 was semi-vegetarian and tried to avoid red meats but liked ham and sometimes pork. R4 liked chicken, fish, tuna, eggs, dairy, and hot cereal. R4 triggered for weight loss related to decreased intakes and agreed to try to eat more. During an interview on 2/10/25 at 3:19 p.m., R4 stated the facility did not have enough vegetarian options. R4 stated they ate chicken, ham, and turkey but did not like other types of meat. R4 stated the facility had alternative options but got the regular entree if they did not sign up for another option before the set time. R4 stated they spoke with the dietician about their food preferences, and R4 believed they would live longer if they cut out certain types of meat. During an interview on 2/11/25 at 12:23 p.m., dietary aid (DA)-A, who also cooked, stated they had a book and white board which listed residents' food preferences. DA-A stated they offer alternative options for meals, and residents had to sign up for the alternative option before a certain time. During observation on 2/11/25 at 1:03 p.m., the white board in the kitchen dish machine room did not indicate any food preferences for R4. The dietary book undated, indicated R4 had No special beverage or food instructions. During an interview on 2/12/25 at 10:40 a.m., nursing assistant (NA)-A stated R4 had a fasting behavior and was not a huge meat person. NA-A stated the facility tried to give R4 smaller portions, or R4 signed up for a meal alternative or wrote no meat. NA-A stated they encouraged R4 to eat what they wanted and leave what they did not want to eat. NA-A stated they have cleared the meat off R4's plate before, so then R4 ate everything else on the plate. During observation on 2/12/25 at 12:06 p.m., R4 was given the barbequed pork with potatoes and an apple, broccoli salad. At 12:10 p.m., R4 was eating the potatoes and salad but not the barbequed pork. At 12:13 p.m., R4 ate a dessert and had eaten everything on their plate but the barbequed pork. The life enrichment director (ACT)-A took R4's plate and threw the meat away. During an interview on 2/12/25 at 12:23 p.m., DA-B, who also cooked, stated they knew residents' food preferences through verbal interactions. DA-B stated R4 wavered and had different preferences. DA-B stated R4 requested no meat at times and other times wanted the meat portion of the meal or a hot dog. During an interview on 2/12/25 at 2:21 p.m., registered nurse (RN)-A stated R4 refused to eat or drink at times. RN-A stated they were not able to leave the second floor to assist in the dining room for meals on the first floor, so the nursing assistants and dietary staff knew residents' food preferences. During an interview on 2/13/25 at 12:35 p.m., NA-C stated R4 fasted at times and encouraged R4 to drink when they did not eat. NA-C stated R4 will pace back and forth from the meal table and make statements such as I can't, I can't. NA-C stated R4 looked ahead at the menu themselves and signed up for an alternative entree if they wanted. NA-C stated R4 ate meat sometimes and other times did not. NA-C stated they let [R4] be when they did not eat the meat portion of their meal and took R4's plate when R4 stated they were done. During an interview on 2/13/25 at 12:32 p.m., ACT-A stated they took R4's plate on 2/12/24, because R4 stated they were finished. ACT-A stated R4 had a thing about meat, such as R4 did not eat the soup for lunch because it had beef in it. ACT-A stated R4 went on fasts sometimes when their weight got higher than what they wanted. ACT-A stated the kitchen offered alternative options, so most residents and staff were good at knowing what food they liked or did not like. ACT-A stated they did not check with R4 if they were full or wanted anything else before taking R4's plate and throwing away the untouched barbeque pork. During an interview on 2/13/25 at 4:03 p.m., the director of nursing (DON) stated the dietician asked residents about their likes and dislikes related to food, and the cook talked to the residents, so they knew about residents' food preferences. DON stated R4's mental illness was not stable and conflicted from hearing negative thoughts related to eating. DON stated R4 requested more vegetables, and R4 was not consistent with what they wanted. DON thought NA-A talked to people who got up late in the day or didn't look at the menu to ask what they wanted to eat before meals. DON stated they observed R4 looking at the menu prior to meals and was able to sign up for alternative entrees. DON stated staff made sure R4 drank enough to avoid weight loss, weakness, and hospitalization . DON stated residents had little control over themselves, so it was important for them to get food they liked. The facility policy New Admission Dietary assessment dated ,d+[DATE], directed the cook to interview each new resident for likes and dislikes, and the dietician to meet with residents for a nutrition related physical exam and initial assessment. The dietician updated resident assessments, progress notes, MDS, and care plan on a quarterly basis.

Based on interview and document review, the facility failed to ensure provider orders code status [e.g. full code or do not resuscitate (DNR)] were updated, consistent, and accurate throughout the resident's medical record for 1 of 4 residents (R4) reviewed for advance directives. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was admitted to the care facility on [DATE]. The MDS indicated R4 had intact cognition, disorganized thinking, verbal behavioral symptoms directed toward others, and diagnoses including orthostatic hypotension (condition where blood pressure drops when standing up from a sitting or lying position), dementia and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R4's care plan dated [DATE], lacked documentation of code status. R4's Health Care Directive dated [DATE], indicated they did not want CPR (cardiopulmonary resuscitation; emergency procedure which combined chest compressions and rescue breathing to help someone who is not breathing or whose heart is not beating) attempted if their heart and breathing stopped. R4 wanted a natural death. R4 understood if they chose this option, they would see their health care provider about writing a DNR order. R4's Transfer Orders from Regions Hospital signed [DATE], indicated R4's code status was full code. R4's Discharge Orders from Regions Hospital signed [DATE], indicated R4's code status was full code. R4's Care Conference note dated [DATE], indicated R4, the social workers, and director of nursing attended the care conference. The note indicated R4 wanted CPR in the past and now changed their mind. R4's Admission Record printed [DATE], indicated R4 did not want resuscitation and did not want intubation. R4's orders printed [DATE], did not indicate R4's code status. During interview on [DATE] at 2:13 p.m., registered nurse (RN)-A stated code statuses were reviewed at care conferences and during admission by the director of nursing (DON). RN-A knew residents' code statuses from the face sheet binder. The face sheet binder had a copy of R4's Admission Record and Health Care Directive, both which did not have a provider signature. During interview on [DATE] at 3:31 p.m., the director of nursing (DON) confirmed there was no provider order or involvement in R4's DNR status. The DON preferred everyone to have a POLST and stated not everyone had one, which included R4. The DON stated provider involvement was important to ensure residents were educated about DNR status by a professional with a higher degree. The DON stated they reviewed code status at each care conference. The facility's POLST policy dated ,d+[DATE], directed staff to assist the resident or resident's guardian/representative with completing a Providers Orders for Life Sustaining Treatment (POLST) form. If the resident or guardian/representative chooses to decline CPR, intubation, etc., HSM staff documented on the POLST, and two staff members witnessed the POLST to become effective. The POLST was then faxed to the primary physician for signature. The facility's Advanced Directives/CPR policy dated ,d+[DATE], reflected the same process as the POLST policy. The policy indicated the care plan reflected resident wishes and whether an advance directive existed. The policy directed staff to reference the Facesheet binder in the event a resident was found without a pulse.

Based on interview and document review the facility failed to ensure a process for missing clothing was followed and residents received appropriate follow up after reporting concerns of missing clothing for 3 of 5 residents (R1, R4, and R9) reviewed for personal property. Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the care facility 7/24/23 and was cognitively intact. During an interview on 2/11/25 at 8:41 a.m., R1 stated missing clothing was a common occurrence in the facility and she was currently missing a blue hoody. R1 confirmed she had let the facility nursing assistants (NA) know but had not received any follow up. R5: R5's quarterly MDS dated [DATE], indicated R5 was admitted to the care facility 10/1/24 and was cognitively intact. During an interview on 2/12/25 at 8:54 a.m., R5 stated she had not been getting all of her clothing back after getting it washed and was currently missing a pair of jeans, socks, and underwear. R5 stated she had told the NA who distributed the laundry and the director of nursing (DON). R5 further stated it had been approximately 1 month and she had not received any follow up. The facility's Missing Item Report, kept in a three-ring binder at the nursing station, dated 9/2/24 - 2/10/25, lacked evidence of R1's and R5's reported missing clothing. During observation on 2/12/25 at 10:30 a.m., a pair of unmarked resident jeans were laying on a chair near the nursing station. Facility staff were unable to confirm who they belonged to. During an interview on 2/12/25 at 11:55 a.m., NA-A stated she was aware R1 was missing a blue hoody and R5 was missing clothing items including a pair of jeans. NA-A stated the process for missing laundry was when an item was reported missing, staff would check the laundry room, laundry cart and other resident rooms for the item. If it could not be found that it should be written on the missing items report kept at the nursing station. NA-A stated R1's and R5's missing clothing was reported off to her by another NA so she did not look for the clothing herself or write it in the missing item report. During an interview on 2/13/25 at 12:59 p.m., the DON stated she was aware of R5's missing clothing but was not aware R1 was missing clothing. The DON stated since there was only one NA and one nurse working at a time, the staff could not be expected to leave the floor and search for missing items every time it was reported. The DON stated she encouraged all staff to use the missing items report, however confirmed the facility lacked follow up on the report and with missing items. The DON also stated clothing was labeled with a sharpie that would wash off after a few washes creating issues of clothing items not being labeled with resident identifying information. 48299 R9: R9's quarterly MDS dated [DATE], indicated R9 had moderately impaired cognition, inattention, disorganized thinking, hallucinations, delusions, verbal and other behaviors, and rejected cares. R9 had no upper or lower extremity impairments and used a walker. R9 required partial and/or moderate assistance for dressing and supervision for footwear application and removal, toileting, personal and oral hygiene, and ambulation. The MDS indicated R9 had arthritis (general term for conditions which cause joint inflammation, pain, swelling, and stiffness), anxiety, and schizophrenia. R9's progress note dated 11/14/24 at 8:17 a.m., indicated R9 had a history of paranoia with staff and/or people taking clothes, or R9 reported missing possessions from their room. During an interview on 2/10/25 at 2:39 p.m., R9 stated they were missing an expensive jacket, and the facility was not able to locate it. During an interview on 2/12/25 at 10:37 a.m., nursing assistant (NA)-A stated they looked in the laundry area, looked downstairs, and in every room when a resident reported a missing item. NA-A stated the facility had a missing item binder where they wrote down a description of the missing item. NA-A stated clothes were initialed and clean clothes were kept behind a label with resident information, so staff knew whose clean clothes were hanging on the rack. NA-A stated they were unaware of a missing jacket for R9. During an interview on 2/12/25 at 12:17 p.m., anonymous resident stated they lost clothes every wash and were missing black pants, jeans, bras, socks, and shirts. Resident stated their clothes had their initials on them, and nursing assistants told resident they looked for their clothes. Resident stated missing clothes was a serious problem and cost the resident a lot of money. During observation review on 2/12/25 at 1:22 p.m., the missing items log did not have an entry for R9's jacket. During an interview on 2/12/25 at 2:10 p.m., RN-A stated the nursing assistants took care of any missing laundry or missing items. RN-A stated the facility had a grievance and missing items log and they were aware R9's family reported a missing jacket. RN-A stated R9 had gained weight and some clothes which were too small for R9 were packed away, so R9 could believe they were missing clothes they were not. RN-A was not sure if the jacket was found or not and knew the family talked to the DON. During an interview on 2/12/25 at 2:43 p.m., NA-B stated they wrote a note or verbally reported to housekeeping when residents brought up concerns of missing laundry. NA-B stated they should get a list started related to missing items. NA-B was not aware of R9's missing jacket. During an interview on 2/13/25 at 3:09 p.m., the director of nursing (DON) stated they thought the life enrichment director checked the missing items log but was not sure if there was a misunderstanding. DON stated the facility had seen R9 wear the jacket which was described as missing. DON stated R9 threw items away at times and outgrew some of their clothes, so staff packed clothes which were too small for R9 outside of their room. DON stated R9's parents went through R9's items weekly and got R9 agitated when they reported items as missing and stolen. DON stated the facility did not find the jacket and talked to the family, and the family was unhappy it was missing. A facility policy related to resident missing items was requested and not available at the time of survey.

