Every finding on record at Mission Nursing Home

Based on observation, interview, and document review the facility failed to ensure appropriate personal protective equipment (PPE) was used for 2 of 2 residents (R11 and R44) who required enhanced barrier precautions (EBP). In addition, the facility failed to ensure nationally accepted standards of practice for bodily fluid removal from catheter drainage bag were followed for 2 of 2 residents (R11 and R44). Findings include: R11's admission Minimum Data Set, dated [DATE], indicated R11 diagnosis included neurogenic bladder and cancer. R11 was total assist with toilet hygiene. R11 had an indwelling urinary catheter. An observation on 5/19/26 at 4:16 p.m., R11's room had a Centers for Disease Control and Prevention (CDC) sign that indicated EBP was to be worn when staff were doing high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. Nursing assistant (NA)-B when in R11's room, put on gloves and told R11 what she was going to do. NA-B did not wear a gown as directed on the sign outside R11's room. NA-B placed paper towels on the ground and put the urinal on them. NA-B opened the catheter drainage bag spout and drained urine from catheter drainage bag into the urinal measuring 750 milliliters (ml). NA-B placed the urinal on the paper towels on the floor. NA-B took soiled gloves off and put on clean gloves. NA-B hooked the catheter drainage bag to the side of the bed. NA-B used a washcloth fresh scent wipe to wipe the spout of the catheter drainage bag and placed the spout in the holder on the catheter drainage bag. NA-B took off soiled gloves and put on clean gloves then emptied the urinal in the toilet and rinsed it out and allowed to air dry. NA-B took the soiled gloves off, washed hands, and put clean gloves on to assist R11 with a brief change. NA-B had assistance from NA-C, she put on clean gloves while assisting R11 to change position. NA-B wiped R11's bottom from a bowel movement with washcloth fresh scent wipes. NA-B took off soiled gloves and put on clean gloves to place brief and secure it in place. Both NA-B and NA-C took off soiled gloves and washed their hands with soap and water. NA-B put new gloves on and took garbage to the soiled bin in the hallway. NA-B took gloves off and used hand sanitizer. An interview on 5/19/26 at 4:40 p.m., NA-B stated she had not worn a gown while assisting R11 and neither had NA-C. C44's Continuity of Care Document, undated, indicted diagnosis of vascular dementia and benign prostatic hyperplasia. An observation on 5/19/26 at 6:14 p.m., R44's room had a Centers for Disease Control and Prevention (CDC) sign that indicated EBP was to be worn when staff were doing high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. NA-A was in R44's room with gloves on emptying the urinary catheter drainage bag. NA-A was standing next to R44's wheelchair holding the urinary catheter drainage bag up to her shoulders and holding the urinal in the other hand under the spout of the catheter drainage bag. NA-A stated there was 600ml in the urinal. NA-A placed the catheter drainage bag on R44's wheelchair and put the spout in the holder. NA-A emptied the urinal in the toilet and rinsed it and let air dry. NA-A did not wipe the spout with an alcohol wipe before putting the spout back in the holder. An interview on 5/19/26 at 6:28 p.m., NA-A stated she had emptied the urinary catheter drainage bag while standing up. NA-A stated she did not wear the gown like the EBP sign indicated. An interview on 5/22/26 at 9:04 a.m., with the infection preventionist (IP) stated urinary catheter cares are done during a skills in-service which is mandatory for staff to attend. IP stated staff should wear gowns and gloves when draining urinary catheter drainage bags. IP indicated that staff should keep the urinary catheter drainage bag below the level of the bladder while draining it and when they secure to the bed or wheelchair. IP stated staff should be cleaning the urinary catheter drainage bag spout with alcohol wipe not a washcloth fresh scent wipe. IP stated urinary tract infections were prevalent at the facility. The facility procedure Emptying a Urinary Collection Bag dated 2001, indicated to keep the collection bag below the level of the resident's bladder. Steps in the procedure include: place the clean equipment on the bedside stand or over bed table. Arrange supplies so they can be easily reached. wash and dry hands thoroughly put on disposable gloves. place a paper towel on the floor beneath the drainage bag, position the measuring container under the collection bag. remove the drain tube from its holder. unclamp the valve on the drain spout and let the urine flow into the measuring container. after the drainage bag has emptied, clamp the valve. wipe the drain with an alcohol sponge or swab, discard the sponge swab into the designated container. replace the drain spout back in its holder. measure and record the urinary output, if indicated. pour urine down the commode, flush the commode. rinse the measuring container and return to its designated storage area. discard all disposable items int designated containers. remove gloves, wash and dry hands. clean the bedside stand and/or overbed table, return the overbed table to its proper position. reposition the bed covers, make resident comfortable. place the call light within easy reach of resident. wash and dry your hands.

Based on interview and document review, the facility failed to monitor and implement interventions per physician orders for 1 of 1 resident (R16) reviewed for heart failure. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 diagnoses included congestive heart failure (CHF), hypertension, and paroxysmal atrial fibrillation (episodes of irregular heart rhythm). R16's Physician Order Report, signed by provider 4/15/26, indicated the following orders:Lasix (furosemide) 20 milligrams (mg) daily as needed (PRN) if weight up over 3 pounds (lbs) in one day or 5 lbs/weekCheck weight daily and update provider if weight is up 5 lbs in one week or 3 lbs in one day R16's weight summary, printed 5/22/26, indicated R16's weight was 208.2 lbs on 4/17/26, and 212.2 lbs on 4/18/26, which indicated a weight gain of 4 lbs in one day. R16's weight continued to be elevated with weights documented as 211.6 lbs on 4/19/26, and 211.6 lbs on 4/20/26. However, R16's record lacked evidence that the provider had been notified of the weight gain. Additionally, Medication Administration Record (MAR) indicated Lasix 20mg PRN was not administered to R16 on 4/18/26, as per provider orders. R16's progress note, dated 4/18/26 at 5:31 a.m., indicated R16 had no signs or symptoms (s/s) of respiratory distress noted. R16's progress note, dated 4/18/26 at 9:29 p.m., indicated R16's lung sounds were diminished in all lobes. R16's progress note, dated 4/19/26 at 9:25 p.m., indicated R16's lung sounds were diminished in all lobes. R16's progress note, dated 4/21/26 at 7:00 a.m., indicated R16 complained of chest pain and left arm pain radiating to his neck since 4-5:00 a.m., and 911 was called. R16's Hospital Cardiology History and Physical, dated 4/21/26, indicated R16 presented with acute-on-chronic systolic heart failure. R16's Hospital Discharge Orders, dated 4/23/26, indicated R16 was hospitalized for heart failure and left shoulder/arm pain likely musculoskeletal in nature, and medication changes included a furosemide (Lasix) dose and frequency increase to furosemide 10mg daily for excess fluid. R16's Provider Hospital Follow-up Visit Progress Note, dated 4/24/26, indicated an order for weight daily; update provider if up 3 pounds in a day 5 pounds in one week for diagnosis of heart failure. R16's Physician Order Report, signed by provider 5/20/26, indicated R16's PRN Lasix was decreased to Lasix (furosemide) 10mg by mouth once a day as needed (PRN) if weight up over 3 lbs in one day or 5 lbs/week, and call to update provider was ordered 4/23/26. R16's progress note, dated 5/15/26 at 10:29 a.m., indicated R16's weight was up 3 lbs in one day, provider was notified, and Lasix 10mg PRN was administered as per orders. R16's weight summary, printed 5/22/26, indicated R16's weight was 210 lbs on 5/16/26, no weight was recorded for 5/17/26, and R16's weight was 217.8 lbs on 5/18/26, which indicated a weight gain of 7.8 lbs in two day. However, R16's record lacked evidence that the provider had been notified of the weight gain. Additionally, Medication Administration Record (MAR) indicated Lasix 10 mg PRN was not administered to R16 on 5/18/26, as per provider orders. R16's Provider Update, dated 5/21/26 at 2:45 p.m., indicated R16 had elevation in weight intermittently with previous hospitalization for acute exacerbation of CHF, chart indicated R16 sent to hospital because of chest pain with pain in left arm and neck, R16 a full code patient with order for Lasix 10mg to be given if weight up 3 lbs., and R16 had known history of ischemic cardiomyopathy (heart's decreased ability to pump blood properly) and reduced ejection fraction of 30% (sign of heart failure). Provider indicated R16 chart revealed staff had not alerted provider of elevated weights. Provider felt R16 would benefit from a scheduled dose of Lasix rather than as needed at this time. R16's Provider Order, dated 5/21/26 at 2:45 p.m., indicated order to give Lasix 20mg currently, and scheduled Lasix 20mg every Monday, Wednesday, Friday, and recheck of basic metabolic profile (BMP) next lab day. Facility staff instructed to continue to monitor for evidence of chest pain or discomfort. During interview on 5/21/26 at 9:43 a.m., registered nurse (RN)-A stated she obtained R16's weight on 5/18/26 before breakfast and verified R16's weight was 217.8 lbs. RN-A verified R16's documented weight on 5/16/26 was 210 lbs, and R16's weight was not documented for 5/17/26. RN-A stated she had not notified the provider of the weight increase on 5/18/26. RN-A stated she was not aware R16 had a Lasix PRN order and she had not administered the Lasix PRN on 5/18/26 as ordered. RN-A stated the provider should have been notified of the missed weight on 5/17/26, and of the weight increase from 5/16/26 to 5/18/26. RN-A stated it was important to follow provider orders to address before things get worse and avoid potential rehospitalization. During interview on 5/21/26 at 10:18 a.m., licensed practical nurse (LPN)-A acknowledged she obtained and documented R16's weight on 4/18/26 as 212.2 lbs. LPN-A verified R16's weight was 207.4 lbs on 4/17/26. LPN-A stated the provider should have been notified of the weight increase as per orders, but she failed to notify the provider on 4/18/26. LPN-A stated she was not aware R16 had a Lasix 20mg PRN order at that time and had not administered it to R16 as ordered. LPN-A stated the provider should have been notified of the weight gain and the PRN Lasix should have been administered as ordered. During interview on 5/21/26 at 1:37 p.m., assistant director of nursing (ADON) verified R16's weights were 207.4 lbs on 4/17/26 and 212.2 lbs on 4/18/26. ADON stated she would have expected the nurse to have administered the Lasix 20mg PRN and to have notified the provider as ordered. ADON stated R16 could have potentially not been hospitalized had orders been followed. During continued interview with ADON on 5/21/26 at 1:37 p.m., ADON stated it was the nurses' responsibility to know resident PRN orders. ADON verified R16's weight was 210 lbs on 5/16/26, and 217.8 lbs on 5/18/26. ADON acknowledged R16's record lacked evidence a weight was obtained on 5/17/26, as per orders. ADON stated R16's record lacked evidence the nurse notified the provider of the missed weight and of the weight gain. Additionally, ADON stated R16's record lacked evidence the nurse had administered the Lasix 10mg PRN as per orders. ADON stated it was important for nurses to follow these orders to prevent rehospitalization. During interview on 5/21/26 at 2:23 p.m., R16's primary provider (PCP) stated facility staff should have notified the provider for elevated weights as ordered. During interview on 5/22/26 at 1:32 p.m., director of nursing (DON) verified R16's documented weights from 4/17/26 and 4/18/26 indicated a 4.8-lb weight gain. DON stated she 100% expected the nurse to have contacted the provider with the weight increase, expected the Lasix 20mg PRN to have been given as ordered, and would have expected R16's weight to have gone down had the PRN Lasix been administered. DON stated R16's rehospitalization could have absolutely been prevented if orders had been followed. Additionally, DON verified R16 was sent to the hospital due to chest pain, and chest pain is a symptom of CHF exacerbation and anxiety. During continued interview with DON on 5/22/26 at 1:32 p.m., DON verified R16's weight was not obtained on 5/17/26, and R16's documented weights from 5/16/26 and 5/18/26 indicated a 7.8-lb weight gain. DON expected the nurse to have notified the provider when a daily weight was missed, expected the nurse to have notified the provider of the elevated weight on 5/18/26, and expected the nurse to have administered Lasix 10mg PRN on 5/18/26 as ordered. DON stated the errors could have resulted in another rehospitalization. The facility's Administering Medications Policy, revised 4/19, indicated medications are administered in accordance with prescriber orders, and medications are administered in a safe and timely manner.

Based on interviews and document review the facility failed to ensure the State Ombudsman for Long Term Care (LTC) was notified of a transfer to the hospital for 1 of 3 residents (R6) when transferred to the hospital for medical treatment. Findings include: R6's Continuity of Care document undated, indicated diagnosis of schizophrenia, diabetes, and epilepsy. A progress note dated 9/4/25 at 9:16 p.m., indicated R6 went to the hospital for seizure activity. The facility notified the provider and family of the hospitalization. R6's medical record lacked evidence the State Ombudsman for LTC was notified of the transfer. The facility Bed Hold Policy and Notification of Transfer dated 9/4/25, indicated R6 had been sent to the hospital. However, there was no verification that the LTC Ombudsman was notified of the transfer. An interview on 5/21/26 at 11:21 a.m. the assistant director of nursing (ADON) stated they could not verify if the LTC Ombudsman had been notified unless the nurses wrote they sent it to the LTC Ombudsman the progress notes. ADON stated that sometimes the nurses will send a bed hold notification to the LTC Ombudsman but there is no way to verify that it was done. ADON stated no one was checking if the nurses were sending notification to the LTC Ombudsman. A facility policy was requested however, none was provided.

Based on interview and record review, the facility failed to ensure that each resident receiving hospice services had a comprehensive written plan of care included both the most recent hospice plan of care and a description of the services furnished by the facility to help the resident attain or maintain their highest practicable physical, mental, and psychosocial well being for 1 of 3 residents (R1) reviewed for hospice services. Findings include:R1's hospital Discharge summary dated [DATE], identified R1's primary diagnoses included repeated falls, Parkinson's disease with dyskinesia and dementia with hospice care as discharge disposition.R1's hospice initial coordination note dated 2/10/26 indicated goals related to pain management as well as the initial visit frequency (once a week for nursing staff and once a month for social workers) but none of these goals or interventions were integrated into the facility's care plan. The note further indicated hospice will deliver to the facility the initial plan of care for R1 which was not provided to the surveyor upon request.R1's activity of daily living (ADls) care plan dated 2/10/26 showed no inclusion of the most recent hospice plan of care (POC) and did not contain any documentation of how the facility would coordinate or provide services to support the hospice interventions.Review of the February R1's medical record showed R1 did not have a comprehensive written plan of care including both the most recent hospice and the services the facility would provide to support the hospice plan of care such as nursing interventions, activities of daily living assistance and pain monitoring.During an interview on 3/5/26 at 1:04 p.m., a nursing assistant (NA)-A stated she knew R1 was on hospice but did not know the specifics of his hospice care needs. NA-A explained she had not been informed of hospice-specific interventions such as the required frequency of pain monitoring or comfort-focused approaches to assisting with (ADLs).During an interview on 3/5/26 at 1:59 p.m., a registered nurse (RN)-A, stated R1 was on hospice care when he was admitted to the facility. RN-B explained R1's comprehensive care plan should reflect individualized goals and interventions to address his hospice care needs. RN-B confirmed she was unable to locate a comprehensive hospice care plan in R1's medical record, explaining that R1's care plan did not include the hospice-specific goals or interventions necessary to guide staff in meeting R1's needs.During an interview on 3/5/26 at 2:50 p.m., RN-B, a hospice nurse stated R1 was enrolled in a hospice care when he was admitted to the facility on [DATE]. RN-A explained she did not provide R1's comprehensive hospice plan of care to the facility, explaining that her primary focus at the time was on R1's medication management. RN-A stated staff should have access to a hospice plan of care which identified R1's needs and focus interventions to prevent unnecessary decline.During an interview on 3/5/26 at 3:55 p.m., the director of nursing (DON) stated the facility relied on hospice to manage their plan of care. The DON reported she was unaware whether the hospice plan of care had been integrated into R1's comprehensive care plan. The DON explained she expected nursing staff to follow R1's individualized care plan, including his hospice related goals and interventions. The DON stated nurse manager should have initiated R1's comprehensive care plan, including the hospice plan of care, but she did not recall whether this had been completed. The DON further explained hospice residents' care plans should include interventions for pain management, anxiety, shortness of breath management, and psychosocial support, but she could not confirm whether these interventions were present in R1's care plan.The facility comprehensive care plan policy was request but not provided.The facility resident assessment policy with no date required a comprehensive care plan for all residents admitted to the facility.

Based on interview and document review the facility failed to protect 1 of 1 resident (R1) from staff to resident abuse when R1 was physically and verbally abused by nursing aid (NA)-A which resulted in psychosocial harm to R1 who was crying and visibly upset during the abuse incident. The facility implemented corrective action, and the deficient practice was corrected on 2/19/26, prior to the survey and was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of stroke and cancer with prognosis less than six months to live. The MDS indicated severe cognitive impairment, no mood or behaviors, no rejection of care and required staff dependance with activities of daily living, occasionally incontinent of bladder and frequently incontinent of bowel. R1's Care Plan (CP) dated 2/19/25, indicated diagnoses of Hemiplegia (total paralysis) and hemiparesis (weakness) affecting one side of the body caused by stroke, aphasia (impaired speech and understanding), dysphagia (difficulty swallowing), post fracture unspecified part of neck of femur, depressed mood and restlessness with anxiety. The care plan indicated his ability to perform ADLs has deteriorated related to diagnosis of right sided hemiplegia and is expected to decline due to end of life. Staff are directed to have consistent approach amongst caregivers, monitor for presence of pain during self-care, provide adequate rest periods between activities, assist of one with incontinent care, Hoyer lift with transfers. The CP also indicated R1 had difficulty with communication following his stroke and directed staff to face him when speaking, obtain his attention before speaking and provide a quiet, non-hurried environment, free of distractions for conversation. The CP further revealed R1 had physical behavioral symptoms, rejection of care, refusal to leave his room, avoid over-stimulation, convey an attitude of acceptance towards the resident, maintain a calm environment and approach to the resident offer choices. He is identified as a vulnerable adult and to be free of abuse, neglect and exploitation, staff to monitor emotional status, monitor for signs and symptoms of abuse, neglect and exploitation. A Facility Reported Incident dated 2/18/26, indicated R1 was lying in bed, nursing assistant (NA)-A took unused briefs out from under resident's pillow and threw them on the floor. NA-A gestured to hit resident with call light cord and began making facial expressions towards the resident who was non-verbal. NA-A stuck middle finger up at resident and cursed at him. On 2/24/26 at 8:15 p.m. video footage of incident on 2/18/26 at 5:44 p.m., indicated the following: -5:44 p.m., R1 in his room lying in bed with incontinent pad on with no other clothing and a sheet half covering him. NA-A was observed to take a clean incontinent pad from under his pillow and toss it on the floor then with her hip, push his bed towards the wall. R1 was observed in a soft voice saying no, no, no while looking at the floor at his pad that was tossed. NA-A stated, you already have one on your body you don't need that one. NA-A was then observed grabbing R1's call light and moving to the other side of his bed towards the wall while R1 raised his left hand, NA-A hit his hand with the call light and said stop and plugged the call light into the wall and stated, I am just trying to help you. NA then moved back to the other side of the bed, picked a pillow up off the floor and lowered R1's bed to floor with his bed remote and placed it on his bedside dresser top handle. -At 5:45 p.m., NA-A started picking up dirty items and the clean incontinent pad off the floor and placed in a clear plastic bag while R1 began pointing at the floor and was heard saying faintly, here, here, here! NA-A was then observed to be standing at the foot of the bed, dropped the clear bag on the floor raised and lowered her right hand and put out her middle finger at R1 three times, then stuck her tongue out at him. -5:46 p.m., NA-A walked past R1 mocking him with facial expressions while grabbing another clear bag picking up dirty linen. R1 then pointed his finger saying no, no, no and NA-A walked out of the room while R1 started crying and placed his left hand over his forehead, his expression was visibly upset. R1 then began to struggle to reach for his bedside remote that was attached to the top handle of his nightstand and raised his bed so he could see his television. -At 5:47 p.m., NA-A was observed to re-enter the room with a blue bedspread in her hands and grunting sounds (mimicking R1,) threw the comforter over him and lowered his bed back to the floor before she placed the bed remote inside his bedside stand, then walked out, leaving all the lights on in the room. R1 never addressed or spoke to R1 while in the room. R1 was then again observed trying to grab his bedside remote, leaning over struggling to grab the cord and pull it out of the drawer. R1 remained laying on his side looking at the floor with the bed still in lowered position on the floor and never raised his bed back up. During interview on 2/24/26, at 12:40 p.m., director of nursing (DON) stated registered nurse (RN)-A was on call on 2/18/26, and was notified by RN-A via text message of rough staff care by NA-A. The DON stated the family had placed a camera in R1's room per their request. The DON stated NA-A was immediately suspended pending investigation. R1's family member (FM)-A called the facility informing him she had seen NA-A pointing the middle finger at R1 and told the facility she wanted it to be reported in the morning. The DON stated they filed a report to the state immediately and notified the local police department. In addition, the DON stated re-education was completed to all staff on vulnerable adults, and staff and resident interviews were conducted to see if there were any concerns of abuse in the facility which there were none. The DON stated there were no injuries noted on R1 and after the facility investigation and review of the video footage was completed their decision was to terminate NA-A's employment due to abuse and according to facility policy. During interview on 2/24/26 at 7:04 p.m., family member (FM)-A stated she periodically checks the camera she placed in R1's room and on 2/18/26 she noticed his bedding torn apart and that was usually a sign he had a wet brief or needed to be changed. FM-A stated she called the facility so someone could help him and then turned the camera on and observed the incident in his room. FM-A stated she then immediately reported the incident to the nurse on duty. FM-A stated he likes to try to be independent and liked his incontinent pad under his pillow since he will try to change himself and that was why in the video he became so upset when the staff took it away and threw it on the floor. In a follow up interview with FM-A on 2/25/26 at 8:05 a.m., she stated R1 briefly cried because of the way he was being treated by NA-A and not being able to communicate or speak up upset him further. FM-A further stated when the staff member threw his diaper across the floor, he wanted it back and that is why he pointed at it. That is what made him very upset and he felt very defeated. FM-A stated in the beginning she felt he was angry and frustrated, then defeated but ultimately, he was so upset he was crying and tearful, that is when NA-A had flipped him off, he just got really worked up and sad. FM-A stated prior to his strokes he was a very passive man who would have laughed at her and made fun of her. FM-A continued to state R1 loved art, painting, and loved to talk. It is so frustrating for him that he cannot talk, he is a kind man, very gentle. He used to live off the grid, he rode his bike to work, was just a free spirt and would never treat anybody like she treated him. FM-A added there was also a note on his door to please keep a pad under his bed and she could just not understand why NA-A would do what she did. During interview on 2/25/26 at 9:15 a.m., FM-B stated the incident that occurred on 2/18/26, made R1 more distrustful of staff, withdrawn and in the moment, it made him cower and cry. FM-B further stated she was certain he felt disrespected, helpless and in danger physically. The facility corrected the deficient practice on 2/19/26, prior to survey entrance 2/24/26, therefore the deficiency is being issued at Past Non-Compliance. Abuse Prevention and Prohibition reviewed 6/20222, indicated Mission Nursing Home (MNH) will not tolerate the maltreatment of its residents, whether overtly by abuse, through omission by neglect or by financial exploitation of a resident's property or funds. Persons found to be maltreating residents will be dealt with to the limits permitted by law. All employees of MNH are responsible for assuring that all residents are free of maltreatment, (see definitions). All employees are expected to be knowledgeable of these policies and procedures and for reporting actual or suspected incidents of maltreatment in accordance with these policies and procedures. MNH also expects other providers of service to its residents, as well as volunteers, to abide by these policies and procedures. MNH will not knowingly employ or contract with individuals who have been convicted of abusing, neglecting or mistreating individuals. MNH will plan for the prevention of abuse of its residents through a Facility Abuse Prohibition and Vulnerable Adults Protection Plan. Reports of maltreatment are promptly and thoroughly investigated. The Director of Nursing and the Social Services Director are designated as the primary investigators for incidents of maltreatment. MNH will cooperate completely with law enforcement authorities and the maltreatment. Prior to the start of the survey the facility-initiated education related to Vulnerable Adult Policy and reporting. The education was verified through interview and document review.

