Every finding on record at Olivia Restorative Care Center

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 nursing assistant (NA)-E appropriately wore PPE (personal protective equipment) and perform handwashing before leaving 1 of 2 sampled residents (R17) who were on droplet/contact precautions. The facility also failed to ensure numerous surfaces in common use areas, such as carpeted floors, handrails, and windows were maintained in order to be able to be cleaned and/or disinfected and also kept free from dirt and insect debris throughout the facility. Additionally, the facility also failed to maintain 1 of 1 resident refrigerator and date and discard food appropriately to ensure safe consumption. This had the potential to affect all 48 residents in the facility. Findings include: PPE R17 accepted 5/31/26 at 11:56 p.m., Minimum Data Set (MDS) identified R17 was admitted in March 2025 and had diagnoses of cancer and diabetes mellitus. He was moderately cognitively impaired and was independent with transfers and mobility. R17's August 2026, Treatment Administration Record (TAR) sheet identified that COVID-19 (coronavirus) testing was to be completed on Tuesday, Thursday, Saturday on day one, three, and five for seven days. The order was to start on 8/11/26. Observation on 8/18/26 at 8:20 a.m., of a sign posted outside of R17's closed room door identified there was a laminated sign that displayed droplet and contact precautions (types of precautions used for airborne or surface infectious diseases). The signage had instructed staff and visitors to put on a gown, gloves, mask prior to entering, and to perform hand hygiene after leaving the room. R17's room door opened from inside and nursing assistant (NA)-E stepped out, turned around, and closed R17's door behind him. NA-E continued down the hall towards the west unit. Interview on 8/18/2026 at 2:20 p.m., with nursing assistant (NA)-E identified they had worked at the facility for 3 years. R17 had posted signage outside of the door that indicated PPE was to be worn upon entering. He was not sure if he needed to apply PPE if he was just getting R17 some water. He acknowledged he had received education at the facility that was related to appropriate precautions to prevent the spread of infections; however, he acknowledged that PPE was to be worn when there was an opportunity to be exposed to a resident's secretion or bodily fluids. He was not sure if PPE was to be used to grab a resident some water and stated he should have followed the isolation requirements that were posted on R17's door. Interview on 8/19/2026 at 4:29 p.m., director of nursing stated that nursing staff were provided with infection control education and directed staff to follow appropriate guidelines when entering and exiting a resident's room that required infection control precautions. NA-E was to follow the appropriate infection control guidelines for entering and exiting a resident's room to prevent the spread of infection. Review of undated, current Transmission-Based (Isolation) Precautions policy identified under the Contact Precautions section, that healthcare personnel that was caring for residents on contact precautions were to wear a gown and gloves for all interactions that may involve contact with the resident, or potentially contaminated areas in the resident's environment. PPE, upon entry to room, was to include (at a minimum) gown and gloves and was to discard the PPE before exiting the room. Healthcare personnel were to wear a face mask for close contact with an infectious resident under droplet precautions, for risk of exposure of mucous membranes, or spraying of respiratory secretions was anticipated, and gloves, gown, googles, or face shield was to be worn. Resident Refrigerator Observation and document review on 8/20/26 at 12:14 p.m., of the North wing dining room resident refrigerator identified a Use of Storage of Food policy was taped to the door. In the policy, it noted All food to be labeled and dated . Inside the fridge was: A half meat and cheese sandwich inside of a sandwich bag, undated and unlabeled. 1 leftover pizza, appearing to be a few days old, was not dated. The pizza had R44's name on it. 1 opened cream cheese fruit dip. No name or use by date were listed. 1 box of fried chicken, undated, belonging to R60. 1 bag of fruit belonging to R27, undated. Numerous other foods from residents that were either not labeled with a name or date of when to discard it. Interview on 8/20/26 at 12:25 p.m., with dietary aide (DA)-B identified he was aware of the refrigerator used to store outside foods for residents but was unaware whose responsibility it was to check and discard refrigerator foods that were outside a safe date range for consumption. Interview on 8/20/26 at 12:31 p.m., with the housekeeping/dietary managing supervisor (DM)-A identified all staff were responsible to clean and manage the resident refrigerator and ensure all foods were labeled with a name and date and discarded appropriately. Environment-Common Areas Observations around the facility on 8/20/26 from 12:08 p.m., through 12:50 p.m. identified all hallway carpets in the facility had numerous large stains and a mold-like smell. In each hall, de-humidifiers had been placed to assist with carpet drying. Handrails throughout the facility were heavily unfinished with no varnish protectant, making them unable to be appropriately cleaned and disinfected. Windows in the North hall day room had large amounts of spiderwebs and insect debris in the sills, and the sills were not closed and contained no protective varnish on the windows. There was also a black mold-like residue on the wood sills. Windows in the main dining room also were observed to have numerous amounts of spiderwebs and insect debris. Those windows as well were lacking in varnish in order to be able to appropriately clean the sills. Ceiling tiles in the Central hallway had water discoloration and a black mold-like staining. Interview on 8/20/26 at 12:31 p.m., with the housekeeping/dietary managing supervisor (DM)-A identified she was aware of the concerns for the carpets being uncleanable. The facility used dehumidifiers to help dry the floors. The facility had a large industrial carpet cleaner staff used several times per week. They were unable to get the carpets cleaned appropriately due to age of the carpet. There had been a discussion about getting new flooring; however, she was not made aware when or if this would occur and agreed this was a concern for a sanitary environment. She agreed unvarnished surfaces were unable to be appropriately cleaned. Observation during environmental tour and interview on 8/20/26 at 3:00 p.m., of the facility common areas with the maintenance supervisor and administrator identified the above-mentioned observations were discussed. The administrator agreed handrails and other wood surfaces needed appropriate sealant on them in order to be cleaned and disinfected appropriately. He had a small can of varnish that had been purchased, however, that had not been done yet. He agreed the ceiling tiles needed to be changed out and water leaks identified. The carpets were a known issue and the facility staff had spoken with upper management on getting floor replacements as the current carpets were heavily stained and had a mold-like smell and could not be cleaned appropriately any longer. He was unaware the windows in the North day room were unable to be closed. He agreed they also lacked varnish and were unable to be closed, but that was likely due to the humidity issue as the building was older. He would like to get window replacements but was unsure if that was in the budget. He also agreed with the lack of appropriate cleaning as insect debris was located in those windows and in the main dining windows. He agreed the main dining windows were also in need of varnish and cleaning. He was aware of the unsanitary concerns brought up by surveyors based off their observations and interviews from resident complaints on day 1 of survey. Staff needed to work on ensuring residents had a safe and sanitary environment. This had the ability to affect all residents. Review of the 3/24/25, Infection Prevention and Control Program policy identified the program was designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. There was no mention of environmental surfaces that would affect residents in common areas. No other policy related to environment was provided by the end of survey.

Based on observation, interview, and document review, the facility failed to ensure numerous surfaces in common use areas, such as carpeted floors, handrails, and windows were maintained in order to be able to be cleaned and/or disinfected and also kept free from dirt and insect debris throughout the facility and in 2 of 2 sampled resident's rooms (R4 and R7). This had the potential to affect all 48 residents in the facility. Environment-Common Areas Observations around the facility on 8/20/26 from 12:08 p.m., through 12:50 p.m. identified all hallway carpets in the facility had numerous, large stains and a mold-like smell. In each hall, de-humidifiers had been placed to assist with carpet drying. Handrails throughout the facility were heavily unfinished with no varnish protectant, making them unable to be appropriately cleaned and disinfected. Windows in the North hall day room had large amounts of spiderwebs and insect debris in the sills, and the sills were not closed and contained no protective varnish on the windows. There was also a black mold-like residue on the wood sills. Windows in the main dining room also were observed to have numerous amounts of spiderwebs and insect debris. Those windows as well were lacking in varnish in order to be able to appropriately clean the sills. Ceiling tiles in the Central hallway had water discoloration and a black mold-like staining. Interview on 8/20/26 at 12:31 p.m., with the housekeeping/dietary managing supervisor (DM)-A identified she was aware of the concerns for the carpets being uncleanable. The facility used dehumidifiers to help dry the floors. The facility had a large industrial carpet cleaner staff used several times per week. They were unable to get the carpets cleaned appropriately due to age of the carpet. There had been a discussion about getting new flooring; however, she was not made aware when or if this would occur and agreed this was a concern for a sanitary environment. She agreed unvarnished surfaces were unable to be appropriately cleaned. Observation during environmental tour and interview on 8/20/26 at 3:00 p.m., of the facility common areas with the maintenance supervisor and administrator identified the above-mentioned observations were discussed. The administrator agreed handrails and other wood surfaces needed appropriate sealant on them in order to be cleaned and disinfected appropriately. He had a small can of varnish that had been purchased, however, that had not been done yet. He agreed the ceiling tiles needed to be changed out, and water leaks identified. The carpets were a known issue, and the facility staff had spoken with upper management on getting floor replacements as the current carpets were heavily stained and had a mold-like smell and could not be cleaned appropriately any longer. He was unaware the windows in the North day room were unable to be closed. He agreed they also lacked varnish and were unable to be closed, but that was likely due to the humidity issue as the building was older. He would like to get window replacements but was unsure if that was in the budget. He also agreed with the lack of appropriate cleaning as insect debris was located in those windows and in the main dining windows. He agreed the main dining windows were also in need of varnish and cleaning. He was aware of the unsanitary concerns brought up by surveyors based off their observations and interviews from resident complaints on day 1 of survey. Staff needed to work on ensuring residents had a safe and sanitary environment. This had the ability to affect all residents. Review of the 3/24/25, Infection Prevention and Control Program policy identified the program was designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. There was no mention of environmental surfaces that would affect residents in common areas. No other policy related to environment was provided by the end of survey. RESIDENT ROOMS During initial tour on 8/17/2026 at 11:34 a.m., of R7's room revealed a strong smell of urine coming from the bathroom. Upon entering the bathroom, a swarm of flies was positioned on the toilet bowel seat, inside the toilet, and on the bathroom sink. The toilet seat had brown fecal smear-like stains across the front of the toilet and on the floor of the bathroom. Inside the toilet bowl had brown fecal smear-like stains along the walls of the toilet with urine and brownish fecal matter floating inside the toilet bowl. Observation on 8/17/26 at 11:48 a.m., at 1 of 2 dining rooms had approximately 10 residents eating lunch. Flies flew around residents' food, cups and silverware while several residents were eating. Observation and interview on 8/17/2026 at 5:27 p.m., with R4 in a wheelchair in his room, identified he had black and green (of what appeared to be food particles) smeared across the floor. His bedside table was partially covered with dry crusted food crumbs, and multiple opened potato chip bags lying next to his television. He had informed the housekeeping supervisor that his floor needed to be clean one morning (unknown date). He was told to wait until the next day. R4 stated he was uncomfortable living in a filthy room and revealed that he saw a cockroach running across the floor on one occasion. He informed the nursing department of his concerns and had not received any feedback or resolution to his concerns. Interview on 8/18/2026 at 10:41 a.m., with housekeeping supervisor (HA)-A identified he had worked at the facility for 7 months. He worked in the laundry and housekeeping department. HA-A stated there was a decline in staffing and he identified that the workload to clean the facility on a daily basis had been a challenge. Carpet cleaning and pest control was to be completed by the maintenance department. The previous maintenance director provided oversight to clean the carpets on a routine basis, however, the previous maintenance director was no longer employed at the facility. When asked if a resident room required cleaning outside of his working hours, who was assigned to complete the task, his response was another housekeeping aide, a nursing assistant, or the administrator would clean it. Observation and interview on 8/18/26 at 1:03 p.m., with R4 in their room identified on the floor there were several small piles of what appeared to be feces-like debris on the floor with flies swarming the debris. R4's room was cluttered with various items laying on the floor, on the bedside table, and R4's garbage was noted to be full. R4 stated housekeeping does not clean his room. Interview on 8/18/2026 at 5:37 p.m., with HA-B identified she had been working at the facility close to 20 years. She worked the evening shift and was to work several hours a day. She received requests from residents to have their trash removed; however, if she was passing by a resident room which appeared to be unkempt, she would require that resident to ask her to clean the room. Interview on 8/19/2026 at 8:43 a.m., with HA-C identified he was hired less than a year ago. His department had staffing challenges and was expected to clean a whole facility alone at times, due to being short staffed and found it to be difficult to maintain. Overall, he identified that the cleanliness of the facility could be improved. Interview on 8/20/2026 at 7:41 a.m., with HA-D identified cleaning requirements of resident rooms and the common areas, was to be completed on a daily basis. Carpet cleaning was expected to be completed on a weekly basis. Overall, staffing the housekeeping department had been a challenge and revealed the facility had adequate supplies to manage the cleanliness of the facility, however, it was not done according to her expectations and housekeeping department standards. Interview on 8/20/2026 at 11:56 a.m., with trained medication aide (TMA)-A and NA-F identified TMA-A stated residents' rooms on the weekends had not received thorough cleaning. Housekeeping staff were found not to be present on the weekends. Both TMA-A and NA-F identified the facility cleanliness was a concern. Interview on 8/20/2026 at 12:29 p.m., with agency NA-G identified employees were directed to pick up trash if seen in a resident room. It was the responsibility of staff to ensure resident rooms were kept tidy. She acknowledged the condition of the facility, in relation to cleanliness was not acceptable. Review of the August 2026, Housekeeping schedule identified 6 categories of cleaning staff were to be scheduled each day as follows: E= 3:30 p.m. to 630 p.m. Routine [cleaning]. N= (North [Hall] routine) 7:00 a.m. to 3:00 p.m., S= (South [Hall] routine) 7:00 a.m. to 3:00 p.m, D= (Deep clean) 7:00 a.m. to 3:00 p.m, L= (Laundry) 7:00 a.m. to 3:00 p.m, PM= ([Evening] disinfecting high touch areas 5:00 p.m. to 7:00 p.m., and W= (Weekend routine) 7:00 a.m. to 3:00 p.m. Out of 31 days in August 2026, the facility failed to ensure all shifts were covered as E had 11 shifts not filled, N had 9 shifts not filled, S had 8 shifts not filled. D was only appeared on to be scheduled each Wednesday and Thursday, however 3 of the 10 days were not listed as having been staffed and S was missing 8 scheduled shifts. Review of the undated, Housekeeping Aide job description identified housekeepers were primarily responsible for maintaining a clean, safe, germ free, and homelike environment for residents, families and staff. Their responsibilities included to pick up and remove hazardous articles from the floor and place in receptacles, wash the floors, corridors, stairwells, partitions and windows from the inside of the building, vacuum and/or wax floor and shampoo carpets and furniture, use hand operated equipment and detergents to scrub and clean lavatories, wash light fixtures, polish wood, metal fixtures and equipment, dispense linens and maintain appropriate inventory, and report the need for building repairs to the director of housekeeping. RESIDENT COUNCIL MEETING Review of the June 2026 Resident council meeting minutes identified under New Business resident council concerns for Housekeeping/Laundry noting concerns with resident rooms not being cleaned regularly or just not being cleaned and clothing not coming back from laundry. Interview on 8/19/26 at 10:00 a.m., with the resident council identified when resident council has voiced concerns or grievances, the facility has not made any changes or reported to the resident council what the resolutions to the concerns were. Resident council reports they have waited several days for housekeeping to clean their rooms and have had to empty their own garbage after waiting more than a week and place the bag of garbage in the hallway.