Based on observation, interview, and document review, the facility failed to assess and monitor skin alterations for 1 of 2 residents (R8) reviewed for skin integrity. Furthermore, the facility failed to follow up with urology after several urinary tract infection and failed to comprehensively monitor and assess (i.e bladder scanning to assess for urine retention, proactive UTI assessments or assessing if R3 required more assistance with toileting or bathing) to timely treat, if needed, and prevent hospitalization for 1 of 1 resident (R3) reviewed for hospitalization . Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact and was independent with most activities of daily living and required set up assistance with bathing. R3's progress notes dated 8/6/24 - 2/12/25, indicated R3 had three UTIs in the past six months resulting in two hospitalization s and was displaying current UTI symptoms. On 8/6/24 it was documented R3 had complaints of strong smelling/cloudy urine and reported falling to her knees last week. Reportedly the director of nursing (DON) was notified. On 8/7 24 it was documented R3 reported feeling weak with ambulation and having intermittent burning pain with urination and odorous urine. R3 further stated she felt like she had a UTI. The note indicated, will updated DON. On 8/29/24 it was documented R3 had a change in condition with increased confusion and inability to stand. R3 was hospitalized , On 8/29/24 it was confirmed R3 was being treated at the hospital for a UTI, 23 days after symptoms started, 23 days after first documented symptoms. On 9/15/24 it was documented R3 had complaints of cloudy and odorous urine, stating she felt weak. It was documented R3 did not appear weak when ambulating and was reminded to drink water. Per progress note next shift notified. On 9/16/24 it was documented R3 denied painful urination but had complaints of feeling weak with ambulation and odorous urine. On 9/25/24 it was documented that R3 had a care conference and voiced concerns about her cloudy urine, stating she feared she may have another UTI. R3 agreed to drink more water. DON was to consult R3's physician. On 9/30/24 it was documented in a pharmacy note that R3 had been referred to urology. On 10/2/24 it was documented the physician wrote an order for a urine culture, 17 days after symptoms started. The physician also increased R3's Mirabegron (a medication used to treat overactive bladder) and discontinued R3's Tamsulosin (a medication to treat urine retention). On 11/6/24 it was documented R3 requested staff visualize her urine which was documented as yellow, slightly cloudy, and odorous, stating she thinks she had pain with urination and felt weak with ambulation. On 11/7/24 it was documented R3 was hospitalized for increased weakness after a fall and was diagnoses at the hospital with acute cystitis (inflammation of the bladder) and had a urine culture pending. On 1/14/25 it was documented R3 stated she wanted a urine culture because she thought she had a UTI again. R3 reported burning with urination, cloudy urine and feeling weak for a couple of weeks. R3 was encouraged to drink water and R3's concerns were passed on at shift change. On 1/18/25 it was documented R3 reported symptoms of a UTI for the past few weeks. The DON recommended R3 to drink more water and to take tub baths and showers. On 2/12/25 it was documented R3 continued to report burning with urination, cloudy urine and feeling weak, 29 days after first reporting symptoms. R3 did not have a fever. The DON was aware and instructed R3 to drink water, which R3 did not like to do. R3's electronic medical record (EMR) lacked documentation of ongoing, comprehensive assessments or updated interventions (i.e bladder scanning to assess for urine retention, proactive UTI assessments or assessing if R3 required more assistance with toileting or bathing) to help prevent and/or timely treat UTIs and hospitalization s. R3's care plan indicated R3 had had an increased risk for Urinary Tract Infection AEB [as evidenced by] acute polynephritis and urinary incontinence. The care plan lacked intervention updates since 9/3/24 despite continued UTIs and current UTI symptoms. During an interview on 2/12/25 at 8:30 a.m., nursing assistant (NA)-A stated R3 was able to let staff know when she felt like she had a UTI, stating it was obvious because R3 would become very weak. NA-A stated R3 was incontinent of bladder but changed her own brief and toileted herself. During an interview on 2/12/25 at 8:45 a.m., R3 stated she felt like she had another UTI and felt weak. R3 stated she wished the facility would treat her for UTIs at the facility instead of sending her to the hospital. During an interview on 2/12/25 at 10:30 a.m., registered nurse (RN)-A stated staff try to encourage R3 to drink water but R3 preferred to drink soda. RN-A stated R3 could often tell staff when she thought she had a UTI but was not always correct. During an interview on 2/13/25 at 12:59 p.m., the DON stated R3 was on a prophylactic antibiotic in the past. At the time it was discovered she had infected kidney stones, and they were removed and R3 had ureter stents placed in March of 2024. R3 saw the urologist on 4/17/24, which was when the prophylactic antibiotic was stopped, and an order was given for R3 to follow up with urology if she started have UTIs again. The DON confirmed R3 had not been back to see the urologist despite multiple UTIs since that time. The DON stated staff would encourage R3 to drink water however R3 preferred soda. The DON confirmed the care planed lacked updated interventions to prevent UTIs stating the facility could not afford a bladder scanner. The DON stated the medical director had not been notified of R3's recurring UTIs but she would notify them and would inquire about getting a urine culture for R3 due to her current UTI symptoms. A facility policy on UTIs was not available at the time of survey. 48299 R8 R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had intact cognition and no delirium. R8 had delusions, verbal behaviors towards others, wandered one to three days, and did not reject cares. R8 had diagnoses of hypertension (high blood pressure), diabetes mellitus (chronic disease which affects how the body uses sugar for energy), arthritis (general term for conditions which cause joint inflammation, pain, swelling, and stiffness), anxiety disorder, depression, and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R8 had no upper or lower extremity impairments and used a walker. R8 required substantial and/or maximal assistance with shower/bathing. R8 required partial and/or moderate assistance with toileting hygiene, toilet transfers, tub/shower transfers, and dressing. R8 was independent with footwear application and removal, rolling left and right, sit to lying and lying to sitting on side of bed, and with chair and/or bed-to-chair transfers. R8 was occasionally incontinent of urine. R8 took antipsychotic, antianxiety, antidepressant, hypoglycemic, and anticonvulsant medication, was not at risk for pressure ulcers, had moisture associated skin damage, and applications of ointments/medications other than to feet. R8's Care Assessment Area (CAA) worksheet dated 7/16/24, indicated R8 required supervision or touching assistance for sit to lying and lying to sitting on the side of the bed, and R8 was at risk for skin alterations, infection, sepsis, increased dependence on staff, decreased leisure, isolation, and further decline. R8's pressure ulcer care plan revised 10/14/24, indicated R8 was at risk for pressure ulcer development related to compression stockings. Interventions dated 5/13/24, directed staff to inform R8/family/caregivers of any new area of skin breakdown and remove compression stockings each evening, wash and hang to dry, and apply clean stockings each morning. R8's incontinence care plan dated 5/13/24, indicated R8 had mixed bladder incontinence related to confusion, impaired mobility, inability to communicate needs at times of confusion. The care plan goal dated 5/13/24, indicated R8 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions dated 5/13/24, directed staff to ensure R8 had unobstructed path to the bathroom, and R8 used Depends for occasional urinary incontinence. R8's Kardex Report printed 2/12/25, indicated R8 received transfer assistance in and/or out of tub/shower and limited to extensive assistance for bathing and more assistance if confused. R8's Order Summary Report printed 2/12/25, indicated an order for miconazole powder with instructions to apply to abdomen, breasts, peri-area as needed twice daily for redness/rash skin irritation (yeast areas) with date of 10/2/24. R8's Skin Observation Tool dated 7/29/24, indicated R8 had a cyst type sore to their posterior right thigh and was tender to touch. R8's Skin Observation Tool dated 1/3/25, indicated R8 had a superficial scratch-like abrasion to their left abdominal fold. No other Skin Observation Tool assessments were recorded from 7/29/24 to 2/13/25. R8's Point of Care Response History had No Data Found for Skin Observation in the past 30 days. R8's progress note dated 1/31/25 at 08:39 [8:39 a.m.], indicated R8's skin was intact. During an interview on 2/10/25 at 4:07 p.m., R8 stated they have a sore in the crack of their butt. R8 stated staff they had the spot for a while, and staff placed cream on the area which helped. During observation and interview on 2/12/25 at 8:23 a.m., registered nurse (RN)-A stated R8 brought themselves to the bathroom and walked into R8's bathroom. R8 had their pants and incontinent product pulled down and bent over by waist with buttocks pulled apart. There was an open spot of skin approximately a quarter to half inch in length and width at the top area of R8's butt crack. R8 was placing their fingernails in the spot and stated the area was sore. RN-A looked closely at the area, looked around R8's bathroom, and stated there were no washcloths in R8's bathroom to wash the area. R8 pointed to the green tube of calmoseptine by their bathroom sink and stated the tube was the cream which helped. RN-A assisted R8 to sit on the toilet and left R8's room. R8 stated they had the spot for a long time, the area hurt when they wiped themselves, and cream helped the pain. R8 was provided privacy to use the bathroom. During observation and interview on 2/12/25 at 8:36 a.m., RN-A entered R8's room. R8 was on their bed with their pants pulled up, and R8 stated they were exhausted. RN-A exited R8's room and stated they could tell someone had taken care of the area previously and had to look at the chart to see if the area was noted before. RN-A stated the area looked like a skin split approximately half to three quarters of an inch. During an interview on 2/12/25 at 8:48 a.m., nursing assistant (NA)-A stated they reported new skin concerns to nursing staff, so they could assess if the area needed barrier cream, nystatin powder, or be left open to air. NA-A stated nurses completed weekly skin checks. NA-A stated R8 was independent most of the time and was already up by the time they got to work in the morning. NA-A stated the night shift reported they placed barrier cream on R8's bottom more than weeks ago, because the area looked red and for comfort. During an interview on 2/12/25 at 2:32 p.m., RN-A stated they did not return to R8 to look at their bottom and still needed to check R8's chart to see if the area was a change in condition. RN-A stated there was not a schedule to complete skin checks, and they facility had a lot of independent residents. RN-A stated the shower aid or other staff would tell them if there were any skin concerns, and then RN-A would check the resident's skin. During an interview on 2/12/25 at 2:53 p.m., NA-B stated R8 did not need help in the bathroom unless they had a bowel movement. NA-B stated they applied barrier cream to a lot of residents, including R8. NA-B stated R8's crack bothered R8, and NA-B applied cream to a red area on R8's bottom after R8 had a shower the week prior. NA-B stated they did not need to let the nurse know, because the area on R8's butt crack was just a little pink. NA-B stated they alerted the nurse when residents had skin changes, such as an open tear. During an interview on 2/13/25 at 3:13 p.m., the DON expected staff to alert nursing staff about any skin alterations, and the nurses documented on resident's skin after a skin assessment. DON stated R8 was independent with toileting during the day and needed more assistance at night. DON stated they were not aware of any open skin area or shearing on R8. DON stated they wanted to ensure R8 had the right treatment to decrease risk for infection and worsening of the area. The facility's Skin Monitoring policy dated 10/2021, directed the nursing assistants to check the residents' skin during each shower and notify the nurse of any skin alterations and any possible explanation. The policy directed staff to complete a Skin Observation Tool assessment for any skin alteration, such as a bruise, rash, open area, skin tear, blister, or any other skin alteration. Staff were to schedule a weekly assessment by a registered nurse as well as a treatment plan for healing when a skin alteration was found. Staff were to notify the DON of any skin issue for follow-up.