Based on interview and document review, the facility failed to perform comprehensive skin assessments (at least weekly) as ordered, which included assessment for new wounds and documenting wound measurements and other wound characteristics for 3 of 3 residents (R1, R2, R3) reviewed for pressure injury. Findings include: R1R1's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, pressure ulcers (PU) upon admission, and risk to develop PU. The MDS data indicated R1 admitted [DATE], discharged [DATE], re-admitted [DATE], and discharged on 1/14/26. R1's diagnoses included cancer, deep vein thrombosis (a blood clot in a deep vein), bowel and bladder incontinence, and malnutrition. R1 was on chemotherapy upon admission. R1 had mobility limitations that required a wheelchair for mobility. R1's provider orders dated 12/5/25 indicated perform skin check, head to toe, to be completed weekly on Fridays. R1 had ongoing pressure wound care orders for both the right and left ischial tuberosities (large bony projection located at the bottom of the pelvis that serves as the primary weight-bearing structure when sitting) wounds and on 12/17/25, a sacral (large bone at the base of the lumbar spine that acts as a foundation, distributing upper body weight and stabilizes the pelvis for walking, sitting, and standing) wound, which indicated R1 was prone to develop PU. R1's care plan dated 12/18/25, indicated R1 had a non-healing open area on skin, a surgical wound, immobility, nutritional risk, and incontinence as risk factors for alteration in skin. R1's skin assessments indicated R1 had skin audits completed upon admission on [DATE], and 12/5/25. An additional head- to -toe skin assessment was completed 12/26/25. R1's electronic health record (EHR) lacked indication of additional weekly skin assessments during the weeks of 11/9/25, 12/12/25, 12/19/25, 1/2/26, and 1/9/26. R1's progress notes lacked indication the omitted skin assessments were completed, nor that they were refused by R1.R1's progress notes dated 12/5/25 indicated when R1 readmitted on [DATE], he had a left above knee amputation. On 2/10/26 at 2:51 p.m., during an interview licensed practical nurse (LPN)-A acknowledged R1 had only one skin assessment but should have had one each week while a resident. LPN-A stated body audits were completed upon admission to assess the skin initially. Wound care notes assessed known wounds. LPN-A further stated body audits and wound care notes did not replace the requirement of the weekly head-to-toe skin assessments which were utilized weekly to assess for previously unidentified skin changes. LPN-A acknowledged R1 had provider orders to perform weekly skin assessments, but only had one skin assessment on 12/26/25, and R1's EHR lacked documentation indicating why the other assessments were not completed as ordered. On 2/11/26 at 9:54 a.m., during an interview registered nurse (RN)-A stated weekly skin assessments were performed on shower days, and were utilized to assess skin for new redness, skin tears, and any type of open area on the skin. RN-A stated if new areas were found, the areas were measured, reported, and dressed with appropriate dressings for the wound type. RN-A further stated if a resident refused a bath or shower, the nurse was still required to perform the weekly skin assessment, or document why it was not performed. The nurse was required to perform the skin assessment, or they would not know about new skin issues. RN-A acknowledged R1 had one weekly skin assessment on 12/26/25 but should have had one weekly while admitted . R2R2's quarterly MDS dated [DATE], indicated intact cognition, PU upon admission, and risk to develop PU. The MDS indicated diagnoses that included peripheral vascular disease (PVD-a progressive circulation disorder involving narrowing of the blood vessels commonly affecting the legs and feet), kidney disease, a neurogenic bladder (dysfunction of the bladder caused by damage to the nerves that control the bladder commonly caused by spinal cord injuries and diabetes), paraplegia, and diabetes. R2 had mobility limitations that required a wheelchair for mobility. R2's provider orders dated 8/26/25, indicated perform skin check, head to toe, to be completed weekly on Fridays. R2 had pressure wound care orders dated 1/26/26 for a sacral wound, indicating R2 was prone to develop PU. R2's care plan dated 9/17/25, indicated an alteration in skin integrity with a stage IV PU (wound with extensive tissue loss, with directly visible or palpable muscle, tendon, ligament, cartilage, or bone) on the sacrum. R2's skin assessments were completed 1/2/26, 1/9/26, 1/23/26, and 2/6/26. R2's EHR lacked indication of weekly skin assessments during the weeks of 1/16/26, and 1/30/26. R2's progress notes lacked indication the omitted skin assessments were completed, nor that they were refused by R2. R3R3's quarterly MDS dated [DATE], indicated intact cognition, current PU, risk to develop PU, and bowel and bladder incontinence. The MDS indicated diagnosis that included PVD, diabetes, lung disease, and mobility limitation that required a wheelchair for mobility. R3's provider orders dated 9/4/25, indicated perform skin check, head to toe, weekly on Sundays. R3's orders dated 1/28/26, indicated ongoing pressure wound care orders for both the right and left ischial tuberosities, indicating R3 was prone to develop PU. R3's care plan dated 10/29/25, indicated potential skin alteration, a non-healing open area, related to diabetes, PVD, immobility, nutrition risk, incontinence, and impaired cognition. R3's skin assessments were completed 1/11/26, 1/25/26, 2/1/26, and 2/8/26. R3's EHR lacked indication of weekly skin assessment the week of 1/18/26. R3's progress notes lacked indication the omitted skin assessment was completed, nor that it was refused by R3. On 2/11/26 at 10:15 a.m., during an interview RN-B stated R1, R2, and R3 should have had weekly skin assessments. Residents had weekly skin assessments or potentially staff may not have identified new wounds. The policy was to document the skin assessments on the Weekly Skin Check form. RN-B stated body audits upon admission and wound rounds did not replace the weekly skin assessments. RN-B acknowledged: - R1, R2, and R3 had orders for weekly skin assessments. - R1 had only one skin assessment, on 12/26/25. - R2 lacked skin assessments on 1/16/26 and 1/30/26. - R3 lacked a skin assessment on 1/18/26. - R1's, R2's, and R3's EHRs lacked documentation indicating why the skin assessments were not performed as ordered. On 2/11/26 at 11:28 a.m., during an interview the director of nursing (DON) stated it was the expectation each resident would have weekly skin assessments to ensure new skin issues were identified. The skin assessments were to be completed even when residents refused showers or baths. The DON stated the wound rounds did not replace weekly skin assessments, and acknowledged R1, R2, and R3 each missed weekly skin assessments. The facility was working on the skin assessments/ wound assessments process and would continue the work. The Prevention of Pressure Injuries policy dated 4/2020, indicated evaluate, report, and document potential changes in skin. The Skin Integrity and Wound Care policy dated 8/2025, indicated follow preventative interventions per the care plan. Conduct thorough skin assessments upon admission, weekly, and with a change in condition. Residents at risk included those with cognitive impairment, limited or no mobility, incontinence, acute illness or rapid decline, poor nutrition, or those with fragile skin from medications such as anticoagulants, steroids, or chemotherapy.

Based on document review and interview, the facility failed to ensure a system of registry verification approved by the State before allowing nursing assistant to do nursing or nursing-related services in the facility for 4 of 7 nursing assistants (NA-A, NA-B, NA-C, NA-D) reviewed for the required certificate status.Findings include:NA-A's registered certificate dated 9/16/2006, indicated NA-A had an inactive registry status effective 8/24/2025, and the personal file did not contain any evidence of renewal.During an interview on 1/7/2026 at 10:42 a.m., NA-A stated he had been working for the facility since 2006 as a nursing assistant and was trained three years ago to administer medications under a nurse's supervision as a trained medication aide (TMA). However, NA-A's personal file lacked evidence of verifying active NA status or TMA certification. NA-A stated he provided nursing related care to residents this morning.NA-B's registered certificate dated 11/21/1995, indicated NA-B had an inactive registry status effective 4/02/23 and the personal file lacked any evidence of renewal.During an interview on 1/7/2026 at 11:14 a.m., NA-B stated he had been working as NA/TMA since 2003 and was not aware he was not current on the registry. NA-C's registered certificate dated 9/12/1995, indicated NA-C had an inactive registry status since 8/24/2025 and the personal file lacked any evidence of renewal.During an interview on 1/7/2026 at 9:46 a.m., NA-C stated he got his NA certificate from Boston in 1995, moved to Minnesota and started working in the facility. NA-C stated he provided nursing related services to the residents including toileting, transfers, and peri cares etc.NA-D's registered certificated dated 1/25/14, indicated NA-D had inactive registry status since 8/24/21 and the personal file lacked any evidence of renewal.During an interview on 1/8/2026 at 2:2 p.m., NA-D stated she did not know if her NA certificate was active or not. NA-D stated in order to work nursing related work; nursing staff have to have an active certificate status. During an interview on 1/8/2026 at 4:05 p.m., the administrator stated they were not able to provide the TMAs documentations for NA-A, NA-B and NA-C. The administrator acknowledged that staff should not be doing nursing related work with inactive registry status and staff member would be removed from the floor until appropriate certification be obtained. Nursing assistant registered job description policy dated 12/21 indicated qualifications of nursing assistant included successful completion of written and skills exam, as provided from a State of Minnesota approved testing location and be in good standing with Minnesota Nursing Assistant Registry.Trained Medication Aide (TMA) job description policy dated 12/21 indicated qualifications of TMAs included completion of approved Nursing Assistant training program followed by an approved trained Medication Aide certification program as well as being in good standing with Minnesota Nursing Assistant Registry.

Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 resident (R4) reviewed for infection prevention and control.Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, impairment of functional range of motion (ROM) on one side and required substantial/maximal assistance with toileting hygiene, upper body dressing, personal hygiene, roll left and right, dependent for lower body dressing, all transfers, and used a manual wheelchair for mobility. He was frequently incontinent of bowel and bladder. Medical diagnoses include stroke, hemiplegia/hemiparalysis (paralysis or severe weakness on one side of the body), and depression. R4's care plan dated 9/26/25, identified self-care deficit with activities of daily living (ADL) and directed staff to provide extensive assistance of one to two staff with all ADL, bed mobility toileting, dressing, grooming, and wheelchair mobility, transfer with assistance of two staff and Hoyer lift, and care always provided in pairs of two. During an observation on 7/2/25 at 12:27 p.m., R4's room call light was noted to be on. He laid in bed on his back covered up with a sheet, and head of bed up approximately 20 degrees. At 12:37 p.m. two nursing assistants (NA)-A and NA-B entered the room with an EZ way smart lift machine. NA-B opened drawers and was unable to find wipes. NA-B exited the room without sanitizing hands and returned shortly thereafter with wipes. NA-A and NA-B applied gloves, and together pulled down his pants and the front of his brief. NA-A wiped the front peri area from front to back. He was turned onto his left side, brief was pulled away from his buttocks, NA-A wiped his rectal area from front to back and stool was visible on the wipe and brief. NA-A was not observed removing her gloves, sanitizing her hands and donning new gloves before she placed a clean brief and the lift sling underneath him. R4 was turned onto his right side, while NA-A placed her gloved hands on his left shoulder and right leg, pulled him over, pulled up brief and pants. NA-A and NA-B each placed a shoe on one foot. NA-A grabbed the EZ lift machine by the handles and pushed it over to the resident while he laid in bed. NA-A hooked up the lift sling loops to the EZ lift machine, raised him off the bed, lowered him down into his wheelchair and removed the lift sheet loops from the EZ lift machine. NA-A straightened the bed sheets, placed dirty linen in two clear bags, removed her gloves, and did not sanitize her hands. She held the dirty gloves in her hand along with the two bags of dirty linen, exited the room, walked down the hallway, entered a dirty utility room, disposed of the two bags and the dirty gloves, all without observation of sanitizing her hands. She then walked back down the hallway, opened the door, entered the nurse's station, and washed her hands at the sink with soap and water, and dried them with a paper towel. During an interview on 7/2/25 at 2:44 p.m., NA-B stated staff were expected to complete hand hygiene prior to the start of and after cares with a resident, prior to when the resident goes to dining room, before they eat, and when gloves were changed. Hand hygiene was important to help prevent the spread of germs from one area to another. During an interview on 7/2/225 at 4:23 p.m., NA-A stated staff were expected to complete hand hygiene before and after resident cares and after removal of gloves. She preferred to use soap and water to make sure hands were thoroughly clean. Hand hygiene was important for resident and staff safety to help prevent the spread of sickness, disease, and infection around by touching something dirty then touching clothing or the resident. NA-A stated she had changed her gloves after she completed R4's peri cares (though this was not in the observation)but did not sanitize her hands prior to the application of a new pair of gloves or exiting the resident's room and should have. She usually had hand sanitizer in her pocket but had forgot it. During an interview on 7/3/25 at 10:15 a.m., assistant director of nursing (ADON) stated staff were expected to complete hand hygiene prior to taking care of a resident, prior to entering their room, exiting their room, in between cares, before and after glove use. Hand hygiene was important to prevent infection. During an interview on 7/3/25 at 1:44 p.m., director of nursing (DON) stated staff were expected to complete hand hygiene prior to resident cares, after cares as they leave the room, after removal of gloves, before clean gloves were applied to prevent infection. The staff should have completed hand hygiene multiple times during the observation with R4's cares and transfer. Facility policy Handwashing/Hand Hygiene dated 10/2023, identified hand hygiene is the primary means to prevent the spread of healthcare associated infections. Hand hygiene was indicated: immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea. Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with resident, equipment or environment of a resident who is on contact precautions. The use of gloves does not replace hand washing/hygiene. Perform hand hygiene before and after application of gloves.