Based on observation, interview, and record review, the facility failed to revise, implement, and enforce their smoking policy for 2 of 2 sampled smoking residents (R11 and R17) who kept cigarettes and/or lighters on their person or were found smoking in their rooms. This had the potential to affect all 48 residents in the facility. Findings include: R11's accepted 8/22/26, Minimum Data Set (MDS) identified that R11 was admitted [DATE] with a diagnoses of conversion disorder (neurological symptoms) with seizure or convulsions, depression and epilepsy. R11's current, undated care plan identified he was at risk for activities of daily living (ADL's) related to impaired balance. R11 required partial/moderate assistance with bathing, dressing and toilet use. He was independent with bed mobility, eating and locomotion in his wheelchair. In addition, R11's care plan identified he was an active smoker. Intervention was for R11 to leave the facility to smoke between 8am and 8pm, sign in and out when leaving the property to smoke, to return lighter, vapes and cigarettes to nursing staff after smoking was complete and to not have lighters, vape, and cigarettes on him while inside the facility. R11's 8/05/26, Smoking Review identified R11 smoked cigarettes, was not oxygen and would smoke 5 to 9 times a day and had reviewed the facility smoking policy related to storage of smoking materials and smoking times. R11's 8/06/26 at 8:44 a.m., progress notes identified that safety assessments was completed before R11 was given clearance to smoke independently. Initial observation and interview on 8/17/26 at 2:29 p.m., with R11 identified he preferred to keep his own vapes and lighter on him at all times. He pointed to a black crossbody bag that hung across his right shoulder and was tucked under his left arm. Further observation and interview on 8/18/26 at 12:47 p.m., with R11 stated he was aware the facility had kept smoking items for residents at the nursing station, however he did not want to leave his items at the nursing station. R11 unzipped his black crossbody bag and pulled out an empty carton of cigarettes that held a black and white BIC lighter. If he needed to replace his lighter, he would wheel himself down to the local store to purchase another one. Further observation and interview on 8/19/26 at 11:25 a.m., with R11 unzipped his black crossbody bag and revealed an opened carton of cigarettes with 6 cigarettes left in the box and one lighter stored in the carton. Observation and interview on 8/19/26 at 11:42 a.m., with agency registered nurse (RN)-A walked over to the nursing station, pulled out a collection of keys and unlocked a drawer at the bottom of the desk behind the nursing station. It revealed that R11 had a single plastic container labeled with his name on the outside of the box. When opened, there was an open empty carton of cigarettes and one vape with liquid contents inside that appeared to be full when shaken. RN-A stated the process was for a resident to be assess to smoke, once approved, the facility allows residents to smoke, but was required to store their smoking material items at the nursing station. Each resident had a designated box to store their smoking items and was to ask a staff nurse for their smoking item, and was to sign in and out of the log book at the nursing station. Once the resident was done smoking, their items was to be given to a nurse and the nurse was to place it back in the locked drawer. He and other staff nurses brought concerns to the director of nursing, when it was identified that there was no proper channels of communication between nurses to identify when residents had requested or returned their smoking items to the nursing station. R17's accepted 8/22/26 at 7:28 p.m., quarterly Minimum Data Set (MDS) identified R17 was admitted [DATE] with a diagnoses of cancer, schizoaffective disorder, anxiety and diabetes mellitus. He was cognitively intact and was independent with transfers and mobility. R17's undated, current care plan identified he was a smoker. R17 was to check in with staff every 15 minutes, was allowed to smoke three times a day between the hours of 8:00 a.m. and 8:00 p.m. to smoke. His lighter items was to be locked in the medication room and R17 was not allowed to take trips to the local store. R17's 6/03/26, Rural Psychiatry progress note identified R17 was seen for medication management follow-up of schizoaffective disorder, insomnia, mild cognitive impairment, alcohol dependence, and cannabis dependence. R17 reported feeling depressed and was experiencing racing thoughts with an inability to concentrate. He had episodes of insomnia and early manic (extreme changes in your mood or emotions) symptoms. Facility staff identified behavioral escalations involving paranoid ideation about family and hyper fixation on discharge planning and family concerns. R17 supported ongoing sobriety from substances and denied recent alcohol or other illicit substance use. R17 was to maintain current antipsychotic dual regimen due to long-term benefit with close monitoring for mania or escalation of psychosis. R17's progress notes identified on:6/07/26 at 5:43 a.m., R17 was found to be non-compliant with smoking and went outside multiple times during the night.6/26/26 at 5:53 a.m., R17 was found to be smoking in his room by staff. Education was provided to R17, however, R17 denied the behavior had occurred. The progress note lacked evidence that a safety assessment had been completed to ensure his smoking items had been removed from the room.6/28/26 at 11:31 p.m., found R17 once again smoking in his room. The odor lingered down the hallway. R17 was reeducated on the facility smoking policy and progress notes lacked indication that a nursing assessment had been completed.6/29/26 at 3:46 a.m., was found, yet again smoking in his room. Staff removed a pack of cigarettes from R17's possession. R17 was offered to go to the ER for emergent needs or have law enforcement explain health risk to himself and others. R17 was removed from his room and sat at the nurses station. R17's sister and ombudsman was updated on R17's behavior.There were no further incidents of smoking attempts identified. Interview on 8/19/2026 at 4:19 p.m., with director of nursing (DON) identified the facility implemented resident smoking items was to be stored at the nursing station and locked, once a resident had been assessed and provided education of the facility's smoking policy. She planned to provide risk vs benefit forms to those residents who was found not to comply with the smoking policy, however, it was not completed. When asked how the facility provides oversight of residents returning their smoking items to the nursing station to prevent a fire hazard and promote a safe environment. The DON had no response. Review of undated, current Comprehensive Care Plan policy identified the facility providing services, as outlined in the comprehensive care plan was to meet professional standards of quality. The comprehensive care plan was to include measurable objectives and timeframes to meet the residents' needs and to provide alternative interventions that was to be documented, as needed. Lastly, qualified staff was responsible for carrying out the interventions initially and when changes are made. Review of November 2025 Smoke Free Facility policy identified smoking, including electronic cigarettes was prohibited in all areas of the facility and facility grounds. The resident was to be informed of the smoke-free policy and to be assessed upon admission, quarterly and during comprehensive assessment process. If a resident does not follow the smoking policy, care plan revisions was to be documented and implemented to promote safety.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R56) was provided with medications upon discharge. The facility failed to complete Quality Control (QC) test for multi-resident use glucometers as required by the manufacturer for 5 of 5 (R6, R14, R26, R34, and R52) sampled residents. In addition, the facility failed to timely reorder pain medication and ensure the narcotic count was accurately filled out and completed to ensure potential diversion did not occur for 1 of 6 residents (R58).Findings include: DISCHARGE R56's 4/21/26, admission Minimum Data Set identified he was admitted to the facility in April 2026 and had diagnoses of sleep related hypoventilation, nicotine and alcohol dependence, tachycardia (fast heart rate) (requiring medicine to control the rate), high blood pressure, major depressive disorder, muscle weakness, unsteadiness on his feet, and mild cognitive impairment. R56's physician orders in effect the day of discharge identified R56 was receiving: Tylenol for pain, Chantix for smoking cessation, Vitamins, Diltiazem CD for heart rate control related to tachycardia, Benadryl for itching, Epinephrine for severe allergic reactions as needed, And metformin, a diabetes medication for blood sugar control. R56's progress notes identified on 7/17/26 at: 9:35 a.m., a late entry note, written on 7/20/26, identified staff noted R56 was discharged to his home/community on 7/17/2026 1:00 PM. R56 had previously gone on a leave of absence (LOA) from the facility to his home for the 4th of July and came back to the facility with his personal vehicle and alcohol in his system and had to be transferred to ER. R56 was found to have ingested alcohol by the emergency department (ED) at that time. R56 then requested to have another LOA trip to the Lake of the Woods, but his medical provider (nurse practitioner (NP)-A) did not sign off (on future LOA) due to the resident's recent LOA trip ending in the ED. R56 was noted to have left AMA. There was no mention the facility had attempted to give R56 his medication to ensure safety upon discharge. 12:59 p.m., R56 was noted to be leaving AMA. Staff discussed with R56 that his leaving was against medical advice. Staff noted no medications and no follow-up appts were made. R56 stated he understood what AMA was and signed the form. R56 then collected all of his items and left in his personal vehicle. R56's AMA form identified the form was titled Release of Responsibility for Discharge Against Medical Advice and noted I, the undersigned, hereby acknowledges that i have been informed of the advisability of, risk inherent in and the probable consequences of leaving the facility against medical advice and / or without a physician's discharge order. I hereby assume all responsibility for the care and custody of myself or of. The form was signed by the resident and 2 staff but was not dated or timed. There was no other information included on the form. R56's 7/17/26, Discharge assessment identified in the section Resident is ok to discharge home with current medications, the facility noted discharged AMA. On 8/19/26 a call was placed to NP-A and a voicemail left; however, no call back was received. Interview on 8/19/26 at 3:24 p.m., with the director of nursing (DON) identified she was unaware a resident should be advised to wait for medications to be provided and given those medications prior to a discharge, if possible, to ensure their safety. The DON agreed R56 had no medications upon discharge and staff had not noted they had actually discussed any need for medications, especially since he was leaving the facility on a Friday afternoon and may not be able to get to a pharmacy in order to ensure missed doses had not occurred. Review of the 3/24/25, Discharge Planning Process identified in cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team was treat this situation similar to a refusal of care. An active discharge plan was to identify medical needs of the resident. There was no mention of providing medications to a resident upon discharge. GLUCOMETER R6's August 2026, Order Summary Report identified R6 was admitted [DATE] with a diagnosis of diabetes mellitus type 2 with foot ulcer. His blood sugar was to be checked four times a day. Nursing staff was to notify the primary physician if R6's blood sugar was less than 70 milligrams/deciliter (md/dL) or greater than 300 mg/dl. R14's August 2026, Order Summary Report identified R14 was admitted [DATE] with a diagnosis of diabetes mellitus type 2. Her blood sugar was to be checked before meals. R26's August 2026, Order Summary Report identified R26 was admitted [DATE] with a diagnosis of diabetes mellitus type 2. Her blood sugar was to be checked weekly on Tuesday. Nursing staff was to call the primary physician if R26's blood sugar was greater than 400 mg/dL. R34's August 2026, Order Summary report identified R34 was admitted [DATE] with a diagnosis of diabetes mellitus type 1 with diabetic neuropathy (nerve damage with symptoms such as pain, numbness, or tingling). Her blood sugar was to be checked every four hours before meals, six times a day. R52's August 2026, Order Summary Report identified R52 was admitted [DATE] with a diagnosis of diabetes mellitus type 2 with diabetic neuropathy. His blood sugar was to be checked before meals. Observation and interview during medication administration on 8/20/26 at 12:58 p.m., with licensed practical nurse (LPN)-A identified the facility provided 1 multi-resident use glucometer to be stored on 1 of 2 medication carts was used for residents on the South and Central hall. LPN-A had identified that R34 required blood sugar checks on the unit using a small black glucometer device labeled True Metrix. Interview on 8/20/2026 at 1:06 p.m., with trained medication aide (TMA)-A identified that the facility designated 1 glucometer to be stored in 1 of 2 medication carts for diabetic residents on the north and central hall. She identified that R26 required blood sugar checks on the unit. Further observation and interview on 8/20/2026 at 1:08 p.m., with registered nurse (RN)-B identified she retrieved a resident list sheet and identified (four residents who required blood sugar checks with the glucometer for R6, R14, R34, and R52. During the 1 of 1 medication room tour on 8/20/2026 at 1:35 p.m., with RN-B identified nursing staff was directed to recalibrate the glucometer machine once a week. Review of the glucometer control logs identified on the: North hall's Quality Control (QC) test for the multi-resident use glucometer was completed 3/12/26, 6/04/26, and 8/17/26. South hall's QC test for the multi-resident use glucometer was completed 3/12/26 and 8/17/26. Overall, both logs lacked evidence that QC test had been completed on a consistent basis by the manufacturer's recommendation. Interview on 8/20/2026 at 2:18 p.m., with director of nursing identified the nursing staff was directed to complete glucometer control checks, however, it had not been completed on a consistent basis. Review of undated, current Blood Glucose Monitoring policy identified nursing staff was to complete calibration checks on glucometers as per the manufacturer's instructions. The policy failed to identify the frequency of when calibration checks was to be completed and had left the section blank. Review of 2024 True Metrix Self-Monitoring Blood Glucose System Owner's Booklet, identified, Control test was to be performed when a new vial of test strips was opened, blood glucose results are found to be unusually high or low, exposure to extreme temperatures, when performance check of the system was required and when the meter was suspected to be damaged. PAIN MANAGEMENT Review of the 6/24/26, report to the State Agency (SA) identified R58 had an order for pain medication upon admission. At some point (unknown date), the facility ran out of the supply of pain medication, and R58 went 24 hours without receiving pain management. R58's current, undated care plan identified she had diagnosis of a left dislocated kneecap and pain related to a fracture. Staff were to anticipate the residents' need for pain relief, respond immediately to any complaint of pain and to evaluate the effectiveness of pain interventions. Staff were to follow dosing schedules and monitor for effectiveness. R58 was able to reposition independently and report to staff what increased or alleviated her pain. The care plan made no mention of what the non- pharmacological interventions were that staff should implement to help reduce R58's level of pain. R58's 6/17/26, physician order identified she was to be administered oxycodone 5 milligrams (MG) immediate release tablet by mouth every 6 hours as needed for severe pain rated 7-10. Review of R58's nursing progress notes identified the following on: 6/19/26 through 6/22/26 there was no documentation to support that nursing staff had reached out to the provider when R58's pain medication supply was getting low. 6/23/26, at 3:57 a.m., physician sent a new prescription to the pharmacy for R58's refill of oxycodone 5mg tab, give half tab every 6 hours as needed. This was a decreased dose, however the medical record made no mention of a rationale for decreasing R58's oxycodone. 6/24/26 the director of nursing (DON) received a call from the mental health worker reporting concerns voiced to them by R58 related to medications. The progress note did not identify what the medication concerns were but identified, they encouraged the resident to voice her concerns to the facility staff so they could help her understand. 6/30/26 the director of nursing reviewed resident concerns. DON identified the concerns that came from R58's mental health worker. The DON interviewed R58 who identified she would now bring concerns to the facility staff and understand the process. The progress notes did not identify any interventions or re-education that had been provided to facility staff or any investigation to identify the medication concerns or the cause of those concerns. Review of an email received by the DON from the pharmacy identified the pharmacy received the new prescription from the physician for a refill on 6/22/26 at 9:45 p.m. The medication was shipped and delivered on 6/23/26 at 8:54 p.m., there was no STAT request made by the facility. Review of R58's Medication Administration Record (MAR) for June 2026, identified she had been administered oxycodone HCI (narcotic pain medication given for moderate to severe pain) oral tablet 5 milligrams (mg) as needed (PRN) every 6 hours for moderate to severe pain (pain scale rated at 7-10) R58's pain scale level was recorded at the same times as medication administration as follows: 6/18/26 at 8:29 p.m. with a pain scale (PS) of 9. 6/19/26 at 9:36 a.m., with a PS of 7 and 10:18 p.m., with a PS of 8. 6/20/26 at 1:11 p.m., with a PS of 9 and 9:29 p.m., with a PS of 7. 6/21/26 at 6:38 a.m., with a PS of 8 and 11:46 p.m., with a PS of 8. 6/22/26 at 6:58 a.m., with a PS of 9 and 4:10 p.m., with a PS 8. 6/23/26, no oxycodone medication was given. R58 consistently took her PRN medication twice per day to manage her pain. R58's last dose of oxycodone was on 6/22/26 at 4:10 p.m. and R58 did not receive another dose of oxycodone until 6/24/26 at 12:45 a.m., just over 24 hours after the oxycodone supply had run out. Review of the facilities narcotic book count for R58's oxycodone identified at the top of the page R58's name, the prescribing physician, oxycodone 2.5 mg, the pharmacy, and instructions to give 1/2 tablet every 6 hours as needed. The narcotic count page further identified on 6/22/26 at 4:10 p.m., the last dose of oxycodone 5 mg was used, and the ending count was zero. Then on 6/24/26 the facility received a new supply of 30 tablets oxycodone 2.5 mg for R58 from the pharmacy. The new supply was added to the same page in the narcotic count book and the documentation at the top of the page appeared to have been altered to show 2.5 mg rather than starting a new page for the changed order. The narcotic count page identified the first 9 doses recorded were documented in the MAR as 5mg oxycodone rather than 2.5 mg. Starting on 6/24/26 the doses recorded were documented in the MAR as 2.5 mg. Due to the discrepancy on the narcotic count page it was unknown if R58 was receiving the correct dose of oxycodone. Review of the MAR identified R58 was administered the decreased dosing of oxycodone 2.5mg every 6 hours PRN as follows. On: 6/24/26 at 12:45 a.m., with a pain scale of 6 (moderate), at 7:08 a.m., with a PS of 9 (severe), and 11:30 p.m., with a PS of 6 (moderate). 6/25/26 at 8:16 p.m., with a PS of 6 6/26/26 at 3:29 a.m., with a PS of 7 (severe), 4:52 p.m., with a PS of 7, and 10:52 p.m., of 7 6/27/26 at 10:23 p.m., with a PS of 0 (no pain) 6/28/26 at 12:06 p.m., and 10:22 p.m., no pain scale noted 6/29/26 at 6:25 a.m., with a PS of 0 and 9:40 p.m., with a PS of 6 (moderate pain) 6/30/26 at 6:00 a.m., with a pain scale of 0 and 10:21 p.m., no PS provided. Review of R58's pain scale assessments during the time the facility had no supply of her oxycodone identified the following on 6/23/26 at: 8:44 a.m., R58 reported a pain rating of 7 out of 10 (severe) 9:02 a.m., R58 reported a pain rating of 7 out of 10 (severe) 1:18 p.m., R58 reported a pain rating of 7 out of 10 (severe) Interview on 8/18/26, at 3:24 p.m., with registered nurse (RN)-C identified they typically order refills of medication when there is about 3-4 days supply remaining. He said for narcotics it can take a couple days to get the new order because the physician has to write a new prescription for the pharmacy but it usually doesn't take more than a day or two. Interview on 8/18/26 at 4:07 p.m., with the DON identified they ran out of R58's oxycodone pain medication on 6/22/26, they gave Tylenol to address R58's pain during the time they were out of her pain medication. The DON noted running out of R58's pain medication could have affected her quality of life and level of comfort and could have led to hospitalization. She expected nursing staff to re-order resident medication refills at least 3 days prior to medication running out. She had not reviewed the notes to see if the nursing staff had ordered the medication timely. In addition, if the mediation had been ordered but not arrived, she would expect nursing to follow up with the pharmacy to see why the medication refill had not yet arrived. She was unable to provide any documentation of re-education provided to staff following this event. Review of the facilities Medication Reordering policy identified they would accurately and safely provide or obtain pharmaceutical services including provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications and observes 6 or less doses left of one kind, that nurse will reorder the medication, time permitting.

Based on interview and document review, the facility failed to ensure medically required, timely, and/or required face-to-face physician visits occurred for 3 of 3 sampled residents (R56, R60, and R61).Findings include: Interview on 8/19/26 at 9:25 a.m., with the Ombudsman identified she had received numerous complaints from residents not receiving required face-to-face visits from providers. Review of the facility's State Waiver for MN Rule 4658.0710 Subp. 3. indicated, A resident must be evaluated by a physician every 30 days for the first 90 days after admission, and then whenever medically necessary. A physician visit is considered timely if it occurs within ten days after the date the visit was required. Your request for a physician extender to make visits in alignment with federal requirements has been approved. The waiver was noted to have gone into effect on 7/27/26. R56's 4/21/26, admission Minimum Data Set (MDS) assessment identified he was admitted to the facility on [DATE], with diagnoses of sleep related hypoventilation, nicotine and alcohol dependence, tachycardia (fast heart rate) (requiring medicine to control the rate), high blood pressure, major depressive disorder, muscle weakness, unsteadiness on his feet, and mild cognitive impairment. R56's provider visits identified:R56 was first reported to be seen in person on 4/21/26, by nurse practitioner (NP)-A for a comprehensive face-to face admission visit where care planning was discussed as well as current medications, code status, his depression, etc. There was no indication the facility had identified R56 was seen for his initial visit by an NP and not by a physician. R56 was then seen via telehealth the next day on 4/22/26 for an Initial practice onboarding Telehealth visit by NP-B. R56 was seen for evaluation and management of high blood pressure and diabetes for ongoing coordination of chronic conditions and to discuss Care Management programs. R56 presented to establish medical care and review chronic conditions. R56 had no acute concerns.R56 was seen on 4/30/26, by physician (MD)-C for complex chronic care management. No acute concerns were noted and no assessments of R56's physical presentation were noted. It was noted R56 gave verbal consent for care management and was advised of potential for cost sharing as only one provider can bill chronic care management per month . The was no indication in R56's note that he was asked to sign any type of form to assume financial liability or if he was made aware of how much he could be billed for extra visits if not covered. On 5/6/26, NP-B saw R56 for a comprehensive behavioral health visit related to R56's mild depression. There were no acute symptoms noted on that visit and no was marked for previous episodes. There was no indication why R56 required a BH visit when R56 had been reviewed on 4/21/26 for depression. R56 was not seen again until 7/14/26. That visit was provided by NP-A and was a telehealth visit and not a face-to face. Review of the physician rounding schedule, provided by the facility, identified MD-C had been onsite at the facility on 4/29/26 and not 4/30/26 as identified in the above note. There was also no indication the facility had identified why R56 needed more visits than required, or that the visits did not reflect the required face-to face visits as required before the waiver went into effect in July 2026. R60's 7/10/26, Social Services Discharge Assessment identified R60 was admitted to the facility on [DATE], and had diagnoses of critical illness myopathy (multiple diseases affecting skeletal muscles) fracture of her first lower back vertebrae, osteoporosis, anemia, history of bariatric surgery, chronic blood clots in her lung, high blood pressure, long term use of anticoagulants (blood thinners), lymphedema (excessive swelling in limbs), major depressive disorder, Post Traumatic Stress Disorder (PTSD), muscle weakness and lack of coordination, neuropathy and irregular heartbeat. R60 was discharged on 7/10/26. R60's provider visits identified on:4/22/26, NP-B made a note of a provider visit titled, Initial practice Onboarding Telehealth. R60 was seen for evaluation and management of her irregular heartbeat and high blood pressure and onboarding coordination of chronic conditions and discussion of Care Management programs. She presented to establish medical care and review her current chronic conditions. There was no indication why this initial visit was being performed by an NP. 4/29/26, physician (MD)-C saw R69 for a chief complaint of MD transitional Care Unit Routine Review, related to weakness, physical conditioning, and high blood pressure. R60 was noted on the report to have been seen at Wabasso Rehab and Wellness Center, which is located at 660 Maple Street, Wabasso MN . and not the facility in which R60 was physically admitted to. R60 presented for a routine review of multiple medical problems as required by Medicare regulatory guidelines. MD-C noted No acute changes or concerns. R60 was seen in the presence of a female nurse aide. R6o expressed frustration at not receiving physical therapy (PT). Staff reported R60 declined evaluation and had not been compliant with PT. No new changes or falls reported. MD-C noted staff were to follow the current care plan for all chronic conditions as they are stable. 6/16/26, NP-A noted R60 was seen for a chief complaint of Transitional Care Unit Routine Review: diarrhea/hot flashes. R60 was noted on the report to have been seen at Wabasso Rehab and Wellness Center, which is located at 660 Maple Street, Wabasso MN .and not the facility in which R60 was physically admitted to. The visit focused on R60's new complaints although NP-A did review her care as a whole in the note. No other visits were recorded in R60's medical record. Review of the physician rounding schedule, provided by the facility, identified no provider was present at the facility on 4/22/26. MD-C had been at the facility on 4/29/26. NP-A was noted to be physically at the facility on 6/16/26. It was unknown if the facility had identified the required visits were not occurring at intervals specific to the regulation for required face to face visits, or if the medical records needed clarification and revision, as the dictation stated they occurred at another facility. R61's face sheet and admission orders identified R61 was admitted [DATE] and discharged [DATE]. R61 had diagnoses of pressure ulcer to the right buttock, adult failure to thrive, high blood pressure, high cholesterol, chronic pain, diabetes, neuromuscular disorder of their bladder, drug induced constipation, insomnia, urinary tract infection, alcohol dependence, non pressure ulcer of the lower left leg that was chronic, a history of sepsis. and paraplegia (paralysis of legs and lower body). R61's provider visits identified on:12/23/24, R61 was seen for an acute concern via phone for a yeast infection by NP-E 1/3/25, R61 was seen for an initial visit via telehealth by NP-D to establish medical care for chronic conditions. There were no acute complaints noted. 1/21/25, R61 was seen by NP-A for a rash and weakness although NP-A did note they reviewed R61 for all systems of health. 1/28/25, R61 was seen by NP-A for weakness and rash. Notations made by NP-A also noted he waqs seen for multiple medical issues including weakness, reduced mobility and raash. An as-needed medication was started to treat the rash. R61 was encouraged to work with therapy to improve strength and mobility. 2/4/25, R61 was seen by NP-A in the facility for psoriasis, rash and weakness. NP-A noted R61's psoriasis continued to flare despite treatment. A Dermatology referral was ordered. R61 reported otherwise, that he was doing well.2/6/25, NP-A saw R61 again for rash, weakness and also this time, insomnia. R61 reported increased insomnia the past couple of weeks, with NP-A noting adjustments having been already made to medications and staff were to monitor for changes. NP-A noted a dermatology referral was started. There was no indication why R61 needed to be seen 2 days after having been seen for the rash with no updates to show anything had changed, nor why the insomnia was not addressed at that time also on 2/4/26, since it was happening over the past couple of weeks. 6/6/25, NP-B saw R61 for a follow-up telehealth visit for high blood pressure and diabetes. Staff were to monitor for complications and provide point of care glucose testing. 7/8/25, NP-B saw R61 again for a telehealth visit for diabetes. Staff were to monitor for complications and provide point of care glucose testing. 8/4/25, MD-F saw R61 onsite for a routine follow-up. R61 was noted to having been refusing cares and his guardianship was still pending R61 denied any specific concerns and a review of systems was attempted and was felt to be reliable. Review of the physician rounding schedule, provided by the facility, identified there were no visit schedules for NP or physicians prior to August 2025 provided. R61's progress notes identified on 8/12/26 at 1:13 p.m., R61 was transferred to a local hospital for evaluation due to decline in his condition and complex wounds. He had no urine output yet that day. R61's family declined to sign a bed hold as their intention was to have R61 transported from the local hospital to a regional hospital and find a facility closer to that area. At 7:42 p.m., R61's family came to the facility to collect R61's belongings and stated R61 was indeed transferred to the regional hospital. There was no indication the facility had identified R61 was not seen appropriately by a physician at the required intervals, nor that R61 was seen for similar concerns days to 1 week apart at times. Interview on 8/19/26 at 4:20 pm with the DON identified she was aware the facility had a waiver now in effect for MD visits but was not aware the above residents were not being seen as required. She was also unaware of repeated visits for no seemingly acute concerns. She did state she was aware of concerns with the previous providers, providing services in accordance with their contract and had a new contract with a different contractor for physician visits. A call was placed to NP-A. A message to return the call was left. No return call was received. Review of the undated, current Physician visits and Physician Delegation policy identified the physician should see resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. Assign alternate physician or physician extender to make visits as appropriate by State law. At the option of the State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician. At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician.