Based on observation, interview and document review, the facility failed to ensure a resident who wished to smoke off facility grounds was properly assessed for safety, and risks of unsupervised smoking were discussed for 1 of 1 resident (R5) reviewed for smoking. The facility further failed to ensure residents at risk for falls were assessed for a root cause and new interventions were put in place to prevent falls for 2 of 3 residents (R10 and R8) reviewed for falls. Findings include: R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. The MDS further indicated R5 utilized a walker for locomotion and was independent with most activities of daily living (ADLs) except bathing. R5's progress note, dated 1/6/25, indicated R5 asked staff if it was okay for her to go outside and walk down the trail. Staff assured R5 it was okay as long as staff knew where she was. That afternoon R5 came back to facility smelling of smoke. R5 confirmed she was aware the care facility was a non-smoking facility but she would like to smoke off property. R5 was also informed that if her decision was to continue smoking, she would need to find alternative placement. R5 verbalized feeling overwhelmed and it was suggested that she take some time to think about what she wanted to do. R5's electronic medical record (EMR) lacked evidence a safe smoking assessment was completed on R5, risks of smoking unsupervised were discussed with R5, and any interventions were care planned to ensure R5's decision to occasionally smoke off campus was as safe as possible (i.e. ensuring staff knew when she was leaving campus, monitoring clothes for burn holes, etc). During an interview on 2/12/25 at 8:54 a.m., R5 stated she wanted to have the right to smoke off campus occasionally but did not want to leave the facility as she liked living there. R5 stated she had gone off campus by walking up the path off the parking lot twice to smoke. R5 stated when she came back the second time the aide had noticed she smelled like smoke and notified the director of nursing (DON). R5 stated she still had a pack of cigarettes and a lighter in her room but had not smoked since. R5 further stated staff had not assessed her for safe smoking, just told her she could not smoke as it was a non-smoking facility. During an interview on 2/12/25 at 10:30 a.m., registered nurse (RN)-A stated she was aware R5 had, and wanted to continue to smoke off campus, stating the facility had put up signs to indicate there was no smoking on the facility grounds. RN-A stated R5 was talked to by the DON and administrator but that a safe smoking assessment was not completed because they [residents] are not supposed to smoke. RN-A further stated R5 was asked about starting a nicotine patch but was not sure if she wanted one and had not been followed up with. During an interview on 2/13/25 at 12:59 p.m., the DON stated they held a meeting with the ombudsman and R5 had stated she did not want to smoke, however a few days ago she had informed the administrative assistant she did want to smoke. The DON confirmed they had not completed a safe smoking assessment for R5 or put any interventions into place to ensure R5 was as safe as possible if she chose to smoke off campus because they were a non-smoking facility, and she did not admit smokers. A facility policy on smoking assessments was requested but not received. R10 R10's quarterly MDS dated [DATE], indicated R10 had moderate cognitive impairment, was independent with ambulation, and had one fall without injury since last assessment. R10's last two fall assessments, dated 9/10/24 and 11/5/24, both indicated that R10 was at risk for falls. R10's progress notes, dated 8/2/24 - 9/14/24, indicated R10 had three falls in the past 6 months, two out of three of them happening on a Thursday. On 8/2/24, it was documented R10 was found on the floor in her room. On 9/13/24, it was documented R10 was hospitalized after a fall in her bathroom while standing at her sink, resulting in a head strike and laceration above her left eye. On 11/5/24, it was documented R10 was found on the floor in her room and reported hitting her head. R10's care plan, printed 2/14/25, indicated R10 had a history of falls, most current on 11/5/24. R10's care plan indicated several fall interventions dated 2/23/24, and 9/17/24, including monitoring orthostatic blood pressure monthly (checking for blood pressure changes with position changes which may cause dizziness), using a wheelchair while at her bathroom sink and reminding R10 to always have her walker with her. The care plan lacked intervention updates for R10's falls in August and November. R10's Kardex, printed 2/14/25, was utilized by the facility nursing assistants (NA) to know what cares to provide a resident and any special instructions. The Kardex lacked any mention of R10 being a fall risk or any fall interventions. R10's electronic medical record (EMR) indicated the last 2 orthostatic blood pressure that were taken or recorded was on 6/13/24 and 9/9/24. The facility's Fall Tracking Book lacked any mention of the fall on 8/2/24. R10's EMR identified that R10 was weak after receiving weekly ETC (Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions) on Wednesdays, however failed to implement new, care planned interventions for falls and post ECT monitoring despite R10 almost always falling on the Thursday after ECT. During an interview on 2/15/25 at 8:30 a.m., NA-A stated R10 was independent with most ADLs, including grooming and ambulation. NA-A stated when R10 came back from ECT she was weak and staff would offer her a wheelchair to go to lunch or watch her close at lunch if she refused her wheelchair. NA-A was unaware of any other fall interventions or post ECT monitoring. During an interview on 2/12/25 at 10:30 am, registered nurse (RN)-A stated R10 had ECT every Wednesdays and she would have the NAs keep her in her wheelchair when she arrived back to the facility. RN-A stated that was the only fall intervention or post ECT monitoring she was aware. During an interview on 2/13/25 at 12:59 p.m., the DON stated it would be expected that will each fall the nurse would be implementing a new intervention and writing the fall, root cause and interventions on the fall log. The DON stated at times she would be included in the conversation to help think outside the box to ensure a new intervention was always implemented. The DON confirmed R10's care plan and Kardex lacked interventions for post ECT monitoring and while staff were monitoring R10 closer when she returned to the community from ECT, the weakness continued into Thursday when most falls were happening. The DON further confirmed it would be expected that orthostatic blood pressures were monitored monthly as stated in R10's care plan. A facility policy titled Falls/Incidents, dated 8/2021, indicated nursing staff should determine the cause of the fall after each fall and implement and record what new intervention was being implemented to help prevent future falls. 48299 R8 R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had intact cognition and no delirium. R8 had delusions, verbal behaviors towards others and wandered one to three days, and did not reject cares. R8 had diagnoses of hypertension (high blood pressure), diabetes mellitus (chronic disease which affects how the body uses sugar for energy), arthritis (general term for conditions which cause joint inflammation, pain, swelling, and stiffness), anxiety disorder, depression, and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R8 had no upper or lower extremity impairments and used a walker. R8 required partial and/or moderate assistance with toileting hygiene, toilet transfers, and dressing. R8 was independent with footwear application and removal, rolling left and right, and with chair and/or bed-to-chair transfers. R8 was occasionally incontinent of urine. The MDS indicated R8 had one fall with no injury since the last assessment. R8 took antipsychotic, antianxiety, antidepressant, hypoglycemic, and anticonvulsant medication. R8's Care Area Assessment (CAA) worksheet for falls dated 7/16/24, indicated R8 was at risk for falls related to fall history and antianxiety and antidepressant medication use. The CAA noted R8 had a history of falls in their room when getting up from their recliner and using their walker. R8 was at risk for falls, injury, discomfort, increased dependence on staff, decreased leisure, isolation, and further decline. R8's Fall Risk assessment dated [DATE], indicated R8 had one to two falls in the past three months, was ambulatory and continent, had intermittent confusion and/or forgets limitations, required use of assistive device, had systolic blood pressure drop less than 20 mmHg (millimeters of mercury) between lying and standing in three minutes, took three to four of medications the medication classes listed within the past seven days, and had three or more present predisposing conditions or diseases. R8 was at risk for falls. R8's Fall Risk assessment dated [DATE], indicated R8 had one to two falls in the past three months, was ambulatory and incontinent, was alert, had normal gait and/or balance, did not have a drop in systolic blood pressure between lying and standing, did not take psychoactive or other listed medication classes in the past seven days, and did not have predisposing conditions or diseases. The assessment indicated R8 was not at risk for falls. R8's fall care plan revised 11/13/24, indicated R8 was at moderate risk for falls related to confusion, gait and/or balance problems, incontinence, poor communication and/or comprehension, psychoactive drug use, and unaware of safety needs. The fall care plan indicated R8's last fall was on 11/13/24. Fall interventions included: -11/13/24, be sure R8's call light within reach and encourage to use call light for assistance as needed. R8 needed prompt response to all requests for assistance. -11/13/24, encourage appropriate use of assistive device. -7/4/24, encourage R8 to sleep in bed and not recliner to promote good sleep and to prevent falls from R8 trying to get out of chair with the footrest up when R8 was confused. -4/13/24, ensure R8 wore appropriate footwear non-skid socks when ambulating or mobilizing in wheelchair. R8's Kardex Report printed 2/12/25, directed staff to keep R8's call light within reach, encourage R8 to use for assistance as needed, and provide prompt response to R8's requests for assistance. Staff were to ensure R8 had an unobstructed path to the bathroom, wore appropriate footwear non-skid socks when ambulating or mobilizing in wheelchair, and encourage R8 to use assistive device. R8's progress note on 1/28/25 at 3:55 a.m., indicated R8 pushed their call light and was found sitting on the floor in front of their recliner in their apartment. The note indicated R8 stated they slid out of the recliner when trying to pick up a blanket which was on the floor. Range of motion of upper and lower extremities were intact and equal, vital signs were stable, and no injuries or pain were noted or reported. R8 used the bathroom and sat in their recliner covered with blankets. The director of nursing was notified. The facility fall book indicated R8 had an unwitnessed fall from their recliner in their room on 1/28/25. The note indicated R8 tried to reach their blankets which were on the floor. Interventions included to remind R8 to use call light all the time to get assistance from staff and encourage R8 to sleep in bed instead of recliner. R8's medical record lacked evidence of fall prevention interventions based on a root cause analysis after the fall on 1/28/25. During interview on 2/12/25 at 10:52 a.m., nursing assistant (NA)-A stated they notified a nurse if they found a resident on the floor, and the nurse completed an assessment and obtained vital signs. Staff asked the resident what happened and what they were trying to do before the fall and assisted the resident back into a wheelchair, recliner, or bathroom. NA-A was unsure of fall interventions for R8. NA-A stated R8 was found on the ground before, and the facility found R8 placed themselves on the floor by reviewing the facility camera footage. NA-A stated R8 had previous falls, and staff helped R8 when needed. During interview on 2/12/25 at 2:53 p.m., NA-B stated fall interventions for R8 were to set up anything they need around them, ensure walker and call light were close by, check on R8 frequently, and remind R8 to use their call light and keep walker close to themselves. During interview on 2/13/25 at 11:55 a.m., licensed practical nurse (LPN)-A stated they have a fall tracker sheet which listed interventions to prevent future falls. LPN-A stated they take vitals, assessed for injury, asked the resident what happened, and completed neurological checks for unwitnessed falls. During interview on 2/13/25 at 3:13 p.m., the director of nursing (DON) stated nurses updated resident care plans with new interventions after a fall. DON brought fall information to QA (quality assurance) to discuss. DON stated R8 had two or three falls at night when first admitted and were recliner related. DON stated R8 knew they slept better in bed and talked about sleeping in bed at care conferences. DON reviewed R8's care plan and confirmed R8's fall care plan was not updated after R8's fall on 1/28/25. DON stated the fall interventions were repeated for R8 as they were unsure if the previous fall interventions were followed. DON thought they educated staff on R8's fall interventions or placed a note in their Homebase app (app used by businesses to assist with scheduling, payroll, communication) but did not provide documentation of such. DON stated if staff captured all the needed fall information in the progress notes and fall book, they would not have to write a four-page fall report. DON stated they have a fall book which they have not implemented yet to further analyze resident falls. DON stated creating and implementing fall interventions were important to prevent R8 from future falls and injury. The facility policy Falls/Incident dated 8/2021, directed staff to complete the Fall/Incident report and a progress note detailing the fall/incident, vital signs, and who was notified. The policy directed staff to chart under Fall Risk Assessments and in the fall tracking book about what type of fall occurred and the intervention implemented to prevent further falls/incidents. The policy directed staff to chart the date of the fall/incident and implemented intervention in the care plan.

Based on observation, interview and document review the facility failed to comprehensively assess pain and attempt non-pharmacological pain interventions for 1 of 1 resident (R11) receiving multiple medications for pain. Findings include: R11's quarterly Minimum Data Set (MDS), dated [DATE], indicated R11 was cognitively intact and had pain almost constantly that frequently effected sleep and day to day activities. The MDS further indicated R11 had received pain medication during the look back period however had not received any non-pharmacological pain interventions. R11's Orders, printed on 2/13/25, indicated R11 received several medications for pain including Ajovy (used to prevent migraine headaches) 225 milligram (mg)/1.5 milliliters (ml) inject subcutaneously once a month for intractable migraines, alpha-lipoic acid (used in alternative medicine to aide treating nerve pain) 300mg by mouth two times a day for polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or malfunction which may cause numbness, tingling, burning or stabbing pain), Gabapentin (commonly used medication for the treatment of neuropathic pain) 1200 mg by mouth three times a day for polyneuropathy, diclofenac sodium gel 1% (a medication used to relieve pain and inflammation associated with arthritis, sprains, and other musculoskeletal conditions) apply to neck, shoulders and arms as needed for pain (self-administered), Humira 40 mg/0.4 ml (a medication used to treat arthritis) inject 80mg subcutaneously one time a day every 14 days for arthropathic psoriasis (chronic inflammatory condition that affects the joints causing joint pain, stiffness and swelling), and Nurtec (a medication used to treat migraines) 75 mg sublingually daily as needed for migraine (received on 2/10/25). R11's care plan, dated 6/26/24, indicated R11 was on pain medication therapy related to neuropathy, bladder spasms, muscle tendon pain and migraines and R11 had chronic pain related to psoriatic arthritis, depression, neuropathy and migraines. The care plan lacked resident specific non-pharmacological pain interventions. R11's electronic medical record (EMR), including the medication administration record (MAR) lacked any pain assessment in the past seven months to include pain goal, what makes pain better or worse and non-pharmacological interventions that were tried and successful or unsuccessful. During an interview on 2/10/25 at 6:00 p.m., R11 stated she had pain almost constantly but did not want to take more medication. R11 denies staff attempting to use non-pharmacological pain interventions and stated staff do not ask her about her pain levels or what makes it better or worse. During an interview on 2/13/25 at 8:21 a.m., licensed practical nurse (LPN)-A stated pain assessments should be conducted at least quarterly but also anytime a resident received a pain medication, the MAR would prompt staff to record the resident's pain level. LPN-A stated R11 had an implanted pain device in her neck and was working with a pain clinic, but they did not use any non-pharmacological pain interventions with her. LPN-A stated they would only implement non-pharmacological pain interventions if it was ordered by the doctor. During an interview on 2/13/25 at 8:27 a.m., nursing assistant (NA)-C stated R11 had complaints of stomach pains and migraines, and most recently had been complaining of pain a lot stating she believed it to be behavioral. NA-C stated she had not been told about any non-pharmacological pain intervention for R11 and had not tried anything herself for R11's pain. During an interview on 2/13/25 at 12:59 p.m., the director of nursing (DON) confirmed that there were no non-pharmacological pain interventions for R11. The DON stated when staff were administering R11's diclofenac sodium gel the nurses were prompted by the medication administration record (MAR) to ask about R11's pain level but since R11 was self-administering the medication the pain assessment piece had fallen off. A facility on pain management was requested and not available at the time of survey.