Based on interview and document review the facility failed to ensure 1 of 3 resident (R2) was free of significant medication errors when physician's orders for Darbepoetin (causes the bone marrow to produce red blood cells and used to treat anemia in people with chronic kidney failure) was not administered as prescribed, resulting in seven missed doses of Darbepoetin.Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no behaviors. R2's quarterly MDS date 5/30/25, identified medical diagnoses of anemia (low red blood cell count), coronary disease (CAD), high blood pressure (HTN), renal failure, neurogenic bladder, diabetes mellitus (DM), anxiety, and depression. Currently taking a diuretic (reduces fluid buildup in body) and daily insulin. R2's emergency department (ED) record dated 8/23/24, identified . labs notable for hemoglobin of 6.8 which is baseline between 8 and 9. Creatinine is 3.2 with prior values between 2.5 and 3.3. Emails exchanged with provider and facility assistant director of nursing (ADON) prior to R2's admission to facility on 3/4/25, revealed the following: -on 2/27/25, from ADON to provider - received all correct documentation, diagnoses, length of time it will be prescribed and a note from a specialty it should be covered, would also need to get from a specialty clinic through our pharmacy so that if you guys are able to do a hemoglobin (hgb) this weekend and administer as needed so that we have time to get the medication, we can do Monday at 10:30 a.m. -on 2/28/25, from provider to ADON: the provider will continue monitoring the injections. We can arrange for continued transportation to and from renal clinic. -on 3/4/25, from ADON to provider: just need the layout of his rides and appointment times . main thing is the injections and make sure labs and rides are set-up, our lab days are Mondays. R2's hospital Discharge summary dated [DATE], identified acute kidney injury/chronic kidney disease (commonly caused by HTN and diabetes) vs end stage chronic kidney disease (CKD), stage four (very poor kidney function, kidneys were severely damaged and close to not working), right lower below the knee amputation. Has had progressively worsening renal function, admitted with encephalopathy (brain damage due to lack of oxygen), anemia likely due to CKD stage four and iron deficiency. No indications for dialysis . patient did not want dialysis . Hemoglobin (hgb) (a protein in the red blood cells that carries oxygen and carbon dioxide) dropped less than 7.0 to 6.7, on 2/2/25, transfused with one unit, 2/3/25 hgb 8.2 , and 2/10/25 hgb 8.4. Plan: will continue monitoring hgb intermittently and transfuse for hgb below 7, iron sucrose 200 milligrams (mg) intravenously (IV) times three days (1/28/25 through 1/30/25), started Darbepoetin 1/30/25, currently at 80 micrograms (mcg) every two weeks, next dose 3/13/25, complete blood count (CBC) should be drawn on 3/12/25 prior to dose and a four week follow up appointment. R2's hospital discharge medication orders dated 3/4/25, identified: -Darbepoetin Alfa, Recombinant injection solution 80 mcg/0.8 millimeters (ml) subcutaneously (SQ) every two weeks. Increase dose for next dose 3/13/25 (last dose 2/27/25), renal following indication: anemia. -Needs renal clinic follow up in one month with CBC and comprehensive metabolic panel (CMP) at Veteran's clinic, provider was arranging. Review of R2's electronic medication record (EMAR) for March 2025, April 2025, May 2025, June 2025, and July 2025, lacked evidence the order written on 3/4/25, for Darbepoetin Alfa, Recombinant injection solution 80 mcg/0.8 millimeters (ml) subcutaneously (SQ) every two weeks. Increase dose for next dose 3/13/25 (last dose 2/27/25), renal following, was not located or signed off as administered while R2 resided at the facility from 3/4/35, through 6/19/25, seven missed doses. R2's labs from 3/4/25 through 6/16/25, identified: - on 3/12/25 the R2's record lacked evidence a lab draw was completed as ordered.-on 3/24/25, Albumin (a protein in the blood plasma, keeps fluid from leaking out of the blood stream) 3.3 grams/deciliter (g/dL) low, carbon dioxide (CO2) (helps maintain acid/base balance in your body) 18 millimoles per liter (mmol/L) low, urea nitrogen (waste product the body removes from the blood) 50.6 mg/dl high, creatinine (waste product from muscle metabolism and excreted in urine) 3.6 mg/dL high, glomerular filtration rate (GFR) (checks to see how well the kidneys can filter the blood) estimate 21 mL/min low, hgb 9.1 g/dL low, and hematocrit (HCT) 28.8 %. -on 4/14/25, CO2 21 mmol/L low, urea nitrogen 49.1 mg/dl high, creatinine 3.90 mg/dL high, GFR estimate 17 mL/min low, hgb 9.2 g/dL low, HCT 29% low. -on 6/16/25, hgb 7.6 g/dL low. Handwritten note: results called to provider office and triage will update nurse practitioner (NP) on 6/16/25. Nurse practitioner (NP) visits dated 3/20/25, 4/10/25, 4/29/25, 5/14/25, and 6/10/25, identified list of current medications included Darbepoetin alfa recombinant injection solution 80 mcg/O ml SQ every two weeks. Increased dose for next dose 3/13/25 (last dose 2/7/25), renal following. Indication: for anemia. R2's provider order's dated 4/1/25 through 4/30/35, 5/1/25 through 5/31/25, 6/1/25 through 6/30/25, signed by provider each month, identified: Start dated 3/4/35 end date: open ended: Darbepoetin alfa recombinant injection solution mcg/0.8 ml solution; 0.8 ml; amt: 0.8 ml; subcutaneous. Special instructions: renal following, anemia. R2's renal consult dated 4/3/25, identified kidney function improved today creatinine 3.1, GFR 22 (best in months). Still would not want dialysis. Hgb at 10, continue same dose of Darbepoetin. Next renal appointment 7/2/25, 2:00 p.m. and labs at 1:00 p.m. R2's progress notes from 6/19/25, through 6/23/25, identified: -on 6/19/25 at 11:20 a.m., writer called NP regarding hgb 7.9 resident complained of extreme fatigue and he was not feeling well. Per provider okay to send to emergency room (ER) for evaluation. Resident was agreeable to go to hospital. -on 6/19/25 at 1:25 p.m., resident sent to hospital for low hgb 7.9 with extreme fatigue. Writer contacted power of attorney (POA), spoke with her and notified her of resident status. -on 6/19/15 at 8:19 p.m., writer called hospital . admitted . and unsure when he would be discharged . -on 6/21/25 at 1:04 a.m., writer called hospital . resident was being followed by renal related to high potassium and creatinine and low hgb . no discharge date at this time. During an interview on 7/2/25 at 1:40 p.m., pharmacist (P) stated the facility sent discharge orders dated 3/4/25, from the hospital and included an order for Darbepoetin. The pharmacy would have been able to fill the order and they could have administered it. This medication was ordered due to the diagnoses of severe anemia. The medication helps make red blood cells in order to keep the hgb up and prevent anemia. This medication was a specialty drug and required clarification/preauthorized of the LTC facility. We contacted the facility for clarification, no response back, and Darbepoetin was not ordered, requested, or provided from our pharmacy. This medication was ordered to be administered every two weeks. During an interview on 7/2/25 at 2:20 p.m., PharmD (PD) stated there was an order for Darbepoetin. On 3/4/25, the medication was entered by health unit coordinator (HUC), verified by licensed practical nurse (LPN)-A, and discontinued on 7/2/25. The Darbepoetin was usually administered for anemia and if received would have helped keep up R2's hgb. He ran and reviewed the resident medications every month, searched order history, Darbepoetin did not show up on his reports (EMAR/TAR/notes), and most likely was missed. He was unable to identify when or if the medication was administered while he was a resident at the facility. During an interview on 7/2/25 at 4:15 p.m., HUC stated she was responsible to enter the orders for a new admission into the EMAR from the orders received. The floor nurse or ADON would be the second staff to verify all ordered entered. On 3/4/25, she entered R2's orders into the EMAR and LPN-A came down from 2nd floor and verified them. She recalled the order for the Darbepoetin and was unsure what happened when it was not located on the EMAR. HUC stated she was unaware of this error until it was brought to her attention today. When an order was placed in the general orders, staff were unable to view it on the EMAR to administer the medication and would have only been seen on the order sheets in the electronic medical records. She did not recall a fax or call from pharmacy for clarification regarding that specific medication. During an interview on 7/3/25 at 9:47 a.m., LPN-A stated the HUC uploads the medication orders into the EMAR and then notifies the nurse to verify them. Two staff were required to verify the orders entered and one of them must be a nurse. LPN-A stated he systematically reviewed each medication with the printed discharge orders from the hospital with the EMAR and had not remembered verification of R2's medications on 3/4/25. He was unaware of a medication error (Darbepoetin) and how that could have happened. During an interview on 7/3/25 at 10:15 a.m., ADON stated the HUC was responsible to enter orders into the EMAR and a staff nurse should have verified them. The Darbepoetin was placed in the general order which meant we were not intending to administer it in house. R2 received a dose of Darbepoetin SQ prior to his discharge from the hospital on 3/4/25 and admitted to our facility. He was to continue to receive the injections at the renal clinic. Labs (CBC) were ordered to be completed on 3/12/25 prior to the next injection on 3/13/25 and were not completed until 3/24/25. The HUC would have been responsible to schedule the follow- up appointment with renal provider, who would then administer the injection. R2 was seen by renal on 3/21/25, order was to continue Darbepoetin injections and was signed off by the facility staff nurse. R2 resided in our facility, he was our responsibility, and we failed to follow through and he had not received the Darbepoetin as ordered. The medication should have been given for his chronic kidney disease. This was considered a medication error and the provider should have been notified. Call placed on 7/3/25 at 1:22 p.m., renal provider, voicemail left, but no return call received. During an interview on 7/2/25 at 4:05 p.m., director of nursing (DON) stated the order for the Darbepoetin was entered correctly by the HUC but it may have defaulted and went into the general flow sheet section instead of the medication flow sheet and therefore did not show up on the EMAR. The nurse verified R2's admission orders were entered into the computer system but was unaware this medication was placed in the general section and not on the EMAR, and so it got missed. R2 had not received the Darbepoetin as ordered. Facility policy Administering Medications dated 4/2019, identified medications are to be administered in a safe and timely manner, and as prescribed. Facility policy Adverse Consequences and Medication Errors dated 2/2023, identified the definition of a medication error as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. An example of medication error include omission of a drug ordered but not administered. A significant medication-related error was defined as requiring hospitalization, or extending a hospitalization, requiring medication discontinuation or dose modification, and requiring treatment with a prescription medication.

Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for 2 of 3 residents (R3, R4) reviewed for dignity. Findings include: Resident council meeting minutes dated January 2025 identified call light times were long, March 2025 meeting notes identified call light times were still long. R3's admission MDS dated [DATE], identified intact cognition and no behaviors. He required substantial/maximal assistant with personal hygiene and upper body dressing, dependent upon staff to provide toileting hygiene, lower body dressing, and chair/bed to chair transfers. He had an indwelling urinary catheter and frequently incontinent of bowel. Medical diagnoses included neurogenic bladder (bladder dysfunction caused by neurologic damage due to brain, spinal cord, or nerve problems), urinary tract infection (UTI), paraplegia (paralysis that affects the lower half of the body on both sides), and seizure disorder. R3's care plan dated 4/22/25, identified self-care deficit with ADLs and directed staff to aid with all personal cares, toileting, and transfers. R4's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and no behaviors. He had impairment of functional range of motion (ROM) on one side and required substantial/maximal assistance with toileting hygiene, upper body dressing, personal hygiene, roll left and right, dependent for lower body dressing, all transfers, and used a manual wheelchair for mobility. He was frequently incontinent of bowel and bladder. Medical diagnoses include stroke, hemiplegia/hemiparalysis (paralysis or severe weakness on one side of the body), and depression. R4's care plan dated 6/9/25, identified self-care deficit with activities of daily living (ADLS) and directed staff to provide extensive assistance of one to two staff with all ADLS, bed mobility toileting, dressing, grooming, and wheelchair mobility, transfer with assistance of two staff and Hoyer lift, and care always provided in pairs of two caregivers. During an observation and interview on 7/2/25 at 11:50 a.m., R3 laid on his back, on his bed fully dressed, call light located outside, above his room door was on and activated before entry to room. R3 stated it had taken a long time for them to answer his call light, placed it on 10 minutes ago. R3 stated, they help him get up into his wheelchair, he wears a brief and was able to make staff aware when he required assistance, adding he was in an accident when his legs became paralyzed so he was unable to walk or self -transfer and wished he could do more for himself. He also indicated call light wait times were up to 15 to 20 minutes or longer and he was not ok with that. He was told by staff they do not want him to self-transfer and fall because they would get into trouble, then do not answer his call light for a long time. The long call light wait times happened all the time, not a certain time of the day/night. He stated it bothered him to have to wait a long time for assistance, made him mad, and felt like staff do not care. At 12:05 p.m. R3's call light remained on (over 15 observed minutes). He wanted to get up for lunch and use the telephone. At 12:12 p.m. nursing assistance NA-A carried two plates of food into his room (not acknowledging the call light) She asked him which one he wanted for lunch, R3 chose, she then turned around to exit the room and he stated can I get up in my chair please? NA-A stopped, turned around an stated, oh yea, and continued to walk down the hallway while she carried the plates of food. He stated the call light was turned on at least 10 minutes prior to the surveyor entering my room and would really like to get up for lunch, and off his back as he had been laying down for quite a while now. At 12:15 p.m. no staff were seen in the hallway. R3's call light remained on and continued to beep approximately every 9 seconds. At 12:18 p.m. (over 28 observed minutes) NA-A was seen walking in hallway towards his room, opened the door and entered a room located right before R3's room. In less than one minute NA-A exited the room and walked towards his room, and stated, this man needs to get up and entered R3's room. She informed him he was not forgotten and she had planned on helping him get out of bed. She left the call light on at 12:20 p.m., exited his room, and walked down the hallway. At 12:25 p.m. (over 40 observed minutes and 50 minutes per resident interview) NA-A and NA-B entered his room with a EZ lift machine, closed the door, and turned call light off. During an interview on 7/2/25 at 2:44 p.m., NA-B stated staff were expected to answer a resident's call light within 15 minutes, adding it would be important to respond to call lights right away in case the resident may have fallen, required assistance to be cleaned up or get up, and their needs/expectations are expected to be met. During an interview on 7/2/25 at 4:23 p.m., NA-A stated staff were expected to answer call lights within 15 minutes. We do not know what they are calling for and may be in need of medications, water, or are on the floor. We should not assume why they requested help. We are expected to respond to the call lights in a timely manner to meet the resident's needs. During an interview on 7/3/25 at 2:00 p.m., family member (FM) stated R4 had an episode in June 2025, when staff did not answer his call light for over almost an hour and he was sick and needed assistance. He continued to have concerns about long call light wait times after meals when he was in his wheelchair and requested to go back to bed so that he could use his urinal. Call light response time was anywhere from twenty minutes up to over one hour. There were times when staff came into his room, turned off call light off, indicated they would have to find another staff to assist and had taken up to one hour to return to his room. FM had received phone calls from R4 and he was incontinent of urine and unable to get assistance. He used a urinal to prevent incontinence but required staff to place the urinal for him while in bed. Prior to his stroke he was a very clean and well-groomed person, it really bothered him, and felt embarrassed to have had urine accidents. During an interview on 7/3/25 at 1:44 p.m. director of nursing (DON) stated staff were expected to respond to call lights in less than 15 minutes. The residents relied on staff for care and it could have been an emergent thing they need assistance with. Facility policy Answering the Call light dated 9/2022, identified staff were expected to response to resident call lights in a timely manner to meet their requests and needs. Calls lights were expected to be answered immediately. If resident required assistance indicate the approximate time it will take for you to respond. If the resident request was something you can fulfill, complete the task within five minutes if possible. Facility policy Combined Federal and Minnesota State [NAME] of Rights dated 6/8/19, identified resident rights was defined as a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident had the right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodations of resident needs.

Based on interview and document review, the facility failed to ensure pain medications were re-ordered and available for administration per physician orders for 1 of 3 residents (R2), who had chronic pain and utilized pain medication. This resulted in actual harm when R2 was not administered the physicians ordered pain medication before a pre-scheduled surgery prior to leaving the facility for surgery, and arrived at the surgery center tearful and in severe pain. The facility implemented immediate corrective action prior to the survey and was therefore issued at past non-compliance. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses which included hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (or stroke, a condition where a part of the brain is damaged or dies due to a lack of blood supply) affecting left non-dominant side, chronic pain syndrome, depression and anxiety disorder. R2's cognition was intact. Further, MDS assessment revealed almost constant pain 8/10. R2's Medication Administration Record (MAR) dated 4/9/25, indicated R2 had a physician order for Acetaminophen 325 mg every 6 hours as needed, and Hydrocodone-acetaminophen 10-325 mg four times daily as well as an order for two additional doses as needed (PRN) per day for pain. Further, R1's MAR revealed an order directing staff to administer the following on the morning of surgery date 4/3/25: Acetaminophen 650 milligrams (mg) and Hydrocodone-acetaminophen 10-325 mg PRN 10-325 mg. Registered nurse (RN)-C signed off on the order indicating the medications were administered, however neither medication was administered (no evidence of supply), and no rationale was identified in the resident's record. After review of R2's orders, R2 could receive up to 6 tabs of Hydrocodone-acetaminophen 10-325 mg a day depending on pain level. Review of facility document titled 2nd Floor 24 Hour Report dated 4/1/25, revealed R2 needed a new Norco script. Review of facility document titled 2nd Floor 24 Hour Report dated 4/2/25, revealed R2 had a doctor appointment on 4/3/35 and leaving the facility at 5:00 a.m. Document lacked evidence of staff following up related to obtaining Norco script. R2's Provider On- call Encounter dated 4/2/25, indicated at 9:11 p.m. floor nurse requested new script for oxycodone-acetaminophen script be sent to pharmacy. The order was reviewed and confirmed to be accurate by floor nurse and new script was sent. Nurse Practitioner signed the document on 4/3/25 at 1:15 p.m. R2's Individual Narcotic Record revealed on 3/27/25, 30 tabs of Hydrocodone 10-325 mg were received and on 4/2/25, the last one was administered to R2 at 11:39 p.m. Review of R2's Narcotic Record, on 4/1/25 when staff first identified R1 needed a new script there were 10 tabs of Hydrocodone-acetaminophen remaining which would cover at minimum 2.5 days if R2 did not require an as needed dose. On 4/9/25 at 1:18 p.m., combined interview with anonymous complainant (AC)-A, AC-B, and AC-C indicated R2 had a pre-scheduled surgery and upon arrival to hospital R2 was sobbing with pain, and R2 reported the facility staff did not administer his pain medications. Further, complainants reported R2 was in severe pain and appeared to be cognitively intact and R2 expressed due to staff not administering his pain medication, R2 did not want to return to the facility following surgery. Complainants reported they were able to administer R2 Tylenol upon arrival to assist with pain and R2 received other pain medications related to surgery later. Complainants reached out to facility regarding R2's concerns and facility staff reported pharmacy did not deliver R2's medications. On 4/9/25 at 3:01 p.m., registered nurse (RN)-B stated R2 had a pre-scheduled surgery and she had entered an order into R2's chart regarding specific medications that were to be administered before surgery which included Hydrocodone-acetaminophen. RN-B stated after reviewing R2's MAR the Hydrocodone-acetaminophen was not administered prior to R2's surgery and there was no evidence in R2's record regarding administration or reason for not administering. RN-B stated the importance of R2 receiving the Hydrocodone-acetaminophen and Tylenol prior to surgery would be for pain management, as R2 was traveling a longer distance for the surgery. RN-B reviewed R2's narcotic record and recalled there was an issue with the pharmacy not delivering the Hydrocodone-acetaminophen prior to R2 leaving the facility the morning of 4/3/35 for his surgery. RN-B confirmed there were zero tabs left. R2 had received the last dose the night before surgery and pharmacy delivered 30 tabs on 4/3/25, after R2 had already left the facility. RN-B stated she had retrained all licensed nursing staff on that day, 4/3/25, regarding ordering medications timely from the pharmacy to avoid running out of a medication. On 4/9/25 at 6:43 p.m., registered nurse (RN)-C stated she was R2's nurse during the overnight shift leading into the day of his surgery on 4/3/25. RN-C stated R2 had an order to administer specific medications and his pain medication prior to leaving the facility for his surgery. RN-C stated R2 had received a Hydrocodone-acetaminophen at approximately 1:00 a.m. on 4/3/24, and that was the last one available so RN-C called the pharmacy twice and was told they would be delivered. However, the medication was not delivered to the facility prior to R2 leaving at 4:00 a.m., Further, RN-C stated R2 was upset and R2 did not want to go to the surgery because, he said he had pain and was afraid for the 45-minute ride and sitting that long. RN-C stated R2 then left the facility without pain medication being administered and R2 had refused Tylenol, but RN-C did not document the refusal. RN-C stated staff were expected to notify pharmacy when there are no less than 8 pills remaining and if a new script would be needed ordering would need to be done sooner, especially if the resident was taking the medication more than once daily. RN-C stated she was not sure what happened, and staff should have ordered the medication sooner. RN-C confirmed she did not reach out to R2's provider for direction or the director of nursing (DON). In addition, RN-C stated RN-B had re-educated staff on 4/3/25, regarding ordering medications timely to avoid running out of the medication. On 4/10/25 at 9:30 a.m., DON indicated medications were refilled weekly on Wednesday or 7 days prior to the medication completion. DON stated there was an emergency medication kit at the facility if needed, however Hydrocodone-acetaminophen was not included in the kit. Further, DON stated the pharmacy delivered to the facility up to four times a day and if there were an urgent situation staff were expected to notify the DON. DON stated he was aware of the incident regarding R2 not receiving the medication and DON stated staff did notify pharmacy on multiple occasions however, the pharmacy did not deliver but was unsure why there was a delay. On 4/10/24 at 11:27 a.m., assistant director of nursing (ADON) stated on 4/1/25, staff passed on in report R2 needed a new script for Hydrocodone-acetaminophen and that was what staff were directed to do when a medication was running low, and the following day on 4/2/25, the nurse on day shift called to obtain the script. ADON stated R2 received 4 doses of Hydrocodone-acetaminophen at minimum a day and then two additional doses as needed for pain, so R2 could run out faster if he needed the PRN medication. ADON stated if staff identified the end of the medication with no refills or needing a new script, they would be expected to call 7 days prior. ADON indicated they educated all licensed staff on 4/3/25, following the incident with R2 regarding ordering medications timely. Review of facility policy titled Mission Nursing Home 14-Day Easypak Inservice, undated, indicated medication that much be reordered by nursing include all controlled medication these would be dispensed on 30-day punch cards. Further, it was recommended that medications are reordered when there is a 3-5-day supply left to allow for any clarifications or needed prescription renewals (5-7 days for controlled medications). Refill orders that are faxed, will have a delay of about 24 hours before the information is available for viewing on the Portal.

Based on observation, interview and document review, the facility failed to ensure adaptive equipment was provided for 1 of 2 residents (R3) reviewed for safety while smoking. Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included chronic obstructive pulmonary disease, schizophrenia, and R3 was cognitively intact. R3's Smoking assessment dated [DATE], indicated R3 used 6-10 cigarettes a day and did not have a preference on time of day he liked to smoke. R3 was assessed to need a smoking apron for adaptive equipment while smoking. Further, interdisciplinary team reviewed and determined R3 had a modified smoking plan, wears an apron for safety and had not been observed falling asleep with current assessment. Review of facility document titled Mission Nursing Home Resident Leveling and Smoke Program, undated, identified R3 as a smoker, on a modified smoking program, and required a smoking apron. On 4/8/25 at approximately 10:00 a.m., R3 was observed to self-propel in his wheelchair to the smoking-room door, where door monitor (DM)-A removed R3's oxygen concentrator and assisted R3 inside the smoking room. R3 was then observed to independently smoke a cigarette. DM-A did not assist R3 with a smoking apron. On 4/8/25 at 11:24 a.m., DM-A stated he was responsible for unlocking the smoking room for the residents and assist with any adaptive equipment that the resident required for smoking safety such as apron. DM-A stated he had a list of residents who smoked and what adaptive equipment they required and referred to the facility document titled Mission Nursing Home Resident Leveling and Smoke Program. Further, DM-A confirmed he did not assist R3 with a smoking apron and stated R3 required an apron for smoking outside but did not require an apron if R3 was smoking in the smoking room. DM-A stated he did not have any safety concerns related to R3 smoking and there had been no incidents he was aware of that resulted in R3 sustaining any burns from smoking. On 4/9/25 at 12:28 p.m., R3 confirmed he did not wear an apron while smoking yesterday and stated some staff put an apron on him and some don't. R3 stated he had not sustained any burns or injuries while smoking. On 4/9/25 at 2:37 p.m., assistant director of nursing (ADON) stated upon admission and as needed staff complete a smoking assessment with a resident who was wanting to smoke, after the assessment was completed the interdisciplinary team (IDT) would then review the assessment and discuss if the adaptive equipment identified in the assessment was appropriate. ADON stated each DM had a list of all residents who smoke and what adaptive equipment was required, and the DM would be responsible to implement those interventions and assist with the adaptive equipment to ensure the resident was safe while smoking. On 4/9/25 at 3:01 p.m., registered nurse (RN)-B stated R3 was alert and orientated and required staff assistance with activities of daily living (ADLs). RN-B stated R3 was identified as a smoker and required an apron while smoking inside or outside to prevent any burns. RN-B stated there had been no incidents or burns for R3 that she was aware of. Further RN-B stated a smoking assessment would be completed with the resident and brought to the IDT meeting to review and determine interventions and adaptive equipment needs. RN-B stated the DMs would then be given a list that would identify interventions and adaptive equipment each resident required, and the DMs would be responsible to implement. On 4/10/25 at 9:30 a.m., director of nursing (DON) stated upon admission a smoking assessment would be completed to determine any adaptive equipment needs and the assessment would then be reviewed at the IDT meeting. DON stated a list, which DON identified as the facility document titled Mission Nursing Home Resident Leveling and Smoke Program, would be provided to the DMs and on the list adaptive equipment required would be identified and DMs would be expected to implement and assist the resident. Review of facility policy titled Mission Nursing Home (MNH) Smoking Policy implemented 2024, indicated any resident with adaptive equipment to safely smoke would be set up by staff, monitoring shall occur by a staff or family member, visitor or volunteer as needed.