Based on interview, and document review, the facility failed to act promptly and provide resolution for resident concerns brought forth at resident council meeting by 4 of 50 residents (R19, R26, R31, and R38). Findings include: Review of the June 2026 Resident council meeting minutes identified New Business resident council concerns for each department as follows:Nursing: long wait times for assistance with toileting and bathing and poor communication between residents and the nursing staff. Housekeeping/Laundry: resident rooms not being cleaned regularly or just not being cleaned, clothing not coming back from laundry.Maintenance: Pothole in the parking lotTherapy: Not getting therapy or an exercise program.Activities: Residents would like new art supplies, more snacks, more trivia games, and more outings. Review of the July 2026 Resident Council meeting minutes identified no mention of a resolution being provided to the residents for the previous month's concerns. Interview on 8/19/26 at 10:00 a.m., with the resident council identified when resident council has voiced concerns or grievances, the facility has not made any changes or reported to the resident council what the resolutions to the concerns were. They had concerns with missing clothes that sometimes were seen being worn by other residents. Call lights take a long time during the night.sometimes over an hour. Staff would come to the residents' rooms and said they would be right back and they did not return. The resident council reported they have had to wait several days for housekeeping to clean their rooms, had to empty their own garbage after waiting more than a week, and then place the garbage in the hallway. They identified concerns with snack time as snacks were left on a cart in the hallway and by the time they were able to access the snack cart, all the snacks were gone. Sometimes snacks had not come out until 9:00-10:00 p.m Interview on 8/19/26 at 10:43 a.m., with the activity director identified she started working as the resident council liaison in April of 2026. The facility provided her with a form to fill out at each resident council meeting. When she receives concerns or grievances from the resident council she brings them to the interdisciplinary meeting (IDT) and verbally discusses the resident council concerns. She was not aware that she was to bring an action plan or resolution of the concerns back to the residents. She stated I thought I was just supposed to bring the concerns to IDT morning meeting. Interview on 8/19/26 at 11:40 a.m., with Social Service (SS)-B identified she reviewed the resident council minutes that were available. She felt the minutes were not being documented properly, and the facility's process was broken. The Activity Director is not following the policy. Review of the Resident Council Meeting policy, implemented in 2025, identified Resident Council is a formal group and the facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council.

Based on interview and document review, the facility failed to have an integrated hospice care plan for 1 of 1 resident (R3) reviewed for hospice.Findings include: R3's accepted 6/28/26, quarterly Minimum Data Set (MDS) assessment identified R3 was receiving hospice services. R3's undated, current facility care plan identified R3 was at the end stage of life and utilizing hospice services. Staff were to call hospice when new physician orders were received and coordinate care with hospice and other end of life services. There was no mention of who the hospice provider was or where to find the phone number if the facility needed to reach the hospice provider. There was also no mention of what services the facility was to provide or what services hospice was to provide. R3's 8/11/26, hospice care plan identified R3's diagnosis was Parkinson's disease. Hospice noted the facility was unable to use a Tabs alarm (a fall device that clipped onto clothing or sensor pad to trigger an audio alert to warn staff when patient attempts to get up unassisted) on the chair for safety. The plan was to have staff increase checking on R3 to try to prevent self-transferring falls. R3 would remain free of falls (R3 had 3 falls in July). Also noted by hospice was that R3 had increased tremors. Hospice utilized volunteers for some visits and pet therapy. Hospice aid would assist with bathing, dressing, elimination, grooming, and mobility as needed and report any changes in status to the facility nurse. R3's quality of care would be enhanced through collaboration with hospice and facility. The facility staff were to provide cares when hospice staff were not present. Hospice staff would provide emotional support and educate on end of life to R3 and family. The facility was to contact the hospice provider with any changes in R3's status. The hospice nurse and social worker would notify the facility prior to visiting and participate in R3's care conference. The hospice nurse would be available 24 hours a day to assist with symptom management and concerns. Hospice provider would provide chaplain, home health aide, skilled nursing, and social services visits. The hospice provider would offer massage therapy, music coordinator, and medication management services. There was no mention that any of the above interventions had been included in R3's facility care plan to identify what services hospice would provide and what services the facility would provide. Interview on 8/18/26 at 2:13 p.m., with registered nurse (RN)-C said he did not know if he could pull a hospice care plan for review. He stated he was unable to find a hospice book for R3 with the hospice information in it. He commented that maybe the assistant director of nursing (ADON) had R3's hospice book as it was not at the nurse's station. Interview on 8/19/26 at 2:19 p.m., with ADON reported that R3's hospice care plan should be scanned into the electronic medical record along with any visit notes from hospice. She reported that the facility was unable to find R3's hospice binder and would be emailing hospice to see where the hospice book was. Interview on 8/19/26 at 10:35 a.m., with RN-B identified R3 was on hospice and when asked where to find the hospice care plan she said Good question.there is no hospice book for R3. For hospice, the facility did all the normal things. Typically, there was a hospice book where you would find the hospice schedule, the hospice care plan, what facility staff were to assist with, and notes from hospice staff after they made a visit. Interview on 8/19/26 at 2:37 p.m., with R3's hospice provider identified that the hospice care plan was faxed over to the facility and she was unsure where they put the care plan once the facility received it. She revealed that they did not provide a hospice book or hospice folder but thought that would be a good idea for the future. Hospice provided the information to the facility but she was unsure where they kept that information. When facilities had paper copies of charts, there was a hospice tab for hospice information. The facility should have a teal-colored sheet with the hospice numbers to call if they needed to reach the hospice nurse. Interview and observation on 8/20/26 at 7:53 a.m., with RN-A reported he was able to look at the hospice care plan and he did not have access to the hospice care plan. He reported that he thought only the director of nursing (DON) had access to the hospice care plan for R3. At 8:05 a.m., RN-A was observed to be talking with the DON and then approached surveyor and stated, the hospice provider got rid of their hospice book for R3 but the hospice care plan could be found under the miscellaneous tab in the electronic medical record. Review of the 2/11/26, hospice provider contract for R3 identified the hospice care plan would be reviewed and modified as needed in coordination with the facility. The facility will follow the hospice care plan to ensure hospice patients are kept comfortable. The facility was responsible for providing facility services based on each hospice care plan to ensure that the level of care was appropriately provided. The coordination of care included when to notify hospice such as a change in condition, a need to alter the hospice plan of care, a need to transfer a hospice patient, or the death of a hospice patient. There was no mention on the facility care plan that they were to notify hospice if there was a need to alter the hospice care plan, a need to transfer out of the facility, or when death occurred. Review of undated, Coordination of Hospice Services policy identified that the plan of care would identify services and care that each entity would provide to meet the residents needs. The facility would communicate with hospice, monitor and evaluate the response to the hospice care plans and monitor for medications and medical supplies to ensure they are provided by hospice as indicated in the care plan. The facility would immediately notify the hospice provider regarding changes in status, complications or emergent situations.

Based on interview and document review, the facility failed to monitor 1 of 1 resident (R17) from repeatedly eloping out of the facility to consume alcohol after several previous elopements. Findings include: R17 accepted 8/22/26 at 7:28 p.m., quarterly Minimum Data Set (MDS) identified R17 was admitted [DATE] with a diagnoses of cancer, schizoaffective disorder, anxiety and diabetes mellitus. He was cognitively intact and was independent with transfers and mobility. R17's undated, current care plan identified he was a smoker. R17 was to check in with staff every 15 minutes, was allowed to smoke three times a day between the hours of 8:00 a.m. and 8:00 p.m. to smoke. R17 was not allowed to take trips to the local store. Staff identified he was low risk for elopement (wandering). Staff were to reassess his elopement status quarterly. Nursing staff was directed to provide structured activities, and reorientation strategies, such as pictures, signs and memory boxes. He was at risk for potential abuse related to his history of chemical dependency. Staff were to anticipate his needs, ensure he abstained from alcohol use, and talk to R17 about his actions and review alternative processes situations. R17's 6/03/26, Rural Psychiatry progress note identified R17 was seen for medication management follow-up of schizoaffective disorder, insomnia, mild cognitive impairment, alcohol dependence, and cannabis dependence. R17 reported feeling depressed and was experiencing racing thoughts with an inability to concentrate. He had episodes of insomnia and early manic (extreme changes in your mood or emotions) symptoms. Facility staff identified behavioral escalations involving paranoid ideation about family and hyper fixation on discharge planning and family concerns. R17 supported ongoing sobriety from substances and denied recent alcohol or other illicit substance use. R17 was to maintain current antipsychotic dual regimen due to long-term benefit with close monitoring for mania or escalation of psychosis. R17's progress notes identified on:6/05/26 at 5:44 p.m., R17 had signed out the facility and went to the local bar. R17's family and primary provider had been notified of potential interactions with medication and alcohol use.6/05/26 at 8:05 p.m., R17, then returned to the facility and confirmed to nursing staff that he had 3 dinks. Vital signs revealed a blood pressure of 157/86, blood glucose 137, 95 % oxygen saturation, pulse 124 and 20 respirations.6/06/26 at 4:47 p.m., R17 had slurred speech and a blood pressure of 148/76, 124 pulse, 24 respirations, oxygen saturation of 94%, temperature 98.2, and blood sugar 146. R17 requested his cigarettes and went outside to smoke. R17 offered to marry and provide his social security benefits to an unknown trained medication aide (TMA).6/06/at 6:55 p.m., R17 was not to leave the premises and was found heading to the local bar. The on-call provider was notified and gave orders to implement 15-minute checks and vitals to be taken every 4 hours. Law enforcement was notified and issued a breathalyzer test on R17. His results was 0.15 blood alcohol content (BAC).6/07/26 at 5:43 a.m., R17 was found to be non-compliant with smoking and went outside multiple times during the night.6/28/26 at 4:39 p.m., with R17 left the facility, went to the local bar and returned hours later. The progress note lacked indication that a nursing assessment had been completed once R17 had returned to the facility.7/05/26 at 1:08 p.m., The center conducted a floor search and was unable to find R17 on the premises. A resident reported seeing R17 walking towards the local store in town.7/05/26 at 1:50 p.m., the facility called R17's cellphone and was unable to reach him. The facility left a voicemail for his sister and notified the director of nursing.7/05/26 at 3:44 p.m., R17 returned to the facility at 3:20 p.m. The Out on Pass policy was reviewed with R17 and he agreed to comply with the rules.7/07/26 at 08:47 a.m., R17 admitted to the nursing staff that he went to the local bar yet again and had two drinks. Family was notified.7/12/26 at 3:08 p.m., R17 admitted he had drank 2 beers at the local bar and denied having alcoholic contents on him. His room was searched by nursing staff and R17 was provided education on drinking that posed a risk to his health. Vital signs was obtained, nursing staff was to monitor R17 every 4 hours for 24 hours. The on-call provider was notified and the pharmacy consultant ordered for his medications to be held.7/14/26 at 4:39 p.m., R17's nurse practitioner implemented orders to allow R17 to have 2 beers or (2) 1 ounce (oz) alcoholic drinks.There were no further incidents of unsafe elopement to consume alcohol identified. Interview on 8/19/26 at 12:45 p.m., with family member (FM)-J stated that R17 had left the facility months ago without informing staff of his whereabouts. The facility called her to inform her of the situation and did not know where he was. She was called hours later by the facility and was informed that R17 was seen at a local bar in town and arrived back at the facility. To prevent R17 from leaving the building to go and drink, the primary provider had written orders in place to ensure that R17 receives at minimum, 2 drinks per day on the unit. Interview on 8/20/26 at , with administrator identified he acknowledge that lack of monitoring of residents leaving the facility without appropriate monitoring in place poses a safety risk and would need to be addressed. Review of undated, current Comprehensive Care Plan policy identified the facility providing services, as outlined in the comprehensive care plan was to meet professional standards of quality. The comprehensive care plan was to include measurable objectives and timeframes to meet the residents' needs and to provide alternative interventions that was to be documented, as needed. Lastly, qualified staff was responsible for carrying out the interventions initially and when changes are made. During survey, missing resident policy was requested and not provided by the end of the survey.

Based on interview and document review, the facility failed to ensure the physician and family were appropriately notified in a timely manner for 1 of 1 resident (R56) who left the facility against medical advice (AMA). Findings include: R56's 4/21/26, admission Minimum Data Set identified he was admitted to the facility in April 2026 and had diagnoses of sleep related hypoventilation (not enough air inhaled while sleeping), nicotine and alcohol dependence, tachycardia (fast heart rate) (requiring medicine to control the rate), high blood pressure, major depressive disorder, muscle weakness, unsteadiness on his feet, and mild cognitive impairment. R56's progress notes identified on 7/17/26 at:9:35 a.m., a late entry note, written on 7/20/26, identified staff noted R56 was discharged to his home/community on 7/17/2026 1:00 PM. R56 had previously gone on an leave of absence (LOA) from the facility to his home for the 4th of July and came back to the facility with his personal vehicle and alcohol in his system and had to be transferred to ER. R56 was found to have ingested alcohol by the emergency department (ED) at that time. R56 then requested to have another LOA trip to the Lake of the Woods, but his medical provider (nurse practitioner (NP)-A) did not sign off (on future LOA) due to residents recent LOA trip ending in the ED. R56 was noted to have left AMA. There was no mention NP-A had been notified immediately via phone as soon as the facility became aware of R56's intent to leave. 12:59 p.m., R56 was noted to be leaving AMA. Staff discussed with R56 that his leaving was against medical advice. Staff noted no medications and no follow-up appts were made. R56 stated he understood what AMA was and signed the form. R56 then collected all of his items and left in his personal vehicle. There was no indication in the progress notes that NP-A or R56's family were notified of R56's departure. R56's AMA form identified the form was titled Release of Responsibility for Discharge Against Medical Advice and noted I, the undersigned, hereby acknowledges that i have been informed of the advisability of, risk inherent in and the probable consequences of leaving the facility against medical advice and / or without a physician's discharge order. I hereby assume all responsibility for the care and custody of myself or of. The form was signed by the resident and 2 staff but was not dated or timed. There was no other information included on the form. On 8/19/26 a call was placed to NP-A and a voicemail left, however, no call back was received. Interview on 8/19/26 at 3:24 p.m., with the director of nursing (DON) identified she was aware R56 had left the facility AMA. She thought staff had notified R56's medical provider and/or family but agreed that was not mentioned anywhere in the progress notes or on the AMA form. She would look to see if she had that information documented elsewhere. Review of an email provided by the facility on 8/21/26 identified on 7/17/26 at 5:09 p.m., an email was sent to NP-A stating [R56] went AMA today. See attached. There was no indication NP-A was actually aware of R56's AMA, as it occurred after business hours and the facility had received no response back, nor was there evidence NP-A had been called immediately when this occurred 4 hours earlier. There was no policy provided related to AMA by the end of survey.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R59) had the right to choose his bathing schedule according to his preference. Findings include: Interview on 8/17/26 at 4:42 p.m., with R59 identified he had not received a bath since he arrived to the facility. He was informed by the nursing staff that he was to wait until the following Saturday (8/22/26), as scheduled. He had informed the nursing staff that he preferred to have a bath every 3 days and felt ignored when nursing staff did not provide him a bath when requested. R59's undated, current admission list identified R59 was admitted [DATE]. R59's 8/15/26 at 4:35 a.m., admission progress note identified he was admitted from an out of state hospital with a left ankle fracture from a fall at home. His left leg was covered with an ACE (elastic bandage) dressing and was to be non-weight bearing. He was continent with bowel and bladder and was to use a urinal at the bedside. R59's undated, current care plan identified R59 was at risk for Activities of Daily Living (ADL's) self-care needs with impaired balance related to his ankle fracture. Nursing staff was to provide partial/moderate assistance with bathing, however, lacked evidence of his choices related to his shower preference. Interview and document review on 8/18/2026 at 5:25 p.m., with nursing assistant (NA)-C identified NA-C did not have access to review R59's orders for scheduled showers. Nursing assistants were directed to review the shower log at the nursing station for resident scheduled showers. Upon review of the shower log, she confirmed that R59 had not been placed on the log for scheduled showers. Interview and document review on 8/18/26 at 5:33 p.m., with registered nurse (RN)-C identified on Point Click Care (PCC) (electronic medical record) orders were placed on PCC when residents were to receive a shower. He stated that R59 was offered and refused a bath after he was admitted and was scheduled to receive a bath on Saturdays. When asked if there was documentation that R59 had refused a bath, RN-C reviewed on PCC and confirmed there was no progress note that identified R59 had refused a bath. Interview on 8/18/2026 at 5:48 p.m., with NA-C identified R50 had requested a bath this evening and staff would assist him with the preparation after supper. Further observation and interview on 8/19/2026 at 10:33 a.m., with NA-D identified during handover report with oncoming staff, discussion was held to confirm daily resident scheduled showers. She reviewed the shower log and identified R59's name was not found on the shower log and was not aware of who was to assign showers to residents on the unit. Interview on 8/19/26 at 10:53 a.m., with NA-B identified the director of nursing was responsible to update the resident shower logs. Interview on 8/19/2026 at 4:10 p.m., with director of nursing identified R59 scheduled bath was not updated on the shower sheet. She acknowledged if a resident requested a shower that was not on their assigned day, the shower room was available 24 hours a day and that resident had a right to be provided with a shower by the nursing staff on the unit. Review of undated, current Comprehensive Care Plan policy identified the facility was to include a comprehensive person-centered care plan that was meant to support the residents in making their own choices and having control over their daily lives.

Based on observation, interview, and document review, the facility failed to obtain appropriate transportation to a dental appointment and reschedule a dental appointment for 1 of 1 resident (R48).R48's comprehensive Minimum Data Set (MDS) assessment identified diagnoses of coronary heart disease, hypertension, diabetes mellitus, and cirrhosis. R48 required partial to moderate assistance with dressing and required substantial to maximal assistance from staff for transfers. Her cognition was intact and she likely had cavities and/or broken teeth. R48's current, undated care plan identified she is at risk for a nutrition/hydration problem related to poor teeth with interventions to eat in her room, monitor weights, offer diet per physician orders, and offer extra hydration between meals. The care plan made no mention of obtaining a dental appointment to address broken and missing teeth. Observation and Interview on 8/19/26 at 3:05 p.m., R48 was tearful throughout the interview and identified that her teeth are broken and her gums are sore. She had been at the facility for several months, when she arrived, she already had a dental appointment set up and she told staff about the appointment, they set up a ride, however, when the ride arrived at the facility on the day of the appointment it was a small vehicle that could not accommodate a wheelchair. She went to the social service designee (SSD)-A and reported that she needed a dental appointment, and the facility would not set one up for her. SSD-A told her to tell the appointment scheduler, but they still have not set up an appointment. She was told she was on a waiting list for a closer dentist, and it would take up to 8 months to get in but that time has passed. R48 showed her gums, observed small shards of teeth protruding from gums, gums are red and appear sore, she has teeth intact. Interview on 8/20/26 at 1:30 p.m., with the appointment and ride scheduler identified R48 came to her last February and said she needed a ride for a dental appointment. She set up the ride but when the ride arrived it was a small compact vehicle and could not accommodate a wheelchair. She called the dentist back and they said we could either reschedule or try to find a dentist that was closer to the facility, that information was communicated to R48 and she said she wanted to reschedule with her original dentist, she told the scheduler that she would only need a ride to the appointment because her friend was going to pick her up after the appointment and take her to her house to pick up some of her personal items and then give her a ride back to the facility. The scheduler told R48 this was not an option. She said she had concerns with R48 returning to her home, so she spoke with SSD-A and explained the situation. SSD-A directed her not to make the appointment at this time as she wanted to speak with the director of nursing about R48's plans. The scheduler never heard anything back from SSD-A after that. In April of 2026, R48 approached her again and said she needed an eye appointment, she asked R48 if she ever got to the dentist, R48 told her she tried to make her own appointment but the dentist told her that she would have to be able to transfer to the dental chair independently or bring someone that could assist her along to the appointment. She did not document any of this information in the medical record and reports was never told until recently that she should be making progress notes in the medical record. Interview on 8/20/26 at 2:31 p.m., with SSD-A identified when a resident needs a dental appointment it's the facilities responsibility to set it up for them and arrange a ride. If the resident is unable to transfer independently, they will reach out to the family or a guardian for assistance. She agreed they did not do that for R48, and they did not get her appointment rescheduled. She was aware of the concerns with R48 wanting to ride with her friend to go to her house and pick up personal items. She was also aware that R48 was upset about not getting an appointment for the dentist. She never had a conversation with R48 about the safety risks of that plan and never attempted to help R48 develop a different plan to obtain needed dental care or transportation. She was unable to provide any documentation that a grievance had been filed or that she had offered to assist R48 to file a grievance on her behalf. Review of SSD-A's job description signed on 7/16/25, identified it was her responsibility to serve as a liaison to departmental staff in the facility on matters related to Social Services policies and procedures and overall resident care policies. To oversee important aspects of resident care focusing on the quality and appropriateness of services being rendered. She is responsible for handling and resolving resident grievances and concerns, advocating on the rights of the residents, and in addition supervises and monitors all direct care services provided.