Based on observation, interview, and document review, the facility failed to ensure alternate interventions were assessed and/or attempted, risks and benefits of bed assist devices were reviewed, and consent was obtained for 1 of 2 residents (R9) reviewed for bed assist devices. Furthermore, the facility failed to remove a bed assist device or re-evaluate its use after an assessment indicated the bed assist device was not needed for 1 of 2 residents (R14) reviewed for bed assist devices. Findings include: R9 R9's quarterly minimum data set (MDS) dated [DATE], indicated R9 had moderately impaired cognition, inattention, disorganized thinking, hallucinations, delusions, verbal and other behaviors, and rejected cares. R9 had no upper or lower extremity impairments and used a walker. R9 required partial and/or moderate assistance for dressing and supervision for footwear application and removal, toileting, personal and oral hygiene, and ambulation. The MDS indicated R9 had arthritis (general term for conditions which cause joint inflammation, pain, swelling, and stiffness), anxiety, and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). The MDS indicated bed rails were not in use. R9's care plan dated 11/13/24, did not indicate use of a bed assist device. R9's admission Bedrails Risk Assessment Flow Chart dated 6/7/24, indicated R9 did not need bed rails. A progress note dated 6/2/24 at 01:35 [1:35 a.m.], indicated staff tied R9's call light to their left siderail. A progress note dated 6/15/24 at 07:27 [7:27 a.m.], indicated staff tied R9's call light to their side rail. A progress note dated 7/15/24 at 06:38 [6:38 a.m.], indicated R9 detached the call light attached to their bed siderail twice. R9's medical chart did not mention anything further on bed assist device use, education of risks and benefits, consent, or attempted alternatives prior to installation of the bed rail. During observation and interview on 2/10/25 at 2:45 p.m., the left side of R9's bed was against the wall, and a bed assist device was on the right-hand side of R9's bed. R9 stated they did not use the device, did not have to sign anything for the device in place, and the device was in place when they admitted . R14 R14's annual MDS dated [DATE], indicated R14 had intact cognition, had no behaviors, and was independent for most activities of daily living. R14 had diagnoses of diabetes mellitus (condition when blood sugar is too high), anxiety, depression, and schizophrenia. The MDS indicated bed rails were not in use. R14's care plan dated 1/8/25, did not indicate use of bed assist device. R14's Bedrails Risk Assessment Flow Chart Tool dated 12/29/21, indicated use of bed rails was beneficial for R14. R14's Bed Rails Risk Assessment Decision to Use form dated 12/30/21, indicated R14 used bed rail for repositioning and easy access to bed controls and personal care items. The form indicated R14 was educated how to use the bed rail, about the need for bed rails, and its use. R14's quarterly Bedrails Risk Assessment Flow Chart dated 6/11/23, indicated bed rails were not needed. R14's chart did not contain any other bed assist device assessments. R14's progress note dated 7/30/24 at 17:51 [5:51 p.m.], indicated staff placed call light to R14's siderail. R14's progress note dated 11/6/24 at 02:48 [2:48 a.m.], indicated staff secured call light to grab bar. During observation and interview on 2/10/25 at 5:28 p.m., R14 had a bed assist device on the right side of their bed. R14 stated they did not use the device and did not remember if anyone educated them about the risks and benefits and obtained consent for use. During an interview on 2/12/25 at 10:37 a.m., nursing assistant (NA)-A stated R9 required supervision to limited assistance with morning activities of daily living. NA-A they were not sure how often R9 used their bed assistive device and saw R9 grab the device to lift out of bed and then grab their walker. NA-A stated R14 required more assistance after a fall but moved back to their original room on the first floor once their strength returned and they were more independent again. During an interview on 2/12/25 at 2:32 p.m., registered nurse (RN)-A stated they did not complete bed rail assessments and was unsure about other nursing staff. During an interview on 2/12/25 at 2:45 p.m., NA-B stated R9 used the device on their bed to get out of bed. NA-B stated R14 was independent. During an interview on 2/13/25 at 2:20 p.m., the administrator stated they installed bed assist devices when the director of nursing (DON) communicated the need to them. During an interview on 2/13/25 at 3:31 p.m., DON stated bed rail assessments were completed upon admission and quarterly. DON stated other nursing staff were able to complete bed rail assessments and told DON what residents needed bed assist devices applied. DON expected notification if any assessment indicated a change in bed assist device use. DON stated they thought they were told R9 needed a bed assist device and verified R9 did not have a consent or education of risks and benefits in their chart. DON stated R14's bed assist device was part of a fall intervention after R14 got out of the right side of bed, slipped, and fell . DON was not aware of R14's bed rail assessment which indicated R14 did not need bed rails. The facility policy Bed Rails Assessment and Use Policy dated 6/2023, directed staff to use the Bed Rails Risk Assessment form to determine if bed rails were appropriate upon admission, quarterly, and as change in resident's health condition. The assessment may result in bed rail removal if determined resident's condition has improved for which the bed rail was installed. The policy directed staff to discuss the need for bed rails, risks and benefits, and obtain an informed consent prior to installation.

Based on interview and document review the facility failed to ensure orthostatic hypotension (characterized by a sudden drop in blood pressure that may lead to dizziness, lightheadedness, or fainting) was communicated the physician to ensure psychotropic medications (which can commonly cause orthostatic hypotension due to their effect on the body's blood vessels) did not need to be reduced to prevent falls, over sedation or complications for 1 of 5 residents (R3) reviewed for unnecessary medications. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the care facility on 9/21/09 and was cognitively intact. R3's Diagnoses, printed 2/13/25, indicated R3 had several medical and mental health diagnoses including bipolar disorder, major depressive disorder and anxiety disorder. R3's Orders indicated R3 was receiving several medications including Venlafaxine (an antidepressant medication which may cause orthostatic hypotension) 225 milligrams (mg) by mouth one time a day for major depressive disorder, dated 5/4/22; Risperdal (an antipsychotic medication which may cause orthostatic hypotension) 0.75 mg by mouth one time a day at bedtime for bipolar disorder, dated 4/10/22; Citalopram (an antidepressant medication) 20 mg by mouth one time a day at bedtime for bipolar disorder, dated 12/21/21; Clonazepam (an antianxiety medication which may cause orthostatic hypotension, especially in older adults) 0.5 mg by mouth one time a day at bedtime for anxiety or agitation, dated 12/21/21; and Lamotrigine (an anticonvulsant medication that may cause orthostatic hypotension) 75 mg by mouth one time a day at bedtime for bipolar disorder. R3's last orthostatic blood pressure reading (blood pressure taken while a person is laying, then sitting, then standing to monitor for changes. Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within 3 minutes of standing up) was recorded on 12/18/24 as 155/90 (lay) and 112/80 (sit) indicating orthostatic hypotension. R3's care plan indicated R3 was at low risk for falls related to psychotropic medication use initiated in 6/30/15 and revised on 8/1/24. During an interview on 2/13/25 at 12:32 p.m., the consultant pharmacist (CP) stated that any drop in blood pressure readings should be reported to the physician for medication review as the resident may need a change or decrease in their medication. The CP stated the conversation should be documented and the resident should have closer fall monitoring initiated. During an interview on 2/13/25 at 12:43 p.m., licensed practical nurse (LPN)-A stated when assessing a residents' orthostatic blood pressure reading, if there was more than a 20-point difference it should be reported to the director of nursing (DON) or directly to the physician if it was more significant. During an interview on 2/13/25 at 12:59 p.m., the director of nursing (DON) stated she would expect that psychiatric provider be notified if there were changes in a residents' orthostatic blood pressure readings. The DON stated she generally reviews the orthostatic blood pressure readings when she completes the MDS but was unaware of R3's drop in blood pressure readings, confirming the physician and/or psychiatric provider was also not notified to assess the resident's medications. A facility policy on psychotropic medication use was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure a residents cardiopulmonary resuscitation (CPR) status was accurately reflected for 1 of 1 resident (R10) who wished to receive chest compressions in the event of a cardiopulmonary arrest (cessation of pulse and respirations). The resulted in an immediate jeopardy (IJ) situation for R10 who would not had received CPR in the event of cardiopulmonary arrest and was at risk for death. The IJ began on [DATE], at 10:54 a.m. when R10's door had a red rectangle beside her name which indicated do-not-resuscitate (DNR). R10's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator was notified of the IJ on [DATE], at 3:15 p.m. The IJ was removed on [DATE], at 7:48 p.m. but non-compliance remained at the lower scope and severity level of D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R10's Face Sheet dated [DATE], indicated R10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact. R10's Providers Orders for Life Sustaining Treatment (POLST) dated [DATE], directed cardiopulmonary resuscitation (CPR): chest compressions only. The POLST was signed by R10 and the physician. A hospital After Visit Summary document dated [DATE], indicated R10 was a full-code (CPR). During an observation on [DATE], at 10:54 a.m. a red rectangle was noted on the exterior of R10's door beside her name. During an interview on [DATE], at 10:49 a.m. the director of nursing (DON) stated if a resident stopped breathing, the nurse would look at the sign on a resident's door for a rectangle. The DON stated a red rectangle indicated DNR, and a green rectangle indicated CPR was to be performed. During an interview on [DATE], at 10:56 a.m. registered nurse (RN)-A verified R10's door had a red rectangle near R10's name. RN-A verified CPR would not be performed on R10 if they were to stop breathing. During an interview on [DATE], at 11:29 a.m. R10 stated, Yes, I want CPR, but not shocked [use of AED or defibrillator]. During an interview on [DATE], at 11:34 a.m. the DON verified R10's door had a red rectangle on it and CPR would not had been performed for R10. Further, the DON stated the rectangle on R10's door needed to be green. The DON placed a green rectangle on R10's door at this time. During an interview on [DATE], at 2:22 p.m. medical doctor (MD)-A stated R10 was to have chest compressions performed. MD-A stated R10 was not to be intubated (breathing tube) or shocked. MD-A verified the POLST in R10's medical record was reflective of R10's current wishes. Facility policy titled Advanced Directives and Informed Consent Policy dated ,d+[DATE], directed LMCC [Lake Minnetonka Care Center] will comply with the best of its ability with any and all advance directives given into its possession relative to a resident's desire to decide in advance their health care choices. The IJ was removed on [DATE], at 7:48 p.m. when the facility developed and implemented a systemic plan which was verified by interview and document review. The plan included: - Green and red rectangle stickers were removed from residents doors on [DATE]. - The DON spoke with all residents/representatives to review POLST documents and ensure accuracy on [DATE]. - The facility updated the Advanced Directives/CPR policy on [DATE], to include a declination of CPR must be witnessed by two staff until a POLST was signed by the physician and a resident's POLST would be reviewed at quarterly care conferences, with a change of condition, or upon resident request. - Nursing staff were provided education of changes to the Advanced Directives/CPR policy. All nursing personnel who were not working were notified education needed to be completed prior to their next scheduled shift. - All resident medical records were audited on [DATE], to ensure code statuses were consistent. - Resident care plans were updated to reflect residents' current code status on [DATE].