Based on observation, interview, and document review, the facility failed to ensure call lights were within reach and accessible for 1 of 3 residents (R2) who was dependent on staff for care. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses which included hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (or stroke, a condition where a part of the brain is damaged or dies due to a lack of blood supply) affecting left non-dominant side, chronic pain syndrome, depression and anxiety disorder. R2's cognition was intact and R2 required substantial assistance by staff for toileting, dressing, and bed mobility. On 4/9/25 at 12:16 p.m., R2 was observed in his room sitting in his standard manual wheelchair. R2's call light was wrapped around the grab bar of his bed on the left side along the window and wall side of his room. R2 was in front of the television and call light was not within reach. R2 stated he would utilize the call light to get staff's attention however its on the side of the bed stating, I tell them not to put it there but that is where it's at. R2 added sometimes he had to call his sister using his personal cell phone to have her call the facility to let the staff know he needed assistance because his call light was not accessible. Further, R2 stated he also had to self-propel himself in his wheelchair to the nurses' station to get staff to assist him, we have had problems with that. In addition, R2 stated he was not able to stand up from his wheelchair without assistance and reach across his bed to get to his call light especially since the left side of his body was immobile following a stroke. On 4/9/25 at 12:24 p.m., registered nurse (RN)-A enters R2's room to offer R2 his lunch options. When asked about the call light, RN-A unwrapped R2's call light from the grab bar and clipped the call light to edge of the bed. RN-A stated staff were expected to ensure R2's call light was within reach if he was not in bed. On 4/9/25 at 12:33 p.m., RN-A approached surveyor and stated she spoke with RN-B and R2's call light was supposed to be tied to the handrail so he can reach over and press it I guess. On 4/9/25 at 3:01 p.m., RN-B stated R2 required staff assistance with all activities of daily living (ADLs) and stated staff would be expected to remove R2's call light from the grab bar and drape it across his bed so R2 could easily grab it. RN-B stated R2 would not be able to stand up from his wheelchair independently as he required assist of two staff with a mechanical lift for transfers. On 4/10/25 at 9:30 a.m., director of nursing (DON) stated staff were expected to ensure call lights were within reach and accessible to all residents. Review of facility policy titled Resident Care-Call Light dated 11/24, indicated residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. Further, each resident would be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to develop a plan that defined measurable goals and create a system to collect feedback from resident and resident representatives. This had the potential to affect all 56 residents in the facility. Findings Include: During entrance interview on 3/10/25 at 12:54 p.m., a request for a copy of the Quality Assurance and Performance Improvement (QAPI) plan was made to the director of nursing (DON). On 3/13/25 at 1:37 p.m., another request was made for a copy of the QAPI plan. On 3/13/25 at 2:25 p.m., the facility's QAPI program policy was provided. On 3/12/25 at 2:44 p.m., the director of nursing (DON) provided meeting minutes for the last four quarters, but failed to provide an overall plan. QAPI meeting minutes included attendees, agenda, and data related to focuses such as infections, wounds, medication errors, admission/discharges, and weight changes. The document lacked evidence of target goals for sustainability. The document failed to provided evidence that resident and resident representative feedback was obtained to assist in determining quality measures. During interview on 3/13/25 at 2:44 p.m., DON stated they do not have a document that specifically states goals and how the facility will evaluate if the focus was successful or not. The DON was unable to state how feedback was collected from residents and resident representatives. Facility QAPI policy dated March 2020, included it was the QAPI committee's duty to establish benchmarks and goals by which to measure performance improvement.

Based on observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed on residents who wished to smoke for 5 of 5 residents (R54, R16, R34, R52 and R19) reviewed for smoking. Findings include: An undated facility document titled Mission Nursing Home Resident leveling and Smoking program identified R54, R16, R34, R52 and R19 as current smokers. R54's admission minimum data set (MDS) dated [DATE], indicated R54 admitted to the facility on [DATE] and had the following diagnoses: Stroke, Non-traumatic brain dysfunction, traumatic brain dysfunction, progressive neurological conditions, and traumatic spinal cord dysfunction. The MDS further indicated R54 was cognitively intact and identified R54 as a current tobacco user. R54's face sheet printed 3/12/25, identified R54 as a current daily smoker. R54's care plan with a last review/revision date of 3/10/25, indicated R54 was an independent smoker, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R54's comprehensive smoking assessment, dated 11/27/24, indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R54's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R54's signature was on the bottom of the form next to the date of 12/27/24. A facility representative signature identified as social services (SS)-A was below R54's signature. R16's admission MDS dated [DATE], indicated R16 admitted to the facility on [DATE] and had the following diagnoses: stroke, high blood pressure, hemiplegia (paralyzed on one side of the body) anxiety and depression. The MDS further indicated R16 was cognitively intact and identified R16 as a current tobacco user. R16's face sheet printed 3/12/25, identified R16 as a current daily smoker. R16's care plan with a last review/revision date of 1/21/25, indicated R16 was an independent smoker, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R16 had a completed comprehensive smoking assessment completed on 6/27/23, four months after his admission. No further smoking assessments were completed or provided. R16's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R16's signature was on the bottom of the form next to the date of 12/27/24. A facility representative signature identified as SS-A was below R16's signature. R34's admission MDS dated [DATE], indicated R34 admitted to the facility on [DATE], and had the following diagnoses: progressive neurological disorders, dementia, vascular dementia and personal history of trans ischemic attack (temporary blockage of blood flow to the brain). The MDS further indicated R34 was not cognitively intact. R34's face sheet printed 3/12/25, identified R34 as a former smoker. R34's care plan with a last review/revision date of 3/3/25, indicated R34 was an independent smoker, who had previously quit but had restarted smoking, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R34's comprehensive smoking assessment dated [DATE], indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R34's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R34's signature was on the bottom of the form next to the date of 9/3/24. A facility representative signature identified as SS-A was below R34's signature R52's admission MDS dated [DATE], indicated R52 admitted to the facility on [DATE], and had the following diagnoses: anemia, high blood pressure, traumatic subdural hemorrhage, anxiety and depression. The MDS further indicated R52 was cognitively intact and identified R52 as a current tobacco user. R52's care plan with a last review/revision date of 2/4/25, indicated R52 was a dependent smoker and would need assistance to smoke as he was unable to hold a cigarette, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R52's comprehensive smoking assessment, dated 12/26/24, (two months after admission) indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R52's medial record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R52's signature was absent on the bottom of the. A facility representative signature identified as SS-A was below R52's printed name and was dated 1/15/25. R19's admission minimum data set (MDS) dated [DATE], included an admitted [DATE]. R19's diagnoses included hemiplegia (weakness on one side of the body), diabetes, and chronic obstructive pulmonary disease (COPD). R19's care plan reviewed 2/6/25, included R19 was an independent smoker. Care plan included resident would be reassessed for smoking annually and with significant change. Progress note dated 1/16/25, included R19 went downstairs for smoking as scheduled. R19's comprehensive smoking assessment dated [DATE], was incomplete with no data entered. During an interview on 3/11/25 at 1:48 p.m., SS-A stated no one person was solely responsible for completing the smoking assessment but it was the responsibility of multiple staff including nursing, social service and therapy services. SS-A stated nursing staff completed the first portion of the assessment which included watching the resident smoke to determine safety. SS-A went on to say a smoking assessment must be completed upon admission before a resident was allowed to smoke independently and then annually and with any significant change of condition. SS-A stated certain behaviors such as smoking outside of the designated smoking areas like in a resident room, or a resident who was noted to have burn marks on their clothing would indicate a necessity to be reassessed for safe smoking. During an interview on 3/12/25 at 10:01 a.m., director of nursing (DON) stated if an assessment was listed as in progress it indicated the assessment was still open and had not been completed. DON stated the initial smoking assessment should be done as part of the admission process and needed to be completed before a resident was allowed to smoke independently. DON went on to say after nursing completed the initial assessment, social services and if necessary, therapy would complete their portion of the smoking assessment and make recommendations for independent smoking, dependent or supervised smoking or needed adaptive equipment for smoking. Further, the DON stated in addition to being assessed as part of the admission process, a smoking assessment would also be completed annually and with any change of condition. DON stated a resident who had not been assessed for smoking, or whose assessment was not completed should not be allowed to smoke either independently or supervised until the smoking assessment was completed in its entirety by all required staff. Additionally, DON stated he expected staff to complete all necessary assessments on time and to communicate the findings of those assessments with the interdisciplinary team to ensure all team members were made aware of individual needs. DON stated completing, documenting, and communicating the results of the smoking assessment was important for resident safety, and to ensure any necessary precautions were being followed to prevent potential injuries to residents. Furthermore, DON confirmed R54's smoking assessment had not been completed, R16 had been assessed four months after admission in 2023 but had not received an annual assessment in 2024 or 2025, R34's smoking assessment had not been completed, R52's smoking assessment had not been started until two months after admission, but had never been completed, and R19 had never been assessed for smoking. Facility Policy title MNH Smoking Policy with a last revised date of 12/2024 indicated all residents who wished to smoke would be assessed for function, cognition, and financial ability to participate in the smoking program. The policy also indicated residents would be assessed upon admission to determine ability to smoke safely with or without supervision and would be reassessed annually, upon significant change (cognitive or physical) and as determined by staff. 49654

Based on interview and document review, the facility failed to ensure a level II pre-admission screen and resident review (PASSAR) was completed prior to admission for 1 of 1 residents (R54) reviewed who required a level II PASSAR screening for mental illness. Findings include: R54 quarterly minimum data set (MDS) dated [DATE], indicated R54 was cognitively intact, and had experienced feeling down, hopeless or depressed, had trouble falling asleep or staying asleep, felt tired or had little energy, and had difficulty concentrating on things at least half or more days in the two weeks prior to the assessment. R54's face sheet printed 3/12/25, indicated an admitted [DATE], identified R54 as a veteran and listed diagnoses to include major depressive disorder, anxiety disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder and opioid dependency. R54's Minnesota Senior linkage Line preadmission screening results dated 11/25/24, indicated R54 met the requirements for a mental illness OBRA Level II assessment. The screening identified a lead agency and provided contact information. R54's medical record was reviewed on 3/10/25 and lacked documentation of results of a Level II assessment. During interview on 3/11/25 at 1:46 p.m., social services designee (SS)-A confirmed R54's chart lacked any documentation of a Level II assessment being completed. SS-A stated R54's admission PASSAR identified suicidal ideations in the six months prior to his admission PASSAR assessment and a Level II PASSAR was required to offer additional resources to R54. SS-A stated it was important to have the Level II PASSAR completed to ensure residents received all available mental health services. Facility policy was requested but not provided.

Based on interview and document review the facility failed to implement a process for antibiotic stewardship to determine appropriate indications, dosage, duration, symptoms, analysis of trends and efficacy of antibiotic use. This had the potential to affect any of the 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April of 2024. The logs identified tracking records of residents with infections, cultures, and antibiotic treatments. However, the facility lacked documentation of analysis, trending of patterns identified or efficacy of antibiotics used. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admitted , room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was isolated or not. Furthermore, the form included sections regarding tracking of infections such as total number of different types of infections, number of new cases with and with out antibiotic resistance organisms, total number of infections, and reporting time period. Four infection control logs were provided by the facility, of those four, two were labeled April of 2024 and two were labeled May of 2024. One of the May of 2024 logs designated 2nd floor as a location, the other three lacked a location. The two infection control logs dated April of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis of antibiotic usage and efficacy within the facility. The two infection control logs dated May of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis of antibiotic usage and efficacy within the facility. The Quality assurance (QA) meeting minutes dated 4/8/2024, listed infection control: Jan-7, Feb-4, March-10. No additional details were provided. On 5/30/24 at 9:31 a.m., the infection preventionist licensed practical nurse (LPN)-A stated since the previous director of nursing (DON) left the facility near the end of March 2024, the current DON was responsible for antibiotic stewardship in the facility. On 5/30/24 at 11:45 a.m., the DON stated since the previous DON had left the facility the infection preventionist LPN-A had been completing antibiotic stewardship. DON had not completed antibiotic stewardship. On 5/31/24 at 1:22 p.m., the DON O-B and LPN-A confirmed neither person had been analyzing the data, usage trends and efficacy of antibiotics in the facility since the exit of the previous DON in late March 2024. DON and LPN-A stated each day during their interdisciplinary team meeting they discuss all new orders and why the resident was placed on the antibiotics. Staff were expected to chart in progress notes if the antibiotics were working or any reactions occurred. However, there was no follow up unless completed by the floor nurses. On 5/31/24 at 3:30 p.m., the administrator stated the the DON had been analyzing and trending the antibiotic stewardship program. They were informed the DON had stated it had not been completed. Administrator stated they also discussed them at QA, however deferred to nursing to provide the information discussed. The Antibiotic Stewardship Policy last reviewed in 2024, indicated the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in our residents. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents.

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (quarter one), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the facility Payroll Based Journal Report (PBJ) [NAME] Report 1705 D for quarter one (10/1/23 to 12/31/23) identified a 1-star staffing rating and failure to submit PBJ data. Review of staffing schedules identified the facility had a registered nurse at least 8 hours of every 24 hours and/or a licensed nurse 24 hours seven days a week per requirement for the above-mentioned dates and therefore the data reflected in the PBJ to CMS was inaccurate. When interviewed on 5/31/24 at 3:00 p.m., the payroll manager stated he used to submit the facility PBJ report quarterly but had lost access to the CMS submission site and so then the administrator took over the submissions. When interviewed on 5/31/24 at 3:00 p.m., the administrator stated he started submitting the PBJ report after the payroll manager lost access and acknowledged he had inadvertently failed to submit direct care staffing information for quarter one. There was no policy related to PBJ entries provided by the end of the survey.

Based on interview and document review the facility failed to ensure the infection control program included symptom tracking and ongoing analysis of trending of resident infections to prevent the spread of infections. This deficient practice had the potential to affect all 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April 2024. The logs identified tracking records of residents with infections, cultures, and treatments. However, the facility lacked documentation of analysis and/or trending of patterns identified. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admitted , room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was isolated or not. Furthermore, the form included sections regarding tracking of infections such as total number of different types of infections, number of new cases with and with out antibiotic resistance organisms, total number of infections, and reporting time period. Four infection control logs were provided by the facility, of those four, two were labeled April of 2024 and two were labeled May of 2024. One of the May of 2024 logs designated 2nd floor as a location, the other three lacked a location. The two infection control logs dated April of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis or tracking of symptoms and infections within the facility. The two infection control logs dated May of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis or tracking of symptoms and infections within the facility. The Quality assurance (QA) meeting minutes dated 4/8/2024, listed infection control: Jan-7, Feb-4, March-10. No additional details were provided. On 5/30/24 at 9:31 a.m., the infection preventionist licensed practical nurse (LPN)-A stated since the previous director of nursing (DON) left the facility near the end of March 2024, the current DON was responsible for symptom tracking and antibiotic stewardship in the facility. On 5/30/24 at 11:45 a.m., the DON stated since the previous DON had left the facility the infection preventionist LPN-A had been completing symptom tracking and antibiotic stewardship. DON had not completed either task. On 5/31/24 at 1:22 p.m., the DON and LPN-A confirmed neither person had been analyzing the data and trends with symptom tracking and antibiotic stewardship in the facility since the exit of the previous DON in late March 2024. On 5/31/24 at 3:30 p.m., the administrator stated they believed the DON had been analyzing and trending symptom tracking and antibiotic stewardship. They were informed the DON had stated it had not been completed. Administrator stated they also discuss them at QA, however deferred to nursing to provide the information discussed. The Infection Control-Surveillance Policy last reviewed 7/2023, indicated the infection preventionist or designated personnel was responsible for gathering and interpreting surveillance data. Interpreting Surveillance data: Analyze the date to identify trends, compare previous timeframes. The infection preventionist and quality assurance committee will review data quarterly to identify predominant pathogens or sites of infection or in particular units by recording month to month and observing trends.

Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R19) reviewed for dignity. Findings include: R19's admission minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS-cognitive test) score of 15/15 indicating cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included but were not limited to hemiplegia (weakness or paralysis of one side of the body), bipolar disease (a mental health condition that causes mood swings), and hypertension (high blood pressure). R19's care plan dated 2/14/24 indicated R19's ability to perform activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive staff assistance of one to two staff for toileting, dressing, bathing, grooming and bed mobility. Total dependence with Hoyer lift (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) for all transfers. R19's occupational therapy assessment dated [DATE] indicated R19 had diagnoses of hemiplegia and muscle weakness which required the need for assistance with personal cares. The assessment further indicated R19's left upper extremity to include shoulder, forearm, elbow, wrist, and hand were impaired with decreased strength and movement. During observation on 5/29/24 at 03:04 p.m., R19 was driving an electric wheelchair in hallway outside his room and through doorway into his room. R19 was wearing a light brown T-shirt, black basketball shorts, white ankle socks and tennis shoes. R19's shorts were tucked under abdominal fold and t-shirt was pulled up over the abdomen, above the belly button exposing approximately six inches of R19's stomach. A tan Hoyer sling was noted under resident with straps hanging loose. During observation on 5/30/24, at 02:12 p.m., R19 was driving an electric wheelchair towards smoking room on first floor wearing black basketball shorts and green t-shirt. R19's shorts were tucked under abdominal fold, legs During interview on 5/30/24 at 10:26, a.m., certified nursing assistant CNA-B stated after transferring a resident into their wheelchair staff should make sure their clothing was pulled down and neat. were bunched together and the shorts were pushed in towards his groin, T-shirt pulled up over abdomen exposing approximately 4 inches of R19's stomach. [NAME] edges of adult incontinent product was exposed at side waist band of basketball shorts. A tan Hoyer sling was visible under R19. During interview on 5/30/24 at 10:51 a.m., CNA-C stated if a resident's clothes were pushed up or under after a transfer, we fix them. During interview on 5/30/24, at 10:59 a.m., DON stated she expected staff to fix the residents clothes after transfers and expected staff to make sure they were happy with how they looked. Additionally, any refusals needed to be documented. DON stated not doing so could be embarrassing to the resident and affect their dignity. DON went on to say it was important to assist residents and ensure they feel good about how they look and feel. During observation on 5/31/24, at 09:19 a.m., R19 was seated in wheelchair in front of nurse desk wearing gray t-shirt, black basketball shorts, white ankle socks and tennis shoes. T-shirt pulled up exposing approximately 3-5 inches of stomach. [NAME] edges of adult incontinent product observed over waist band of basketball shorts. A tan Hoyer sling was under R19 with sling straps behind and to the outside of knees. During interview on 5/31/24, at 11:50 a.m., R19 stated he did not like the sling left under him after transfers, and right now my diaper is showing. R19 went on to say when his shirt was not pulled down everyone can see my fat and stretch marks .it makes me feel bad and people make fun of me. At 12:56 p.m., after transfer from bed to wheelchair R19 asked staff if his pants were up and stated I feel like my diaper is hanging out. Its embarrassing. CNA-D adjusted R19's shirt and shorts to cover R19's exposed skin. A facility policy was requested but none provided.