Based on interview and document review, the facility failed to ensure continuation of physical therapy (PT) services for 1 of 1 sampled resident (R18) who intended to be discharged back to a group home after receiving strengthening services from PT.Findings include: R18's accepted 6/18/26, quarterly Minimum Data Set (MDS) assessment identified R18 had severe cognitive impairment, used a wheelchair and required substantial assistance with care. R18 was dependent on staff for transfers. R18's accepted 12/26/25, comprehensive MDS identified her overall goal for discharge was to discharge to another facility. Active discharge planning was to be occurring for R18. R18's current diagnosis list identified hemiplegia (one side weakness) following a stroke, lack of coordination, mild cognitive impairment, major depressive disorder, weakness, dysarthria (difficult or unclear speech) following a stroke, and diabetes. R18's progress notes identified R18 was reported to be waiting for admission to a group home:2/12/26, R18's guardian emailed social services earlier that week requesting care conference to discuss how R18 had been doing. Social services worked with PT and the guardian to schedule a video call.2/12/26, video call was held with guardian, PT and the group home director. The group home was noted to be adapting for R18's return back upon discharge from the facility. PT reported that it would take R18 about 1-2 months to achieve safety with transfers at the facility at that time.6/4/26 PT was awaiting insurance authorization for more therapy.No additional notations were documented as to the progress of the prior authorization for therapy. Interview on 8/19/26 at 7:54 a.m. with physical therapy assistant (PTA)-A identified she had not worked with R18 since starting and she was very new to the facility. She looked up R18's last therapy discharge summary and reported she was discharged pending prior authorization from Medicaid. She stated it looked like the facility did not get that prior authorization approval. Interview on 8/19/26 at 8:15 a.m., with physical therapist (PT) identified R18 had been discharged from therapy related to payment issues. The previous director of rehab (DOR) was responsible for obtaining prior authorizations. She recently moved out of the country and now the therapy department had an interim director of rehab (IDOR). She identified she did not have access to their electronic records system but would like to know if the authorization was obtained. The IDOR had just been at the facility last month for a visit. The IDOR was now responsible for the prior authorizations. R18 should be in physical therapy. R18 had been working on transfers previously in therapy and needed to continue to work on stand/pivot transfers. Once the facility gets that authorization, R18 would be back in therapy. Review of 6/23/26, physical therapy discharge summary identified R18's discharge identified progress to treatment was limited, as the facility had not received insurance approval (prior authorization). Interview on 8/20/26 at 12:45 p.m., with IDOR identified she was the regional director of operations. She was working as the IDOR during the hiring process for a permanent DOR, and she started covering this facility as of 8/1/26. R18 did have Medicaid, and as of 1/1/26, the State of Minnesota required a new prior authorization after 12 physical therapy visits and 24 occupational therapy visits. R18 was not on the list that she needed prior authorization for as of last week that she could find. R18 was not currently on physical therapy. She was unaware that R18 required therapy and was not receiving therapy due to the lack of the facility obtaining a prior authorization. Therapy could complete another evaluation without prior authorization and would complete that this week. The IDOR reported she had not submitted a prior authorization for R18 as she was unaware R18 needed one. Therapy should complete the evaluation first and then investigate the need for prior authorization. She said, truth be told, after the last DOR left; they were still trying to figure out the communication and process at the facility. She felt R18 had been missed somehow. Currently the therapy department was waiting on some prior authorizations, however those residents were still receiving therapy. She confirmed R18 had visits left on her previous schedule, before she would have needed prior for more visits. It was both the facility and her responsibility as she worked remotely, to provide oversight of the therapy department. Review of R18's 6/16/26, care conference notes identified that R18 had plans to return to her prior living arrangement a group home but could not return until she was able to pivot transfer. There was no mention in the care conference notes that the therapy department was waiting on prior authorization or if anyone had followed up on the status of the authorization. Interview on 8/20/26 at 12:30 p.m., with administrator identified that the facility communicated during interdisciplinary team (IDT) meetings with therapy as they were invited to that meeting. During those IDT meetings, the facility did review the resident's payor source. He reported that if there was an issue with the resident's payor source, the facility did rely on therapy to handle that. The previous DOR would get the order for therapy and confirm the payor source before the resident started therapy. The PT company was contracted to provide the oversight for therapy and ensure communication and training was in place and complete. When asked who was overseeing the contracted PT company to ensure they completed their contractual obligations, he stated, I will have to kick that back to therapy that is why we contract them to make sure therapy was getting done. There was no indication the facility had a system in place to ensure contracted therapy services had been provided. Review of 10/7/24, therapy management services agreement and facility identified they would provide in-house therapy services of physical, occupational, and speech for residents in need of such services. The therapy department would perform the following services management and oversight by regional rehab director. Clinical services education and consulting, maintained therapy documentation, compliance training and audits, end of month billing, therapy budget expenses, medial review and audits, staffing recruitment oversite and guidance, and additional services as agreed upon.

Based on observation, interview, and document review, the facility failed to ensure expired or discontinued medication was not stored with in-use medication in 1 of 1 medication room. Findings include: Observation and interview on [DATE] at 1:12 p.m., with registered nurse (RN)-B inside 1 of 1 medication room identified in 1 of 2 locked medication fridge identified the following: 1) R19's Comirnaty (COVID vaccine) 30/0.3 milliliters (ml) unopen injection syringe had an expiration date of [DATE].2) R26's Ozempic (treats diabetes mellitus type 2 and assist with weight management) opened insulin pen that appeared empty, had an open date of [DATE] and a use by date of [DATE].3) R35's Comirnaty 30/0.3 ml injection syringe, had an expiration date of [DATE].4) R45's, Comirnaty (COVID vaccine) 30/0.3 milliliters (ml) injection syringe had an expiration date of [DATE].5) R48's, Flu-cel Vax ( used to prevent the flu) injection syringe had an expiration date of [DATE]. Interview on [DATE] at 1:34 p.m., with registered nurse (RN)-B stated the medication had not been checked, because she was busy on the floor. RN-C confirmed the medications were expired and should be thrown away. Review undated, current Medication Storage policy identified that the facility was to ensure that unused medications was to be routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels.

Based on observations, interview, and document review, the facility failed to obtain a dental appointment for 1 of 1 residents (R48) who had broken and missing teeth and c/o tooth pain. Findings include: R48's 12/5/25 comprehensive, Minimum Data Set (MDS) assessment identified diagnoses of coronary heart disease, high blood pressure, diabetes, and cirrhosis (scarring of the liver leading to permanent damage). R48 required partial to moderate staff assistance with dressing and required substantial to maximal assistance from staff for transfers. Her cognition was intact and she had obvious or likely had cavities and/or broken teeth. R48's current, undated care plan identified she was at risk for a nutrition/hydration problem related to poor teeth, with interventions to eat in her room, monitor her weight, offer her diet per physician orders, and offer her extra hydration between meals. The care plan made no mention of obtaining a dental appointment to address her broken an/or missing teeth. Observation and interview on 8/19/26 at 3:05 p.m., identified R48 was tearful throughout the interview and stated her teeth are broken and her gums were sore. She had been at the facility for several months. When she arrived, she already had a dental appointment set up and she told staff about the appointment. They set up a ride; however, when the ride arrived at the facility on the day of the appointment, it was a small vehicle that could not accommodate her wheelchair, so she was unbale to make her appointment. She went to the social service designee (SSD)-A and reported that she needed a dental appointment, and said the facility would not set one up for her. The SSD-A told her to tell the appointment scheduler, but they still have not set up an appointment as of 8/19/26. She was told she was on a waiting list for a closer dentist, and could take up to 8 months to get in to the dentist. That time had passed. R48 showed her gums. This surveyor observed small shards of teeth protruding from her gums, which were deep red and were causing her pain. Interview on 8/20/26 at 1:30 p.m., with the appointment and ride scheduler identified R48 came to her last February 2026 and said she needed a ride for a dental appointment. She set up the ride, but when the ride arrived it was a small compact vehicle and could not accommodate her wheelchair. She called the dentist back and they said the facility could either reschedule or try to find a dentist that was closer to the facility. That information was communicated to R48 and she said she wanted to reschedule with her original dentist. R48 then told the scheduler she would only need a ride to the dentist, because her friend was going to pick her up after the appointment and take her to her house to pick up some of her personal items, and then give her a ride back to the facility. The scheduler told R48 that was not an option as she had concerns with R48 returning to her home. The scheduler spoke with the SSD-A and explained the situation. The SSD-A then directed her not to make the appointment at that time as she wanted to speak with the director of nursing about R48's plans. The scheduler never heard anything back from SSD-A after that. In April of 2026, R48 approached her again and said she needed an eye appointment. She asked R48 if she ever got to the dentist. R48 told her she tried to make her own appointment, but the dentist told her that she would have to be able to transfer to and from the dental chair independently or bring someone that could assist her along to the appointment. She did not document any of this information in R48's medical record and reported she was never told until recently that she should be making progress notes in the medical record. Interview on 8/20/26 at 2:31 p.m., with SSD-A identified when a resident needs a dental appointment it's the facilities responsibility to set it up for them and arrange a ride. If the resident is unable to transfer independently, they will reach out to the family or a guardian for assistance. She agreed they did not do that for R48, and they did not get her appointment rescheduled. She was aware of the concerns with R48 wanting to ride with her friend to go to her house and pick up personal items. She was also aware that R48 was upset about not getting an appointment for the dentist. She never had a conversation with R48 about the safety risks of that plan and never attempted to help R48 develop a different plan to obtain needed dental care or transportation. She was unable to provide any documentation that a grievance had been filed or that she had offered to assist R48 to file a grievance on her behalf. The facilities undated, Dental Services policy identified they would assist residents in obtaining routine and emergency dental care. Emergencies include services needed to treat an episode of acute pain in teeth, gums, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Dental needs would be identified through the MDS assessment and addressed in the care plan. Referrals were to be made as appropriate. The Social Services Director was to maintain contact information for providers of dental services that are available to the facility residents at a nominal cost. The facility will, if necessary or requested, assist the residents with making dental appointments and arranging transportation to and from the dental services' location. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

Based on interview and document review, the facility failed to ensure medications used to manage pain were provided timely after being ordered, despite a supply of the medication being available in the onsite emergency kit (E-Kit), for 2 of 3 residents (R2, R3) reviewed. Findings include: R2: R2's provider orders dated 7/15/26 instructed pregabalin (a medication for nerve pain) 20 milligrams (mg) per milliliter (mL) oral solution give 3.75 mL via G-tube (a flexible medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications) in the evening (5:00 p.m.) and 6.25 mL at bedtime (8 p.m.) for polyneuropathy.R2's Brief Interview for Mental Status (BIMS) dated 7/20/26 indicated intact cognition. R2's diagnoses list dated 7/21/26 included hypertension, anxiety, injury of the esophagus, polyneuropathy (numbness and tingling usually in the feet and hands) and pain.R2's medication administration record (MAR) for July 2026 identified R2 did not receive 9 doses of the ordered pregabalin from 7/15/26 through 7/20/26 as indicated by a blank box (lack of administration information) or a 9 which instructs see progress note.R2's nursing note dated 7/17/26 indicated R2 was sent to the hospital at 1:00 p.m. for a scheduled procedure and a nursing note on 7/18/26, identified she returned between 5:00 p.m. and 8:30 p.m. R2's nursing note dated 7/19/26 at 12:30 a.m., indicated pregabalin was not available.R2's nursing note dated 7/19/26 at 5:14 p.m., indicated pregabalin will administer as soon as pharmacy delivers.R2's nursing note dated 7/19/26 at 8:21 p.m., indicated pregabalin was not available.R2's nursing note dated 7/20/26 at 8:29 p.m., indicated pregabalin was not available. R2's nursing notes, from 7/19/26 through 7/20/26, lacked evidence staff contacted the pharmacy, the provider, or utilized available pregabalin from the E-Kit in relation to this medication not being available. A pharmacy email, sent to the facility on 7/22/26 at 3:52 p.m., indicated the following was identified from the pharmacy call logs: A Script was received on 7/21/26 at 9:14 a.m. A Call was received on 7/21/26 at 6:38 p.m.: checking on status - facility staff informed pregabalin would be on 1st delivery. Medication delivered 7/21 at 10:10pm.During an interview on 7/21/2026 at 11:16 p.m., R2 stated she took pregabalin for neuropathy in her feet, but it had not been working as well lately. In the past she did not have pain or tingling in her feet but now she does. R2 was currently utilizing an opioid pain medication that relieves the pain but not the tingling.R3: R3's provider order dated 7/14/26 instructed pregabalin give 150 mg by mouth three times a day for pain.R3's BIMS dated 7/16/26 indicated moderately impaired cognition.R3's diagnoses list dated 7/21/26 included encephalopathy, aspiration pneumonia, acute respiratory failure and hypertension.R3's MAR for July 2026 identified R3 did not receive 21 doses of pregabalin from 7/14/26 through 7/21/26 as indicated by a documented 9.R3's nursing notes dated 7/14/26 through 7/21/26 identified the pregabalin tablets were not available, medication not delivered by pharmacy, will f/u, medication not on hand, waiting on pharmacy new resident, waiting on order, med not available. Nurse notified, and medication not here charge nurse called pharmacy and it will be delivered tonight.A pharmacy email, sent to the facility on 7/22/26 at 3:52 p.m., indicated the following calls from the facility were found on the pharmacy call logs: Call received 7/15/26 at 12:51 a.m.: the tech informed facility staff that they did not receive scripts with admission. Script received 7/18/26 at 10:20 a.m.: patient name and date of birth (DOB) on the script did not match what was on file wih the pharmacy. Call received 7/20/26 at 7:57 p.m.: the tech informed facility staff that they still had not received a script for pregabalin. I believe this is because of the mismatched name spelling and DOB. Call received 7/21/26 at 4:52 p.m.: checking on status - facility staff informed pregabalin would be on 1st delivery. Call received 7/21/26 at 7:16 p.m.: E-Kit code requested for Lyrica (pregabalin). On 7/21/26, at 10:10 p.m., the medication was deliveredDuring an interview on 7/21/2026 at 1:31 p.m., R3 stated he had neuropathy that made his feet very tingly. Usually, the pregabalin took the tingling away, but right now the tingling has been bad. R3 thought he was taking pregabalin but could not remember if he took it that morning. During an interview on 7/21/2026 at 1:39 p.m., trained medication assistant (TMA)-A stated that if a medication was not in the medication cart, he would look for it in the medication room. If the medication was not in the medication room, he would notify the nurse and document that the medication was unavailable and that the nurse had been notified.During an interview on 7/21/2026 at 3:53 p.m. TMA-B stated if a medication was not in the medication cart, she would look for it in the medication room. If the medication was not in the medication room, she would notify the nurse and document that the medication was unavailable.During an interview on 7/21/2026 at 2:20 p.m., licensed practical nurse (LPN)-A stated a nurse needed to reorder any controlled medications. The TMA would notify the nurse when the medication was getting low. The nurse would contact the pharmacy to see if any refills remained. If the medication required a new order, the nurse would contact the provider for an order. If there was an active order, the nurse could obtain a code for the E-Kit from the pharmacy so the medication could be administered at the correct time. LPN-A did not recall if she was notified about R2 or R3's pregabalin.During an interview on 7/21/2026 at 2:39 p.m., the pharmacist (Pharm-D) stated when the pharmacy needs a prescription for a medication, they will put the information into the electronic record and pharmacy dashboard. The order will be flagged as needing a prescription. Pharm-D stated the pharmacy did not receive a prescription for R2's pregabalin until 7/21/26. Pharm-D confirmed there was no communication from the facility regarding R2's pregabalin. Pharm-D stated they received a prescription for R3's pregabalin on 7/18/26 but R3's date of birth was incorrect. Pharm-D stated there were notifications to the facility about contacting the provider to correct the date of birth , but the pharmacy did not receive the corrected prescription until 7/21/26. Pharm-D confirmed the facility had pregabalin in the e-kit, but the facility had not contacted pharmacy for the code required to access the E-Kit.During an interview on 7/21/2026 at 4:09 p.m., the director of nursing (DON) stated a TMA would alert the nurse if a medication was unavailable. The nurse would contact the pharmacy to see why the medication had not been sent. The nurse should request a code for the E-Kit if the resident had a current prescription or should contact the provider for a new prescription. The nurse should document calling the pharmacy and any provided information as well as if the provider was notified about needing a prescription and/or the resident not receiving ordered medication. The nurse manager and DON had access to the pharmacy dashboard where communication was placed from pharmacy about medication that had been reordered, medications that were ordered too early, medications that were being sent in the next delivery, medications that needed new prescriptions and other information about medication. DON stated she had just found out R2 and R3 had not been receiving their ordered pregabalin and confirmed there were no notes written by a nurse about contacting the pharmacy or provider. DON stated all residents should receive their ordered medications so they can be stable and free of pain.A call was placed to nurse practitioner on 7/21/2026 at 3:27 p.m. with no return phone call.The Medication administration policy dated 6/12/24 instructed medications to be administered as ordered by the physician.

Based on interview and document review the facility failed to report an allegation of abuse timely to law enforcement and the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse.Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency on 11/23/25, alleged staff to resident sexual abuse when on 11/21/25, R1 reported that on 11/4/25, during his bath, nursing assistant (NA)-A put her fingers in his rectum, washed his genitals too long, and gave him an erection. R1 reported this embarrassed him. This incident was reported to the director of nursing (DON), and assistant director of nursing (ADON) on 11/21/25. The DON verbalized awareness of the alleged abuse and had done an investigation. The report noted the alleged sexual abuse had not been previously reported to law enforcement. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had intact cognition, required staff assist with transferring, toileting, dressing, and showering. R1 diagnoses included osteonecrosis (death of bone tissue due to lack of blood supply), major depressive disorder, and generalized anxiety disorder. R1's care plan last updated initiated on 5/29/25, identified R1 had a history of traumatic sexual abuse. During an interview on 12/1/25 at 2:05 p.m., the DON indicated she became aware of R1's allegation of abuse on 11/18/25, when she learned that R1 had told multiple staff that NA-A had sexually abused him on 11/14/25. The DON stated she did an investigation but did not report the allegation to the SA or law enforcement as R1 has a history of making false accusations against staff and when interviewed, R1 questioned his perception of the alleged event.During an interview on 12/3/25 at 2:35 p.m., licensed practical nurse (LPN)-A indicated R1 required two staff assist for all cares due to history of allegations LPN-A identified on Monday, 11/17/25, R1 reported that NA-A had him in the shower alone and put her fingers up his butt and he did not know how to interpret it. R1 wanted to talk to the DON. LPN-A stated she reported the allegation to the DON that morning but could not remember what time. During an interview on 12/3/25 at 2:47 p.m., social service designee (SSD) indicated she became aware of the allegation of abuse during the facility's morning meeting on 11/17/25. The SSD stated R1 did have a history of making false accusations against staff but had not made any accusations of sexual abuse by staff in the past that she was aware of. The SSD stated, if it was any other person [resident], we would have reported it [to the SA]. During an interview on 12/3/25 at 3:30 p.m., the administrator indicated he did not know the exact date when he became aware of R1's allegations of abuse but it was the same day as the DON. The administrator stated the facility did not report the allegation to the SA or law enforcement because R1 had a history of manipulation and lies. The administrator further stated if it were any other resident [other than R1], the facility would have reported. The undated Abuse, Neglect, and Exploitation Policy, indicated the facility was to report all alleged violations to the administrator, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specific time frames. Immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview, and document review, the facility failed to correctly transcribe medication orders according to physician instructions, for 2 of 4 (R10 and R11) residents reviewed for transcription of orders. This error resulted in R10 missing four doses of her long- acting insulin that led to her re hospitalization to intensive care units (ICU) due to diabetic ketoacidosis (DKA), a serious complication of diabetes. Findings include:R10's face sheet, undated, identified she was admitted to the facility on [DATE] with diagnoses of type one diabetes (dependent on insulin to control blood sugars).R10's hospital Discharge summary dated [DATE], indicated R10 was admitted to ICU on 8/11/25, for DKA and septic shock from a urinary tract infection (UTI). R10's insulin regime was readjusted at discharge.R10's hospital discharge orders dated 8/14/25, indicated to inject subcutaneously (SQ) 25 units of insulin glargine (Lantus)100 units/milliliter, every evening.R10's electronic medical record (eMAR), dated for August 2025, identified the following orders:-8/1/25 thru 8/14/25 Lantus (insulin glargine) Solostar inject 20 units SQ in the morning. R10's eMAR lacked any order for Lantus 25 units every evening at bedtime, upon R10's return from the hospital to the facility on 8/14/25. R10's physician orders included the following:-check blood sugar five times daily at 8:00 a.m., 11:00 a.m., 4:30 p.m., 7:00 p.m. and 10:00 p.m., start date 7/7/25,Novolog (fast-acting insulin) scheduled as followed:-4 unit at 8:00 a.m., start date 8/1/25-9 units at 12:00 p.m. and 5:00 p.m., start date 8/1/25 Novolog sliding scale, dated 8/1/25, five four times daily at 8:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. -If blood sugar (bs) 191-220 give 2 units (u) SQ,-If bs 221-250 give 3units SQ,-If bs 251-280 give 4units SQ,-If bs 281-310 give 5units SQ,-If bs 311-340 give 6units SQ,-If bs 341-700 give 7units SQ, call physician with blood sugar over 400 mg/dl. Novolog 4 units one time dose, dated 8/15/25 at 11:00 p.m. R10's eMAR blood sugars and Novolog insulin administration reviewed from 8/14/25 through 8/18/25, identified the following:8/14/25 at 4:30 p.m., blood sugar was 308 mg/deciliter (dl), received scheduled 9 units, plus sliding scale 5 units of Novolog, 8/14/25 at 7:00 p.m., blood sugar was 222 mg/dl, received no sliding scale insulin, 8/14/25 at 10:00 p.m., blood sugar was 186 mg/dl, received no sliding scale insulin, there was no indication the 25 unit insulin glargine was given.8/15/25 at 8:00 a.m., blood sugar was 394 mg/dl, received scheduled 4 units and 7 units of sliding scale Novolog,8/15/25 at 11:00 a.m., blood sugar was 419 mg/dl, received scheduled 9 units and 7 units of sliding scale Novolog,8/15/25 at 4:30 p.m., blood sugar was 574 mg/dl, received schedules 9 units and 7 units of sliding scale Novolog, physician notified at 5:41 pm of elevated blood sugar, 8/15/25 at 7:00 p.m., blood sugar was 395 mg/dl, received no sliding scale insulin, 8/15/25 as 10:00 p.m., blood sugar was 293 mg/dl, received no sliding scale insulin, there was no indication the 25 unit insulin glargine was given.8/16/25 at 8:00 a.m., blood sugar was 313 mg/dl, received scheduled 4 units and 6 units of sliding scale Novolog8/16/25 at 11:00 a.m., blood sugar was 542 mg/dl, received scheduled 9 units and 7 units of sliding scale Novolog,8/16/25 at 4:30 p.m., blood sugar was 389 mg/dl, received scheduled 9 units and 7 units of sliding scale Novolog, 8/16/25 at 7:00 p.m., blood sugar was 279 mg/dl, received no sliding scale insulin, 8/16/25 at 10:00 p.m., blood sugar was 260 mg/dl, received 4 units of sliding scale Novolog, there was no indication the 25 unit insulin glargine was given.8/17/25 at 8:00 a.m. blood sugar was 355 mg/dl, received scheduled 4 units and 7 units of sliding scale Novolog,8/17/25 at 11:00 a.m., blood sugar was 185 mg/dl, received scheduled 9 units and no sliding scale Novolog,8/17/25 at 4:30 p.m., blood sugar was 225 mg/dl, received scheduled 9 units and no sliding scale Novolog,8/17/25 at 7:00 p.m., blood sugar was 248 mg/dl, received no sliding scale Novolog, 8/17/25 at 10:00 p.m. blood sugar was 346 mg/dl, received 7 units of sliding scale Novolog. there was no indication the 25 units insulin glargine was given. R10's progress notes identified the following:-8/14/25 at 10:11 p.m., criteria not met for sliding scale,-8/15/25 at 7:20 a.m., R10 HS blood sugar was 186 mg/dl and at 3:00 a.m. was 319. Record lacked any intervention for BS of 319. -8/15/25 at 5:41 p.m. phone call to nurse practitioner (NP)-A, R10's blood sugar was 574 and given 9 scheduled and 7 units per sliding scale. R10 asymptomatic. -8/15/25 at 10:10 p.m., R10's blood sugar was HI, phone call to provider and R10 was administered 7 units per sliding scale plus 4 extra units per order. there was no indication the 25 unit insulin glargine was given.-8/17/25 at 6:53 a.m., R10 blood sugar was high most of the night, pushed water with effectiveness. R10 is alert and no hyperglycemia symptoms.-8/18/25 at 6:05 a.m. R10 was lethargic due to Hi blood glucose, with blood pressure (b/p) of 86/42, temperature (t)of 101.2, respirations (R) of 22, pulse (p) of 78 and oxygen saturations (O2 sat).During an interview on 8/19/25 at 2:40 p.m., RN-H indicated she had miss read the orders as discontinue medications instead of discharge medications. RN-H remembered talking to LPN-E about the hospital sending R10 back without any long-acting insulin, but did not call the physician for verification of the orders.During an interview on 8/20/25 at 9:35 a.m., LPN-C indicated she questioned R10's lack of order for long-acting insulin but did not call for verification of order.During an interview on 8/20/25 at 10:30 a.m., LPN-D indicated she had questioned why R10 did not have long-acting insulin but did not call for verification.During an interview on 8/19/25 at 5:35 p.m., NP-A, indicated was not made aware of the omission of R10's long-acting insulin and the missed doses led to her re-admission to the ICU with DKA. R11R11's face sheet indicated R11 was admitted to the facility on [DATE], with the following diagnoses end stage renal disease, on dialysis, atrial fibrillation, type 2 diabetes, and chronic obstructive pulmonary disease.R11's hospital discharge orders dated 8/15/25, included the following:-cinacalcet (Sensipar-medication used to help manage parathyroid and calcium disorders) 0-180 milligrams (mg) by mouth on Monday, Wednesday, and Friday,-metoprolol (medication used to treat conditions affecting the heart rate and blood pressure) 50 mg (three tabs) daily,-Stiolto (an inhalation spray used to manage symptoms of COPD) 2 puffs daily,-calcium acetate 667 mg (medication used to help manage high phosphate level in patient undergoing dialysis) take three capsules three times daily at mealtime,-famotidine (medication used to reduce stomach acid) 20 mg by mouth every other day. R11's eMAR date 8/15/25 to 8/19/25 indicated the following:-Cinacalcet 90 mg daily Monday, Wednesday and Friday, the admission order was not clarified to read how much to take, received one dose of this order,-Metoprolol 50 mg daily, 100 mg less than ordered dose, received four doses of this order,-Stiolto 1 puff daily, 1 puff less than ordered, received 4 doses of this order,-Calcium acetate 667mg instead of 2,001 mg total before meals as the physician ordered. -Famotidine was not found listed on the eMAR, even though R11 had an order for this medication.During an interview with DON on 8/19/25 at 2:25 p.m. and subsequent interview at 4:25 p.m., DON indicated it was her expectation that all medication orders are transcribed correctly for the correct medication, dose, route, and time and all orders double checked per facility policy by two different nurses. DON further stated that she put in the orders and LPN-C had double checked but neither of them had caught the five medication omission errors. During an interview on 8/20/25 at 9:35 a.m., LPN-C stated she had double checked R11'd admission orders and did not see the medication errors. During an interview on 8/19/25 at 5:35 p.m., NP-A was made aware of these medication errors during his visit add today (8/19/25) DON. He reviewed R11's the medication list with the director of nursing (DON) for accuracy and changed to medications to read as per physician hospital discharge orders dated 8/15/25. NP-A stated R11 was to have dialysis the following day and they would check his lab for calcium and phosphate levels as R10 did not receive the correct amount of calcium acetate for 8 doses. NP-A further stated it was his expectation that staff transcribed and verify medication orders as written by physician and if questions contact NP-A or MD for clarification.Review of facility undated procedure titled MD order process was reviewed and identified the following: 2. enter order with diagnoses/indication in electronic health record10. Sign and date order11. Put in SECOND CHECK BOX for second nurse to double check14. Second nurse signs and dates order15. put in scan bin for health unit coordinator. Review of facility undated policy titled Medication Orders indicated the following:3. Elements of the medication order:b. name of medication, c. dose of medicatione. time or frequency of administrationg. route of administrationi. hour of administration 4. Documentation of Medication Orders:a. each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the medication administration record (MAR).b. clarify the orderf. transcribe newly prescribed medications on the MAR, ensure the order is in the electronic MAR correctly.