Based on interview and document review, the facility failed to prevent an elopement and provide safety for 1 of 3 residents (R1) identified at risk for elopement. R1 successfully eloped from the building, undetected, and was found by a citizen about five blocks away. This deficient practice resulted in immediate jeopardy (IJ) for R1. The IJ began on 7/24/21, when R1, who was on 15 minute checks, successfully eloped from the facility through two alarmed doors, went off the facility grounds, and was found five blocks away by a community member. The facility was unaware R1 was gone from the building and the police brought R1 back to the facility. On 7/28/21, the director of nursing (DON) was notified of the immediate jeopardy for R1. The IJ was removed on 7/31/21, at 11:30 a.m. but noncompliance remained at a lower scope and severity level of D- isolated scope and severity level which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5/15. The MDS also identified R1 had diagnoses that included unspecified dementia with behavioral disturbances, major depressive disorder, [CONDITION(S)] disorder, generalized anxiety disorder, [CONDITION(S)], and hypertension R1's Wandering Risk Scale dated 7/4/21, indicated R1 was evaluated as a high risk to wander and had wandered in the last month. R1 had a history of elopement or attempted elopement on 5/18/2020, 5/20/2020, 9/13/20, 1/31/21, 4/23/21, 6/30/21, and 7/24/21. R1's care plan updated 7/14/21, indicated R1 wears a Keruve GPS watch at all times. (Keruve watch is a GPS locator composed of a watch and a portable receiver that communicate to each other through the cell phone network). R1's care plan updated 7/15/21, identified he was to have a staff member visually check on him every 15 minutes. During an interview on 7/26/21, at 9:25 a.m. DON stated facility outside camera showed R1 left the facility 12:31 p.m. without detection. R1 was gone for about 40 minutes before he was returned to the facility by a Deephaven police officer. During an interview on 7/26/21, at 9:25 a.m. DON stated on 7/24/21, at 12:15 p.m., registered nurse (RN)-A assigned nursing assistant (NA)-A to watch R1. RN-A left the area to care for another resident. NA-A observed R1 go upstairs. NA-A then assisted another resident to eat. NA-A did not continue to observe R1 and did not complete the 15-minute checks as identified in the care plan. During an interview on 7/26/21, at 9:25 a.m. DON stated the video tape was reviewed. and on 7/24/21, at 12:31 p.m., R1 departed the building by himself. Neither NA-A nor RN-A knew R1 had left the facility. Neither heard the door alarm sound. There was a system on the door that was supposed to send an audible alarm to the nurses cell phone. This device did not activate an audible alarm. DON stated this device worked sporadically, and delivered a silent banner alert but did not consistently activate an audible alarm. The facility 15-Minute Checks for R1 checklist for observations on 7/24/21, identified the initials for RN-A were entered every 15 minutes from 7:00 a.m. though 1:00 p.m. A checkmark was entered next to the initials. The space for the time 1:15 p.m. has the words [R1] eloped entered. During an interview on 7/26/21, at 11:00 a.m. DON was asked about the initials present on the checklist from 12:30 to 1:00 p.m., since according to security camera footage, R1 had eloped at 12:31 p.m. DON was asked if the checklist was accurate with initials that indicated a 15 minute check was completed when R1 had already left the building. DON indicated the 15 minute log was inaccurate for the time R1 was out of the building. An e-mail sent to the Minnesota Department of Health on 7/24/21, at 2:33 p.m. by Police Officer-B described R1 had walked five blocks from the facility where a firefighter recognized him and brought him to the police station. The police officer recognized R1, notified the facility, and returned R1 to the facility. R1 was not harmed. The temperature that day was 82 degrees Fahrenheit. Surveyor: [NAME] Tallarita During an observation on 7/28/21, at 9:15 a.m. R1 was found in his room on the second floor. R1 wore a black watch band on his right wrist, and a white device on his left wrist. R1 stated he liked having a watch, but he did not know what the white band was for. R1 stated he wanted to go on a health walk for 30 minutes every day. During an observation on 7/28/21, at 9:24 a.m. R1 walked downstairs into the day room where he stood in front of the deck door but did not go outside. During an observation on 7/28/21, at 9:27 a.m. R1 walked to another door in the day room and looked outside. He then sat down in a different chair. During an observation on 7/28/21, at 9:29 a.m. R1 got up and walked to the deck door. During an observation on 7/28/21, at 9:35 a.m. R1 walked down the hall and back, then sat down in a different chair. During an observation on 7/28/21, at 9:47 a.m. R1 got up and walked to the door and looked outside. Then he sat down in a chair close to the side of the house door. During an observation on 7/28/21, at 10:48 a.m. R1 sat in a chair located closest to the exit door. During an interview on 7/28/21, at 9:29 a.m. nursing assistant (NA)-B stated some residents were allowed to leave the facility. R1 used to have a watch band with attached GPS. NA-B stated when she returned to work on 728/21, she was briefed on the new white device on R1's left wrist. The device will go off R1 was within 11 feet of the door when the door was open. NA-B stated there was a camera on the outside post parallel to the door that alerted the nurse when someone was outside. NA-B stated R1 had severe dementia. NA-B felt confident in the new system and felt it would prevent R1 from leaving the facility. During an interview on 7/28/21, at 11:37 a.m. RN-B stated she learned about R1's elopement on 7/24/21, from the DON. RN-B stated she was told the police found R1, and returned him to the facility. RN-B stated she did not know the full story. RN-B stated R1 continued on 15 minute checks and she used the nursing station cameras to help locate R1 every 15 minutes. RN-B stated the resident's rooms were the only place without a camera. During an interview on 7/28/21, at 2:04 p.m. NA-A stated she worked on 7/24/21, when R1 left the facility. NA-A stated after lunch she observed R1 go upstairs. NA-A stated she left to help another resident eat, while her supervisor helped another resident. NA-A stated another family member exited the back door around the same time as R1 left. NA-A stated she did not hear an alarm when R1 left because the door was not shut completely and would prevent the alarm from sounding. NA-A stated they didn't know R1 was gone until the police called and asked if they had a resident that was missing and provided a description. NA-A stated they looked all over the building and were unable to locate R1. The police returned R1 to the facility. NA-A stated the facility installed a new alarm on 7/26/21. This alarm would be triggered anytime R1 was close to a door while the door was open. NA-A stated she felt the new alarm would be safer, because the device would continue to alarm until staff manually reset the device. During an interview on 7/28/21, at 2:24 p.m. RN-A stated she worked on 7/24/21, when R1 left the facility. RN-A stated staff were responsible to check on R1 every 15 minutes. RN-A stated she completed all the 15 minutes checks during the shift except for the time period from 12:30 p.m. to 1:00 p.m. RN-A asked NA-A to complete the 15-minute checks when RN-A assisted other residents with cares. RN-A stated she did not receive a door alert on the phone when R1 left the facility and NA-A told her R1 was upstairs. RN-A did not realize R1 had left the facility until the police inquired about R1's where about's. Later, RN-A learned NA-A did not physically look for R1, but assumed he was still upstairs. RN-A asked R1 why he left. R1 was educated on the risks, and he stated he would consider her advice. RN-A stated R1 would watch and wait until the staff are busy before he attempts to leave the facility. During an interview and observation, on 7/28/21, at 4:02 p.m. the DON demonstrated all of the facility alarms. The DON demonstrated how the two back door alarms work. During observation, both doors only sounded for one second. The alarms could only be heard clearly in the nursing station. The DON pointed out two small receivers on the door frame and door. The DON stated if the door was left ajar, the two receivers do not connect, and reset the alarm. A motion sensor camera was located outside the facility adjacent to the back door. When someone left the building, the motion sensor alarm's the nurse's phone with live feed of the activity. DON stated because of the overloaded facility Wi-Fi, and motion sensor was not always reliable. DON stated on 7/24/21, when R1 left the facility, the first back door alarm was unplugged. Facility Door Alarm policy dated 5/2020 identified the front and back door were alarmed. The policy further included: The alarm chimed when the door was opened. Video cameras were also positioned at the doors with a monitor located at the nursing station and administrative office. When staff heard the door alarm, they were to physically view the front or back door or may view in on the camera monitor. If there was a resident at the door the facility had identified as a risk for independence outside the facility, staff were to intervene with the resident and re-direct them back into the facility. The IJ was removed on 7/31/21, at 11:30 a.m. after it was verified through observation, interview and record review the facility provided interventions to prevent R1 from eloping from the facility. The facility initiated one to one staff observation for R1 by a paid companion who would be at the facility from approximately 7:00 a.m. to 10:00 p.m The companion would not provide any cares for R1 but would provide observation for R1 while he was awake. This would remain in effect until an alternative placement was found for R1. All staff were educated on 15 minute checks and all staff were responsible to ensure R1's safety. All staff were trained in person by the DON on elopement prevention measure for R1, that included where each door alarm and speakers were located and how to change the batteries, where the motion detectors were located, 15 minute resident safety check, and how to check the security phone when it alerted that motion was detected. In addition 15 minute checks for R1 were reviewed for the dates of 7/29/21, 7/30/21 and 7/31/21. The above was verified with one NA, one RN and the paid companion on 7/31/21 from 9:30 to 11:00 a.m.

Based on interview and document review, the facility failed to prevent an elopement and provide safety for 1 of 3 residents (R1) identified at risk for elopement who successfully eloped from the building, undetected, and was found a block and a half away approximately twenty minutes later. This deficient practice resulted in immediate jeopardy for R1. The elopement immediate jeopardy (IJ) began on 6/30/21, when R1 successfully eloped from the facility, through two alarmed doors and went off the facility grounds. The facility did not know R1 had left. On 7/13/21, at 4:14 p.m. the director of nursing (DON) was notified of the IJ for R1. The DON was notified that the immediate jeopardy was removed on 7/15/21, at 12:30 p.m. but noncompliance remained at a lower scope and severity level of D- isolated scope and severity level which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Face Sheet dated 7/13/21, indicated diagnoses of dementia, [CONDITION(S)] disorder, hypertension ([CONDITION(S)]) and anxiety disorder. R1's annual Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. R1 walked independently in his room and in the corridor. The MDS indicated R1 wandered one to three times out of seven days. R1's Physician Orders dated 7/13/21, indicated to complete a wander risk scale monthly and to wear a Keruve GPS Watch (GPS wristwatch which has a portable receiver; when the locate button on the receiver is pushed, the precise position of the person who wears the watch was shown on the screen's map.). R1's care plan dated 5/26/21, indicated R1 enjoyed health walks and should be encouraged to take his health walks on the deck and/or walk with staff. Staff were to encourage R1 to use an inhaler prior to exercise. R1 was a high elopement risk and wanderer due to his impaired safety awareness and dementia; R1's last elopement was on 6/30/21. There were no additional interventions indicated to keep R1 safe after his elopement on 6/30/21. R1's Wander Risk assessment dated [DATE], indicated R1 exhibited/expressed fear and/or anxiety. R1 was disoriented and was forgetful/short attention span. R1 was independent with mobility and was a known wanderer and had a history of wandering. R1's Wandering Risk Scale dated 6/16/21, indicated R1 was at high risk to wander; had a history to wander and had wandered in the past month. R1 had a history of elopement and wore a Keruve GPS watch for safety on those occasions when staff did not see R1 leave. R1 was not safe to go out in the community independently as he would not remember where he lived. R1's Falls/Incident Report dated 6/30/21, indicated R1 had an incident of an elopement 9:00 a.m. The Falls/Incident Report indicated staff noticed R1 was missing, conducted a whole house search, and then used the Keruve GPS watch to locate R1. The Keruve GPS watch indicated R1 was within the two-block radius of the facility; therefore, staff went to find him. R1 was redirected back to the facility. The report indicated the cause of the incident was because R1 wanted to go on a health walk. The Nursing Home Incident Report dated 7/2/21, indicated R1 left the building while staff were distracted in another resident room. According to another resident, R1 walked to the end of the block and back twice; then he went around the block. The Keruve GPS watch alarm did not sound because R1 did not leave the 1 1/2 block radius set on the Keruve GPS watch system. The system depends on satellite to locate the GPS device that R1 wore. The facility's Nursing Safety Checklist Log dated 6/21, lacked indication R1's Keruve GPS watch safety check had been completed on the morning of 6/30/21. Also, the Nursing Safety Checklist Log lacked indication the front and back doors alarms were checked on 6/30/21. R1's Wandering Risk Scale dated 7/4/21, indicated R1 was a high risk to wander and had wandered the past month. R1's progress notes indicated previous wandering and elopement attempts, and unsafe behaviors occurred on: -1/23/21, R1 attempted to leave the facility through the back door. -1/31/21, R1 was missing from at least 1:30 p.m. until 2:20 p.m. R1 was wheezing upon arrival back at the facility. A new intervention was to keep R1's winter coat behind the nurses station. -2/8/21, the back vestibule door was open when R1 walked down the hall for his health walks. -3/3/21, R1 reported he had been trying to remove his Keruve GPS watch for the past two days. -3/17/21, R1 went out the back of the facility for a health walk. R1 wore his Keruve GPS watch but had not left the two block radius for it to sound. -4/13/21, registered nurse (RN)-A was in another resident's room when she was informed by a nursing assistant (NA) that R1 had walked outside and down the block. RN-A went outside and met R1 on the corner of another block. R1 was in jeans, a sweatshirt and hat; it had been snowing a few minutes before and the temperature was below 40 degrees Fahrenheit (F). R1 did not realize it had been that cold and told RN-A he had a list of things to get from the store. When R1 arrived back to the facility he experienced shortness of breath (SOB) and his breathing went back to normal after a few minutes. -4/14/21, R1's Keruve GPS watch appeared to have been tampered with during an attempt to remove it as the band had light scratches on it with markings of ink pen that was used to release the mechanism. -4/16/21, R1 opened the back door three times within 10 minutes. R1 was also seen in the day room fidgeting with the front door handle. R1 wanted to see what the weather was outside, but staff directed R1 to the deck. R1 agreed to go to the deck but kept circling back and opening the back door. -4/23/21, R1 left the facility but staff found R1 outside, on the facility grounds. R1 stated he went for a health walk. -5/17/21, R1 did not know the name of the facility nor what day or year it was. -5/23/21, R1 ambulated independently and liked to walk. R1 appeared to be bored at times and would pace the hallway which R1 called a health walk. -5/28/21, one out of two of R1's Keruve GPS watches did not function correctly which could not track his location. -6/10/21, R1 had two Keruve GPS watches. One watch was not charged, and the other watch did not work correctly as it could not locate R1. -6/30/21, R1 was noted to not be in the facility at 9:20 a.m. after a whole house search. The Keruve GPS watch indicated R1 was still within two blocks of the facility therefore staff went to find him. R1 was found about 1.5 blocks from the facility and brought back to the facility. R1 was reminded he shouldn't leave the facility since he could not find his way back. R1 stated he understood; sometimes when he took a walk he could not find his way back. The progress note also indicated R10 reported she had seen R1 walk back and forth on the road in front of the facility a few times and then turned down another street. The progress note indicated no other interventions were needed. -7/9/21, R1 tried to elope out the back door but a housekeeper steered R1 back into the facility. -7/12/21, indicated R1 did not have his Keruve GPS watch on as it needed to be charged. During an observation and interview on 7/12/21, at 1:48 p.m. the back alarmed door was visually wide open to the outside. The DON stated the back door got stuck if it was left open. The back door alarm would not sound if te door was left open. The back door, was one of two alarmed doors which R1 went out the day he left the building unattended on 6/30/21 and staff was not aware it sounded. During an observation on 7/12/21, at 3:15 p.m. R1 was in the dining room by an alarmed door and did not have his Keruve GPS watch on. During an interview on 