Based on observation, interview and document review, the facility failed to assess and implement interventions for 1 of 1 residents (R1) with escalating behaviors, including a newly recorded incident of physical assault. These findings resulted in an immediate jeopardy (IJ) situation for R2 and potentially other residents who R1 may become verbally or physically aggressive with. The IJ began on 5/12/2021, at 4:26 p.m. when R1, who had a documented history of verbal aggression and threatening behavior, hit R2 on the right side of the face. R1 was subsequently removed from the facility by law enforcement for a felony arrest warrant and was returned to the facility on [DATE] at 6:15 p.m. Upon his return, R1 was not comprehensively assessed and interventions were not implemented to mitigate risk to others. The director of nursing (DON) was notified of the IJ on 5/18/2021, at 6:00 p.m. The IJ was removed on 5/20/2021, at 11:05 a.m. when the facility implemented an acceptable removal plan. Non compliance remained at a lower scope and severity of a D, isolated, 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], indicated R1 was cognitively intact and independent with activities of daily living (ADL). R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan last updated on 2/16/2021, identified R1 had behavioral symptoms and directed staff to leave resident alone if R1 was threatening physical aggression towards staff and return when R1 was calm, provide redirection as needed and staff are not to personalize any negative statements R1 makes towards them. Additionally, R1's care plan indicated R1's [CONDITION(S)] drug use and directed staff to allow R1 to vent feelings, monitor mood, behaviors daily and notify R1's physician if these occur. Pharmacy consultant to review medications as scheduled and Associated Clinic of Psychology (ACP) referral. Review of R1's progress notes since 2/16/2021, included multiple entries indicating aggressive behaviors, physical threats towards residents and verbal threats toward staff, including but not limited to the following: A progress noted dated 2/16/2021, at 9:45 p.m. indicated during dinner meal, R1 was heard threatening another resident that lived in the room next to him, due to making noise and yelling in am. R1 likes to sleep in and skip breakfast and lunch and becomes very angry and aggressive if woken. R1 stated to the other resident that if the noise continues in the morning, HE [R1] will stop it permanently. Writer intervened after hearing the threat and told R1 that threats toward other residents in that manner would not be tolerated. R1 replied, That is not a threat that is a promise! R1 was again asked to be patient with the other resident due to resident being hard of hearing and unaware of the noise he makes. R1 then started making comments about writer to table mate, stating, I would like to lay that [OBSCENITY] out and other comments against writer and nursing staff. R1's behavior will continued to be documented and administration was made aware of comments. A progress noted dated 2/20/2021, at 10:32 p.m. R1 accused resident in RM 1405 of taking the TV remote out of the TV room. R1 was swearing and belligerent toward the other resident. At one point R1 jumped out of wheel chair and started to charge at resident in RM 1405 and also threatened him. Resident in RM 1405 told R1 that he did not take the remote nor did he know where the remote was. Resident in RM 1405 did say things back to R1 and writer could not hear what the resident was saying. A progress note dated 3/15/21, at 11:41 p.m. included R1 curses and belittles with real vehemence. This intense verbal hostility lurks close to the surface all of the time. It is not possible to detect any substantial changes in R1's personality or behavior as a result of the addition of [MEDICATION(S)] to his regimen of medications. A progress note dated 4/5/21, at 6:55 p.m. included R1 triggered an intense, short verbal confrontation concerning the [NAME] trial with another resident. R1 exploded when the other resident expressed a differing opinion about the cause of [NAME] Floyd's death. The residents exchanged a stream of insults and racist epithets and threatened one another physically. Nurses and staff got between the two men and removed the other resident from the dining room at his request. R1 was told to cut off discussion of the topic and he largely complied. A progress note dated 5/11/2021, recorded as a late entry on 5/13/21 indicated, This resident is rude and belligerent to staff; he also slings racial slurs at employees of other countries. Over the last 24 hours, he has provoked several arguments with other residents, and actually right hand punched the other resident in the face, causing redness and swelling. The police were called, and this resident was found to have an outstanding warrant. He was taken into custody this morning for felony assault in another county. A progress note dated 5/14/21, at 11:51 p.m. indicated per PM shift, resident returned from jail around supper time. An evaluation by Associated Clinic of Psychology (ACP) on 3/7/2021, indicated R1 expressed anger over someplace that R1 used to stay. R1 reported that many of his belongings were stolen, including several personal items that were emotionally important to him. R1 spontaneously stated that he wanted to go to his other storage facility, get his gun, return to the facility and shoot people, particularly targeting anybody that would have had access to his belongings in storage. The ACP note further indicated R1 apparently told the same threat to a Hennepin County caseworker a few days ago who was concerned enough to let ACP know about the threat. During interview on 5/17/21, at 12:06 p.m. the director of nursing (DON) stated R1 is verbally abusive to staff calling staff the N word, making sexually inappropriate comments towards staff and would become verbally abusive towards other residents. To protect others from R1 verbally and physical threats, the DON stated they were closely monitoring R1 since the assault. Further, the DON stated R1 stayed in his room for the most part with the exception of coming out for dinner. Additionally, the DON stated the facility was working on getting R1 discharged from the facility. During observation and interview on 5/17/21 at 2:00 p.m. R1 came up to the 2nd floor conference room that was at the opposite end of the hall from the elevators. R1 resides on first floor and he came up unattended. R1 stated he is polite to everyone and does not get into conflict. He further stated in regards to the incident where he recently hit another resident, R1 stated his hand had a mind of its own and he is not sure why he hit R2. R1 then referenced an earlier argument that he had with R2 when R2 woke R1 up. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated a BIMS score of 13 (cognitive assessment score that indicates cognitively intact) and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with R2 on 5/18/2021, at 10:45 a.m. R2 indicated R1 used his fist and hit him on the temple and that he thought it was because he had woke up R1 earlier and R1 was mad at him about that. R2 stated he was not aware he was supposed to stay away from R1 and that he has had contact with him since the incident. R2 further stated he is staying away from R1, not because he is afraid of him, rather because R2 is afraid he will hit R1. R2's progress note dated 5/12/2021, at 6:11 p.m. indicated R2 was struck on right side of the face with another residents fist, causing redness and pain to the right cheekbone. R2's progress note date 5/13/2021, at 8:06 p.m. indicated interdisciplinary (IDT) discussed event. The alleged perpetrator (AP) was sent to jail for assault and will be discharged to a shelter if the police return him. Post incident skin checks and pain assessment for 5 days. Residents will be kept separated while in commons area. R2's Care Plan with a last review date of 5/2/2021, did not include any information regarding the assault incident including keeping R1 and R2 separated. During interview with the DON on 5/18/2021, at approximately 11:00 a.m. when referencing the visit from R1 the previous day in the conference room when R1 was unattended, the DON apologized and stated she would have been afraid to be alone in a room with R1. During interview on 5/18/2021, at 11:05 a.m. nursing assistant (NA)-B stated she was not aware of any special monitoring of R1 and R2, nor any requirement to keep them separated. During interview on 5/18/2021, at 12:25 p.m. NA-A stated he was not aware of any special monitoring for R1 and R2. R7's quarterly MDS dated [DATE], indicated R7 had a BIMS score of 12 (moderately impaired) and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 5/18/2021, at 12:42 p.m. R7 stated he knew R1 from his past and felt that R1 was a threat to the facility and eventually something bad will happen for instance R1 will jump out of R1's wheelchair and stand over other residents yelling abusively at them in an aggressive manner, especially towards cognitively impaired residents. Additionally, R7 stated, He is a bad [NAME] and should not be in the facility. Further, R7 stated R1 is a criminal and a felon and is a threat to residents who cannot protect themselves. During observation on 5/18/2021, at 1:08 p.m. R1 was observed wheeling out of his room past several residents with no staff in close proximity to monitor R1. During interview on 5/18/2021, at 2:49 p.m. registered nurse (RN)-B stated R1 had very little self-control, has a foul temper, is unpredictable. Further, RN-B stated R1 threatens violence with staff and residents and that RN-B caters to [R1] more than he should so [R1] does not hurt anyone or get into a conflict. RN-B also stated R1 is not appropriately placed in the facility and the changes to R1's psychiatric medications have had little to no effect on R1's mood or behavior. RN-B also stated R1 will deliberately jump down other residents' throats in an absolutely more aggressive manner than any other resident in the facility and R1's threshold is so low and that R1 is easily provoked. The IJ that was called on 5/18/21, was removed on 5/20/2021, when it was verified that the facility had reassessed R1 as well as other residents at risk, had educated staff and developed policy and procedures to follow in the event of any future incidents or verbal or physical aggression. In addition, R1 was discharged from the facility on 5/19/21. Progress Note dated 5/19/21, indicated R1 was given a written notice to discharge today, although this has been discussed the last couple of days. Due to his escalating behaviors, including physical aggression toward another resident, he was discharged today. The facility Abuse Prevention and Prohibition Policy revised 11/4/20, identified a risk of residents admitted who had committed a violent crime or act of physical aggression toward others, and the Social Services Director and/or DON would screen potential residents for indications of abusiveness, history of abuse, and the potential to abuse others. The policy further indicated specific measures would have been identified, and an individual abuse prevention plan would have been completed by Social Services, placed behind the care plan in the medical record and reviewed quarterly. Additionally, the policy indicated the individual abuse prevention plan would have been revised at the time of incidents of alleged abuse, interventions would have been developed, and specific resident's aggressive behaviors would have been discussed at behavior management meetings.

Based on interview and document review, the facility failed to ensure a safe environment was provided to protect residents from sexual abuse for 3 of 5 residents (R1, R2, and R3), reviewed for allegations of resident to resident sexual abuse. The facility was aware R4 had previous incidents of sexual assault towards other residents and did not ensure R4 was assessed and supervised to prevent further sexual assault. R1, R2, and R3, experienced actual harm when they were sexually assaulted by R4 and were not cognitively able to consent. Findings include: R1's Quarterly Minimum Data Set (MDS), dated (MONTH) 31, (YEAR), indicated the resident had severe cognitive impairment, required extensive staff assistance with all activities of daily living (ADL)'s, was unable to walk, and required the assistance of one staff person to move around the unit. R1's care plan dated (MONTH) 16, (YEAR), indicated the resident had impaired memory, judgement, and decision-making skills. R1 was not responsive to the surrounding environment, and staff were directed to refer to R1's power of attorney (POA) for healthcare decision-making as R1 was unable to make his own decisions related to cognitive impairment. R1's facility Abuse Prevention Plan (APP), dated (MONTH) 28, (YEAR), indicated the resident had cognitive impairment which increased his susceptibility to maltreatment. The APP indicated the resident had Alzheimer's dementia with short and long-term memory deficits, and impaired judgement and decision-making. R1 was also noted to to have mood and behavior issues that increased his risk for mistreatment. R2's Quarterly MDS, dated (MONTH) 21, (YEAR), indicated the resident had moderately impaired cognition and disorganized thinking. R2 was independently with mobility, and required extensive staff assistance with dressing, toilet use, and personal hygiene. R2's care plan, dated (MONTH) 12, (YEAR), indicated the resident had dementia with short and long-term memory impairment. R2's care plan directed staff to assist the resident with daily decision-making. R2's facility APP, dated (MONTH) 12, (YEAR), indicated the residents cognitive impairment increased his susceptibility to maltreatment. R2 had short and long-term memory deficits, denial of his deficits, and impaired judgement and decision-making skills. Staff were directed to assist R2 with daily decision making to minimize the resident's risk for mistreatment. R3's Significant Change MDS dated (MONTH) 16, (YEAR), indicated the resident had severe cognitive impairment. The resident was unable to ambulate, had mobility impairment in both arms, and required extensive assistance from staff with ADL's. R3 had impaired mobility to both of his arms. R3's care plan, dated (MONTH) 12, (YEAR), indicated the resident was unable to express his emotions or share information. R3 often responded to questions by shaking his head yes or no. The care plan indicated R3 had alcohol-induced dementia and [MEDICAL CONDITION], and at times became confused or agitated. R3's care plan directed staff to anticipate the resident's needs at all times as the resident does not speak and can not always makes his needs known. R3's facility APP dated (MONTH) 25, (YEAR), indicated the resident had increased susceptibility to maltreatment related to cognitive impairment. R3 was identified as having alcohol-induced dementia with short and long-term memory deficits, and impaired judgement and decision-making skills. R3 also had difficulty communicating, which his APP indicated put him at risk for mistreatment. R4's Quarterly MDS, dated (MONTH) 2, (YEAR), indicated the resident had moderately impaired cognition. The resident did not ambulate and required extensive staff assistance with all ADL's except eating. R4's care plan, dated (MONTH) 27, (YEAR), indicated the resident had mood and behavior issues due to dementia, anxiety, depression, and mood disorder. The care plan indicated the resident had a history of [REDACTED]. The care plan indicated the resident had current episodes of masturbating in common areas of the facility, and was verbally and physically inappropriate towards female staff. R4's care plan also indicated the resident had episodes of touching other residents to sexually stimulate them. Staff were to redirect the resident when he was displaying inappropriate behaviors, set firm boundaries, and keep R4's guardian updated about the resident's behaviors. R4's Psychiatric assessment dated (MONTH) 26, (YEAR), indicated the resident had been engaging in sexually inappropriate behavior with female staff and physically threatening others. R4 was found masturbating in an activity room, and also in the presence of a staff person. The assessment indicated R4 had mild to moderate cognitive impairment, had short and long-term memory problems, and continued to display disinhibited behaviors. The Psychiatrist recommendations included ensuring R4 was not alone in the same room with vulnerable residents to deter them from engaging in sexually inappropriate behavior together. Staff were directed to document each incident of sexually inappropriate behavior towards others to determine if any patterns could be identified and to provide insight into R4's behaviors. Staff were encouraged to consistently be clear with R4 that his sexual behaviors were inappropriate. Recommendations related to R4's cognitive impairment included to rule out medical causes or medication side effects when staff observes a sudden change in R4's behavior. R4's Psychiatric Evaluation dated (MONTH) 17, (YEAR), indicated the resident had a history of [REDACTED]. The psychiatrist indicated R4's [MEDICAL CONDITION] medications would not be adjusted because the medication appeared to have helped R4's sexual behaviors to become less frequent. A facility incident report dated (MONTH) 6, (YEAR), indicated at 10:35 a.m. the director of activities (DOA)-C returned to the activity room and found R4 had exposed and was manipulating R3's penis. DOA-C told R4 to put his penis away, and she covered up R3. Shortly after the incident, another resident alerted DOA-C to R4, who again had exposed his penis and was manipulating it. The incident report indicated DOA-C again asked R4 to put his penis away and brought R4 to the nursing station. A nurse brought R4 back to his room. The report indicated the intervention was for staff to supervise R4 when he was in common areas. Staff did not add an intervention to R4's care plan directing staff to keep him in view at all times when out of bed until (MONTH) 11, (YEAR). Attached to the incident report was a physician's medication order for R4 dated (MONTH) 26, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) twice a day (BID) for restlessness and agitation. The physician also prescribed [MEDICATION NAME] 0.25 mg every four hours as needed (PRN), for restlessness and agitation. R4's physician discontinued R4's PRN [MEDICATION NAME] on (MONTH) 26, (YEAR), and discontinued his scheduled BID [MEDICATION NAME] on (MONTH) 6, (YEAR). Handwritten on R4's medication orders was, Failed GDR (gradual dose reduction). R4's progress note, dated (MONTH) 6, (YEAR) at 11:37 a.m., indicated the incident involving R4 and R3 occurred as described above. R3's progress note, dated (MONTH) 6, (YEAR) at 2:35 p.m., indicated his guardian was updated regarding another resident touching his penis in the activity room. R4's progress note, dated (MONTH) 8, (YEAR) at 9:41 a.m., indicated the facilities interdisciplinary team (IDT) committee reviewed R4's sexual behavior incident, and the plan was for the resident to remain in the eyesight of staff when he was in common areas. An incident report, dated (MONTH) 9, (YEAR), contained an attached written statement from NA-G, also dated (MONTH) 9, (YEAR). NA-G's written statement indicated at 10:10 a.m. she saw R4's penis exposed, and he was feeling on R1. NA-G notified the nurse manager. The incident report indicated R4's medication, which had been discontinued a month prior, was restarted on (MONTH) 9, and staff would continue to closely monitor R4 when he was in public areas. R4's progress note, dated (MONTH) 9, (YEAR), at 10:26 a.m., indicated at approximately 10:15 a.m. a NA (Nursing Assistant) saw R4 in the library manipulating his exposed penis with his right hand, while grabbing at R1's penis through R1's pants with his left hand. The note indicated R4 was told to stop and cover himself, and R4 and R1 were removed from the library and R4 was brought to his room. R1's progress note, dated (MONTH) 9, (YEAR) at 10:39 a.m., indicated the same as above. R4's progress note, dated (MONTH) 10, (YEAR) at 7:38 a.m., indicated he was manipulating his penis with his right hand in the dining room prior to breakfast. Staff told R4 to remove his hands from his pants and brought him back to his room to wash his hands. R4's progress note, dated (MONTH) 11, (YEAR), at 10:25 a.m., indicated a staff person found R4 in the library manipulating his penis with his right hand while his left hand manipulated R2's penis. The note indicated R4 was told to stop and put his penis back in his pants. R2 was covered and R4 was immediately taken to his room. R2's progress note, dated (MONTH) 11, (YEAR) at 10:45 a.m., indicated at approximately 10:15 a.m. a staff person found R4 masturbating himself in the library with his right hand, while manipulating R2's penis which R4 had exposed. Staff told R4 to stop and put his penis back in his pants and R2 was covered up. Staff brought R4 back to his room. An incident report, dated (MONTH) 11, (YEAR), contained an attached typed statement from Health Unit Coordinator (HUC)-B, also dated (MONTH) 11, (YEAR). HUC-B's written statement indicated when she went to the library to look for another resident, she saw R4 with his left hand on his exposed penis, and his right had on R2's exposed penis. HUC-B removed R4 from the room and summoned the nurse. The incident report indicated staff were to closely observe R4 when he was in common areas. The physician restarted R4's antipsychotic medication on (MONTH) 9, (YEAR). Although the incidents of non-consenting sexual contact occurred on (MONTH) 6, 9, and 11, (YEAR), staff did not change R4's care plan to direct staff to increase his monitoring until (MONTH) 11, (YEAR). R4's care plan, dated (MONTH) 11, (YEAR), directed staff to keep R4 in view at all times while he was out of bed. R4's facility APP dated (MONTH) 16, (YEAR), indicated he had increased susceptibility to mistreatment related to cognitive loss due to a [DIAGNOSES REDACTED]. R4's APP indicated he had a history of [REDACTED]. Specific measures to minimize the risk for mistreatment related to R4's cognitive impairment included for staff to explain information in simple terms, to provide memory prompts and cues as needed, to remind and redirect R4 when necessary, for staff to keep R4 in view at all times while out of bed, R4 was in a private room, and for staff to remove R4 to his room if being sexually inappropriate in the common areas. Although R4 had lived at the facility for almost a year, the APP was not created until (MONTH) 16, (YEAR), after the sexual abuse had already occurred with R1, R2, and R3. R4's care plan, updated (MONTH) 16, (YEAR), indicated that R4 would have a private room and directed staff to take him there if he was being sexually inappropriate in common areas. A form titled, Target Behavior & Interventions, indicated staff charted behaviors, interventions, and their effectiveness for R4 from (MONTH) 3, (YEAR) to (MONTH) 22, (YEAR). Day staff omitted charting on the sheet 11 out of 20 times, and evening and night staff omitted charting on the sheet only 1 out of 20 times. All of the sexual incidents involving R4 occurred during the day. None of the interventions listed on the Target Behavior and Intervention sheet directed staff to keep R4 in sight when he was out of his room. When interviewed on (MONTH) 23, (YEAR), at 10:36 a.m., R2 stated a couple of weeks ago a resident sexually touched him while he was sleepy and dozing off in the television (TV) room (commons area). R2 did not know the resident's name, but stated he would feel a lot better if the facility kicked the resident out because he might touch someone else. R2 denied being in fear and stated the resident did not pay attention to him anymore. During an interview on (MONTH) 23, (YEAR) at 10:58 a.m., R4 denied touching any residents inappropriately, and declined to speak any further. When interviewed on (MONTH) 23, (YEAR) at 11:10 a.m., R1 did not verbally express himself. When asked if another resident had inappropriately sexually touched him or exposed himself, R1 shrugged his shoulders. When asked if he feared any residents touching him inappropriately, R1 nodded yes, and then touched his left arm by his wrist, where he had a small, rectangle shaped abrasion. R1's medical record contained no information on the abrasion, and staff were unaware of how the abrasion occurred. During an interview on (MONTH) 23, (YEAR) at 1:13 p.m., Registered Nurse (RN)-A stated on (MONTH) 10, (YEAR), she and a nurse manager were in the dining room before breakfast and saw R4 had exposed his penis and was masturbating. The two staff told R4 he needed to cover up and his behavior was inappropriate in a public place. RN-A stated R4 had a blank look on his face and did not appear to understand. RN-A stated the next day, (MONTH) 11, she was in the basement preparing to eat lunch when HUC-B called her to go to the library immediately. When RN-A got to the library R2 was sitting in a reclining chair close to the TV, and R4 was in a chair alongside R2, close enough to touch him. HUC-B told RN-A R2 was reclining in his chair and not responding while R4 was manipulating his own penis with his right hand, and R2's penis with his left hand. RN-A stated HUC-B told her there was another NA in the room with the residents who did not intervene during the sexual behavior. RN-A stated none of the residents on the unit had the capacity to consent to sexual contact due to dementia or some form of cognitive impairment. RN-A was unfamiliar with R4's care plan but thought he had a history of [REDACTED]. RN-A stated R4 was placed on 15-minute checks after the incident with R2 on (MONTH) 10, (YEAR), however, she was still concerned because R4 was impulsive and required 1:1 monitoring to protect the other residents from sexual abuse. RN-A stated she could not remember the specific day, but at one time staff initiated 15 minute checks for R4, and then the next day they were just not being completed. RN-A stated R4 was taking deliberate actions to get to other residents by maneuvered his wheelchair to be near them. When interviewed on (MONTH) 23, (YEAR), at 2:24 p.m., HUC-B stated she witnessed the incident on (MONTH) 10, (YEAR) between R2 and R4. HUC-B stated R4 was sitting next to R2, and there were other residents in the room. HUC-B stated R4 had his left hand on his exposed penis, and his right hand on R2's exposed penis. HUC-B stated R2 was laying back in the recliner, and R4 was committing the action. There were no other staff in the room when she arrived and observed R4 and R2. HUC-B left the room and summoned RN-A. HUC-B stated there were three separate incidents where R4 sexually touched other residents. She was not aware of the incidents with R4 until observing R4 and R2. HUC-B stated she should have been told about R4's sexual behavior so she could have kept an eye on R4 and ensured he was not left alone with other residents. HUC-B stated she was not aware of R4 having any increase in staff monitoring including any 15-minute checks or any 1:1 monitoring. HUC-B stated she is responsible to provide staff the correct forms to document when they are completing increased monitoring of a resident and she had not done any for R4. During an interview on (MONTH) 23, (YEAR), at 3:20 p.m., R3 denied any residents sexually touched him inappropriately, he denied being witness to any sexual inappropriate touch, and he denied having any concerns with other resident's at the facility. During an interview on (MONTH) 23, (YEAR), at 3:53 p.m., Director of Activities (DOA)-C stated one morning at about 10:35 a.m. she was in the activities room with approximately eight men, and she left for two or three minutes to get a beverage for a resident. When she returned, she saw R4 manipulating his penis with one hand and R3's penis with his other hand. DOA-C stated R4 was sitting next to R3, and it should have set off a warning in her mind, however, R4 had not had sexual behaviors for about a year, and she was not aware R4's antipsychotic medication was discontinued. When R4 was manipulating R3's penis R3 was sitting as he normally did and not respond, and R3 never verbalized anything. DOA-C separated the residents, told R4 to stop, and pulled-up R3's pants. A little while later, a resident alerted DOA-C that R4 had his penis exposed. DOA-C told R4 to cover himself up, and then she took R4 to the nurse's station so R4 could be brought back to his room. During an interdisciplinary team (IDT) meeting, she brought up the recent change in R4's medication, which occurred in (MONTH) (YEAR). DOA-C stated when R4 first came to the facility he was started on a specific medication (Risperidal) that reduced his uninhibited sexual behaviors, and the medication had been discontinued the month before the sexual incidents began occurring again. When interviewed on (MONTH) 23, (YEAR) at 5:22 p.m., the Director of Nursing (DON) stated in the event staff witnesses a potentially harmful situation, the administration immediately strategizes to ensure the safety of residents involved, performs a root cause internal investigation, and reviews and updates care plans. The DON stated for the initial sexual incident involving R4 and R3, R3 did not have the capacity to consent, but she did not know if R1 and R2 had capacity to consent. R4's care plan directed staff to redirect him and provide opportunities for privacy when he was masturbating in public areas; however, the DON did not think R4's care plan specifically addressed R4's potential for sexual behaviors with other residents. The DON stated the physican had reduced and then discontinued R4's [MEDICAL CONDITION] medication before the sexual incidents occurred. The DON stated after the first sexual incident staff was suspicious R4's sexual behavior was related to the discontinuation of his [MEDICAL CONDITION] medication. Staff contacted R4's physician and the physician restarted the antipsychotic medication on (MONTH) 9, (YEAR). The DON did not think staff started 15-minute checks with R4, rather the order was changed to increase his monitoring, and R4's care plan was updated after his third sexual incident with another resident. The DON stated she thought staff was adequately supervising R4 while around other residents when the three incidents occurred, and the facility was not equipped to provide 1:1 coverage of every resident. The DON stated since R4's Risperidal was re-started the sexual behaviors have improved. During an interview on (MONTH) 26, (YEAR) at 10:57 a.m., R3's guardian (G)-F stated R3 does not have the capacity to consent to sexual activity. G-F stated the facility called her on (MONTH) 6, (YEAR), about inappropriate sexual touching with another resident, not initiated by R3, and G-F was told R3 and the other resident (R4) were on 15-minute checks to prevent any further sexual contact. When interviewed on (MONTH) 26, (YEAR) at 11:36 a.m., NA-G stated on (MONTH) 9, (YEAR) she was passing by the library she saw R4 reaching over and grabbing and touching R1's genitals, over R1's sweat pants. NA-G did not see either resident's genitals exposed, and R1 appeared to not know what was happening. NA-G stated there were no other staff in the area at that time. NA-G was not aware of R4's prior sexual behaviors. NA-G stated she told R4 to stop and then told the nurse who came and separated the residents. NA-G stated she had not observed R4 being sexually inappropriate in the past with other residents. NA-G stated all of the staff on the unit was told to keep an eye on R4, but there was no specified frequency of monitoring. NA-G was not aware of R4's two other sexual incidents with residents. During interview on (MONTH) 26, (YEAR), at 1:37 p.m., R4's guardian, G-H, stated she received a call from the facility after each incident of R4's sexual behaviors. On (MONTH) 11, (YEAR), after R4's third incident, G-H was told R4 was not to be out of staff's sight, and the facility was reviewing R4's [MEDICAL CONDITION] medication. G-H stated R4 had a history of [REDACTED]. G-H stated R4 has severe dementia and is not competent or capable of consenting to sexual activity. A facility policy, dated (MONTH) 2, (YEAR) and titled, ABUSE PREVENTION and PROHIBITION, indicated all employees of Mission Nursing Home are responsible for assuring residents are free from maltreatment and it is essential to minimize the residents' risk of physical and emotional harm and neglect because of their decreased physical, psychological or cognitive functioning. The policy indicated all residents are vulnerable adults but those who are cognitively impaired are more vulnerable because of their inability to understand or seek help. The care plan indicated, Residents will be assessed for their vulnerability to abuse and neglect at the time of admission. Resident's histories and current status will be reviewed for potential to abuse others within and outside the facility. An individual abuse prevention plan will be completed by Social Service and placed behind the care plan in the medical record. The individual abuse prevention plan will be reviewed quarterly at the time of the care conference. (If any incidents of alleged abuse occur the plan will also be revised at that time as well.) The policy indicated staff were to observe for abuse (verbal, physical, mental, sexual), resident to resident abuse, and neglect, and the DON and the Director of Social Service (DSS) would routinely review all incident reports for occurrences, patterns and trends. Under the heading, Protection, it indicated, All efforts will be made to protect residents from abuse through the above components. In the event that abuse occurs the resident will be protected from further abuse and, b. if the AP (alleged perpetrator) is another resident, ensure residents are kept separate from each other. The facility's policy indicated sexual abuse included sexual contact that results from the inability of the person to give consent.