Based on interview and document review, the facility failed to have licensed nursing coverage on staff for 24 hours a day, based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed - Quarter 2, 2025, (January 1 to March 31st), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 39 residents living in the facility.Findings include: Review of the 2/09/25, Daily Assignment Sheet identified 1 charge nurse was assigned for the day and 1 charge nurse for the evening shift (minimum 12 hr. shifts). Licensed practical nurse (LPN)-E was listed as having worked the day shift. Registered nurse (RN)-C was listed as having worked the night shift. Review of 2/09/25, Individual Daily Staffing [NAME] Report 1702D identified the facility data submitted for Provider Based Journal (PBJ) noted of the floor staff working that day, there was noted to be 1 registered nurse (RN-C), and 1 contract LPN (LPN-E) captured for hours worked. Review of 2/09/25, staff timesheet punches provided by the facility identified only RN-C was clocked in as having worked. There was no way to verify LPN-E had worked the hours documented on the assignment sheet and as captured in the PBJ. Interview on 7/10/25 at 9:53 a.m., with director of nursing (DON) identified the facility had revised staffing hours according to resident care needs. Nursing staff hours was reviewed and discussed every day at their interdisciplinary team (IDT) meetings and communicated with the administrator. The DON would expect nursing schedules to be reviewed daily, identify gaps of nursing coverage, and communicate those concerns effectively to reduce inadequate staffing on the units. Interview on 7/10/25 at 9:58 a.m., with administrator identified the facility's new administration team implemented tracking of RN coverage and nursing staff shortage on the units. The facility currently overstaffs their employees on the units above the required allotted hours needed daily to ensure services and care needs for the resident population. Review of April 2025, facility assessment staffing plan portion identified it was based on the facility and community risk assessments, in addition to patient per day (PPD) methodology to determine the maximum number of hour available per day. Staffing assignments and variances was managed by moving staff, calling staff off, or calling in relief or extra staff, after staffing requirements was completed. Direct care staffing hours identified to be required were: 1 RN or LPN per day shift and 1 RN or LPN per evening/night shift. A copy of contract staff timesheets was requested but not received.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days per week, for 6 of 90 days reviewed. This had the potential to affect all 39 residents living in the facility.Findings include: Review of the facility schedule and timesheets for January 2025, February 2025, and March 2025 identified on:1) January, there was no RN coverage for 2 of 31 days: 1/24/25 and 1/31/25.2) February, there was no RN coverage for 3 of 28 days: 2/09/25, 2/14/25, 2/15/25.3) March, there was no RN coverage for 1 of 31 days: 3/02/25. Interview on 7/10/25 at 9:53 a.m., with director of nursing (DON) identified the facility had revised staffing hours according to resident care needs. Nursing staff hours was reviewed and discussed every day at their interdisciplinary team (IDT) meetings and communicated with the administrator. DON would expect nursing schedules to be reviewed daily, identify gaps of nursing coverage, and communicate those concerns effectively to reduce inadequate staffing on the units. Interview on 7/10/25 at 9:58 a.m., with administrator identified the facility's new administration team implemented tracking of RN coverage and nursing staff shortage on the units. The facility currently overstaffs their employees on the units above the required allotted hours needed daily to ensure services and care needs for the resident population. Review of March 2025 Nursing Services-Registered Nurse (RN) policy identified the facility was to utilize the services of an RN 8 consecutive hours per day, 7 days per week. The director of nursing (DON) may service as a charge nurse when the facility had a daily occupancy of 60 or fewer residents. In addition, the facility, was to submit timely and accurate staffing data through CMS payroll-based Journal (PBJ) system.

Based on observation, interview, and document review, the facility failed to ensure infection control practices were maintained to ensure dietary staff were wearing a hair net and/or beard nets while in 1 of 1 kitchen and during meal services. The facility also failed to ensure 1 of 2 dining room refrigerators remained clean, and food was dated within the refrigerator to ensure it was not used beyond expiration. Additionally, the facility failed to ensure all Chlorine test strips for monitoring the dishwasher chemical level were not expired. Findings include:Observation and interview on 7/7/25 at 11:32 a.m., identified upon entrance to the kitchen for initial tour, dietary aide (DA)-A was preparing drinks for transportation to the dining rooms for the noon meal. DA-A had no hair net on. DA-A reported she was supposed to be wearing a hair net and there was no reason she did not have it on. Observation and interview on 7/7/25 at 11:40 a.m., cook (C)-A was standing behind the steam table outside of the north dining room and dishing up food for residents' noon meal. C-A had a hair net on but no beard net on. C-A had a mustache and beard. C-A reported he had never worn a beard net before; he was unaware he needed to wear one and was not even sure if the facility had any. Observation on 7/7/25 at 12:07 p.m., of the refrigerator in the central dining room which contained 2 large metal bins of individually wrapped 1/2 sandwiches that were undated. There was something pink spilled all over the bottom of the refrigerator and on the inside door of the refrigerator. The floor directly in front of the refrigerator was extremely sticky and dark brown/black in color. Observation on 7/7/25 at 5:24 p.m., C-A was standing behind the steam table in the central dining room dishing up food for the resident evening meal. C-A had a hair net on and no beard net on. Observation on 7/8/25 at 9:40 C-A just finished serving breakfast and had no beard net on. Observation and interview on 7/8/25 at 10:00 a.m., of the dishwasher cycle and DA-A testing the dishwasher chemical level with Hydrion Chlorine Test strips identified that the test strips had expired on 6/1/25. DA-A was unaware the test strips had expired and discarded the testing strips and obtained a new packet. Observation on 7/9/25 at 8:36 a.m., of the refrigerator in the central dining room with DA-A and maintenance director who confirmed pink juice had been spilled all over the bottom of the refrigerator and the inside part of the refrigerator door. The floor area just in front of the refrigerator was dirty with dark brown/black sticky substance on the floor. C-A reported she believed that housekeeping was responsible for cleaning the refrigerator and floor. The maintenance director agreed that the floor was very sticky, and the refrigerator was dirty and needed to be cleaned. Observation and interview on 7/9/25 at 8:45 a.m. with dietary manager assistant (DMA)-A removed items from the bottom shelf of the refrigerator in the central dining room and agreed that the refrigerator was dirty with some sort of juice spilled all over the bottom of the refrigerator and the inside door of the refrigerator. She reported that it was dietary responsibility to clean the inside of the refrigerator and housekeeping responsibility to clean the outside and the floors in the dining room. She further confirmed that all dietary staff should be wearing hair nets and beard net if needed in the kitchen and when serving food. If there are no beard nets available staff can use a hair net to cover their beard. Staff should be checking the expiration date on the chemical test strips prior to checking the chemical level in the dishwasher. Interview on 7/9/25 at 9:02 a.m., with dietician identified all food in the refrigerators should be dated. The dietary staff should be monitoring the refrigerators for expired foods and cleaning on a regular basis. Her expectation was that staff would be wearing hair net and/or beard nets when in the kitchen and during food service. The chemical strips should be monitored for expiration and new ones ordered when needed. Review of undated, Dietary Employee Personal Hygiene policy identified all dietary staff must wear hair restraints including beard restraints to prevent hair from contacting food. Review of undated, Routine Cleaning and Disinfection policy identified routine cleaning, and disinfection was maintained to ensure safe, sanitary environment and to prevent transmission or development of infections to the extent possible. Cleaning of visible soil from objects and surfaced and frequently touched surfaces would be performed. Review of undated, Low Temperature Dish Machine Guidelines identified the wash and rinse cycle should be maintained between 120-145 Fahrenheit. The low temperature sanitizer level should be checked daily with the Chlorine test strip with an acceptable range from 50-100 ppm.

Based on observation, interview, and document review, the facility failed to provide assessed supervision needs for 2 of 3 residents (R1, R4) who were at risk for elopement. R1 was able to leave the facility undetected for one hour despite having a wander guard on, which resulted in an immediate jeopardy (IJ). The IJ began on 5/21/25, when R1, while wearing a wander guard bracelet, successfully eloped from the building without the alarm sounding. R1 was allowed out of the locked front entrance by an unknown responsible party (had the pin code to the locked door), crossed a highway, and was found by community members approximately one mile from the facility an hour later, winded but unharmed. The administrator, director of nursing (DON), and nurse consultant were notified of the immediate jeopardy on 5/29/25 at 9:30 a.m. The immediate jeopardy was removed on 5/29/25, but noncompliance remained at the lower score and severity of D, which indicated no actual harm with potential for more than minimal harm which is not immediate jeopardy. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 required a walker for mobility and had moderately impaired cognition. R1's care plan, as of 5/27/25, indicated R1 was at risk for elopement related to diagnoses of disorientation, dementia, weakness and as evidenced by comments and attempts to leave the facility, anger outbursts, use of a wander guard, impaired safety awareness, and independence with ambulation. Further, R1's care plan directed staff to: distract resident from wandering by offering pleasant diversions, structured activities of interest, food/fluids, conversation, television books and personalization of resident room. To reduce likelihood of R1 removing wander guard, remove sharp objects from room such as razors, toe nail clippers, forks, knives, and do not allow him to have scissors; resident is on a one-to-one staff until further notice starting on 5/21/25; rights is a high risk elopement; resident was able to leave the property with direct supervision and was not able to leave the facility alone; resident needs direct supervision when outside; and wander guard placed on resident's ankle. Review of facility report number 360612 to the State Agency dated 5/21/25, revealed R1 was looking to acquire a ride to the VA (Veteran Affairs) office to get his benefits. The VA office was on [NAME] (a street located in Minneapolis) and the VA office was in the Government Center. The facility investigation, revealed R1 had left the facility after 9:30 a.m. and walked to the Government Center. The Government Center notified staff of R1 being there at roughly 10:15 a.m. R1 was in the building. R1 returned to the facility agitated, was assessed for injury, and none noted. Further, R1 eloped as he removed himself from the facility and made his way out of the safe zone to a building in town. Conclusion was R1 left the building at the same time as another resident being brought out for an appointment, despite being on 15 minute checks R1's Visual Check Sheet every 15-minutes dated 5/21/25, revealed at 9:30 a.m., R1 was observed to be in his bedroom and then the front door. From 9:45 a.m. until 10:45 a.m., there was no record of R1's 15 minute checks being conducted. On 5/27/25 at 3:42 p.m., licensed practical nurse (LPN)-A stated R1 was at risk for elopement, wore a wander guard and often put on his jacket and stated he wanted to go home. LPN-A stated R1 had recently eloped from the facility and walked to the courthouse which was on the highway. LPN-A stated the front entrance was locked and staff were the only ones who know the code to unlock the door to let a visitor or resident out of the building. On 5/27/25 at 4:06 p.m., community member (CM)-A stated one of the custodians at the government center brought R1 into her office and stated he was in the hallway and needed a ride. CM-A stated R1 appeared to be tired and was provided a chair and a glass of water. CM-A stated CM-B called the facility to inform them he was at the Government Center. On 5/27/25 at 4:12 p.m., CM-B stated R1 appeared to be out of breath and tired when he got to the Government Center, he had on shoes but did not have a walker with him. CM-B stated she informed the Sheriff's department at 10:11 a.m. on 5/21/25, and asked if they had any missing persons reports, which they did not. CM-B stated she then called the facility and asked if R1 was a resident there and they confirmed he was. CM-B stated she then informed the facility R1 was at the government center to which staff replied, Oh he is there? We will send someone right there. CM-B stated the facility staff was not aware R1 was not at the facility at the time, which was approximately at 10:30 a.m. On 5/27/25 at 5:12 p.m., DON stated R1 had impaired cognition, was at risk for elopement, and required staff supervision while out of the facility. DON stated she was informed at approximately 10:15 a.m. on 5/21/25, that R1 was not in the building. Further, R1 was on 15-minute safety checks and was last seen by staff at approximately 9:30 a.m., confirming 15-minute checks were not being completed. DON indicated the facility's internal investigation for R1's incident revealed R1 speculated he had to have left with the transportation services as they were in the facility around that time; she also confirmed staff were the only ones who knew the code to open the door, so staff would have had to let the transportation services out of the door and would have seen R1 exit, however no staff would confess. On 5/28/25 at 8:31 a.m., LPN-B stated R1's cognition and safety awareness were impaired. R1 required a walker while ambulating to help stability and was determined to be at high risk for eloping and had a wander guard on his ankle. LPN-B stated she was working with R1 on 5/21/25, the day of the incident, and she last observed R1 at 9:00 a.m. in his room not exhibiting any exit seeking behavior. LPN-B stated she was not aware R1 was missing from the facility until the administrator was notified. Further, LPN-B indicated R1 required 15-minute safety checks due to his exit seeking behaviors and elopement history, and she had been completing those safety checks until 9:00 a.m. until NA-D was assigned to R1's care but added, NA-D was not aware R1 required 15-minute checks. In addition, LPN-B stated R1 had reported he waited for staff to unlock the front entrance for the transportation driver and he followed the driver out the front door. On 5/28/25 at 9:17 a.m., NA-D stated she was assigned to R1's care on 5/21/25, and that day was also her first shift working at the facility, as she was a contracted agency staff. NA-D stated she was late for her shift that day and arrived at the facility at approximately 6:30 a.m The previous overnight aid was in a rush to get off her shift, so NA-D stated she did not get any verbal report regarding R1 or his safety checks. NA-D also stated she did not receive training prior to the start of her shift and did not have access to any resident's care plans until management arrived at the facility at approximately 9:00 a.m. NA-D confirmed there was a lack communication by facility staff to NA-D regarding which residents were high risk for elopement. Further, NA-D stated she was unsure of the exact time she last saw R1, but did last see him in his room making his bed prior to taking a break. NA-D was not aware R1 was out of the facility until staff received a call from the government center. Observation on 5/28/25 at 10:01 a.m., R1 was in his room making his bed with a staff member sitting outside in a chair directly outside his room. R1 stated he had been a bad boy and lifted his pant leg to reveal a wander guard on his ankle. Further, R1 stated he had walked right out of the building on 5/21/25 and if he sat and watched long enough staff would open the door and he could take off. R1 stated he walked to the government center, was unsure how far away it was, but denied getting hurt. On 5/28/25 at 11:16 a.m., administrator stated he was made aware of R1's elopement and went to the government center to pick up R1 himself. He indicated the facility's internal investigation determined R1 exited through the front entrance with a visitor or vendor. Administrator stated staff were the only ones who were provided the code, and the only way a visitor or vendor would know the code was if a staff shared it or if they watched a staff input the code. Staff are expected not to share the door codes. On 5/28/25 at 2:17 p.m., NA-E stated she was a contracted agency staff and had worked since 5/21/25. NA-E stated she had not been provided with education recently regarding elopements, residents at risk for elopement or who to not unlock the entrance for. On 5/28/25 at 3:33 p.m., LPN-A stated she had not been provided with education recently regarding elopements, residents at risk for elopement or who to not unlock the entrance for since the incident with R1 had occurred. LPN-A stated she was not here the day of the incident but worked on 5/26/25. On 5/28/25 at 3:40 p.m., DON stated she had sent a text message to staff regarding completing the elopement training but had missed sending the message to LPN-A. DON stated she did not provide a date to the staff to have the education completed by, and would be expected to track and ensure all staff have completed the education, but did not have a process in place to do so at this time. The immediate jeopardy that began on 5/21/25, was removed on 5/29/25, and was verified through observation, interview, and document review when the facility implemented the following interventions: -R1's care plan was updated to include interventions to deter elopement such as putting on a war movie and talk about farming and [NAME]. -R1 was currently on a one-to-one staff 24 hours a day -Other 8 residents who were identified as high risk of elopement with wandering tendencies would be updated with wandering interventions and identification of exit seeking behaviors. Care planned interventions would be reviewed with interdisciplinary team and floor staff from all departments on 5/29/25. -Kardex's with interventions for staff who missed the meeting would be printed and distributed to the department managers or designee to review prior to the start of their next shifts -All staff will be educated on Missing Persons, Elopements, Interventions for wandering and door alarms by education video or in-person meeting before their next shift. Education would be completed in the building with all staff members on 5/29/25. Quiz was attached to the video for staff members to submit electronically. -Agency staff members received an educational video that needed to be completed prior to starting the floor. The educational video included Missing Persons, Elopements, Interventions and what to do if the door alarms. Agency staff would notify DON of this being completed prior to their shift. -List of High-Risk Elopement residents would be attached to competency checklists for agency staff to have on their person for information. -A list of high-risk elopement resident was distributed to all departments electronically weekly and with changes for the managers to distribute to their staff members. R4's quarterly MDS dated [DATE], indicated R4 had diagnoses that included dementia, and cognitive communication deficit. R4 had no cognitive impairments and did not exhibit wandering behaviors. R4's care plan dated as of 5/27/25, indicated R4 was an elopement risk and R4 had a history of attempting to leave the facility. Further, R4's care plan identified R4 as a high risk for elopement, required direct supervision while outside and directed staff to ensure sign in/out log when family was taking resident out of building. R4 had a wander guard on his ankle. Observation on 5/27/25 at 1:42 p.m., an unidentified male resident approached dietary cook (DC)- A and asked DC-A to assist him with unlocking the front door to go outside. DC-A agreed and using a code on the front door, let the resident out of the building along with R4,who followed behind with his walker and was wearing a jacket. The alarm on the door sounded. DC-A closed the door and walked away. DON came out of office, looked outside through the glass door and headed directly outside where she was observed talking to R4 and visitors. Upon her return, DC-A turned around and stated what, was he not supposed to be outside? and continued to walk down the hallway. At 1:45 p.m., DON approached DC-A and stated R4 had family outside but otherwise he was not allowed outside unsupervised. DC-A responded with he was suited up and ready to go, I didn't know. On 5/27/25 at 1:47 p.m., DON stated R4 was assessed to be an elopement risk and required supervision while outside the facility. Today R4 happened to have family sitting outside so was not put at risk when he was let out of the building by DC-A. Further, DON stated elopement risk and interventions were identified in each resident's care plan, however dietary or housekeeping staff do not have access to resident care plans and would need to be notified verbally by their supervisors of residents who were at risk for elopement and required supervision. Review of facility policy titled Elopement and Wandering Residents, undated, indicated the facility ensure that residents who exhibit wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility was equipped with door locks/alarms to help avoid elopements, but alarms were not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. Further, the facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.