7/12/21, at 8:40 a.m. DON stated R1 wore a Keruve GPS watch which alerted staff if R1 went farther than a two-block radius of the facility. The DON also stated the facility could look up on a tablet where R1 was located within the two-block radius but could not look where R1 was if he went beyond the two-block radius. The DON further stated the Keruve GPS watch did not work correctly or consistenly if there were weather conditions outside. During an interview on 7/12/21, at 9:00 a.m. R1 stated he liked to go on a health walk every day for a half hour and planned to go for a walk later that day. R1 stated he took health walks around the facility but preferred to take a walk outside to get a good sweat. R1 stated he had a certain route he took around the block by himself if he did not walk to a store. R1 also stated he had gotten lost before when he was alone and had struggled to figure out how to get home. R1 stated he would get lost when he overthought things and possibly turned on the wrong road. R1 further stated it was his routine of [AGE] years to take a health walk and he liked to go early in the morning or first thing after lunch. During an interview on 7/12/21, at 9:12 a.m. nursing assistant (NA)-B stated R1 tried to go on walks alone outside but needed staff to go with him. NA-B also stated when R1 tried to leave the alarm doors should sound but if it does not, he had a Keruve GPS watch where staff can look up on the tablet where R1 was if he was within a two block of the facility. During an interview on 7/12/21, at 10:17 a.m. RN-A stated there were four alarmed doors in the building. RN-A stated there were two alarms on the back doors, one alarm on the door by the day room and an alarm on the upstairs balcony. RN-A further stated she would not be able to hear the door alarms go off if she was on the second floor doing cares. During an interview on 7/12/21, at 12:03 p.m. NA-A stated she worked on 6/30/21, the day R1 successfully left the facility. NA-A stated she realized R1 left when she went to his room to get him for his shower and realized he was not there. NA-A stated she told the DON after she could not find R1 when she looked throughout the facility. The DON looked on a tablet which helped track the location of R1. NA-A stated she got into her car and found R1 down the street, approximately 1.5 blocks away. NA-A stated it scared her that R1 got into the car with her since R1 did not really know who she was as NA-A did not work often. NA-A further stated R1 had bad dementia and R1 went with her even though he didn't know who she was; anyone could have picked him up. NA-A stated after this incident she was not aware of any new interventions that were put into place as they already had the door alarms and Keruve GPS watch that would alert staff if he went past two blocks of the facility. NA-A further stated she did not hear the door alarm sound when R1 left the faciity on [DATE]. NA-A stated she guessed it was likely related to the two back alarmed doors were left open therefore the alarms did not sound. During an interview on 7/12/21, at 12:23 p.m. activities director (AD)-A stated R1 walked out the back door often and was sneaky. AD-A stated when she worked in the evening R1 tried to leave two or three times during a shift and she had to redirect him back. AD-A stated if R1 left the building he could get hurt within the two-block radius by falling. AD-A also stated she did not take R1 for health walks and R1 did his health walks within the building. During an interview on 7/12/21, at 1:18 p.m. RN-A stated if R1 left the facility he would not know how to get back to the facility. RN-A stated it was hard to respond to the door alarms with all the people going in and out. RN-A stated R1 ate during the first meal round and liked to walk up and down the hallways after he ate. RN-A stated she would redirect R1 back to his room since RN-A was busy assisting other residents for the second meal shift. RN-A further stated R1 has left before and snuck out the back door. RN-A stated on 4/13/21, R1 successfully left after lunch when she was busy giving another resident medication, the NA was in the day room, and they did not hear the door alarm go off when R1 left. RN-A further stated on 4/13/21, she looked for R1 once she realized he was gone and found him walking down the block. RN-A further stated R1 also left out the back door on 3/17/21, but staff were able to intervene before he left the facility grounds. RN-A stated she knew it was a trigger for R1 to want to go on a walk after meals, but they just redirected him back to his room. RN-A stated on 5/18/20, R1 was found after lunch time by police sleeping under a park bench and had garbage all around him. RN-A further stated staff were busy, and they could not keep an eye on R1 24 hours a day seven days a week therefore he wore a Keruve GPS watch to find him when he left the building. During an interview on 7/14/21, at 12:26 p.m. R10 who had intact cognition (brief interview of mental status (BIMS) was 15 for 4/2/521 quarterly MDS) stated she saw R1 walk outside her window on 6/30/21, around 9 a.m., after breakfast. R10 also stated the DON was on a video chat with someone when she tried to inform the DON that she saw R1 outside. R10 stated she was not sure if she heard the door alarm go off or not when R1 left on 6/30/21. During an interview on 7/12/21, at 2:05 p.m. the DON stated NA-A searched the facility but could not find R1. The DON pushed locate on the tablet and found R1 down the road. The DON further stated after R1 was found there were no additional interventions put in place since they followed R1's care plan and could find him with the Keruve GPS watch. The DON stated if R1 left the two-block radius she would get notified by an alarm but R1 was within the two-block radius therefore his Keruve GPS watch did not notify the DON. The DON stated she did not think anything bad would happen, or anyone would harm R1 within the two-block radius of the facility since it was a good neighborhood. The DON additionally stated the Keruve GPS watch would not work if there was bad weather or if it was too cloudy. The DON stated R1 has tried to remove his watch in the past. The DON stated she could not provide the exact length of time R1 was gone on 6/30/21, but thought it was for approximately 20 minutes. The facility Elopement/Wandering Policy dated 7/21, indicated a patient who leaves the facility without notice in a nursing home setting was known as elopement. The IJ was removed on 7/15/21, at 12:30 p.m. after it was verified through observation, interview, and record review the facility provided interventions to prevent R1 from eloping from the facility. - at 9:59 an observation of the facility door alarms on all the exit doors were set to the highest sound level. An observation was also made of three new security cameras which were installed outside of each exit that would send an audible alert to a device which the nurse on duty would always have. -at10:02 a.m. RN-A showed the new device and how it functioned. -at 10:08 a.m. the DON explained the process on how staff would offer to accompany R1 to go for a walk or offer to walk within view in the neighborhood to provide R1 the ability to complete his exercise routines. -at approximately 10:15 a.m. until 11:44 p.m. an observation that R1's location was monitored every 15 minutes during waking hours to make sure they knew where R1 was at within in the building. -at 11:44 a.m. RN-A and housekeeper were observed to receive education to ensure doors were completely shut to ensure the door alarms go off and the interventions put into place to keep R1 safe. Additionally, the facility elopement policy was updated to reflect the addition of the outdoor motion cameras and staff were educated on the new systems in place.

Based on observation, interview and document review, the facility failed to assess safety risk for 1 of 3 residents (R5) who were allowed to go into the community unsupervised, which placed R5 at risk for serious injury, impairment or death. R5 returned to the facility, which was located a block and half from a lake, wet from the chest down, had a [CONDITION(S)] which required emergency room care for staples, and was missing his shoes. In addition to the resident in immediate jeopardy, the facility failed to ensure the porch and deck area were free of potential accident hazards for 3 of 3 (R12, R5 and R2) who were on the deck area while decking boards were being removed which had the potential for harm that is not immediate jeopardy. The immediate jeopardy began on 5/9/21, when R5 attempted to climb over a gate on the 2nd floor of an outside deck, was unable to free himself from the gate, and the facility failed to assess R5 for safely leaving the facility independently. Subsequently on 6/9/21, R5 had returned from an unknown location to the facility wet from the chest down and with a [CONDITION(S)]. The immediate jeopardy was identified on 6/16/21. The director of nursing (DON) and administrator were notified of the immediate jeopardy (IJ) on 6/16/21, at 3:16 p.m. The immediate jeopardy was removed on 6/18/21, but noncompliance remained at the lower scope and severity level of a D- isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], included severe cognitive impairment with diagnoses including dementia and [CONDITION(S)]. R5 had signs and symptoms of [CONDITION(S)] including inattention and disorganized thinking that fluctuated, and also had hallucinations and delusions. R5 required supervision and oversight for transfers and ambulation and the assistance of one person. R5 had 2 or more falls since the prior assessment. R5's cognitive loss/dementia Care Area Assessment (CAA) dated 8/24/20, included, R5 required more assistance with cares, had difficulty completing tasks, and had impaired daily decision making skills such as choosing to wear inappropriate clothing for the weather. R5's falls CAA dated 8/24/20, identified risk for falling and had 3 falls from attempting to sit in a chair and did not safely judge how he could do so safely. R5's care plan dated 2/12/21, identified, has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia, impaired decision making, long term memory loss, short term memory loss. R5's care plan included interventions: Cue, reorient and supervise as needed, remind [R5] to always let staff know where he is going when he goes for a walk, make sure he is dressed appropriately and is appropriate at the time for independence outside of the facility. A written note dated 5/9/21, indicated R5 attempted to leave without notice via the upper deck and sustained an injury and the new intervention indicated, new door alarm installed on upstairs emergency exit. R5's care plan further detailed R5 as having a court appointed guardian as R5 was unable to make safe decisions for himself. R5's care plan also identified the risk for falls detailing, R5 is high risk for falls r/t confusion, gait/balance problems, medications, lack of safety awareness and [CONDITION(S)], with hand written notation dated 5/9/21: needs ^ [increased] supervised 30 min checks, and [R5] will be supervised by staff. Followed by note dated 5/19/21, Staff will assist him when sitting in a chair in dayroom. R5's progress note dated 5/9/21, at 11:43 a.m. indicated the facility received a phone call from a neighbor, someone was stuck on the steps. R5 was found straddling a gait from the back upper deck of the facility. R5 reported he had been there for 2 hours, he had blood running down his leg and reported to staff that he had been bitten, by weasels. Facility staff assisted R5 into the home but he was too weak and shaking to assist to the main level of home. Staff left R5 seated on the bed while she went to get supplies to assist to clean area on leg and when she returned R5 was on the floor bleeding from his head. R5 was sent to the hospital via ambulance. R5's facility fall/incident report dated 5/9/21, at 5:30 a.m. described R5's incident, fall and attempt to leave, location of incident noted, bedroom and upper deck. Nursing notes section further detailed, resident was discovered on upper deck attempting to climb over gate. He had small laceration on his leg and toe. Returned to his bedroom he then fell and hit his face, lacerations above left eye sustained - 911 called and he was sent in. The report detailed R5 has a history of falls and impaired safety awareness/judgement, as well as dementia and [CONDITION(S)]. R5's Fall Risk assessment dated [DATE], identified R5 was at high risk for falls and had 3 or more falls in the past 3 months, had intermittent confusion, vision was poor, and had a balance problem while ambulating, Even though R5 was at high risk for falls, he had not been assessed for safety while going for walks in the community independently. R5's progress note dated 5/16/21, indicated his gait was, off, and was leaning to the side. R5's Fall Risk assessment dated [DATE] identified R5 was at high risk for falling due to confusion, poor vision, balance problem while standing and ambulating, medication use and predisposing conditions. Even though R5 was at high risk for falls, he had not been assessed for safety in going for walks in the community independently. R5's progress note dated 5/20/21, identified he required extensive assistance with transfer and ambulation and was leaning to the left. However, he had not been assessed for safety in going into the community without supervision and his care plan had not been updated. R5's late entry progress note dated 6/7/21, at 6:32 p.m. indicated R5 returned from a walk in wet clothing from the chest down, missing his shoes and bleeding from a laceration on his head. R5 was unable to recall where he was or what happened. R5 was sent to the hospital via ambulance. R5's facility fall/incident report dated 6/7/21, at unknown evening time, described R5's incident as a, mechanical fall location outside. Res [resident] presents with a laceration to R [right] forehead, small abrasion to L [left] back and no shoes on. Res unable to state where his shoes are or how he fell , agreeable to every suggestion. Laceration continues to ooze blood so he was sent via ambulance to Methodist for evaluation. Residents clothing was also wet and he could not explain why. Lake Minnetonka, a large body of water, was located within a block and a half of the facility. R5's emergency department summary dated 6/7/21, noted R5 had a, jagged laceration to his scalp above his hairline that required 3 staples for closure. R5 was discharged the same day and diagnosed with a traumatic injury of the head with laceration and fall. The facilities nurse communication log book, dated 6/14/21, directed staff: [R5] is no longer allowed to go outside for walks without staff supervision. R5 did not have an assessment and his care plan had not been updated. When interviewed on 6/15/21, at 1:05 p.m. nursing assistant (NA)-C stated R5 is able to go for walks without supervision as long as he is properly dressed for the weather. NA-C stated she was aware of R5's recent falls and the incidents on 5/9/21 and 6/7/21, however, there were no new interventions and R5 was still able to go for walks unsupervised. On 6/15/21, at 3:13 p.m. NA-B stated R5 was allowed to go out on walks by himself, he was unsteady and had memory problems, but was not aware of any new guidance for him. Staff typically checked on R5 at beginning of shift, at meal times and when offering him assistance with toileting every couple of hours. There was an alarm on the doors and staff tried to see who went out when it would alarm. On 6/15/21 at 3:33 p.m. registered nurse (RN)-A, stated R5 was resistant to redirection for cares, would wear clothing inappropriate for the weather, walked with a shuffling gait and had a propensity for falls. R5's cognitive ability was variable, and would ask nonsensical questions and was unable to make decisions for himself. However, R5 was allowed to sign out and leave the building on his own. R5 liked to walk down the road watch the construction workers, he may sit in a swing in the yard. RN-A stated one time R5 was lost in the community and someone brought him back. If there were any concerns for R5's location, the local police department would likely find him and bring him back, as the local police were familiar with the facility residents. R5 had previously worn a GPS unit, but that had been discontinued because R5 would remove it. RN-A had never completed an elopement or safety assessment for R5. RN-A was not aware of any new interventions for R5. On 6/15/21, at 4:15 p.m. the activity director (AD) reported R5 would previously swing in the yard and walked to watch the construction workers at a nearby site in the neighborhood on his own, without staff supervision. AD reported R5 had problems a couple times recently and was now not able to go out on his own. AD explained the door bell would go off when staff, residents or visitors entered or exited the building. When it rang, staff were supposed to check and see who was entering or exiting and redirect if the resident was not safe to go outside on his own. AD explained R5 did not have shoes. AD described she was working in the kitchen one evening when R5 returned from the community and was wet, had no shoes on and had a cut on his forehead. AD explained R5 was supposed to sign out, but had noted R5 had not signed out that day. AD explained R5's pants were wet and thought R5 might have walked to a nearby public beach, approximately one block away, took his shoes off and walked in the sand. R5 was not able to articulate where he had gone. R5 had returned wearing a pair of jogging pants and a t-shirt. R5 was gone for about an hour. AD reported the DON told her that night that R5 could no longer go outside on his own. AD reported R5 took direction well, but was hard headed at times, was sometimes forgetful of where he placed belongings and would get anxious and would require staff redirection as he wore multiple coats while it was hot outside and winter boots while walking up and down the stairs at the facility. When interviewed on 6/15/21, at 1:33 p.m. licensed practical nurse (LPN)-A stated I would not let him out on my shift unless he goes with staff, his cognition is hit or miss, along with his medications that have