Based on document review and interview, the facility failed to ensure residents were free of any significant medication errors for one of four residents, (R1), reviewed when staff did not administered R1's anti-[MEDICAL CONDITION] medication. R1 had [MEDICAL CONDITION] and was hospitalized for [REDACTED]. Findings include: R1's medical record was reviewed. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's brief interview for mental status (BIMS) completed January 9, 2016 indicated a score of 4 out of 15, indicating severe cognitive impairment. R1 needed staff assistance for medication administration to control his [MEDICAL CONDITION]. R1's care plan dated July 29, 2016 indicated R1 had history of [MEDICAL CONDITION] activity that resulted in a left humerus fracture. The care plan indicated R1 would have no [MEDICAL CONDITION] activity and instructed staff to administer medications as ordered. R1's physician order [REDACTED]. R1's laboratory record dated October 13, 2016 indicated R1 had a [MEDICATION NAME] level of 8.1 micrograms/milliliter (mcg/ml); the normal expected range is 6-46 mcg/ml. R1's Medication Administration Record [REDACTED]. R1's pharmacy dispense history dated December 6, 2016 indicated the pharmacy delivered 473 ml of [MEDICATION NAME] liquid to R1's facility. R1's pharmacist indicated in the dispense history that a quantity of 473 ml should last 23 days based on R1's physician order [REDACTED].>R1's pharmacy dispense history dated December 27, 2016 indicated the pharmacy delivered 473 ml of [MEDICATION NAME] liquid to R1's facility. R1's MAR for January 1, 2017 indicated R1 received the ordered dose for the anti-[MEDICAL CONDITION] medication on that day as prescribed. R1's nursing progress note dated January 2, 2017 at 12:26 a.m. indicated R1 was found on the floor in his room having [MEDICAL CONDITION] on January 1, 2017 around 11:25 p.m. The note indicated R1 had foam coming from the mouth with the back and neck arched, lips blue, and breathing labored. R1 did not respond to verbal stimuli. Staff called the emergency medical services (EMS). The staff assessed R1 and applied oxygen until EMS arrived at the scene at 11:50 p.m. and transported R1 to the hospital at 12:10 a.m. The note indicated R1 had another [MEDICAL CONDITION] activity, [MEDICATION NAME] approximated 30-45 seconds, after EMS arrived. The hospital medical record dated January 2, 2017 at 7:29 a.m. was reviewed and indicated R1 was admitted for [MEDICAL CONDITION], noted to have bitten his lip/tongue with blood around his mouth and hospital staff manually assisted R1's breathing with Ambu (breathing) bag. R1 had additional two [MEDICAL CONDITION] and was given intravenous [MEDICATION NAME] in the emergency room . The January 2, 2017 record indicated R1's laboratory results ([MEDICATION NAME] 8.5, repeat 7.9; venous pH 7.14, and venous pCO2 31) were consistent with [MEDICAL CONDITION]. The January 2, 2017 record indicated R1 had a very low level (2.4 mcg/ml); normal range is 6-46 mcg/ml) of [MEDICATION NAME] in his blood at admission. Hospital physician consultation note dated January 3, 2017 indicated R1 was seen by a neurologist for his [MEDICAL CONDITION]. The January 3, 2017 note the neurologist concluded R1's very low level of [MEDICATION NAME] was most likely the reason for his [MEDICAL CONDITION]. The facility's investigative report dated January 3, 2017 indicated R1 has had no [MEDICAL CONDITION] activity since admission January 19, 2016. The report indicated R1's had a 24-day supply (473 ml) of [MEDICATION NAME] delivered on December 6, 2016 with order to administer 10 ml twice daily. With all doses signed by staff as administered, R1's bottle should have been empty on December 30, 2016. Instead of being empty, the December 6th [MEDICATION NAME] bottle contained 250 ml of [MEDICATION NAME], indicating 223 ml was actually administered. The director of nursing (DON) was interviewed on February 15, 2017 at 5:11 p.m. and stated she conducted an investigation regarding R1's [MEDICAL CONDITION]. The DON stated R1's [MEDICATION NAME] bottle should have been empty if staff had administered the medication according to the physician's orders [REDACTED]. R1's neurologist physician was interviewed on July 13, 2017 at 2:36 p.m. R1's physician stated the two reasons to explain R1's [MEDICAL CONDITION] were either R1 refused his [MEDICATION NAME] as ordered or staff did not administer the medication as ordered. The physician stated R1's [MEDICAL CONDITION] and admission to hospital could be attributed to R1 not receiving his anti-[MEDICAL CONDITION] as ordered given the very level of the medication in his blood upon admission to the hospital. The facility's policy and procedure titled Documentation indicated drugs are to be given in strict accordance with the physician's most recent orders.