Based on observation, interview, and document review, the facility failed to comprehensively assess supervision needs, develop individualized person-centered interventions to mitigate risks and hazards for 1 of 3 residents (R1) reviewed for elopement risk. This resulted in an immediate jeopardy (IJ) when R1 left the facilty without staff knowledge and was found 12 blocks away, unharmed by a community member. The immediate jeopardy began on 5/5/25 when R1 left the facility and was found by a community member several blocks away confused, and returned to the facility by local police. The IJ was identified on 5/8/25. The administrator, director of nursing (DON), director of operations, and director of clinical operations were notified of the immediate jeopardy on 5/8/25 at 5:10 p.m. The immediate jeopardy was removed on 5/12/25, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's hospital Discharge Placement Referral dated 1/14/25, indicated R1 required long term care placement due to not being safe or able to care for self at home. The referral further indicated R1's memory is poor, thinking is delusional, and family was in the process of getting power of attorney and working with Adult Protective Services on placement. R1's Medical Diagnoses report dated 1/15/25, identified R1 had diagnoses of lumbar spondylosis (degeneration of the lumbar spine), disorientation, moderate dementia with behavioral disturbance, hypertension, weakness, right shoulder arthritis, and macular degeneration (medical condition that causes blurred vision or no vision in the center field). R1's Care Plan Report focus initiated 1/17/25, identified R1 has moderate dementia with behavioral disturbance and was an elopement risk/wanderer related to impaired safety awareness. Intervention history included on 2/4/25, Wanderguard was placed on R1's right ankle to alert staff if attempting to leave the building on his own; on 4/17/25, Wanderguard placed on R1's walker. In review of R1's record between 1/17/25 through 4/17/25, the record did not include an assessment or notation of rationale for the implementation of the Wanderguard that was placed on 2/4/25 on R1's right ankle nor why it was changed to his walker on 4/17/25. During an interview on 5/9/25 at 2:35 p.m., police officer (PO) indicated R1 had eloped from the facility previously on 2/23/25 but the facility found him before the police responded so the facility cancelled the call. PO stated the report indicated R1 was very confused, eloped from the facility, a nurse followed R1's walker tracks in the snow and were able to locate him. No other information was available due to the call being cancelled by the facility. Review of R1's record did not identify an accounting of this incident, nor were there updated interventions reflected in the care plan after R1 eloped in February 2025. Further there was no indication the facility completed an incident report with an investigation. R1's Fall Risk assessment dated [DATE], indicated R1 was at high risk for falls due to R1's intermittent confusion, balance problem while walking and standing, use of assistive devices, and took three to four high risk medications. R1's ROM (range of motion) and Mobility assessment dated [DATE], identified R1 had impairment of one upper extremity, was steady with walking at all times, and used a walker. R1's Elopement Risk assessment dated [DATE], indicated R1 was at risk for elopement related to R1's habit of wandering or attempting to leave the building, asking to go home or other specific destinations, diagnoses of dementia, eloping from this setting or a previous setting. R1's family voicing concerns that the resident may have a tendency to wander or elope, and taking medications that could cause confusion. Interventions implemented were recreational activities of interest, check in and out log, staff awareness of elopement risk, personalization of room and Wanderguard (bracelet wander management system that ensures resident safety with customizable door access) in place on R1's ankle. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, was independent with activities of daily living and mobility, did not have any behaviors of wandering, exit seeking, and did not wear any exit alarms even though the facility elopement assessment identifed R1 was at risk and had a wanderguard alarm. R1's progress notes dated 5/1/25, at 11:56 a.m., R1 was exit seeking in the morning, stating he wanted to go home, needed to go to the bank. At 10:00 a.m., had coat on and attempted to leave facility when another resident opened the front door. Staff redirected and told social service designee (SSD). R1 stated he was going to walk to the (out of town] bank. R1 did have a Wanderguard on and door did lock when resident was walking to chair by front entry. Review of R1's record did not include a comprehensive assessment of R1's risk for elopement for appropriate interventions including level of supervision following the elopement attempt on 5/1/25. Further, no indication R1's care plan interventions were re-evaluated for effectiveness and/or new interventions were developed and implemented to prevent or mitigate the risk for R1 to elope. In addition, R1's record did not include a comprehensive cognitive assessment that would identify R1's functional capacity for safe decision making and/or identify R1's ability to be safe in the community independently. A vulnerable adult report submitted to the State Agency dated 5/6/25 indicated on the morning on 5/5/25 R1 had been walking on a sidewalk looking lost as he crossed an intersection. R1 had planned to walk back to his home (approximately 30 miles away). Local law enforcement was contacted. Review of Facility event/incidents reports did not include a report nor an investigation for R1's elopement on 5/5/25. Furthermore, there was no accounting of the elopement in R1's record nor evident a comprehensive assessment completed and there was no care plan updates/revisions prior to the start of the survey on 5/7/25. During observation and interview on 5/7/25 at 3:45 p.m., R1 was observed lying in bed with a Wanderguard on his left ankle under his sock. R1 indicated a couple of days ago (5/5/25) he was able to flee the facility and was gone for about an hour before the cops busted him and made him go back to the facility. R1 used a fingernail file to cut his bracelet (Wanderguard) off his ankle and went for breakfast. No one had noticed his bracelet was off. He watched the door until no one was watching, he pushed the door open, and seized the opportunity. R1 had intended to walk to a neighboring town about thirty miles away to a place where he knew a friend would be and then get the friend to take him home. R1 did not like being in the facility and had no intention of ever returning to the facility, but the cops made him go back. Then the facility put another bracelet on his ankle to keep him in, but he had gotten out before and was planning to attempt it again. The next time he would bring a club so no one could get close enough to take him back to the facility. R1 further explained a couple of months prior he had cut his Wanderguard off and got out and that time he was gone for about 20 minutes before the staff noticed. R1 then stated, they don't like me here, I am trouble, and I am very angry about having to be here [in the facility]. During an interview on 5/8/25 at 10:47 a.m., community member (CM) indicated on 5/5/25 at approximately 8:45 a.m., she noted an elderly gentleman, later identified as R1, walking in a residential area about a block away from a major highway. CM stated, R1 looked lost and approached him as he was crossing the street. CM further indicated R1 was determined to get to [NAME] [neighboring town about 30 miles away] by walking along that highway. The CM walked about a block visiting with R1 and learned that he was a resident of the facility and did not intend to go back to the facility. CM then called the police, and they were unaware of any missing persons from the facility. CM identified the residential neighborhood that R1 was found in was about 12 blocks from the facility and the route included crossing over a busy major highway and a railroad tracks. During an interview on 5/9/25 at 2:35 p.m., police officer (PO) identified on 5/5/25 at 8:50 a.m., the police department received a call that an elderly man (identified as R1) walking about 12 blocks away from the facility while attempting to walk to [NAME]. R1 did not want to go back to the nursing home but, the PO did not feel R1 was safe to be walking in the community without his walker. R1 would have had to cross the railroad tracks and the major highway to get to that location he was found at. During an interview on 5/8/25 at 8:45 a.m., family member (FM)-A denied notification by the facility of R1's elopement on 5/5/25 and this was her first knowledge of the incident. FM-A stated, I am not surprised, it's not his first time escaping the facility. FM-A indicated the first time R1 eloped, it was winter, and staff found him about 7-8 blocks from the facility and further stated, he [R1] is absolutely not safe to be out of the building [facility] on his own. FM-A identified R1 was admitted to the facility because he was having delusional thoughts, paranoia, and erratic behavior due to his dementia. R1 was not safe to live independently anymore and needed 24-hour supervision. During an interview on 5/7/25 at 12:40 p.m., nursing assistant (NA-C) indicated R1 was not safe to go outside without staff supervision. R1 liked to sit by the front entry and when a family member or another resident went outside, R1 would go out too and staff would bring him back in. During an interview on 5/7/25 at 1:10 p.m., NA-A, indicated R1 was an elopement risk and not able to be outside without staff. R1 wore a Wanderguard and cannot go outside alone but stated, he [R1] is sneaky and would sit by the door until another resident went out and would try to get out with them. On 5/5/25, R1 was last seen eating breakfast but not sure what time that was. When NA-B was going to administer his medications, she could not find him. A search of the facility was done. The police called the facility to inform them R1 was found by someone in the community. During an interview on 5/7/25 at 1:45 p.m., NA-B identified on 5/5/25 at approximately 8:40 a.m., she was looking for R1 to administer his morning medications and could not find him but noted R1's walker to be parked by the front door. The director of nursing got a phone call at 8:50am - 8:55 a.m. that someone had found R1 on the other side of town and called the police. NA-B further stated R1 was an elopement risk and had a Wanderguard bracelet on but did not have the Wanderguard on him when the police brought him back. NA-B stated two nail clippers were found in R1's room so he must have cut off his Wanderguard again. NA-B further explained R1 had almost cut it off on the evening shift a while ago but could not recall when it happened. NA-B sated R1 had gotten very, very, very far from the facility this last time and it was a long way to walk. During an interview on 5/7/25 at 1:19 p.m., licensed practical nurse (LPN)-A, indicated the morning of 5/5/25, maintenance staff told her R1 was gone and we needed to look for him. LPN-A could not remember the time this was reported to her. LPN-A identified R1 wore a Wanderguard which meant he had to be supervised if he goes out of the facility. The police returned R1 to the facility and R1 was on 15-minute checks but was not sure where those checks were documented or who did them. During an interview on 5/7/25 at 2:00 p.m., registered nurse (RN)-A indicated she was not in the facility when R1 eloped on 5/5/25 but interdisciplinary team (IDT) discussed the incident on 5/6/25 and a Wanderguard had been put back on R1. RN-A indicated R1 always wanted to go home but was an elopement risk and not safe to go outside without supervision. During an interview on 5/7/25 at 2:20 p.m., health unit coordinator (HUC) indicated on 5/5/25 at approximately 8:10 a.m. the DON told him to look for R1, so he drove his car around town to try to find him, but the police brought R1 back. HUC further identified R1 was an elopement risk and could not go outside independently so R1 wore a Wanderguard so the doors would alarm if he left the facility. During an interview on 5/7/25 at 3:07 p.m., RN-B indicated on 5/5/25, R1 was at breakfast and, all of a sudden he was gone. R1 talked to her when he returned to the facility, he was very upset. R1 explained to RN-B that he wanted to get home so he went downtown and crossed the highway with the intention to walk to his hometown. RN-B further identified R1 had been planning this [elopement] and watched the door until no one was around and booked it. The only intervention that was communicated after the elopement was that another Wanderguard was placed on R1's ankle and some forks and a razor were taken out of his room. During an interview on 5/8/25 at 4:18 p.m., NA- D identified R1 could not go outside unsupervised because R1 was not safe alone in the community because he may fall with no one around to help. During an interview on 5/8/25 at 4:28 p.m., NA-E indicated R1 can go outside only if staff are with him because if R1 were to go outside by himself, he could take off again and get confused, dehydrated, or get hit by a car. During an interview on 5/8/25 at 4:52 p.m., NA-G indicated R1 has a Wanderguard bracelet on his ankle which meant he could not go outside without staff. R1 was not safe to go outside, he could elope again and not be found. During an interview on 5/8/25 at 1:45 a.m., the social service designee (SSD) indicated R1 signed his name in the sign out book, so SSD did not consider R1 leaving the facility unsupervised and without staff knowledge an elopement. SSD identified R1 as an elopement risk but did not consider him a high elopement risk and stated, everyone in the facility is an elopement risk. The SSD then indicated she did not know whether R1 had an assessment completed to determine if he was safe in the community without supervision and did not know why R1 wore a Wanderguard. The SSD said R1 has the right to be out in the community and he had intentions of returning to his hometown to be on the planning committee for the hometown celebration and parade. SSD stated it was not safe for anyone to walk the highway, not even herself. During an interview on 5/8/25 at 4:24 p.m., director of nursing (DON) indicated on 5/5/25 at approximately 8:45 a.m., she was alerted by staff that R1 was not in the building. The DON further explained R1 signed his name in the sign-out book but did not have a time or date when he left so they started to get worried about him and the police returned him to the facility shortly after they realized R1 was gone. The DON stated the IDT team debated about it during a meeting on 5/6/25 and it was determined R1 had a BIMS (brief interview for mental status) of 12 [moderately impaired cognition], was able to make his needs known, signed out in the book so did not feel it was an elopement. The Wanderguard was just to alert staff that he was going outside by himself because he will try to leave without signing out approximately monthly. The DON indicated the IDT has debated on whether R1 was safe to be outside on his own and it was not clear. DON indicated there was not an assessment completed to determine if R1 was safe in the community without supervision. During an interview on 5/8/25 at 9:45 a.m., the administrator indicated the facility notified him by phone on 5/5/25 at approximately 8:45 a.m. that they were looking for R1, but the police found him and brought him back to the facility. R1 had cut his Wanderguard off but he could sign himself out and go out of the facility independently. Administrator indicated he did not consider the incident an elopement because R1 was returned by police shortly after the staff noticed him missing and stated, it [elopement] wasn't on my radar. The administrator indicated he did not know the details of R1 getting out of the facility unnoticed, but they removed the fingernail clippers from R1's room, changed the door code, and have the front door always locked now. The administrator did clarify a resident leaving the facility without staff knowledge would be an elopement and reportable to the state agency (SA) but the elopement was not reported and was unaware of any of R1's previous elopements from the facility and did not know if nursing did an assessment to determine if R1 was safe to be outside unsupervised. The undated facility policy titled Elopement and Wandering Residents, included the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy defines elopement as occurring when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Compliance guidelines include alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Procedure post-elopement a. A nurse will perform a physical assessment, document, and report findings to physician. b. Any new physician orders will be implemented and communicated to the family/authorized representative. c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults. d. The resident and family/authorized representative will be included in the plan of care. e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. g. Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. The immediate jeopardy that began on 5/5/25, was removed on 5/12/25, when the facility reviewed R1 for a Safety Plan through determination of an elopement risk assessment and a SLUMS; review by IDT, R1 received 1:1 staff supervision; R4 remained in the facility until cognitive and safety assessments and interventions had been determined and a safety plan implemented; reviewed elopement assessments of all residents; care plan were reviewed for appropriate interventions; resident care plans reviewed and revised; DON or designee educated staff on procedures pertaining to residents leaving the facility, missing persons, elopement, and Wanderguard system; nurses received education on comprehensively assessing and reviewing residents for safety in regards to elopement, falls, and cognitive impairment prior to working their next shift. , but the noncompliance remained at the lower scope and severity level of D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview, and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Respiratory Syncytial Virus (RSV- an infection of the respiratory tract). As a result, the facility developed an outbreak where 8 residents (R10, R13, R14, R11, R12, R17, R6, and R16) tested positive for RSV and 3 residents were suspected to have RSV (R15, R7, R18); 2 residents (R10 and R12) were seen in the emergency department (ED) and 3 residents (R11, R13, and R14) were hospitalized at a higher level of care. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility resulting in an immediate jeopardy (IJ) which placed all residents at a high likelihood of serious illness and/or death by contracting a communicable respiratory disease. The Immediate Jeopardy (IJ) began on 3/23/25 when R10 tested positive for RSV and the facility failed to implement infection control strategies to mitigate the risk and spread of RSV in the facility. The Administrator and director of nursing (DON), were notified of the IJ on 4/4/25 at 3:30 p.m. The IJ was removed on 4/8/25 at 6:32 p.m., but noncompliance remained at the lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: Definitions: Isolation: Isolation separates sick people with a contagious disease from people who are not sick. Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. Personal protective equipment (PPE): Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. These items may include a gown, gloves, eye protection and face mask. Enhanced barrier precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Gowns and gloves are used as PPE. Transmission based precautions (TBP): refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) to prevent or control infections. Airborne, contact, and droplet are the three subcategories under TBP. Contact precautions: refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Use with gloves, and gowns as PPE. Droplet precautions: refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, masks are used as PPE. Upon entrance to the facility on 4/1/25 at 11:15 a.m., there was no signage posted alerting that the facility had an RSV outbreak. Surveyor was informed the facility had one case of RSV in the building and resident (R12) was on precautions. This was observed on 4/1/25 at 11:54 a.m., of the south hallway with signage on R12's door. Trained medication aide (TMA)-F was using PPE when entering the room to administer medications. R10 symptom onset 3/16/25; positive RSV on 3/16/25 R10's face sheet dated 4/11/25, identified diagnoses of morbid (severe) obesity with hypoventilation, obstructive sleep apnea, heart failure, chronic obstructive pulmonary disease (COPD- lung diseases that cause persistent airflow obstruction and breathing difficulties). R10's record reviewed between 3/11/25 through 3/15/25 did not identify any symptoms of respiratory illness. R10's progress note dated 3/16/25 at 12:45 p.m., indicated R10 stated he was not feeling well and thinks he has COVID. Lung sounds with noted rhonchi (rattling lung sounds). COVID test performed with negative results. R10's medical record did not identify R10 was placed on isolation precautions (droplet/contact precautions) when respiratory symptoms were identified. R10's record did not indicate droplet/contact precautions were initiated at symptom onset. R10's progress notes dated 3/16/25 at 1:22 p.m., indicated R10 had not been feeling well for four days with coughing. R10's lung sounds with rhonchi and cough and R10 agreed to be sent to emergency department (ED). R10's hospital emergency department (ED) note dated 3/16/25, identified R10 was seen for evaluation for an ongoing cough over past few weeks and increasing shortness of breath. R10's ED record identified lung sounds to be diffuse rhonchi (sounds like snoring or gurgling) throughout and tested positive for RSV. R10's diagnoses at discharge from the ED included RSV bronchiolitis (swelling, irritation, and buildup of mucus in the small airway of the lung) and acute exacerbation of COPD. R10 discharged back to the facility with nebulizers and steroids. R10's progress note dated 3/16/25 at 4:56 p.m., identified paperwork from hospital reviewed and R10 diagnosis of RSV and COPD exacerbation. Staff updated on airborne (sic) precaution, reminded to wear masks, gloves, and wash hand. However, review of R10's record did not identify a physician order for precautions nor was TBP identified in R10's care plan. R10's record reviewed between 3/17/25 through 4/4/25 did not identify ongoing symptom monitoring, isolation, transmission precautions, or removal of isolation. During an interview on 4/3/25 at 11:12 a.m., director of nursing (DON) stated if a resident is positive for RSV they are put on precautions and isolation and encouraged to wear a mask when coming outside of their room. DON stated they did not have any protocols for nurses to follow for monitoring residents for any symptoms to identify new cases immediately. DON confirmed facility had not done any active screening of residents to identify illness and had not completed comprehensive respiratory assessments for residents with suspected/confirmed RSV cases. During a subsequent interview on 4/4/25 at 11:11 a.m. DON confirmed R10 was removed from isolation on 3/23/25, R10 did not have a respiratory assessment to determine if symptoms resolved prior to removing from isolation, R10 was removed from isolation because he no longer needed nebulizer treatments. DON further stated after research on the Centers for Disease Control and Prevention (CDC) website for RSV, a resident should have been in isolation and precautions for ten days, however, the facility did not follow CDC guidelines and removed R10 at seven days. R13 symptom onset 3/25/25; positive on 4/3/25 R13's face sheet date 4/10/25, indicated diagnoses of dementia and weakness. R13's record between 3/16/25 through 3/26/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R13's progress note dated 3/27/25, identified R13 complained of sore throat for two days. R13 was given cough drop and COVID test performed with negative results no other tests were completed. R13's progress noted dated 3/30/25, identified R13 received cough syrup for cough. R13's progress note dated 4/2/25 at 12:37 a.m., identified R13 was coughing with congestion and feeling cold/chills. At 3:56 p.m. R13 was feeling weak and complaining not feeling good. Lung sounds wheezing with crackles was coughing with congestion and feeling cold and chills. R13 was given a nebulizer with no relief. R13 was placed on oxygen. Physician notified of change in condition and recommendation to monitor in facility and will reassess next day. R13's progress note dated 4/3/25 at 9:50 a.m., identified R13 became short of breath (SOB) while on toilet and unable to stand. Oxygen was placed on R13 and given a nebulizer with oxygen saturations going as low as 80% (normal ranges are 92 to 100%). Provider was notified. At 10:28 a.m. R13 was seen by the nurse practitioner who ordered RSV test, antibiotics, and steroids. At 10:59 a.m. R13 was short of breath with low oxygen saturations and was sent to the ED. R13's record between 3/25/25 through 4/3/25, identified despite R13 demonstrated respiratory symptoms TBP was not implemented. During an observations on 4/1/25 through 4/3/25 at 11:00 a.m., R13 did not have TBP precaution signs on his door. During an observation and interview on 4/3/25 at 11:00 a.m., trained medication aide (TMA)-D came out of R13's room without PPE and stated R13 was being sent to ED due to difficulty breathing and possible RSV. TMA-D stated R13 had been sick since 3/30/25, and he complained of a sore throat and was not put on precautions or isolation when he developed symptoms. During an interview on 4/3/25 at 11:21 a.m., registered nurse (RN)-B stated R13 was sent by ambulance for possible RSV. RN-B stated R13's roommate, R14 was in the hospital for unknown reason. RN-B also stated the facility had three known cases of RSV, R10, R11 and R12. RN-B stated R12 was the only resident currently on isolation for RSV in the facility. RN-B stated if a resident became symptomatic a comprehensive respiratory assessment should be completed daily, however a nursing order was not in the charts to direct staff on what to monitor for. RN-B further stated symptomatic residents should be put on droplet precautions, notify physician, and tested for RSV. R13's ED hospital record dated 4/3/25, indicated R13 was seen in ED for shortness of breath. R13 required supplemental oxygen to maintain oxygen level greater than 92%. R13 indicated that he had not been feeling well for the past 3 weeks. R13 lung sounds revealed right and left wheezing through with decreased lung sounds in right middle and bilateral lower fields. R13's heart rate was 90-150 (normal range is 60 - 100) with no known history of atrial fibrillation. R13 was admitted to the local hospital and started on intravenous antibiotics (IV) and IV cardiac medications were started also. R13 tested positive for RSV and was transferred to higher level of care for further care with diagnoses of respiratory failure, sepsis, and Atrial fib with rapid ventricular response. R13 returned to the facility on 4/7/25, with hospital diagnoses of pneumonia of right lower lobe due to infectious organism and was started on oral antibiotics. R14 symptom onset 3/25/25, positive for RSV on 4/1/25 R14's face sheet dated 4/10/25, indicated diagnoses of CHF and chronic respiratory failure with hypoxia. R14's record between 3/16/25 through 4/1/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R14's progress notes dated 3/8/25, identified R14 required continuous oxygen to keep saturations greater than 90%. R14's progress notes dated 3/25/25, identified R14 had complaints of not being able to breathe from his nose being stuffy, however R14's medical record did not identify implementation of TBP when symptoms identified. R14's progress notes dated 4/1/25, R14 received two puffs of albuterol inhaler (medication to help open airway) as R14 was struggling to breathe, wheezing and had congestion. R14 had chills and was shaking. Vital signs were blood pressure 155/104 (normal is less than 120/80), pulse 105, respirations 22 (normal range is 12-22) and oxygen saturations 72% on three liters of oxygen. R14 was transported to local ED via ambulance. R14's hospital ED note dated 4/1/25, indicated R14 presented per ambulance, unresponsive after sudden onset of shortness of breath. R14's lung sound indicated chest lung congestion bilaterally with mottling (bluish/graying skin color meaning lack of oxygen). R14 was intubated emergently (a tube is inserted into the trachea to help person breathe). R14's temperature was 103 degrees (normal is 96.4 to 98.6). R14 was tested positive for RSV and was transferred via air ambulance to higher level of care with diagnoses of septic shock (a life-threatening condition) and acute respiratory failure. R14's hospital pulmonology noted dated 4/2/25, identified R14 was on mechanical ventilation and had a diagnosis of acute on chronic hypoxemic hypercapnic respiratory failure -improving and RSV pneumonia complicated by left lower lobe pneumonia. R14's progress notes dated 4/3/25, identified social worker at hospital called and R14 was sedated, on a ventilator, and positive for RSV. R14's hospital note dated 4/9/25, R14 remained at a higher level of care, on three liters of oxygen, with no return dated noted. During an interview on 4/3/25 at 1:00 p.m., DON stated R14 was in the hospital for aspiration pneumonia but had been negative for RSV. During an interview on 4/4/25 at 10:58 a.m., assistant director of nursing/infection preventionist (ADON -IP) stated she was not aware of R14's positive RSV test result until 4/3/25 after looking at the hospital records. ADON-IP stated R14's onset of RSV began on 4/1/25 with the positive test and was unaware of symptom onset of a stuffy nose on 3/25/25. R11 symptom onset 3/28/25, positive 3/28/25 R11's face sheet dated 4/10/25, indicated diagnoses of congestive heart failure (condition where heart does not pump as well as it should), respiratory failure (condition where the lungs are unable to adequately exchange gases, resulting in either insufficient oxygen intake and/or inadequate carbon dioxide removal) with hypoxia (lack of oxygen), and morbid obesity. R11's record between 3/16/25 through 3/28/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R11's record did not identify R28 had symptoms prior to 3/28/25. R11's progress note dated 3/28/25 at 1:32 p.m., identified R11 was not feeling well after 12:00 p.m., and appeared to be shaky, unable to transfer self, and needed supplemental oxygen, and 911 was called. Note at 2:16 p.m., identified R11 was transferred to hospital via ambulance. R11's progress note dated 3/28/25 at 4:44 p.m., identified hospital called and R11 had tested positive for COVID and RSV. R11's hospital ED note dated 3/28/25, indicated R11 presented via EMS for evaluation of difficulty breathing, shaking, nausea, tachycardia, and low blood pressure. Heart rate in 140's with oxygen sats in the 70's and temperature of 100.4. R11's lung sounds were decreased with wheezing and rales present. R11 was transferred to higher level of care due to hypoxia secondary to new diagnosis of RSV and COVID. R11's progress notes dated 4/7/25, indicated R11 remained in ICU, was hallucinating, and was restless and needing supplemental oxygen at 4 liters per nasal cannula. R12 symptom onset 3/31/25, positive 3/31/25 R12's face sheet dated 4/10/25, indicated diagnoses of cancer of the prostate, CHF and dementia. R12's record between 3/16/25 and 3/30/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 3/31/25. R12's progress notes dated 3/31/25, indicated R12 was showing decline in health, slightly diaphoretic (sweaty) and slightly elevated blood pressure. R12 was sent to ED for evaluation. R12's ED progress notes dated 3/31/25, indicated R12 was seen in ED following a fall and had mentation changes. R12 had a cough and nursing home staff reported increased lethargy. R12's assessment indicated a congested cough with rhonchi (abnormal lung sounds caused by secretions or obstruction of airway) in left lower lobe. R12 tested positive for RSV in ED and was discharged back to the nursing home by private vehicle. R12's progress note dated 3/31/25 at 3:01 p.m., identified R12 returned to facility with a diagnosis of RSV. R12's record did not identify if and when TBP were implemented after return from ED. R12's progress notes from 3/31/25 through 4/8/25 lacked an ongoing symptom monitoring and utilization of TBP. During an observation on 4/1/25 at 5:07 p.m., R12 was noted in the hallway outside conference room without a mask on. Three staff walked by him. Nursing assistant (NA)-P stopped, applied gloves, and turned R12's wheelchair around, explained to R12 he needed to stay in his room as he was sick. NA-P was not wearing a mask and did not apply or offer one to R12 as he took him back to his room. During an observation on 4/3/25, at 5:12 p.m., approximately 15 residents were eating in the main dining room, 3-5 residents per table, without masks on. Resident were seated two to three feet apart. R12, who was RSV positive on 3/31/25, was seated a few feet from R15, neither one had mask on. Multiple staff were in the dining room, serving the meals and did not identify R12 should have been eating in his room. DON entered dining room and applied a mask to R12 and walked him out to his room from the main dining room. DON stated R12 should have been eating in his room and not in the main dining room. During an interview on 4/3/25 at 5:25 p.m., NA-H stated R12 was supposed be eating in his room due to RSV, and if staff noticed him coming out of his room, staff walked him back to his room. During an interview on 4/4/25 at 10:58 a.m., ADON-IP stated she was not employed in the facility when the first case of RSV was detected and had not implemented contact tracing since she had started, however had started a map of the positive cases. ADON was not aware how many cases constituted an outbreak, but thought it was three or more. R12, R13, and R14 all ate meals together and she believed this was part of the spread and had just made that determination today on 4/4/25. If residents were exposed to another positive resident who had RSV they should have been kept in isolation, monitored closely for symptoms, and tested if symptoms develop. R17 symptom onset 4/4/25; positive for RSV on 4/9/25 R17's face sheet dated 4/10/25, indicated diagnoses of diabetes, paraplegia (paralysis of the legs and lower body), and diabetes. R17's record between 3/16/25 through 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/4/25. R17's progress note dated 4/4/25, R17 had reported he did not feel good but was not ill. R17's record did not include respiratory assessments until 4/8/25. R17's record did not identify a respiratory assessment/screener between 4/5/25 to 4/7/25. R17's progress note dated 4/8/25, indicated R17 had cough with congestion. However, the record indicated R17 was not tested for respiratory illness until 4/9/25. R17's laboratory report dated 4/9/25, indicated R17 tested positive for RSV. R6 symptom onset 4/6/25; positive for RSV on 4/9/25 R6's face sheet dated 4/10/25, indicated diagnoses of cerebrovascular accident (stroke), hemiplegia or hemiparesis (weakness on one side of the body). R6's record between 3/16/25 and 4/5/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/6/25. R6's progress note dated 4/6/25 at 8:45 p.m., R6 requested an RSV test as he was having a sore throat and raspy voice. R6's progress note dated 4/8/25, identified R6 was on quarantine due to unspecified outbreak. R6's progress notes dated 4/9/25, identified lab results received by facility and tested positive for RSV. R16 symptom onset 4/7/25; positive for RSV on 4/9/25 R16's face sheet date 4/10/25, indicated diagnoses of CHF, Parkinson's Disease (a progressive neurological disorder characterized by gradual loss of nerve cells in the brain, leading to tremors, slow movements, and rigidity), obstructive sleep apnea, myasthenia gravis an autoimmune disorder) and respiratory failure. R16's record between 3/16/25 and 4/6/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/7/25. R16's progress note on 4/7/25 identified R16 had developed a cough with wheezing. R16 was placed on precautions and tested. R16's laboratory results dated [DATE], indicated R16 tested positive for RSV. R15 symptom onset 4/7/25 R15's face sheet dated 4/10/25, indicated diagnoses of chronic viral hepatitis C and sheltered homelessness. R15's record between 3/16/25 and 4/6/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/7/25. R15's progress note 4/7/25, identified R15 had developed sore throat. R15's laboratory report dated 4/9/25, indicated R15 tested negative for RSV, COVID and influenza. R7 symptom onset 4/8/25 R7's face sheet dated 4/10/25, indicated diagnoses of multiple sclerosis (MS- a chronic autoimmune disease that affects the brain and spinal cord). R7's record between 3/16/25 and 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/8/25. R7's progress notes dated on 4/8/25, R7 had developed a sore throat, and hoarse voice. R7's laboratory results dated [DATE], indicated R7 tested negative for RSV, COVID and influenza. R18 symptom onset 4/8/25 R18's face sheet dated 4/10/25, indicated diagnoses of obstructive sleep apnea. R18 ' s record between 3/16/25 and 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/8/25. R18's progress notes dated 4/8/25, R18 was noted to be coughing, stated it was his normal and respiratory assessment completed without any other symptoms noted. R18 was put on droplet/contact precautions, however refused to be tested for COVID, influenza and RSV. During an interview on 4/4/25 at 8:57 a.m., licensed practical nurse (LPN)-B stated monitoring for respiratory symptoms would include lung sounds, looking for symptoms like runny nose or cough. If new symptoms were found then the provider would be notified, the resident tested, and precautions put into place. LPN-B was not aware of any symptom monitoring being done for any residents at this time and this should be done. During an interview on 4/3/25 at 3:24 p.m., registered nurse (RN)-B stated if staff call in sick with respiratory symptoms, they would be asked to test for COVID, however, if negative then it must just be a cold, and could work while wearing a mask. If a resident became symptomatic then staff would test and monitor symptoms, however, was not aware if the facility was doing that. RN-B stated she believed full facility masking and monitoring of all the residents for symptoms of RSV should have been initiated after the first case of RSV was in the facility. During an interview on 4/3/25 at 1:00 p.m., DON stated if there was a respiratory outbreak, the following would need to be initiated: staff masking, encourage resident masking, reduce the number of residents in activities, and limit numbers in dining room for meals. However, none of these activities had been done at this time, due to not identifying the cases of RSV as an outbreak. DON also stated not all the RSV cases had been added to a surveillance log to track the cases. DON stated a map of the cases in the facility had not been completed at this time to allow the facility track trend the infection. Staff illness was tracked, and no cases of respiratory illness had been identified. During an interview on 4/4/25 at 10:31 a.m., medical director (MD)-A stated was not aware of the facility's RSV outbreak until 4/3/25. His expectations during a respiratory outbreak would be for the facility to follow their policies on infection control/respiratory illnesses, notify the medical director, and follow recommendations from CDC/MDH on TBP. Any type of respiratory illness with a resident with other contributing factors, such as COPD, could lead to the likelihood of serious harm, impairment, or even death. The immediate jeopardy that began on 3/16/25, was removed on 4/8/25. when it was verified, the facility implemented the following: -Facility provided education to all staff pertaining to PPE, implementation and removal of TBP, physician notification, active screening, and staff illness. -Facility updated the surveillance log -Facility implemented and developed a tracking log for staff illness. -Facility developed screening and monitoring tools for respiratory illnesses. -Facility developed and implemented a process for implementing and removing TBP's and physician notification. -Facility developed and implemented a process for testing residents. -Facility identified high risk exposures to RSV and placed those residents on isolation, -Facility implemented active screening on all residents to identify early symptoms and implemented TBP as applicable. -Implemented mask use for staff and visitors. -Facility provided education to all staff pertaining to PPE, implementation and removal of TBP, physician notification, active screening, and staff illness. -Facility updated the surveillance log -Facility implemented and developed a tracking log for staff illness. Review of facility's Infection Outbreak Response and Investigation Policy undated, identified an outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. Prompt recognition of an outbreak: The following triggers shall prompt an investigation as to whether an outbreak exist: -A sudden cluster of infections in a unit or during a short period of time. -A single case of a rare or serious infection. Implementation of infection control measures: -symptomatic residents will be considered potentially infected, assessed for immediate need, and placed on empiric precautions while awaiting physician orders. -symptomatic employees will be screened by the Infection Preventionist/or designee. -In the event of a known communicable disease outbreak, the facility should screen visitors for signs and symptoms of the communicable disease in accordance with national standards. -Transmission based precautions will be implemented as indicated for the particular organism. -Surveillance activities will increase to daily for the duration of the outbreak. Outbreak investigation: -Last page was not provided Review of facilities undated and unsigned, Transmission Based (Isolation Precautions) Type and Duration of transmission-Based Precautions Recommended for Selected Infections and Conditions, chart dated 2024, indicated for RSV infection in immunocompromised adults, contact precautions was needed for duration of illness and to wear a mask according to standard precautions. Review of facility policy, dated 3/24/25, Infection Prevention and Control Program, indicated the following: 3. Surveillance: a. a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteer, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. c. The registered and licensed practical nurses participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in house reporting of communicable diseases and infections. 13. Resident/Family/Visitor Education and Screening a. Residents, family members and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions for which to notify the nursing staff. 19. Respiratory Illness Reporting: a. The facility must input the following information into the NHSN reporting module weekly: 3. confirmed resident cases of COVID 19, influenza, and RSV; 4. hospitalized residents with confirmed cases of COVID 19, influenza, and RSV (overall and by vaccination status).

Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, revise the care plan and implement appropriate interventions to prevent and/or reduce the risk of falls with major injury for 2 of 3 residents (R20, R22) who had falls. This resulted in an immediate jeopardy for R20 who had a history of traumatic brain injuries and sustained a fall that resulted in a subdural hematoma and was hospitalized . The IJ began on 3/28/25 after R20 had a fall, the facility failed to assess and implement appropriate interventions to prevent/mitigate risk for falls which resulted in R20's fall on 4/4/25 in which R20 suffered an intercranial brain injury and hospitalization. The Administrator, director of nursing (DON) were notified of the IJ on 4/8/25 at 6:32p.m. The immediate jeopardy was removed on 4/9/25 at 4:40 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more that minimal harm that is not immediate jeopardy. Findings include: R20's face sheet dated 4/9/25, identified R20 was admitted on [DATE] with diagnoses including subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), fracture of skull, and intracranial injury. R20's Brief Interview for Mental Status (BIMS) dated 3/27/25 identified R20 had severe cognitive impairment. R20's fall risk assessment dated [DATE], identified R20 was high risk which identified risk factors of disorientation at all times; three or more falls in the past three months; poor vision; balance problem while walking; requires assistive device; and required 1-2 medications that could cause lethargy or confusion. The report also identifed R20 had 1-2 predisposing diseases that increased R20's risk for falls but did not specify which pertained; the listing of risk diagnoses included circulatory, neuromuscular/functional, orthopedic, perceptual, psychiatric/cognitive, infection, pain/headache, fatigue/weakness, weight loss, vitamin D deficiency and history of falls. R20's progress note dated 3/26/25, director of nursing (DON) identified R20 was admitted with multiple facial fractures and a traumatic brain injury. Report from the hospital said his blood pressure runs low most of the time, does not remember this and gets up alone, wanders outside of his room, and goes to the bathroom alone. R20's progress note dated 3/27/25 at 11:07 a.m., identified R20 can use the bathroom independently. R20's progress note dated 3/28/25 at 12:57 a.m., identified R20 was independent with toileting, transfers, and ambulating. R20's record between 3/26/25 through 4/3/25 did not include a care plan for falls despite R20's high risk for falls identified on the fall risk assessment completed on 3/26/25. R20's unwitnessed fall incident report dated 3/28/25 at 6:00 a.m., identified R20 was found sitting on the floor by his bathroom. Intact range of motion. Denied pain and alert and oriented x 1 with some confusion. Unable to use the call light. R20 was given gripper socks which he had taken off. Staff to check often (frequency not specified). The report did not identify if R20 was incontinent and/or he was attempting to use the toilet. Although the report identified potential causal/risk factors of confusion, unable to use the call the call light, and had taken off gripper socks, the report did not include a comprehensive fall analysis. The report indicated on 3/31/25 the facility developed a fall intervention to add a soft touch call light and gripper socks. However, R20's care plan did not identify R20's high risk for falls or include the interventions of soft touch call light, gripper socks, and staff to check often. Further, R20's record did not include a comprehensive assessment that identified the level or frequency of supervision that corresponded with the intervention of staff to check often. R20's progress note dated 3/29/25 at 11:52 a.m., included R20 had wandered into hallway three times and needed to be redirected back to room. R20's physical therapy noted dated 3/31/25, included R20 was a fall risk and ambulates to the bathroom without asking for assistance. R20 was educated on the call light and coordination with nursing. The note did not identify what was coordinated with nursing. R20's unwitnessed fall incident report dated 4/1/25 at 10:00 p.m., identified nursing assistant went to check on resident per nurse request and R20 was found on floor by television. R20 was towards the door and head by the bedside table with head of bed elevated. R20 stated he missed his bed walking backwards. No other information was included. R20's record did not include a comprehensive fall assessment/analysis that identified probable causal factors/root cause with corresponding individualized interventions to prevent and/or mitigate the risk of falls. Interventions that were identified included room was re-arranged and bed moved against the wall and frequent (was not specified) checks at night initiated. However, R20's care plan for falls was not developed (there was no care plan) and the record did not include a comprehensive assessment that identified the level or frequency of supervision that corresponded with the intervention frequent checks at night. R20's progress note dated 4/4/25 at 4:25 a.m. indicated R20 had an unwitnessed fall in his room. Staff heard a loud noise and found R20 leaning on the wall by the television. R20 reported he hit his head and was complaining of pain in both lower and upper extremities, R20 was given Tylenol, vital signs were taken. and he was sent to the emergency room (ER) R20's hospital imagining report dated 4/4/25, identifed a head computed tomography (CT) was performed following a fall with head injury with a critical result of a new intercranial hemorrhage or herniation. R20's hospital emergency department to hospital Discharge summary dated [DATE], identified R20 admitted to hospital on [DATE] to 4/5/25, following a fall and was noted to have a subdural hematoma on computed tomography (CT) scan. R20 was discharged back to facility on 4/5/25. R20's unwitnessed fall incident report dated 4/4/25 at 4:20 a.m., identified a loud noise heard from room and R20 found leaning on the wall by the television. R20 stated he hit his head and complaining of pain in ribs and left arm. R20 sent to emergency room for evaluation. R20's record did not include a comprehensive fall assessment/analysis that included potential causal factors/root cause for the development of individualized interventions to prevent or mitigate the risk of falls and/or falls with major injury. Additionally, no additional fall interventions were documented in the fall report. R20's progress note dated 4/5/25, identified R20 returned to facility after being sent to the hospital following a fall and sustaining a subdural hematoma and report from the hospital there will be no changes. Review of R20's record did not identify the care plan was revised/updated upon or after R20's return from the hospital. R20's progress note dated 4/7/25 at 9:09 a.m., identified R20 was walking to the bathroom and staff witnessed R20 falling by his closet door, and he was then assisted to ground. R20 had been seen less than 15 minutes before the fall. R20 reported he became dizzy while self-transferring. R20 was wearing gripper socks. Immediate intervention was orthostatic blood pressures and prompted to use the toilet. Pharmacy was notified for medication review. Review of R20's physician orders/treatments identified the directive to obtain orthostatic blood pressure was not transcribed until 4/8/2025. Additionally, review of R20's record did not identify a comprehensive analysis for causal factors/root cause. Further, R20's record identified although the care plan had been revised on 4/8/25 to include every 1-2 hours prompting for toilet use, the record did not include a corresponding comprehensive bowel/bladder assessment that would identify the appropriateness of the intervention to meet R20's individualized toileting needs. Although the facility developed and implemented R20's fall care plan on 4/4/25, the care plan did not include the interventions of 'soft touch call light', and 'staff to check often' that were identified on 3/28/25 fall report and did not include 'frequent checks at night' and bed up against the wall that was identified on the 4/1/25 fall report. R20's fall focus care plan initiated on 4/4/25, identified R20 was high risk for falls related to unspecified intracranial injury, anxiety disorder, traumatic subarachnoid hemorrhage, atrial fibrillation and incontinence. R20 will often get up on his own, not use the call light to alert staff even with numerous staff reminders and encouragement. Interventions included: anticipate resident's needs, be sure call light is within reach and encourage to use it for assistance, prompt responses for all requests for assistance, and ensure wearing appropriate non-slip/non-skid footwear when ambulating or mobilizing in wheelchair. During an interview on 4/8/25 at 10:15 a.m., nursing assistant (NA)-K stated R20 did not use his call light and has attempted to self-transfer many times since admission due to being confused at times. Staff have been doing frequent checks, however at times when NA-K was busy assisting other residents he could not check on R20 as frequently as he should. NA-K also stated R20's care plan did not identify a timeframe of how often the frequent checks should be done. NA-K explained frequent checks means for staff to just look in [R20's] room to see what he was doing, NA-K was unable to define the time frame of frequent checks as the care plan was not specific. NA-K indicated he thought there was a form for R20's checks staff were supposed to complete, however, was not aware of the location of where it was kept so had not completed the form. During an interview on 4/8/25 at 10:50 a.m., trained medication aide (TMA)-D stated since admission R20 will self-transfer and had been found wandering in the hallway; staff would then assist him back to his room. Staff check on R20 often to ensure he was not self-transferring. TMA-D further explained to her check often meant look in R20's room every time she would passed by. TMA-D could not define a specific timeframe of how often checks were supposed to be completed and was not aware how often staff pass by R20's room. TMA-D was unaware of any other fall interventions in place for R20. During an interview on 4/8/25 at 11:12 a.m., licensed practical nurse (LPN)-C stated R20 would self-transfer to the bathroom on his own without asking for help. LPN-C stated a visual every 15-minute paper checklist was implemented for R20 on 4/8/25, it was kept in a binder at the nurse's station. LPN-C reviewed the checklist for 4/8/25 and noted the checks were not consistently completed so far today (4/8/25). LPN-C then reviewed the care plan and noted the intervention for every 15-minute checks was not identified on R20's care plan. During an interview on 4/9/25 at 12:57 p.m., registered nurse (RN)-C stated she completed the care plans for all of the residents in the facility upon admission. RN-C verified R20's admission fall risk assessment identified him as a high fall risk and that R20's fall risk care plan had not been initiated until ten days after admission. RN-C indicated fall causal analysis was completed by the interdisciplinary team (IDT). RN-C used to be a part of that team but no longer was. When she was part of the team she would assist in determining the appropriate interventions and then would add them to the care plan. During a phone interview on 4/4/25 at 12:38 p.m., emergency room medical doctor (MD)-H reported concerns pertaining to falls. R20 had been seen in the emergency department (ED) due to a fall in the facility and sustained a subdural hematoma and needed to be transferred to another hospital for further evaluation. During an interview on 4/9/25 at 4:23 p.m., certified nurse practitioner (CNP) stated R20 was extremely elevated risk for falls due to confusion and ability to transfer independently. CNP's expectation would have been for the facility to put fall prevention interventions in place on admission to the facility. CNP also stated due to R20's history of previous brain injuries prior to admission with any future falls with head injury could have the likelihood of serious injury, harm, impairment or even death. During an interview on 4/8/25 at 12:40 p.m., director of nursing (DON) identified R20 did not have a fall prevention care plan until after his fall on 4/4/25. DON stated R20 should have had a baseline care plan completed during the first forty-eight hours to identify his fall risk and had interventions in place at admission. DON also stated a comprehensive assessment of his falls, causal analysis, or root case of the falls to add appropriate interventions to prevent further falls had not been completed for any of R20's falls and should have been done. The IJ began on 3/28/25. was removed on 4/9/25 at 4:40 p.m., when it was verified, the facility implemented the following: 1. Facility reviewed and revised fall program and policies to define protocols for documentation with new templates developed and implemented. The revisions included role/responsibilities for the IDT. 2. Facility provided education with knowledge check to nurses on the fall program process, completing the falls checklist, completing the implemented documentation, implantation of interventions, reviewing the effectiveness of the intervention, and updating the care plan. A knowledge test was attached to the fall education. 3. Facility provided education NAs on care plan and roles in the facility's fall program. 4. Facility provided education to IDT on roles and responsibilities pertaining to the fall program. 5. Facility reviewed R20's chart for fall incidences and fall analyzes. Care plan were reviewed and updated with fall interventions. Interdisciplinary team reviewed R20 to see if other modifiable risk factors can be implemented for resident. 6. Like residents were identified, facility completed comprehensive analysis, reviewed and revised care plans as appropriate. R22 R22's face sheet dated 4/10/25, identified R22 was admitted on [DATE] with diagnoses of fracture of right fibula, fracture of right rib, degeneration of nervous system, and schizoaffective disorder. R22's fall risk assessment dated [DATE], identified R22 was high risk for falls with 1-2 fall in past 3 months, chair bound, with predisposing disease or circulatory/heart, neuromuscular/functional, orthopedic, psychiatric/cognitive, infection, pain, weakness, and history of falls. R22's fall incident report dated 3/23/25 at 4:10 p.m., identified R22 was found on the floor next to his bed. R22 stated he was attempting to reach his remote to the television and slid from the bed. Incident report was not completed to include mental status, predisposing physiological/environmental factors/situation factors. On 3/31/25 incident report identified new intervention of reached out to pharmacist of new recommendations. R22's care plan did not identify a fall focus care plan had been initiated, or any fall prevention interventions added. A post-fall root cause analysis worksheet was provided for R22's fall on 3/23/25, identified R22 was found on floor next to his bed, R22 was laying in bed watching television and dropped the remote and wanted to get it from the floor, call light was in reach, last toileted at 3:50 p.m., was not incontinent at time of fall, and had gripper socks on. Interventions put in place of frequent call light checks and request nursing assistants to check on resident often. Although the worksheet identified possible causal factors of the fall, no conclusion of the data was identified in the medical record to determine the root cause of the fall. R22's fall incident report dated 3/24/25 at 9:30 p.m., identified R22 was being assisted with transfer from bed to wheelchair and resident became weak and was lowered to the ground. Incident report was not completed to include mental status, predisposing physiological/environmental factors/situation factors. R22's care plan did not identify a fall care plan focus medical record did not identify comprehensive assessment, causal analysis, or root cause of the fall. R22's fall care plan focus dated 3/25/25, identified R22 was high risk for falls related to non-weight bearing of right foot, repeated falls, schizoaffective disorder bipolar type, spondylosis, inability to follow directions and impulsivity. Interventions included: anticipate and meet the resident's needs, be sure call light is within reach and encourage and remind the resident to use it for assistance as needed. R22's activities of daily living (ADL) focus care plan dated 3/25/25, identified R22 required assist of two for all transfers and not able to follow directions for non-weight bearing of right foot. R22's consultant pharmacist review on 3/29/25, a medication review done due to frequent falls and recommended adjustments to fall risk medications. Review of R22's progress notes from 3/29/25 to 4/7/25 did not identify physician notification of consulting pharmacist recommendations until 4/8/25. R22's fall incident report dated 3/26/25 at 5:30 p.m., identified R22 was on floor sliding to the bathroom attempting to toilet himself. R22 was in bed prior to the fall and call light was on the bed. R22 was last toileted at 2:30 p.m., repositions self and had a large loose bowel movement. Fall mat was place on the floor and frequent checks to assure needs are met, and soft touch call light. R22's post-fall causal analysis worksheet dated 3/26/25, identified the aforementioned fall description and identified R22 was incontinent at time of fall. Although the worksheet identified possible causal factors of the fall including R22 was incontinent, no conclusion of the nor evident comprehensive assessment completed that addressed R22's toileting needs. Further R22's care plan did not identify the new interventions of fall mat, frequent checks, nor soft touch call light that were identified on fall report. Furthermore, R22's record identified although the care plan had been revised on 4/8/25 to include frequent checks-15 min checks. R22's record did not include a comprehensive assessment that identified the level or frequency of supervision that corresponded with the intervention frequent checks. R22's progress note dated 4/7/25, identified R22 was found sitting on the fall mat because he slipped due to slippery floor. R22 was coming back from bathroom. Immediate intervention to offer toileting every hour. R22's care plan was not revised on 4/7/25 to include offer toilet every hour. R22's record identified although the care plan had been revised on 4/9/25 to include every 2 hours prompting for toilet use, the record did not include a corresponding comprehensive bowel/bladder assessment that would identify the appropriateness of the intervention of either every one hour or two hours to meet R20's individualized toileting needs. During an interview on 4/9/25 at 1:17 p.m., director of nursing (DON) stated R22's medical record did not identify a comprehensive analysis of his falls nor identify a root cause of the falls. DON further stated a root cause analysis work sheets had not been consistently completed for each fall to better determine the root cause of falls and ensure appropriate fall prevention interventions were in place. Review of the facility's Fall Prevention Program undated, identified each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. -The nurse will indicate on the (area left blank) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk of Low/Moderate Risk protocols when determining primary interventions. -High Risk Protocols: -Indicate fall risk on care plan. -Place fall prevention indicator (such as star, color coded sticker) on the name plate to resident's room. -Place fall prevention indicator on resident's wheelchair.