changed, his speech pattern difficult to understand him, and indicated overall R5 was not safe out in the community without supervision. LPN-A stated R5 used to have a GPS tracking device, but it was on hold and did not know why. R5 was supposed to sign out when he would leave for a walk, but often forgot due to his dementia. The Lake Minnetonka Care Center May/June 2021, Release of Responsibility for Leave of Absence sign out form failed to identify R5 had signed out to go for a walk at all on 6/7/21. When interviewed on 6/16/21, at 8:27 a.m. Director of Nursing (DON) stated, on 6/7/21, R5 had still been allowed to go out for walks unsupervised, she did not feel he was an elopement risk as he had always come back to the facility, even though he has severe cognitive impairment, delusions and [CONDITION(S)] and had fallen many times. The DON stated in the past, community members had brought R5 back to the facility and if he fell while out on a walk, a community member would help or the police would. R5 used to wear a GPS watch, but it was stopped as R5 would normally just stay on the road the facility was located on. R5 was supposed to sign out each time he went for a walk, however, often would forget and did not sign out on 6/7/21. On 6/7/21, they did not know how long he had been gone, or where he had walked to, R5 returned to the facility with a head injury, had dirt and leaves in his beard and was wet. R5 stated he had fallen into rocks while walking up a hill. The DON stated they gave R5 a shower as they did not know why he was wet, but assumed it could have been from a sprinkler system in the community. When interviewed on 6/16/21, at 10:49 a.m. Psychiatric Nurse Practitioner (NP)-E stated, R5 should not go for walks in the neighborhood alone due to his balance issues, [CONDITION(S)] and dementia. When interviewed on 6/17/21, at 9:10 p.m. R5's primary physician (PCP) stated the situation of R5 walking around the neighborhood unsupervised did not come up during his visits with R5, but was aware R5 had recent falls. PCP stated with R5's most recent falls he had concerns related to the disease process of R5's Parkinson effecting his mobility, as well as R5's overall cognitive functioning. PCP further added after the 6/7/21 fall that R5 not be advised to go out in community without supervision again. During observation on 6/16/21, at 12:30 p.m. with the administrator the following was observed: On the second floor there was a door open to a small deck leading to a set of several stairs. At the top of the stairs there was a worn and weathered wooden gate that was the width of the stairs and about 3 feet in length, that reached to approximately 4 feet off the ground. There were sticks and leaves on the deck. This had been the deck and gait R5 had been trapped in on 5/9/21. The administrator stated the gait had not been assessed for safety before or after R5's incident. When interviewed on 6/16/21, at 2:52 p.m. R5's legal guardian (LG) stated he was unaware if R5 was allowed to walk around in the neighborhood without staff supervision and had assumed staff were present, but was aware R5 walked the grounds of the facility. Guardian stated, I would not favor R5 walking around in the community. A facility policy titled, Elopement/Wandering Policy, dated 05/2020, included: Lake Minnetonka Care Center (LMCC) will assess for elopement/wandering concerns upon admission to our facility. Proper training will be given to all employees regarding the monitoring and handling of such residents who may be at risk. Procedure: 1. LMCC's Director of Nursing will assess residents for elopement/wandering. concerns upon admission to our facility. Quarterly assessments will be completed thereafter. For residents that have been identified at high risk, monthly assessments will be completed. All staff will be made aware of at risk residents. 2. Resident care plans will list interventions being used for wandering/elopement. 3. Staff are to document wandering in Target Behavior book. 5. Proper training will be given to all employees regarding the monitoring and handling of residents who may be at risk. 6. Training will include but not be limited to routine room checks, door alarm procedures, GPS watch monitoring (if applicable), and general resident demeanor (signs/triggers for possible elopement escalation). 9. In the event a resident appears to have eloped, all staff on duty will be alerted and will assist with immediately checking the facility and grounds along with the local neighborhood. If unable to locate resident, Charge Nurse will contact the local police and report a missing person. 10. The Charge Nurse will then contact the Administrator and Director of Nursing. 11. Either the Administrator or Director of Nursing will file a Vulnerable Adult report online. 14. Upon location of the resident, an assessment will be completed as to the physical, emotional and mental well-being of the resident to determine if hospitalization is required. 15. Staff will discuss the situation to evaluate what happened and how this could be avoided/handled if a future situation were to occur. 16. Reports will be completed and all parties notified. 17. Close monitoring of the residents' whereabouts and demeanor will be a priority. The immediate jeopardy which began on 5/9/21, was removed on 6/18/21, at 12:13 p.m. when it was verified through record review the facility had completed a Wandering Risk Assessment and Wandering Risk Scale for R5, R5's care plan was updated to include R5's legal guardian or staff were now required to accompany him to all appointments and outings. An Angel Sense monitor, which is a GPS tracking device had been ordered and verified by FedEx to arrive on 6/18/21. Until then, staff were to be alert for R5 exiting the facility via the door alarms, this was verified by documentation of education and staff interviews with RN-B, LPN-B, NA-A, NA-C and NA-D. R5 was to have 30 minute checks which were being signed out by staff as completed. The facility had also completed Wandering Risk Assessments on all facility residents. It was determined 10 residents (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11) were unsafe to leave the facility independently, other than the deck. The list of residents was placed in the office nursing staff use, in the kitchen and utility room. Each residents care plan was updated to reflect this. Education sign in sheets indicated all staff working had been educated on the elopement policy, residents who were unsafe to leave the facility independently, training on the door alarms and 30 minute checks was provided. Staff had been alerted they were required to attend this training prior to starting their next shift. This was verified by staff interview on 6/18/21, between 9:00 a.m. and 12:00 p.m. However, noncompliance remained at the lower scope and severity level of a D- isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy, because R5's sensor had not arrived yet and continued education was required. R12's MDS dated [DATE], included, cognitively intact and had impaired vision. R12 required supervision with walking in corridor and was not steady, but able to steady without human assistance while walking. R2's MDS dated [DATE], included, moderate cognitive impairment, required extensive assistance of one person for walking in corridor. R2 was not steady, but able to steady without human assistance while walking. During observation on 6/16/21, at 12:40 p.m. a large board, approximately 4 inches by 10 feet, was missing on the porch. There was no posted warning of the missing board. R5 came shuffling out of the building onto the porch, the surveyor alerted the administrator who had to hold R5's arm and guide him around the hole in the floor of the porch. R2 and R12 were sitting on the porch and required staff to assist them around the missing board into the facility. NA-A had been sitting near the door and did not assist R5 out. NA-A stated she did not see this as a safety hazard, the residents could have spoken up if they needed assistance. The administrator stated maintenance was working on replacing the boards of the porch and should have notified staff and residents of this hazard. The policy or procedure on maintaining a safe environment for residents was requested but not provided.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) was free from significant medication errors. This resulted in actual harm for R1 when R1 was administered another resident's medications, experienced adverse medication reactions and received IV fluids and was observed at the hospital overnight with [CONDITION(S)] (altered brain function) and [CONDITION(S)]. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], included, cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was independent with activities of daily living (ADL's). R1's cognitive loss/dementia care area assessment (CAA), dated 3/16/21, included, [CONDITION(S)] (inattention and disorganized thinking) and behavioral symptoms related to long-standing mental health problems. R1's care plan dated 3/29/21, included, impaired thought processes related to impaired decision making and [CONDITION(S)] drug use. Staff were directed to: Administer medications as ordered. Monitor/document for side effects and effectiveness, and to Monitor/document/report PRN [as needed] any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. R1's facility incident report summary, submitted on 6/9/21, at 6:09 p.m. identified a medication error which occurred on 6/5/21, at 8:00 a.m. The nurse placed a medication cup on [R1]'s meal tray that belonged to someone else and she immediately took them. When the nurse turned to another resident she realized that she had given [R1] the wrong medications. [R1] finished eating and went up to her room where she felt okay until about 30 minutes later when she vomited and became Somnolent. She was assessed by the nurse and found to have a blood pressure of 79/58 [normal blood pressure 120/60]. 911 was called to take the resident to the hospital for evaluation. R1's emergency department summary dated 6/6/21, indicated R1 was admitted on [DATE], and vitals taken at 9:37 a.m. which noted R1's pulse at 85; respirations at 14 and blood pressure was 93/58. Summary further detailed R1's admission reason: multi-drug overdose with resulting toxic [CONDITION(S)] [affected brain function] and [CONDITION(S)] [low blood pressure]. [R1] apparently had somehow taken another patient's medicines today. Per the list of the other patient's medicines, [R1] took [MEDICATION(S)] [an antipsychotic medication] 150 mg, [MEDICATION(S)] [an anticonvulsant medication] 300 mg, [MEDICATION(S)] [an antidepressant] 12.5 mg, [MEDICATION(S)] [a beta blocker to treat high blood pressure] 12.5 mg, [MEDICATION(S)] [[CONDITION(S)] medication] 125 mcg, tamsulosin [urinary medication used for enlarged prostate] 0.4 mg. [R1] was noted after this ingestion to become more confused as well as hypotensive and was seen by paramedics, treated with IV fluids, and brought to the emergency room for further evaluation, where [R1] was initially hypotensive with systolic blood pressures in the 80's. [R1] had subsequently received 1500 ml [milliliters] of normal saline with blood pressures improving to the low 100 ranges. [R1] is unable to give a good history. [R1] has somewhat slurred speech. Some of [R1] words and some of [R1] responses are appropriate, although others are not. [R1] PCP [primary care provider] is from FV [Fairview] system. R1 was discharged back to the nursing home on 6/6/21. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Tamsulosin HCl Capsule: Give 0.4 mg by mouth two times a day; - Senna [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides): Give 2 tablet by mouth two times a day; - [MEDICATION(S)] Tablet ([MEDICATION(S)]): Give 12.5 mg by mouth two times a day; - [MEDICATION(S)] Tablet ([MEDICATION(S)]): Give 300 mg by mouth one time a day; - [MEDICATION(S)] Sodium Tablet: Give 125 mcg by mouth one time a day every Mon, Tue, Wed, Fri, Sat; - [MEDICATION(S)] HCl Tablet: Give 12.5 mg orally one time a day, Take 12.5mg in the morning; - [MEDICATION(S)] Tablet 400 MCG: Give 1 tablet by mouth one time a day; - [MEDICATION(S)] Tablet: Give 1000 mcg by mouth one time a day; - [MEDICATION(S)] Tablet: Give 150 mg by mouth one time a day and - [MEDICATION(S)] Tablet: Give 2000 unit by mouth one time a day. When interviewed on 6/9/21, at 9:48 a.m. R1 stated, I got the wrong pills. I was eating breakfast and she [RN-A] left the wrong ones and I didn't look at the cup. I remember going upstairs then I sat on the stairs, and I woke up in the hospital, I was there [at the facility] Saturday morning at 8:30 a.m. then I woke up at 2:00 p.m. The meds took effect real fast - they gave me my medications too and that didn't really help. R1 further recalled vomiting when she got back up to her room. When interviewed on 6/9/21, at 10:27 a.m. registered nurse (RN)-A stated on the morning of 6/5/21, there was a change in the dining room seating arrangements for the residents which caused atypical commotion during morning medication pass. It is usual procedure to set up several resident's medications in advance, place them in medication cups tabled with the resident name and bring them all to the dining room at once to administer them. RN-A stated, I remember walking to another resident, and I didn't have her meds then I said to [R1], don't take them. RN-A noted it was too late and observed R1 had taken her morning medications along with another resident's a.m. medications. RN-A added, I gave it to her in error and as soon as I realized the mistake, I sent a text to the director of nursing (DON) and called the on-call medical doctor, described all the medications administered in error and called 911 and R1 was sent to hospital. RN-A added she could not remember if R1 had eaten her breakfast that morning or not, however noted R1 vomited roughly 20 minutes after ingesting her own and R2's of medications. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . When interviewed on 6/9/21, at 10:46 a.m. nursing assistant (NA)-A stated after breakfast RN-A told NA-A to go upstairs and have R1 come back down to the main floor. NA-A attempted to have R1 walk down the stairs but was R1 was unable to stand, she was drooling and was not making sense, she was limp and weak. NA-A and RN-a had to provide extensive assist to R1 to get to the first level of the home. NA-A and RN-a assisted R1 into a wheelchair and checked R1's blood pressure and it was very low, 70/50. R1's Weights and Vitals Summary report from 3/6/21 through 6/5/21, identified R1 did have blood pressures in the range of 72/55 to 129/70, and lower than normal (120/80) blood pressures were not unusual for her. When interviewed on 6/10/21, at 8:38 a.m. Sterling pharmacist stated the medications administered in error can cause a person to be sedated and to lower their blood pressure. Pharmacist further stated the administration of [MEDICATION(S)] can cause cardiovascular side effects such as [CONDITION(S)] (fast heart rate). The pharmacist stated it was fortunate R1 had vomited shortly after taking them. When interviewed on 6/9/21, at 1:18 p.m. the DON stated she had been notified by RN-A via text message of the medication error RN-A administered to R1 the morning of 6/5/21. DON stated the facility practice was to set-up of medications for two residents at a time moments before staff administer the medication to the residents. DON added, Yes and this is an acceptable practice here. DON further presented a tray with the names of the all the residents to corroborate the facilities' accepted use of prepping several resident medications at a time, prior administration. R1's late entry progress note dated 6/5/21, at 10:38 a.m. described, At 0800 [8:00 a.m.] this morning [R1] took her medication, which I (RN-A) provided her with. While this writer was passing other medications and approaching another resident, [R2] I (RN-A) noticed that R2's medication cup was missing. [RN-A] turned around and saw the empty medication cup on R1's tray. Time lapse was ~ 10 second, but R1 had taken R2's medication. There was a lot of activity going on the Day Room, e.g., additional residents waiting for the next seating, questions from multiple individuals asking about the new seating arrangement, requests for timing of next PRN [as needed] medications, etc. so this writer was distracted by the activity. Although I (RN-A) don't recall giving R1's, R2's medications specifically, I (RN-A) am assuming I (RN-A) placed R2's medication cup on R1's tray on error, since helping herself to her own medications is not something I (RN-A) am aware of R1 ever doing. I (RN-A) notified the DON of the above at 0813 [8:13 a.m.]. I (RN-A) called R1's MD [medical doctor] at Bethesda Medical at 0820 [8:20 a.m.]. The on-call MD [medical doctor] returned the call at 0840 [8:40 a.m.] with instructions to send R1 into the ER. I (RN-A) called 911 as soon as I (RN-A) completed the MD [medical doctor] call at ~0845 [8:45 a.m.]. The Deephaven Police arrived ~0850 [8:50 a.m.] and the ambulance arrived at ~0900 [9:00 a.m.]; departing at 0905 [9:05 a.m.] V.S. [vital signs] at the time of departure were: T [temperature] 97.3; R [respirations] 24; O2 [oxygen saturation] 94%; P [pulse] 93 and BP [blood pressure] 79/58. At 10:30, I called Methodist ER for a update on [R1]'s condition and was told she is sleeping; BP [blood pressure] remains at 80/60. The facility policy titled, Medication Administration, dated 6/2021, detailed: Policy: To administer resident's medications in accordance with doctor's orders. Procedure: 1. Nursing staff will wash hands before administering medication. 2. EMAR will be used to dispense correct medications. 3. Obtain medication from the cart with the correct resident utilizing the correct color sticker for the current administration time. 4. Medication should be dispensed into med cup after observing the resident's name on the medication card, the correct medication corresponding with the EMAR, the correct dose and the right route. 5. Medication will be given directly to resident with nurse observing that the resident takes all of the medication. 6. Medication is signed off in the EMAR as having been given immediately after dispensing.