Based on interview and document review, the facility failed to comprehensively assess, and develop safety interventions related to alcohol consumption to reduce the risk of significant harm to residents or others, and to monitor for withdrawal for 3 of 3 residents (R11, R51, R54) who were known to consume alcohol, become intoxicated and who were not being medically monitored. This resulted in an immediate jeopardy (IJ) situation for R11, R51 and R54. Findings include: The immediate jeopardy began on 7/1/15, when R51 had an extremely elevated breathalyzer reading and clinical symptoms without appropriate intervention. During review it was determined R11, R51, and R54 had the potential for significant harm due to multiple incidents of intoxication without intervention by the facility including comprehensive assessment and/or implementation of appropriate interventions based on facility protocols. On 5/12/16, at 3:54 p.m. the facility administrator, director of nursing (DON), and social services director (SSD) were notified of the IJ for R11, R51, and R54. The IJ was removed on 5/17/16, at 2:30 p.m., but noncompliance remained at an isolated scope and severity level, with actual harm that is not immediate jeopardy (Level G). The facility policy Alcohol and Drug Use, undated, identified: Purpose: A primary mission of Mission Nursing Home is to provide care to residents who are chronically chemically dependent. While encouraging and supporting the efforts of residents to maintain sobriety, the facility also recognizes that some persons will relapse or continue to use alcohol and drugs. This policy is adopted to provide guidelines on the use of alcohol and drugs, with the goals of a safe and healthy environment in mind, while also supporting and encouraging sobriety. In addition the policy included: 1. Mission Nursing Home will support any and all efforts at sobriety and is available to give you assistance at all times. 2. In order to participate in the Gazebo program, the resident will be assessed by therapy, nursing, and the behavior management committee. 3. The use or possession of alcohol in the building is not permitted. Random room searches are conducted to ensure there is no alcohol in the building. 4. Inappropriate behavior resulting from the use of alcohol will not be allowed and will be addressed according to the facility behavior management policy. An undated facility policy titled Behavior Policy, indicated violent, criminal or inappropriate sexual behavior in public will not be tolerated by Mission Nursing Home. Residents who engage in such behavior in public will be discharged from the facility. Examples of such behavior included assault (including threats of assault). The policy also identified other inappropriate behavior in affecting the health, safety, or welfare of the resident and/or the community would not be allowed. Residents who engage in such behavior in public and who repeat the behavior twice will be discharged from the facility. Examples of such behavior included self-endangerment. The back side of the policy was titled Informed Consent for Random Search of Room, which residents signed authorizing staff to do random room/surroundings searches whenever there was reasonable suspicion of alcohol or drugs present. The policy indicated Failure to authorize the search can result in immediate discharge planning procedures. The facility's Gazebo Alcohol Program (A program run by the facility, which allows residents to drink a physician approved, set amount of alcohol provided by staff, in a specific area of the building at a specific time each day) Contract, undated, identified in part: 1. Drinking can only be done in the designated area, usually in the barbershop. No drinking is allowed anywhere else in the building or on the grounds. 2. If you drink alcohol in the building, outside of the gazebo program, alcohol is found in your room or on your person, you will be placed on level 4 (cannot go out of the building without an escort) and you will be restricted from the gazebo as follows: First violation = one week Second violation = two weeks Third violation = off program 3. When you receive or buy alcohol give it to the door monitor. 4. Upon return from any outings, you will be searched for alcohol. 5. There may be a search of your room or person if staff suspects that you are hiding alcohol. 9. If you return from an outing, and you have been drinking alcohol, you cannot go to the gazebo that day. 10. If you fall, get into a fight, are belligerent or aggressive, and/or display any other disruptive behaviors after you go to the gazebo and drink alcohol, you will be put on a 3 day restriction from the gazebo program. Multiple offenses will result in increasing restrictions. 11. If you are caught giving or receiving alcohol to each other you will be restricted from the gazebo for 3 days. 12. You will be breathalyzed before participating in the program that day. Refusal to cooperate with breathalyzer will result in restrictions. 13. If you have to go to detox, hospital, or create a dangerous health situation, your level will change to a level 4 (cannot go out of the building without an escort), and will be restricted from the gazebo for two weeks. An undated facility policy, Resident Monitoring System, identified a leveling system for all residents. The purpose of this system was to keep the residents safe and prevent them from behaviors while out in the community. Classification assessments were conducted at admission and annually thereafter unless there was been a change in condition. The levels were reviewed at each quarterly care conference. Classifications were: Level I: A resident can go out without restrictions. Level II: A resident can sign out and walk around the building for up to half an hour. If the resident does not return within half an hour, the door monitor will go out and find them. The resident could be changed to another more restricted level for failing to follow the limitations of this level. Level III: Residents in this category must remain within eyesight of the door monitor (in the front yard). Level IV: Residents in this category must have an escort at all times when outside the facility. Residents who have had significant behavioral issues or significant cognitive deficits are also in this category. Level V: Residents in this category must stay on their individual floor and cannot go to the other floor without escort. A color coded listing of all resident levels was available at the front door, each nursing station, and with each social worker. Per the policy, all residents sign to acknowledge an understanding of all rules related to the use of alcohol/drugs within the facility and when out on pass. This included the use of alcohol and the privileges available when the rules were followed. Review of resident records indicated that although these policies were in place, the provider did not consistently use the leveling system, or have any consistent protocol for use or refusal of the breathalyzer, vital sign monitoring, or frequency and length of clinical and safety monitoring for intoxicated residents. R11's quarterly Minimum Data Set ((MDS) dated [DATE], identified admission to the facility on [DATE]. It also identified R11 had modified independence with cognitive skills for daily decision making, and demonstrated feeling down, depressed or hopeless. R11 was noted to be independent with activities of daily living (ADLs). Active [DIAGNOSES REDACTED]. The MDS also identified R11 exhibited other behavioral symptoms not directed toward others, and rejection of care. R11's behavioral symptom Care Area Assessment (CAA) dated 7/2/15, identified R11 had episodes of impaired judgment and poor decision making, noting an episode in which he was in a verbally aggressive altercation with another resident which lead to threatening and physical aggression. He also has been warned about not going out into the community to drink alcohol or take drugs and/or bring anything back in with him. The CAA documentation lacked any direction or guidance in dealing with these behaviors. R11's medical record lacked a comprehensive assessment related to safety of alcohol use. R11's medical record lacked a signed Alcohol and Drug Use policy. The face sheet identified R11 as his own responsible party. R11's care plan dated 4/8/16, identified a potential alteration in cognition related to alcohol dependence. It also identified a history of going out 'for a few drinks'. Interventions included: encouraging sobriety, Level I monitoring (date initiated 12/11/11), private room due to inability to get along with roommates, and identifying physical and verbal aggression. The care plan also indicated R11 was at moderate risk for falls due to alcohol or drug use. Interventions included: independent with transfers, and observe orthostatic blood pressure monthly. The care plan lacked specific interventions related to alcohol use. The facility provided a Resident Classification Listing by Room dated 4/18/16. R11 was identified as a Level II (which contradicted information provided on the care plan). On 5/16/16, at 10:01 a.m. the social service director (SSD) was asked about the conflicting level information for R11. The SSD stated she was unsure why R11 was a Level II on the Resident Classification Listing. The SSD stated, (R11) is a Level I, and has been since 9/23/12. Everyone knows this. R11's Fall/Safety Risks Evaluation and assessment dated [DATE], identified no falls in the last 90 days. Additionally, no seizures were noted on the form. The assessment did indicate R11 had a current issue with alcohol and/or drug use, an extensive history of alcoholism, alcoholic cirrhosis of the liver, drunkenness, and alcohol-induced persisting dementia. R11 was identified with no fall risk on this assessment. The assessment indicated occasionally resident is confrontational with staff and other residents, especially if drinking alcohol. The Medication Administration Record (MAR) for 4/15, identified a physician's orders [REDACTED]. If the breathalyzer was refused, he was to be on 15 minute checks. The order lacked a length of time the 15 minute checks were to continue. Review of R11's progress notes dated 4/22/15 through 5/14/16, identified the following: - 5/4/15, at 10:24 p.m. R11 went for a walk at 6:55 p.m., and returned at 9:10 p.m. Refused breathalyzer, stating, I'm not on the Gazebo program. I don't have to do that anymore. - 5/23/15, at 3:50 a.m. R11 exited his room, agitated, jumping from one subject to another, at times not making sense, talking about drinking in his room. - 5/23/15, at 9:45 a.m. R11 had been speaking to staff in a foul language. It also noted R11 shared with dietary staff he had been drinking. The documentation included: In a brief glance around room do not see any alcohol bottles/containers. - 5/24/15, at 3:30 a.m. identified at 9:50 p.m. R11 was observed blocking the door entrance, with the door monitoring staff outside. R11 began yelling racial slurs to staff and threatening to physically harm the door monitor. R11 walked toward staff in a threatening manner, swearing, and was informed if he physically harmed staff, the police would be called. R11 went to his room, and returned at 10:05 p.m. cursing, gritting his teeth, and leaning on the nursing station. He was informed the police would be called if he didn't calm down. It was also noted R11's eyes were extremely blood shot. R11 was checked on x 2 (twice) and appeared to have calmed down. - 6/17/15, at 12:00 p.m. R11 confronted and had a verbal altercation with a peer, and when being escorted out of the dining room, began to threaten the peer, making the motion of a fist, and attempted to get back in the dining room. The note indicated R11 had slurred speech and suspected he had been drinking. R11 stated, Did he laugh at me, I'm gonna knock the[***]out of him. A corresponding incident report dated 6/16/15 was completed, but lacked any additional content. On 5/11/16, at 4:21 p.m. the DON stated she would expect a breathalyzer to have been offered, and if refused, 15 minute checks initiated. - 6/17/15, at 5:55 p.m. the SSD and administrator discussed recent behaviors with R11, and he was informed he could not drink in or out of the building unless in the gazebo program. If he gets intoxicated he has to cooperate with the nurses when they ask for a breathalyzer and if he doesn't comply he will be sent to the hospital and/or the police will be called to assist. He stated that he understood and certainly did not want the police called due to his behaviors. Finally he was told that he will be given a notice to discharge if there are any more incidents, he responded with I am leaving soon anyway and when asked where he was going he could not give an answer. Administrator reiterated everything one final time and he again said that he understood. A couple of hours later he came up to this writer and said if he was given a discharge notice we would have to find a place for him to go and this writer responded yes. - 6/19/15, at 9:30 a.m. (documented as a late entry) identified R11 was told that he would be given notice to leave if his behaviors continued. - 7/5/15, at 5:36 p.m. R11 had a verbal altercation with a peer, threatening to beat each other up. Four staff intervened until the peers walked away from each other. - 7/7/15, at 7:46 p.m. R11 was in a verbal altercation with a peer, entering peer's room, yelling and cursing at peer. - 7/10/15, at 3:12 p.m. R11 complained of abdominal pain, and an abdominal x-ray was ordered. R11 stated, Don't send them in my room, I'll kill them. -8/20/15, at 1:24 a.m. R11 was complaining about issues to staff. He then began cursing and became agitated. - 9/4/15, at 4:32 p.m. staff reported to nurse R11 appeared to be drunk. The SSD and administrator entered R11's room with the breathalyzer. When asked if he had been drinking last night or this morning, R11 denied it. His speech was somewhat slurred. Breathalyzer read 0.204, and a retest of the breathalyzer was 0.203. This writer and Administrator then reminded him of a discussion in which he stated that he understood that if an incident like this happened again he would be given a notice to leave. He said that he remembered this. This writer then informed him that a referral would be made for the Glennwood, (wethouse) (a residential facility for chronically alcoholic and homeless men and women), so that discharge planning could begin. He stated understanding of this. On 5/11/16, at 4:21 p.m. the DON stated she would expect 15 minute checks to be completed for refusal of the breathalyzer, and an incident report to be completed. On 5/17/16, at 12:50 p.m. SSD stated R11 was referred to the Glennwood, but he was not accepted there, due to having a colostomy (surgical procedure that brings one end of the large intestine out through the abdominal wall), despite the fact that R11 is independent in the cares for this. The reason provided was that residents share a bathroom. - 9/8/15, at 10:22 p.m. R11 was found on the floor near the door in his room. He appeared drunk but refused breathalyzer and vital sign assessment. Resident stated don't call the police I am already in trouble. Corresponding incident report completed, identified plan to possibly give resident a 30 day notice to discharge. On 5/11/16, at 4:21 p.m. the DON verified no documentation was available related to 15 minute checks for refusal of the breathalyzer. - 9/9/15, at 5:44 p.m. Staff reported R11 appeared drunk. SSD and another staff entered R11's room. R11 refused breathalyzer. He was informed if he did not do the breathalyzer, it was the same as saying that he had been drinking. R11 continued to refuse, and closed his eyes. - 10/19/15, at 6:15 p.m. R11 left facility at 8:30 p.m. and returned at 9:50 p.m. Breathalyzer read 0.105. - 10/23/15, at 10:19 p.m. R11 went out from 5:45 p.m. - 9:35 pm. Breathalyzer read 0.162. - 10/31/15 at 7:15 p.m. R11 had a verbal altercation with housekeeping. A corresponding incident report completed on 10/31/15 lacked any further information. - 11/7/15, at 7:27 p.m. R11 went out at 6:50 p.m., returning at 7:11 p.m. Breathalyzer read 0.022. - 11/9/15, at 9:45 p.m. R11 left at 8:00 p.m., and returned at 8:50 p.m. Breathalyzer read 0.077. - 11/16/15, at 12:30 a.m. R11 to the nurses station asking for medication he had previously refused. He became very upset and began cursing. Staff attempted to talk with R11, but he refused to listen and walked off to his room. - 11/16/15, at 6:30 p.m. R11 out of the building from 6:30 p.m. - 8:30 p.m. Breathalyzer was 0.08. On 5/11/16, at 4:21 p.m. the DON stated an incident report should have been completed, as well as 15 minute checks. - 11/19/15, at 10:54 p.m. R11 out of the building and breathalyzer read 0.06 upon return. When interviewed on 5/11/16, at 4:21 p.m. the DON stated breathalyzer was below the legal limit, and she wouldn't expect any increased monitoring. The DON stated she was not notified, and would expect herself or the SSD to have been notified of any incident involving drinking of any amount, and would expect an incident report completed. - 12/24/15, at 5:30 p.m. R11 was found with two cans of beer in his room, observed to be dumping it down the drain when staff entered. R11 began cursing, slammed the cabinet door shut with his foot. On 5/11/16, at 4:21 p.m. the DON stated no breathalyzer was done. The DON also stated a room search revealed no further alcohol, and she was notified of this incident. There were no further symptoms, and she would not expect 15 minute checks. Further, the DON stated R11 was aggressive, but he was also aggressive without alcohol. - 3/29/16, at 9:13 p.m. R11 left the facility at 6:20 p.m. and returned at 9:20 p.m. R11 reported being down by the lake, and breathalyzer reading was 0.143. - 4/13/16, at 9:06 p.m. R11 left the building and refused breathalyzer upon return. - 5/7/16, at 6:40 p.m. R11 left the facility at 2:05 p.m. and returned at 6:39 p.m. Breathalyzer read 0.256. Resident went to his room. When interviewed on 5/11/16, at 4:21 p.m. the director of nursing (DON) stated incident reports should have been completed, as well as enhanced monitoring when there was a refusal of the breathalyzer. The DON stated there was no protocol for enhanced or increased monitoring. However, the DON stated R11 should have been on 15 minute checks for refusal of the breathalyzer per his physician order. On 5/11/16, at 4:21 p.m. the SSD stated R11 was not on the Gazebo program because he didn't want to follow the rules, and it was his right to drink. The DON also verified that on 5/7/16 when R11's breathalyzer reading was so high, R11 had gone to his room. The DON was unable to provide any documented assessment at that time such as vital sign readings, or increased clinical and safety monitoring having been done. The DON stated she would have expected an incident report and 15 minute checks to have been completed. R11's Social Services Review notes dated 3/10/16, identified He does display some short term memory deficits some of which could be selective memory. He has episodes of impaired judgement. The notes also included, He can also be verbally aggressive towards staff especially when they want him to do something. He does not want anyone in his room even after knocking. He has episodes of drinking inside or outside of the building and then denying that he has. Social Service will remain actively involved through 1 to 1 visits and behavior management interventions as needed. During observations on 5/11/16, at 2:25 p.m., 5/13/16, at 10:41 a.m., 5/15/16, at 11:44 a.m., 5/16/16, at 1:10 p.m., and 5/16/16, at 3:00 p.m., R11 was asleep in bed, and did not reply when spoken to. On 5/11/16, at 6:55 a.m. the DON reiterated that if a resident returned intoxicated, she would expect a nursing assessment to be completed, and with a breathalyzer reading of 0.256, she would expect increased monitoring to be done. She also stated R11 had a history of [REDACTED]. R51's quarterly MDS dated [DATE], identified the resident had modified independence in cognitive skills for daily decision making, behavioral symptoms not directed toward others, and required the use of a wheelchair. [DIAGNOSES REDACTED]. R51's CAA dated 11/3/15, identified [DIAGNOSES REDACTED]. It also identified behavior problems including disruptive, loud talking in the dining room especially after Gazebo/alcohol program. The CAA noted impaired balance during transitions, and difficulty maintaining sitting balance as well as agitation and decreased mobility. The CAA lacked any direction or guidance in dealing with these behaviors. R51 did not have a comprehensive assessment related to the safe use of alcohol. R51's medical record included a signed contract to participate in the Gazebo program dated 8/7/15. However, there was not a signed Alcohol and Drug Use policy. The face sheet identified R51 as his own responsible party. R51's care plan dated 4/27/16, identified a self care performance deficit related to alcohol use. It also identified R51 had a potential risk for falls related to being wheelchair bound, and the use of alcohol with the Gazebo program. The plan of care indicated both long and short term memory problems, and poor judgement and decision making due to alcohol dependence. The care plan also identified an alteration in mood and behavior related to acute alcohol intoxication/withdrawal. Interventions included to remind of the rules around the gazebo/ alcohol program. The care plan failed to identify R51's alcohol monitoring level. The Resident Classification Listing By Room form, dated 4/18/16, identified R51 as a Level III. Review of R51's progress notes from 4/28/15 - 5/15/16, identified the following: A physician progress notes [REDACTED]. Patient continues to smoke and consume controlled amount of alcohol here at the facility. - On 7/1/15, at 6:47 p.m. it was reported that resident (R51) was drinking outside the Gazebo program. Client monitored closely. Blood pressure upon waking is 75/54 and heart rate 75. Given meal tray and drank 300 ml (milliliters) of water. Blood pressure at 6:30 p.m. 87/53. Physician notified and orders received to check blood pressure every four hours and continue to encourage fluids. Other notes from this date identified resident left at 10:35 a.m. with his niece and returned at 1:05 p.m. He was searched and breathalyzer was 0.258. Staff found a bottle of whiskey in his room, which was locked in the liquor cabinet. An incident report was completed for this incident on 7/1/15, noting Resident was instructed to not drink. The record lacked evidence their Gazebo policy was followed. On 5/11/16, at 3:02 p.m. the SSD stated, if they mess up like this when in the program, they would be suspended for 3 days, or a week if they are sent to the hospital or detox. - On 7/2/15, at 10:48 a.m. a note indicated R51 had been seen by the nurse practitioner, and the note indicated R51 is an adult and can drink and smoke when he wants. He is not hurting himself or anyone else. - On 7/2/15, at 1:59 p.m. a note identified R51 was on a three day suspension from the Gazebo program. A physician progress notes [REDACTED]. It noted resident had a breathalyzer reading of 0.258, and blood pressure was noted to be low at 87/56, with a retake at 75/54. The note indicated during interview with the physician the resident had stated, I am fine, I went out with someone and had some drinks. I am an adult and I will do whatever I want. I am here because I can drink and smoke. If I get the opportunity again, I will do it. I am not hurting myself or anyone else when I drink, so I should be left alone. The nursing progress notes indicated R51 was allowed to sleep it off, there was no report of aggressive behavior towards staff and included, Patient will be off Gazebo program for three days. Nursing will continue to monitor for any sign of withdrawal. - On 7/8/15, at 1:20 p.m. the notes indicated R51 was restricted from the gazebo program due to having the bottle. - On 8/6/15, at 10:11 p.m. notes indicated the resident had left with his niece at 2:15 p.m. and returned at 3:45 p.m., appearing drunk and very talkative. Social worker notified, and resident will be monitored. It was also documented R51 had refused the breathalyzer as well as other assessments. The record lacked evidence the Gazebo policy was followed. On 5/11/16, at 3:02 p.m. the DON stated enhanced monitoring should have been completed as well as an incident report for these incidents. - 8/17/15, at 3:51 p.m. resident left after the Gazebo program in a taxi at approximately 3:13 p.m., attempting to take a peer with him. The documentation indicated the SSD had attempted to stop the resident, but he'd left anyway and had returned at approximately 3:46 p.m. with a brown paper bag, and a bottle of alcohol in it. The notes indicated staff had taken the bag, and the resident was verbally abusive toward staff. The record lacked evidence the Gazebo policy was followed. On 5/11/16, at 3:02 p.m. the DON stated the alcohol was taken from R54 and locked up in a cabinet. A Code B (a behavior that cannot be controlled, where all available staff come to help) was called since R54 was following the staff and threatening her. When the nurse went in, R54 was intoxicated, slurring his words. Breathalyzer at this time was 0.336, and his blood pressure was running low. The on call physician was called, and instructed staff to monitor resident, encourage fluids, and to call back if there was a decline. DON stated the blood pressure was stable later. Further, DON stated there is not policy or procedure to follow and the physician does not specify a frequency of the checks. - On 8/17/15, at 11:10 p.m. noted resident was examined by a registered nurse in his room at approximately 7:25 p.m. He was clearly intoxicated, fatigued, and slurring his words. Breathalyzer was 0.336. Blood pressure 94/59 and 86/54. Physician notified and orders received to monitor resident and encourage fluids. Call back with a decline. At 10:00 p.m. blood pressure was 146/82. Also noted at this time to be more awake, not slurring words, and drinking fluids. The record lacked evidence the Gazebo policy was followed. On 5/11/16, at 3:02 p.m., the DON stated the only documentation of checks was in the note from the nurse which indicated R54 was checked on every 1-2 hours. She would expect that an incident report and increased monitoring were completed. - On 8/18/15, at 2:57 a.m. noted at approximately 12:15 a.m. staff attempted to obtain vital signs, and resident was increasingly agitated, using foul language. Noted staff obtaining frequent checks on resident every one to two hours for safety. A physician progress notes [REDACTED]. The note indicated the vital signs were now normal and resident is back to his baseline. During interview with the physician, R51 stated he was angry that the social worker can not allow him to bring his own 'Booze' into the facility. He was also angry that he will be off the Gazebo program for 3 days since he got himself intoxicated. The progress note identified no education and no orders were provided for increased monitoring when R51 was intoxicated. Then note indicated nursing was to continue to monitor for any signs or symptoms of withdrawal. - On 9/28/15, at 10:36 p.m. resident returned to the facility via taxi at approximately 6:00 p.m. and was met at the door by SSD. He turned in his alcohol bottles, and breathalyzer was 0.141. Resident was informed by SSD that he will not be attending Gazebo tomorrow. On 5/11/16, at 3:02 p.m., the SSD stated R51 liked to go out and drink with his meals. She verified the Gazebo policy identified that drinking outside the program would result in a one week suspension, which had not been enforced in this case. At that time, the DON also stated, we are assuming that he is going to go out and drinking. The DON stated there was no assessment available to use for residents consuming alcohol. She indicated an incident report and increased monitoring should have been initiated. - On 10/24/15, at 1:33 p.m. notes indicated R51 had refused to shower the evening before, and had been informed he could not attend the Gazebo program, so had become very upset and angry. - On 11/5/15, at 11:24 p.m. identified R51 had returned at 5:35 p.m. from going out on a visit with his brother (left at 12:05 p.m.) The note indicated he was drunk and went to his room after being searched. The record lacked evidence the Gazebo policy having been implemented. On 5/11/16, at 3:02 p.m. the DON stated an incident report should have been completed, a breathalyzer offered, and enhanced monitoring completed. At that time the SSD also stated there should have been a restriction for not following the gazebo contract. - On 12/4/15, at 10:26 p.m. the notes indicated R51 had gone out at 12:05 p.m. At approximately 6:00 p.m. a call had been received about the resident being drunk at a local liquor store, and being under supervision of the police. R51 had been sent to the hospital. The hospital visit note dated 12/4/15, indicated R51 had arrived via ambulance. Report that patient was outside a liquor store in Plymouth with intoxication. Police were called. Arrives with appearance of intoxication and slurring words. Patient is wheelchair bound. Reportedly lives at Mission detox center. Further information included, Patient was conversing in room when he had loss of consciousness on the cart lasting about 30 seconds. Patient unresponsive to sternal rub. Came to after 30 seconds and started yelling incoherently. The last note from this visit identified Pt (patient) increasing agitation; numerous requests for his belongings and to be allowed to leave. MD (physician) in room speaking with pt. On 5/11/16, at 3:02 p.m. the DON stated dispatch had called the facility regarding the 12/4/15 incident. The SSD also stated R51 had gone out to eat, and the restaurant was across from a liquor store. The SSD stated R51 had left the restaurant and gone to the liquor store. Staff at the liquor store had subsequently called the police, reporting someone intoxicated. The SSD stated the facility did not have a copy of the police report. The DON stated she'd instructed dispatch to take R51 to the hospital for evaluation. Upon return to the facility after six hours, R51 had refused the breathalyzer or vital signs. The DON said R51 had been demanding staff call the police and hospital to return his alcohol. Staff had calmed him down and R51 returned to his room. The DON stated no alcohol levels or reports were a

Based on observation, interview and document review, the facility failed to provide supervision and assessments for 3 of 5 residents (R48, R72, R62) who participated in the Gazebo/alcohol consumption program and who smoked unsupervised at the Gazebo. This resulted in an immediate jeopardy (IJ) for R48, R72, and R62 who required direct staff supervision and were left unsupervised drinking and smoking in the Gazebo on a daily basis. In addition, the facility failed to provide supervision for 1 of 4 residents (R54) who fell while he still attended the Gazebo program; failed to provide supervision for 1 of 1 resident (R43) who required supervision during a shower and the facility failed to provide supervision and intervention for 1 of 3 residents (R85) after multiple resident to resident altercations. The IJ began at 4:16 p.m. on 7/27/12, when at 11:27 a.m. on 7/27/12, R48 stated, "All my friends go to the Gazebo, no facility people are there." R48 described taking his cigarettes and a bottle of alcohol, which was provided by the facility and sitting at the Gazebo unsupervised. At 1:30 p.m. on 7/27/12, R48 was observed to be at the Gazebo, unsupervised while consuming alcohol and smoking. R48's care plan directed staff to escort to location and required supervision with smoking. At 4:16 p.m. on 7/27/12, the administrator, the director of nursing (DON) and director of social services (DSS) were notified of the IJ. The IJ was removed at 12:30 p.m. on 7/31/12, but noncompliance remained at the lower scope and severity level of an E. The IJ that began on 7/27/12, was removed on 7/31/12, when the Gazebo program was suspended on 7/28/12 (until removal plan was accepted), supervision of the Gazebo program was established, the policies for the program were revised, an assessment of the residents involved with the Gazebo program was developed for before and after the program, the residents were assessed and the residents and staff were educated on the IJ removal plan. Monitoring visits were conducted on 7/28/12, 7/29/12, and 7/30/12. The noncompliance remained at the lower scope and severity level of E. The administrator was notified of the IJ was at 4:16 p.m. on 7/27/12, which was removed at approximately 12:30 p.m. on 7/31/12. Findings include: The facility offered a Gazebo/alcohol program, which was located behind the facility and down a hill. The Gazebo was a wooden (shed like) building with plywood walls and floor, and a broken window facing the facility that was covered by a plywood wall from the inside. The Gazebo was paddle-locked unless Gazebo/alcohol hours were in operation. The Gazebo contained a yellow plastic box built into the wall, where a communicator two-way radio had been installed. The communicator had been in for repairs at Advanced Wireless (AW) since May 2012. The facility did not have staff at the Gazebo during the hours of operation, nor did the facility put a communication system in place after the two-way communicator malfunctioned. Five residents smoked and drank in the unsafe environment. At 2:45 p.m. on 7/27/12, the Gazebo was observed to be a wooden shed structure with a shingled roof with several spruce and pine trees around it. The floor of the Gazebo was observed to be exposed plywood which bowed and moved with the weight of a person walking inside the Gazebo. The plywood floor was observed to have many scattered gray ashes throughout the inside floor, under the bench and chairs, behind the door and around the ash trays. Two black vinyl straight back chairs were observed to be in the back of the Gazebo (facing forward and in). Both chairs were observed to have a rip in the vinyl seat, approximately six inches long and three inches wide exposing the internal foam and presenting a potential fire hazard. A varnished wooden bench was observed to the left side (facing in) with an open black plastic ashtray stored on the bench. The bottom of the ashtray appeared used and soiled with ashes. Stored next to the open black plastic ashtray was an empty Kleenex box. On the right side of the Gazebo (facing in) and stored on the floor were two rusty, large coffee cans, one contained approximately five partially smoked cigarette butts. A large garbage can was observed to the right of the door to have empty cans of soda and beer in it. Behind the door was a red metal garbage can with an enclosed metal lid and partially full of cigarette butts. Next to the red garbage can that contained the cigarette butts, was a broom and a plastic dust pan. A yellow box was observed to be inserted directly to the wall and to the right of the door into the Gazebo. Two black wires were observed to be hanging from the yellow box. The ends of the wires were exposed. The inside of the Gazebo was observed to lack any means for extinguishing fires, such as covered ashtrays, a fire blanket or a fire extinguisher. In addition, the Gazebo lacked a means to call for help, such as an intercom system. Each of the five residents had a classification code assigned to them to determine what level of monitoring they needed while on the facility grounds. The Resident Monitoring Classification form noted the following: Level I - Independent Level II- Around the grounds Level III- Within sight Level IV- Requires escort Level V- restricted to the floor The facility did not ensure the residents were monitored according to their classification system. R48 attended the Gazebo Program. R48's [DIAGNOSES REDACTED]. At 1:16 p.m. on 7/27/12, R48 was observed to be sitting in the lobby and asked by the receptionist if he was "going out." R48 replied,"Yes." He then stood and called down the hallway to R49, "Let's go." R48 was given a 20 ounce (oz), clear Gatorade bottle, partially full. R49 was handed a white bag and they proceeded out the facility's main door. The door monitor stated, "They are the first to be signed out today." The door monitor further stated, "The department heads usually tell you who was restricted. The names are on the bottles and the bottles were provided by the department heads." At 1:30 on 7/27/12, R48 was observed at the Gazebo with alcohol and cigarettes, sitting at a picnic table due to the Gazebo had remained paddle-locked. When asked about the communicator that was available for them, R48 and R49 both stated, "It was in the big yellow box on the wall, but had broken and it had been gone for months now. You cannot call for help even if you need it." R48's care plan for potential alteration in mood and behavior initiated 3/9/10, indicated he had a significant history of alcohol use which had "alienated much of his family," and he had a history of [REDACTED]. A care plan for alteration in cognition revised 2/2/12, indicated he had intermittent disorientation, was forgetful, and had a significant history of alcohol use which impaired his judgement and decision making. The section for mood/behavior revised on 2/2/12, indicated R48 had fallen asleep in the smoke room while smoking a cigarette, he was verbally aggressive and sexually inappropriate after the Gazebo program. The care plan interventions directed to observe R48 after the Gazebo program because alcohol affected his judgement. A goal updated 2/10/12, identified R48 would not consume alcohol while at Mission Nursing Home (MNH). The undated care plan interventions were to encourage R48's sobriety while at MNH, observe for changes in behavior, Level IV monitoring (escort required). The care plan interventions initiated 7/18/12, directed R48 required monitored smoking "as needed" and to monitor for changes in behavior after the Gazebo program. A Care Area Assessment (CAA) dated 1/31/12, indicated R48 had cognitive loss/dementia, a history of non-psychotic disorder and alcohol use. The CAA indicated these contributed to his cognition and decline in continence. A Minimum Data Set (MDS) quarterly review dated 4/25/12, indicated R48 was unable to complete the Brief interview for Mental Status (BIMS), had poor short-term memory and moderately impaired cognitive abilities, poor decision making ability and he required cues and supervision. The MDS indicated R48 was not steady, but able to stabilize without human assistance for balance during transitions and walking. The Resident Classification dated 4/26/12, noted R48 was a level II monitoring (around the grounds), which conflicted with his care plan, which indicated a level IV monitoring (must be escorted by staff). The nurse progress notes were reviewed and noted the following: - At 10:16 p.m. on 11/16/11, the note indicated R48 was not able to get out of the smoke room because he was not able to open the door. A breathalyzer showed R48 had an Alcohol level of 0.012, his speech was slurred and R48 had impaired gait and balance. After 30 minutes staff had difficulty arousing R48 and could not keep him awake. R48 mentioned he had taken a pill and was not able to tell staff who gave him the pill or what it was for. R48 was sent to the Hennepin County Medical Center (HCMC) emergency room via 911, and a drug toxicity test was not done. Resident returned from HCMC at 2:35 p.m. on 11/18/11, an incident/accident report was not located for that date. - On 12/22/11, the note indicated R48 went to the Gazebo and when he came back he appeared to be more sexual and laughed a lot. - On 2/21/12, the note indicated R48 was found with a cigarette pack and cigarettes in the container, one cigarette was white and the other one was brown in color. The resident stated to the nursing assistant (NA) and registered nurse (RN) he was taking other cigarettes from the ash trays. The NA searched the resident's room and nothing was found. The door monitor was notified to be more observant of the resident in the smoking room. The resident was placed on 15 minute safety checks. - On 4/9/12, R48 was noted to be walking between a resident's electric wheelchair and the wall and caught his right foot on the wheelchair's wheel. The note indicated R48 fell forward and landed on his right side. The resident denied any pain or injury and had no visible injury noted. A falls risk assessment dated [DATE], was completed by the facility after a fall at 2:00 p.m.. The assessment revealed a score of 45, which indicated R48 was at high risk of falls (high risk = score of 45 and higher; moderate risk = score of 25-44; low risk = score of 0-24). The assessment indicated R48 was at high risk for falls related to the Gazebo program, weak-used touch for balance, and "forgets limitations." A quarterly fall risk assessment dated [DATE], revealed a score of 70 which indicated R48 had fallen in the last 90 days, had increased fall risk related to Gazebo program, weak-used touch for balance, and "forgets limitations." - On 4/29/12, the note indicated the therapeutic recreation aide (TRA) found R48 at the Gazebo at 5:10 p.m. (40 minutes after the Gazebo was supposed to be closed). The note described R48 as being very unsteady and visibly intoxicated. R48 was lowered to the ground and then assisted into a wheelchair. The resident became unresponsive and slid out of wheelchair, had an pulse oximetry level of 75%, his skin was cool to the touch, he had an elevated heart rate and blood pressure. R48 began to regain consciousness, denied drinking any extra alcohol, denied getting alcohol or drugs from another resident, and denied taking any pills. His pupils were noted to be pinpoint. The facility called 911 and transported R48 to the emergency room at HCMC. The facility investigation indicated "fall after Gazebo, off the Gazebo program for three days." A HCMC discharge summary dated 4/30/12, revealed R48 had an alcohol level of 0.09 and a U tox (a toxicology screen refers to various tests to determine the type and approximate amount of legal and illegal drugs a person has taken) that was positive for both Methadone (a medication which was not prescribed for R48, which causes alteration in response to pain; produces analgesia, respiratory depression, and sedation) and Seroquel (which was not prescribed for the resident, and was an antipsychotic medication). An Extended Care physician progress notes [REDACTED]." R48 had been given R72's "identified" alcohol bottle. At 10:25 a.m. on 7/27/12, the physical therapist (PT)-A stated R48 was reassessed by physical therapy (PT) after a fall with laceration on 6/23/12, and was given PT until discharged from PT on 7/8/12. PT-A stated the falls committee decided who needed a PT assessment after a fall. At 11:27 a.m. on 7/27/12, the administrator and DON were interviewed. The administrator verified R48 remained participatory in the Gazebo program and received approximately three ounces of alcohol daily. The DON stated, "The alcohol is poured in sterilized Gatorade bottles and the bottles are marked." At 11:45 on 7/27/12, R48 stated, "All my friends go to the Gazebo, no facility people are there. You go to Gazebo at 12:30 take your smoke with you and a little bottle about this big, (spread thumb and forefinger widely apart) of beer or vodka, and you go down and sit down there until you are through with it." R48 stated he did not know where the Seroquel and Methadone the hospital found in his system came from, "I couldn't say, I don't know." At 12:00 p.m. on 7/27/12, the facility Medical Director (MDr) stated the Gazebo program was monitored "very closely." The MDr stated the Gazebo program participation was evaluated, and if there was abuse (of the program), the privileges were reduced. "The DON monitors how much alcohol the residents get, the philosophy is to not tell them to quit drinking, but to monitor." The MDr agreed R48 should have been assessed before alcohol was given. The MDr further stated he was "led to believe" the alcohol was measured. At 1:15 p.m. on 7/27/12, the door monitor was observed to have the box of bottles next to her. None of the residents had signed out to the Gazebo yet. At 3:00 p.m. on 7/27/12, the DON was interviewed regarding R48 being sent to hospital on 4/30, after Gazebo hours, and after they found Seroquel and methadone in his system. The DON stated, "The facility had not been able to find out where he got that (Methadone and Seroquel), he did not even remember where he got that." and "No way you can possibly find out anything, his memory is not all that good." When asked about the physician progress notes [REDACTED]." At 3:15 p.m. on 7/27/12, the DON stated R48 did not have a alcohol poured for him on 5/1/12. The DON stated, "He mistakenly received R72's bottle from the new door monitor, and to prevent that from happening again we are now labeled the bottles using a nickname for R48 and a full first name for R72." R48's plan of care was not followed as R48 was left unsupervised for smoking in the Gazebo, although the care plan indicated staff would monitor the smoking of R48. R48 was left unsupervised when R48 went to the Gazebo in which he required an escort when he left the building. R48 was left unsupervised in the Gazebo with no means of staff supervision and no means of communication should an emergency occur. R72 attended the Gazebo program daily. R72 had [DIAGNOSES REDACTED]. The care plan lacked any indication of monitoring level. A resident classification and care conference form dated 3/27/12, indicated R72 required Resident Monitoring Level III (within sight). A fall risk care plan initiated 1/9/12, indicated R72 had a history of [REDACTED]. An alteration in mood and behavior care plan initiated 2/3/12, indicated R72 has a history of leaving against medical advice (AMA) from the facility, had a history of [REDACTED]. The care plan indicated R72 could be very child-like in his mannerisms and wanted everyone to like him. The care plan interventions were to observe for changes in mood and behavior, monitor Gazebo use and to "make changes as needed." A potential alteration in cognition related to [DIAGNOSES REDACTED] care plan initiated 2/3/12, indicated R72 displayed some forgetfulness, and was alert and generally oriented. R72 had a history of [REDACTED]. An annual MDS dated [DATE], indicated R72 had a BIMS score of 15 (a score of 15 indicated intact cognition), he had difficulty focusing attention and was easily distracted. On 6/26/12, a care conference was held and indicated R72 was to discharge to a group home, and was looking to move into assisted living, where he could drink. "Continues on the Gazebo program." R72's plan of care was not followed as R72 was left unsupervised when he went to the Gazebo, even though it was identified he was required to be within eyesight of staff when he left the building. R72 was left unsupervised in the Gazebo with no means of staff supervision and no means of communication should an emergency occur. R62 attended the Gazebo program daily. R62 was admitted with [DIAGNOSES REDACTED]. The care plan for mood and behavior dated as initiated on 2/14/12, indicated R62's level of monitoring was listed as "level II," but "varies with alcohol intake." A quarterly MDS dated [DATE], indicated a BIMS score of 10 which indicated moderate cognitive impairment. A resident classification and care conference document dated 5/8/12, listed the resident as monitoring level III (within sight of staff, which differed from the care plan monitoring level). R62 continued to drink at Gazebo and yelled out at others after drinking. An incident report at 3:00 p.m. on 5/23/12, revealed the resident had been told he only had one hour to drink that day, since bad weather was expected. At 3:00 p.m. R62 had not returned to the facility and the writer and NA went in search of R62. "He was noted to be way down by the lake and walking even further into the woods. Writer yelled to him come on you need to go back inside and he responded, 'I'm coming, I'm coming' and 'He was waving his right arm as if to say get going.' His being in the woods after drinking was suspicious so the writer and the NA searched the woods but could not find anything. The resident was very mad that the facility staff was in the woods. R62 yelled at the facility staff, 'Come on, Come on.' When we got close to him he was very mad. Writer told him he is not to be down by the woods. He said that he was going there for 3 years. Writer told him he is not supposed to be going down there" and he knew it. He said, 'You're not the boss'. He said this several times and he was very angry. Writer told him that I am the boss actually. He responded, 'Get going boss. Freak.' He repeated this several times so writer told him he was restricted from the Gazebo and to get back in the building." The administrator was informed of R62's behavior and agreed R62 needed to be restricted from the Gazebo for "no less than one week." R62's communication care plan initiated 2/14/12, indicated his speech became slurred when consuming alcohol. The mood and behavior care plan initiated 2/14/12, identified R62 had alcoholism and failure to thrive, was resistant to cares, verbally abusive, withdraws, had reduced social interaction, and participated in the Gazebo program. The care plan interventions indicated he required level II monitoring, which "varied with alcohol use." "Remind of Gazebo/alcohol program rules and encourage compliance, set up two cigarettes to bring down to the Gazebo." The altered cognition care plan indicated R62 was forgetful, had episodes of impaired decision making, "especially after alcohol use." The mobility care plan initiated 2/14/12, indicated R62 transferred independently, ambulated behind wheelchair occasionally, was at risk for falls due to a history of hip pain, an unsteady gait and alcohol use. The care plan interventions initiated 2/14/12, indicated, "Offer stand by assist, especially after alcohol use, preferred to isolate self and go to the Gazebo drinking, with the goal of continuing to go to the Gazebo to drink alcohol daily as the weather and behaviors permit. Provided proportioned alcohol at the Gazebo program, inappropriate behaviors verbally redirected." R62's plan of care was not followed as R62 was left unsupervised when R62 went to the Gazebo, although it was identified R62 was required to be within eyesight of staff when he left the building. R62 was left unsupervised in the Gazebo with no means of staff supervision and no means of communication should an emergency occur. R49 attended the Gazebo program daily. R49 had [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE], identified R49 had a BIMS score of 13, which indicated he was cognitively intact. At 1:30 on 7/27/12, R49 was observed at the Gazebo with alcohol and cigarettes, sitting at a picnic table, because the Gazebo was paddle-locked. When asked about the communicator that was available for them, R48 and R49 stated it was the "big yellow box on the wall," but it had been broken, for months now. "You cannot call for help." R49's resident classification and care conference form dated 4/10/12, indicated a monitoring level II (around the grounds), noted he refused eye doctor appoint, had poor hygiene, needed reminders for shaving and changing clothes, and he would follow the MNH alcohol/Gazebo policy. A care conference note dated 7/10/12, identified, "(R49) continued to be poorly groomed, resistant to shaving, involved in the Gazebo and eats poorly if Gazebo is closed, will follow MNH alcohol /Gazebo policy." R49's risk of falls care plan revised 1/13/12, indicated he had a history of [REDACTED]. The care plan interventions directed R49 participated in the Gazebo/alcohol program, received a fall risk assessment quarterly and as needed. The alteration in mood and behavior care plan revised 1/13/12, indicated he had alcohol dependence, dementia and daily participation in the Gazebo program. The care plan interventions directed to ensure he had lunch prior to the Gazebo, he received level II monitoring (around the grounds), assist him with moderating alcohol use by having him drink only the allotted amount he gets through the Gazebo program. R49's impaired cognitive function care plan revised 3/11/11, indicated he had alcohol dependence and alcoholic dementia; poor short term memory and occasional episodes of delusions (believing things which are not real). The care plan interventions directed R49 needed assistance with decision making, he spent time isolated in his room sleeping and going to the Gazebo; R49 needed reminders to come to meals and eat. R49's plan of care was not followed as R49 was not monitored while on the grounds of the facility which included the Gazebo. R49 was left unsupervised in the Gazebo with no means of staff supervision and no means of communication should an emergency occur. R29 attended the Gazebo daily. R29 was admitted with [DIAGNOSES REDACTED]. A Resident Classification and Care Conference form dated 4/12/12, revealed R29 required level I monitoring, which indicated independent movement. The care conference note lacked information on R29's daily attendance to the Gazebo program. The quarterly MDS dated [DATE], indicated R29 had a BIMS score of 15, which indicated intact cognition; he required set up support for personal hygiene only. A care conference note dated 7/12/12, indicated, "Continues (to be) independent with all ADL's, smokes and spends a great part of his day in the lounge." The Care Conference note lacked information on R29's daily attendance to the Gazebo program. R29's alteration in mood and potential alteration in behavior care plan initiated 12/2/11, indicated R29 had a history of [REDACTED]. R29 used alcohol daily through the Gazebo program, had a history of [REDACTED]. The care plan goal was for R29 to follow the facility alcohol and smoking policies, and to use coping mechanisms other than alcohol. The care plan interventions directed to remind R29 of the facility's alcohol and smoking policies, staff was to dispose of alcohol found in the building during room searches, staff was to observe for ingestion of other substances such as mouth wash, staff was to send R29 to the detoxification unit if "very" intoxicated. R29's cognitive care plan initiated 12/2/11, indicated he was forgetful and had episodes of impaired judgment and decision making. R29 tried to compensate by writing notes to himself and his cognition was generally decreased after going to the Gazebo/alcohol program. R29's psychotropic drug use care plan initiated 1/17/12, indicated R29 received a psychotropic medication to treat hip, neck, and back pain (Nortriptyline). R29 was at risk of falls related to alcohol use and psychotropic medication use. The care plan interventions directed, "Discourage alcohol use, level I monitoring (independent)." The mobility care plan revised 7/9/12, indicated he was independent with ambulation with a two-wheeled walker or rolling seated walker. The care plan interventions directed, "Continue to provide a wheelchair after alcohol use as needed." R29 was assessed for fall risk quarterly and as needed, ambulated with a walker, and was provided a wheelchair when his gait was unsteady after alcohol consumption. The altered nutrition care plan revised 5/10/12, indicated R29 had malnutrition, low body weight and alcohol use which impeded his ability to gain weight. The care plan interventions directed R29 required dining room supervision, preferred to sleep in, chose to alternate breakfast and, "Agreed to drink Carnation Instant Breakfast every morning, encourage fluids at meals." R29's plan of care was not followed as R29 had a history of [REDACTED]. R29 smoked unsupervised in the Gazebo. R29 was left unsupervised in the Gazebo with no means of staff supervision and no means of communication should an emergency occur. At 2:45 on 7/25/12, TMA-C stated the director of nursing (DON) and the director of social services (DSS) set up the alcohol for the residents, took the box to the front door, and the front desk monitor handed the bottles of alcohol to the residents as they exited the building. At 1:00 p.m. on 7/26/12, the Director of Medical Records (DMR) stated there were "no specific alcohol orders" and the DON and DSS "do the Gazebo program." "You will need to check with those two." At 1:05 p.m. on 7/26/12, the desk monitor (desk monitor-B) stated the Gazebo hours were 1:15 p.m. to 4:30 p.m.. Desk monitor-B also commented, "Usually, the Gazebo program is canceled in extreme cold and extreme heat." Desk monitor-B stated, "The desk monitors know which residents are allowed to go to the Gazebo because a sign is posted with the residents names on it (Resident Classification Listing By Room). The box (cardboard box containing the Gatorade bottles with alcohol in them, labeled for individual resident use) was provided to the front desk." Desk monitor-B identified one resident drank beer, which was put into a white bag. Desk monitor-B stated the Gazebo was also used for smoking. "Residents are signed out and signed in by the front desk staff and the empty bottles are returned to the desk monitor." Desk monitor-B also stated the residents were usually restricted from going off the property. If a resident attempted to leave facility after Gazebo visit, the desk monitor would call first and second responders. The training provided to the desk monitor was included in the sign out book; desk monitor-B produced a copy of Gazebo program, with some highlighted areas. The highlighted areas included as needed (PRN) breathalyzer and mandatory searches. At 1:25 p.m. on 7/26/12, the registered nurse (RN)-A stated she did not work afternoons, but stated when the residents return from the Gazebo, "I would check them out to make sure they are okay, offer them water, especially if it was really hot. It closes at a certain time, if they were not back, I would go check on them. I would ask if they were doing okay, feeling okay, and made it up okay. I know they are required to eat lunch and dinner." At 2:00 p.m. on 7/26/12, the DON stated the Gazebo program hours changed with the season. She stated the Gazebo was closed for specific temperatures and for snow, or any situation "that would make it difficult or dangerous to get to the Gazebo." The DON stated residents entered the facility to participate in the Gazebo program, all were considered eligible, then evaluated, and currently the facility had six people in the program. The Interdisciplinary Team (IDT) decided who was restricted from the program. The DON stated, "There was no assessment of the residents after the Gazebo, unless they fall, then just do vital signs and range of motion (ROM)." The DON stated all resident alcohol amounts were first started at providing a "few ounces" of alcohol, the facility then evaluated how they were doing "by walking and talking," and "go up from there." The DON further stated it was a "known policy" the residents "cannot leave after going to the Gazebo," the outing listings were posted with resident names, if they go to Gazebo, and they are not allowed to go on an outing. At 3:00 p.m. on 7/26/12, the DSS stated when a resident was first started on the Gazebo program, they started with a minimal level alcohol amount, then slowly increased to the point the facility "thought" they (residents) could tolerate. The DSS indicated nursing focused on the resident review medically and the DSS focused on the resident review psychosocially. At 11:27 a.m. on 7/27/12, the administrator and DON stated there were no staff in the Gazebo to monitor residents. The DON stated the MD (medical doctor) and NP (nurse practitioner) reviewed all the medications when they see the residents and would be able to determine which medications had contraindications to alcohol consumption; and further stated the facility medical director was also aware of who was on the program. The DON stated residents were admitted to the facility because the facility had the Gazebo program and were all eligible to be considered for the program if they desired to participate. At 12:00 p.m. on 7/27/12, the medical director stated the Gazebo program was monitored very closely, that there was an evaluation, if abuse (of the program) occurred, privileges were decreased. The medical director stated the DON "monitors how many ounces (of alcohol) they get." The medical director stated the philosophy of the Gazebo program was not to tell the residents to quit drinking, but to monitor their drinking. When the medical director was informed the alcohol was poured into empty Gatorade bottles, the medical director stated, "I thought the alcohol was measured." At 1:42 p.m. on 7/27/12, the director of environmental services (DES) was asked for any work order and e-mails related to the missing communicator in the Gazebo. He provided an email dated at 1:44 p.m. on 7/27/12, which communicated, "Advanced Wireless is still in possession of our Gazebo two-way radio. Do you have an estimate for the repair and