Based on interview and document review the facility failed to assure that 2 of 2 residents (R1, R2) reviewed for resident to resident altercations were free from abuse. R2 assaulted R1 who sustained harm when he suffered [MEDICAL CONDITION] that required staples. The facility had implemented corrective action so this deficiency is being cited as harm at Past Non-compliance. Findings include: R1's admission Minimun Data Set (MDS) assessment dated [DATE], indicated R1 is [AGE] years old with a BIMS score of 9 (Brief Interview for Mental Status. Score of 9, indicates moderate cognitive impairment). The MDS indicated R1 exhibited no hallucinations, delusions or behaviors affecting others; and was independent with supervision for activities of daily living (ADLs). R2's annual MDS dated [DATE], indicated R2 was a [AGE] year old with a BIMS of 9 who was experiencing delusions and daily behaviors not directed at others, but had the potential to affect others. R2's MDS further indicated R2 was independent with all ADLS except eating, for which he required supervision. R2 utilized no psychoactive medications according to the MDS. R1's record review revealed no history of previous resident to resident altercations. R2's record review revealed a history of resident to resident altercation when residing at another facility in (YEAR). Review of the medical record for R2 indicated R2 had [MEDICAL CONDITION] disorder, was not taking antipsychotic medications, was refusing medications prescribed to treat [MEDICAL CONDITION], and was refusing his heart medications. In addition, the record indicated R2 exhibited behaviors of refusal of care including refusing showers or changing his clothes, and had been noted to hoard things in his room. An Incident Report dated 7/7/19, indicated Licensed Practical Nurse (LPN)-A had heard noises upstairs and investigated. The report indicated LPN-A observed R2 with a metal weight bar in one hand and a shower brush in his other hand. LPN-A's report documentation indicated there had been blood observed on the shower brush bristles, and R2 was observed beating on the door trying to get back into his room. According to the report, R1 was holding the door closed so that R2 could not re-enter the room. The report further identified it was unknown how R2 had ended up out of the room, with R1 being able to shut the door and hold it closed. The report indicated 911 had been called immediately and the police and ambulance were called to the facility. R1 was bleeding from injuries to his head, arms, legs, and said he had been beaten in the abdomen. There was blood on R1's bed and on the floor of the room. R1 was transported to a local emergency medical center (HCMC-Hennepin County Medical Center) by ambulance. The Incident Report indicated R1 had sustained a laceration (cut) to the right side of his head that was 2.5 centimeters (cm) long and 8 millimeters (mm) deep and required 7 staples to repair. R1 also sustained a laceration to the left side of his head, closer to the eye socket which was 2 cm long and required 3 staples to close. R1 was discharged back to the facility after a repeat CAT scan was unchanged, with [DIAGNOSES REDACTED]. The medical record progress notes indicated R2 was transported to HCMC psychiatric crisis center by the police department on 7/7/19 for an emergency hold. The notes indicated R2 was agitated and aggressive with [DIAGNOSES REDACTED]. The notes indicated R2 had refused antipsychotic medications and had refused medications for his medical conditions of [MEDICAL CONDITION] and Heart Failure, he had been refusing to shower and change his clothing for the last 3 months. The progress notes indicated R2 was admitted to the APS (Acute Psychological) unit at HCMC for a 72 hour hold. According to the notes, R2 was quite irritable with nursing staff and stated he would repeat his behaviors at the nursing home. R2 believed the altercation was his roommate's fault and had reported he had only struck R1 with his slipper. However, the notes indicated R2 had evidence of paranoia, was considered a danger to others, and a medical emergency had been declared. R2 was started on antipsychotic medications of [MEDICATION NAME] 0.5 mg twice a day and [MEDICATION NAME] 2.5 mg IM (intramuscularly) if R2 refused to take the oral medications. On 7/11/19, at 4:26 p.m., R1 was interviewed at the facility regarding the altercation that had occurred with R2. R1 stated R2 had just started beating him with a piece of pipe. R1 denied any continued headaches or any pain from the assault. On 7/12/19, at 2:12 p.m. the DON stated R2 had been seen by Psychiatry on admission in (YEAR), but because he had not been taking any antipsychotic medications he had not been on the schedule to be seen routinely by Psychiatry. Although the facility failed to ensure R1 was free from abuse by another resident, and R1 sustained [MEDICAL CONDITION] that required staples in his head, the facility had immediately called 911 for ambulance and police, had notified the State Ombudsman of the hospital transfer, and State agency of the assault by R2. The facility educated residents of the importance of reporting any abuse. On 7/12/19, at 3:00 p.m. the administrator and DON explained that resident to resident altercations in the facility were difficult because of the limited space in the facility and verified staff had received feedback and training regarding the need for close supervision by staff when resident behaviors were escalating. R2 was hospitalized for [REDACTED]. The facility's corrective action was verified during the onsite survey on 7/12/19 as having been implemented as of 7/8/19, therefore this deficient practice is being cited at Past Non-compliance.

Based on interview and document review, the facility failed provide residents with adequate supervision to prevent elopement for one in four residents reviewed (R1) when R1 eloped from the facility two times in three days. On the first elopment, R1 eloped and went to a police station. On second elopement, R1 was found on a lake in very cold weather without appropriate clothing in a suicide attempt, suffered hypothemia, and was hospitalized . Findings include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. R1's discharge summary from hospital dated October 31, 2016 indicated R1 was admitted on [DATE] for delusions. R1's discharge instructions required R1 to follow up with psychiatrist and psychologist at the receiving facility. R1's medical record did not include a temporary or comprehensive care plan to identify care areas, goals and interventions for cognitive loss, mood state, falls, nutritional status, and psychotropic drug use. Review of facility's record indicated the facility received a Pre-Admission Screening Assessment (PAS), completed by the hospital, for nursing facility placement dated October 28, 2016. The PAS indicated that R1's behavior needed staff's cueing and redirection four or more times per week. The PAS also indicated that R1 had minor forgetfulness and was mentally unable for protect self from harm or death. The facility's activities evaluation dated October 31, 2016 indicated that R1 preferred walking. The same evaluation indicated R1 was independent with ambulation. R1's was characterized as shy, depressed and anxious. Review of the psychiatric progress note dated November 2, 2016 indicated R1 had 19 admissions in the past eleven months due to psychiatric illness. R1 was started on new anti-psychotic medication for psychosis. The progress note indicated that R1 required close monitoring of medical condition and medication regimen in collaboration with facility staff. Review of psychologist's assessment note dated November 5, 2016 indicated R1's had impaired memory and warned staff to watch for triggers or indication of mood changes. Nursing progress note reviewed for the week following R1's first elopement indicated R1 had escalating episodes of delusions and paranoia. R1's psychiatrist was notified on December 13, 2016 about R1's delusions and paranoia. R1 wanted to leave facility, refused to participate in outing as s/he liked in the past, thought s/he was being picked up by the Air Force, refused shower, and stated the president was kidnapped and assassinated. The progress note indicated R1 was sweating, pacing his/her room, had bag packed, and stated feeling more depressed. R1's medical record did not indicate R1's psychiatrist called back regarding R1's delusions and paranoia, but did not call the facility back. The facility did not assess R1 for adequate supervision to prevent elopement and self harm. Nursing progress note reviewed for the day before R1's first elopement indicated DON contacted R1's case manager. R1's care manager told DON that R1 had cycles of hospitalization s every two months due to delusions and paranoia. R1 also wanted to go to the hospital. R1 called emergency services twice, the sheriff department stating s/he wanted to turn self in, and was called and reported to sheriff department that the president has been kidnapped and assasinated. Nursing progress note dated December 14, 2016 indicated R1 wanted to leave the facility because s/he was worried about the cost of living at the facility. The director of nursing (DON) reassured R1 s/he could afford living there. DON stated she asked R1 to have breakfast, but R1 wanted to go outside and would return shortly. Police record dated December 14, 2016 indicated R1 showed up at the police station, which was 0.4 mile from the facility. The police transported R1 back to the facility. Nursing progress note dated December 14, 2016 indicated DON took away R1's coat, hat and gloves and kept them at nursing station to prevent R1 from leaving the facility in the future without supervision in dangerous weather. Review of nursing progress note dated December 15 indicated R1 told facility's housekeeper that s/he threw his/her cell phone battery in the garbage. Activity participation note dated December 16, 2016 indicated R1 thought his/her decaffeinated coffee was caffeinated, even after the coffee shop brewed an individual cup for him/her. Nursing progress note dated December 17, 2016 indicated that R1 had a packed bag and wanted to leave facility because s/he was in financial trouble. Staff reassured R1 and s/he returned to his/her room. R1 came back later and wanted to leave the facility again. Staff stated R1 went outside, walked to facility's mailbox, and came back inside. Police report dated December 17, 2016 indicated a police officer and a county water patrol officer found R1 on a lake wearing jeans and a t-shirt in negative seven degree Fahrenheit weather. The report indicated R1 expressed suicide ideation, suffered hypothermia, and was transported to a hospital. Review of hospital record dated December 18, 2016 indicated R1 had some pain, swelling and tingling of both hands, blisters on right hand and left wrist, and frostbite. In an interview on December 21, 2016 at 12:00 p.m., the director of nursing (DON) stated that R1 did not have a care plan. The DON stated that R1 eloped on December 14, 2016. DON stated facility found out that R1 eloped from the property on December 14, 2016. DON stated she called the police and R1 was brought back to the facility by the police. DON stated the outdoor temperature was five degrees Fahrenheit and R1 was dressed appropriately when s/he eloped from the facility on December 14, 2016. The facility did not assess or evaluate R1's elopement risk. DON stated when R1 eloped again on December 17, 2016 and was found at the lake, R1 was not assessed or evaluated for elopement risks. DON als stated that R1 did not have care plan to guide his/her care at the facility. DON stated she was aware of R1's past cycles of hospitalization every two due to his/her psychiatric illness. In interview dated January 9, 2017 at 3:46 p.m., (RN)-F stated that responding to door buzzer was difficult due to most residents's independence with ambulation and staff engagement with care. RN-F also stated she was not aware that R1 had previously eloped on December 14, 2016. RN-F also stated that she got report that R1 was a high risk of elopement on December 17, 2016. The facility policy and procedure titled Community Assessment and Safety dated August 2012 indicated a physician's orders [REDACTED]. The policy also indicated the facility will determine the extent to which each resident is appropriately safe to venture into the community. Facility's policy and procedure titled Decompensated Resident Management dated June 1991 indicated each staff member is to prevent an acting-out resident from injuring him/herself or others. Facility's policy and procedure titled Incident/Accident Reporting dated November 1991 indicated the facility should report and document any incident or accident involving a resident. The policy did indicate how soon the report must be completed. Facility's policy and procedure titled Leave of Absence policy dated July 2016 indicated that facility's staff must ensure residents sign out and sign in the date and time when they returned and left the facility. Facility's policy and procedure titled Vulnerable Adults Protection Policy dated February 2001 indicated that must report and investigate possible abuse or neglect of any resident. The facility's policy and procedure did not include components for screening, training, prevention and identification of abuse, neglect, and exploitation of resident, and misappropriation of resident property.