Based on interview and document review, the facility failed to complete an assessment including, vital signs and general condition, when a change in condition was reported to a nurse for 1 of 3 (R1) residents reviewed for quality of care. This resulted in harm for R1 who continued to decline and later that day required emergency medical care and passed away. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of multiple sclerosis, sepsis (a serious infection), and acute ischemia of the intestine (when the blood flow to the intestine is suddenly cut off). R1's MDS indicated she required substantial assistance with all activities of daily living (ADLs) and was cognitively intact. R1's care plan, dated [DATE], indicated R1 was dependent on staff assistance for bed mobility, dressing and personal hygiene. R1's care plan indicated she was dependent on the assistance of staff to pivot transfer to/from the bed to the wheelchair or commode. A Physicians Order for Life Sustaining Treatment (POLST), dated [DATE], indicated R1 wanted cardiopulmonary resuscitation (CPR) attempted, if she had no pulse and was not breathing. A progress note on [DATE] at 4:15 p.m., indicated R1 was ill that morning with nausea and vomiting and did not keep her pills down. R1 continued to have vomiting and diarrhea throughout the day. R1 refused all meals and told nursing assistant (NA)-A she did not feel well. When NA-A provided cares around 1:00 p.m., R1 was alert and talking. NA-B observed R1 to have a nosebleed around 3:30 p.m. and became unresponsive. 911 was called. At 3:44 p.m. R1 became blue and had no pulse. Registered nurse (RN)-A started CPR. RN-A began CPR and sent staff to get the AED (automated external defibrillator, device used to analyze heart rhythm and deliver electric shock to restore normal rhythm during cardiac arrest). AED was applied and shock was not advised. CPR resumed for three cycles of CPR and analyzing via the AED. R1 still didn't have a pulse and was bleeding from the nose and mouth. CPR ceased when ambulance arrived. Emergency medical services (EMS) staff hooked resident up to their monitor. R1 was asystole (a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely). RN-A indicated she notified the director of nursing (DON) of the R1's death. R1's progress notes lacked notification to the provider of R1's deterioration in condition prior to her death. On [DATE] at 1:33 p.m., NA-C stated he was working on [DATE]. NA-C stated he assisted RN-A and NA-B in CPR efforts for R1. NA-C stated he could not remember how long they performed CPR. NA-C stated EMS staff asked RN-A why they stopped CPR and RN-A replied, she died . On [DATE] at 2:04 p.m., RN-A stated she worked from 6:00 a.m. to 6:30 p.m. on [DATE]. R1 had nausea, vomiting, and diarrhea all day. RN-A stated she became aware of R1's change in condition around 7:45 a.m. when R1 vomited after taking her morning medications. RN-A stated R1 refused breakfast and lunch. She did not contact R1's provider because it was a Saturday. She did not do a physical assessment to further investigate R1's change in condition and did not take her vital signs (blood pressure, temperature, pulse, and respiratory rate) even though R1 was ill. RN-A stated there was a virus going around the building, where other residents had similar symptoms of nausea, vomiting and diarrhea. RN-A stated R1 had a nosebleed and became unresponsive around 3:00 p.m. RN-A stated she called 911 and then started CPR. RN-A stated she could not recall a timeline. The staff completed two-to-three cycles of CPR with AED in place. RN-A stated, When they (EMS) got there, we kind of stopped. RN-A stated CPR should not have been stopped prior to EMS arrival. On [DATE] at 3:09 p.m., the DON stated she was informed CPR was performed on R1 on [DATE]. The DON stated RN-A told her EMS staff took over when they arrived. The DON stated she would not expect CPR to cease prior to EMS taking over. On [DATE] at 3:45 p.m., EMS-A stated a NA met the EMS staff at the door, upon their arrival, stating CPR was in progress. EMS-A stated when they entered R1's room, nobody was doing CPR and RN-A was removing her gloves and stated, I am done doing CPR. She is gone. EMS-A stated the AED was out and the pads were on R1's chest. EMS-A stated she would not have expected CPR to cease prior to their arrival. On [DATE] at 4:18 p.m., EMS-B stated as she was entering the facility with equipment, EMS-A met her in the hall to inform her staff discontinued CPR. EMS-B stated she was surprised CPR was discontinued as it is usually continued until EMS takes over. EMS-B stated RN-A told her 5 cycles of CPR were completed, which would be approximately ten minutes. EMS-B stated they applied the pads of their equipment to determine R1 was asystole and pupils were fixed and dilated. On [DATE] at 5:35 p.m. nursing assistant (NA)-A stated, on [DATE], he informed RN-A around 7:00 a.m., R1 was not feeling well. NA-A informed RN-A, R1 had vomiting and diarrhea. R1 had several more episodes of vomiting and diarrhea. R1 refused her breakfast and her lunch. NA-A stated he informed RN-A of these concerns throughout his shift (6:00 a.m. - 2:30 p.m.). NA-A stated he observed RN-A enter the room to provide R1 her medications around 7:45 a.m. NA-A was not advised by RN-A to obtain vital signs for R1. On [DATE] at 10:12 a.m., NA-B stated she checked on R1 around 3:30 p.m. on [DATE]. NA-B observed blood coming from R1's nose. RN-A came into the room and said she was going to call 911, without completing vital signs or an assessment. NA-B stated she was preparing to wash R1 to get her ready to go to the hospital when she observed R1 was no longer breathing. While NA-B and RN-A were both in R1's room, NA-B informed RN-A R1 was not breathing. NA-B stated the head of R1's bed was lowered, and she went to gather the crash cart and AED. When she returned to the room, RN-A was performing CPR on R1. NA-B stated she applied the AED pads and the AED said not to shock R1. They performed two cycles of analyzing with the AED. RN-A was using the ambu-bag (a device used to deliver breaths to a person) to deliver breaths while NA-C did compressions. NA-B stated she exited R1's room when she saw the ambulance in the parking lot and met the EMS staff at the door. NA-B informed EMS staff CPR was in progress. When NA-B and EMS staff returned to R1's room, the staff were no longer performing CPR. NA-B stated she did not know why CPR was stopped. RN-A just stated they stopped. NA-B stated she heard EMS staff asking RN-A why they stopped doing CPR. NA-B stated R1 was on a hospital bed, with a mattress, while CPR was performed. NA-B stated there was a CPR board on the crash cart, but it was never placed under R1. She stated nobody thought to grab it. On [DATE] at 10:53 a.m., the director DON stated RN-A should have updated the provider with R1's change in condition on [DATE] after she vomited her morning medications. The DON stated she expected vital signs and assessment should have been completed more than once throughout the day. On [DATE] at 2:39 p.m. the medical director (MD) stated he would have expected RN-A to have completed an assessment and vital signs when she started to show signs of illness. Based on the findings, he would expect RN-A would have had communication with the provider to evaluate R1's condition. On [DATE] at 2:50 p.m., the nurse practitioner (NP) stated he saw R1 on [DATE] and she did not have any of the symptoms noted in the progress note dated [DATE]. The NP stated he would have expected RN-A to complete and assessment with vital signs. He stated RN-A did not inform him of R1's change in condition on [DATE]. The NP stated there is always a provider on-call to address the needs of the residents. A facility document, Notification of Changes, dated ,d+[DATE], directed the facility promptly informs the resident, consults the physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. 2) Significant change in the resident's physical, mental, or psychosocial condition such as a deterioration in health, mental, or psychosocial status. This may include clinical complications. 3) Circumstances that require need to alter treatment. This may include acute condition. A facility document, Cardiopulmonary Resuscitation, dated 2023, directed the facility will follow current American Heart Association (AHA) guidelines regarding CPR. The AHA Adult Basic Life Support Algorithm for Healthcare Providers, dated 2020, directed to start CPR if no breathing and no pulse felt, use AED as it is available, check for shockable rhythm, resume CPR immediately for 2 minutes (until prompted by AED), and continue until ALS (advanced Life Support) providers take over or victim starts to move.

Based on observation, interview, and document review, the facility failed to appropriately assess, monitor, and intervene for 1 of 1 resident (R22) to ensure she received the appropriate consistent carbohydrate diet (CHO). This caused actual harm when R22 required new onset sliding scale insulin to attempt to manage her more than doubled blood sugar levels and had an unplanned 32% weight gain within 6 months. Findings include: R22's 3/3/22, Significant change Minimum Data Set (MDS) identified R22 had intact cognition, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's 6/16/22 quarterly MDS identified her weight rose to 229 lbs. R22's current Order Summary Report identified [MEDICATION(S)] (fast acting) sliding scale (SS) insulin was added to R22's medication regimen beginning 6/17/22. R22 was to have her BS checked 4 x per day. R22 was to receive a CHO diet beginning 12/23/21. R22's progress notes identified on 6/17/22, R22 had ordered SS insulin. If R22's blood sugar rose above 400 milligrams per deciliter (mg/dL), staff were to give 15 units of insulin. R22's 7/5/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's hemoglobin A1C (3-month average of blood sugar levels) was 5.8% 3 months ago. The MD noted R22 just started a sliding scale insulin for mealtimes. R22 received long-acting insulin 27 units of [MEDICATION(S)] twice daily. Her appetite was noted to be stable and nursing does relate that she snacks a fair amount. There was no indication R22's weight increase had been identified by the physician or that the MD was aware R22 had not been receiving her CHO diet as ordered. R22 was noted to have a history of diabetic Ketoacidosis (a life-threatening condition when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic). R22's weights identified: 1) On 11/20/21, she weighed 177 lbs. R22's weight dropped on 1/29/22 to 171 lbs. R22 was not weighed again until 3/1/22. 2) On 3/1/22, her weight increased to 185.5 lbs showing an 8.4% weight increase in a little over 1 month. 3) R22's weight steadily increased to 227 lbs as of 7/29/22, for a weight gain of 32% within almost 5 months. R22's blood sugar levels from 2/16/22 through 3/1/22 identified she ranged from 100 mg/dL to 299 mg/dL. After 3/1/22, R22's BS levels were commonly higher than 300 mg/dL and were consistently over 300 mg/dL daily beginning on 4/6/22. R22's highest BS level was 598 mg/dL on 5/14/22. R22's 6/18/22 at 12:26 a.m., emergency department (ED) note identified R22 was sent to the hospital after an unresponsive episode after feeling lightheaded while eating dinner. R22 developed chest pain radiating to both her arms that resolved with antacid medication in the ED. R22's [MEDICATION(S)] level was low but just at 18 milliequivalents per Liter of blood (mEq/L). Her BS was 402 mg/dL upon arrival. After receiving 1 L of IV fluid, it dropped to 265 mg/dL. R22 noted to the ED staff she had not received her evening insulin at that time. The ED provider documented because R22 was receiving monitoring at the facility, the ED felt comfortable discharging R22 back with strict return instructions. There was no indication the ED provider considered mild DKA as a potential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 8/5/22 at 7:55 a.m., with R22 identified she had very large portions of what appeared to be eggs or eggbake with cheese, a soup bowl sized bowl full of oatmeal with butter and syrup, along with breakfast meats. R22 stated she wasn't on any diabetic diet and was surprised staff had not put her on one. She reported she has asked several times for diabetic or sugar free juice, but staff keep giving her regular juice. R22 stated she like the food at the facility and would eat a lot. R22 had no visit from the registered dietician (RD) but would like to. R22's diet card was displayed on her tray as a regular, no added salt. R22's current, undated care plan identified staff were to ensure R22's food was to be cut as she struggled to cut up her meat. R22 was to have a CHO diet and with a goal to not develop complications related to obesity or diabetes, initiated on 11/14/21. R22's 6/18/22 RD progress note identified she was aware R22's weight had increased and was insidious over the past 6 months (proceeding in a gradual, subtle way, but with harmful effects) and was noted to be at 223.5 lbs. at the time of the RD's chart review. The RD further noted Blood sugars fairly well controlled - insulin ordered. The RD recommended 1) add probiotics while on antibiotic therapy - PCP (MD) to advise for order. 2) offer yogurt daily per dietary. 2) if indicated for pressure wounds, recommend adding Arginade BID - PCP to advise for order. 3) add 500 mg Vitamin daily to help with iron absorption if appropriate - send to PCP to advise. There was no note the RD had physically assessed R22 while at the facility or investigated the source of R22's weight gain and need for additional SS insulin related to the improper diet being administered. There was also no indication she notified the MD with R22's noted insidious weight gain and coinciding increased BS levels. Interview on 8/4/22 at 10:15 a.m., with the dietary manager regarding R22's diet and weight changed identified she was unsure she has ever notified the RD or nursing staff about R22's weight gain. Interview on 8/5/22 at 8:50 a.m., with licensed practical nurse (LPN)-A identified she was unaware R22 was receiving a regular diet and not a CHO as ordered. She was aware of R22's weight gain and had addressed the need for increased new SS insulin but did not investigate potential causes. There isn't a very good system for communication. Interview on 8/05/22 at 10:57 a.m., with the RD identified she is unaware if she had ever performed a physical assessment with R2. She goes to several nursing homes and if there is a positive COVID case, she will not enter the building as she feels she would have to isolate all the time. She agreed she needed to provide physical assessments and dietary oversight for residents at least quarterly and more often if needed. Interview on 8/05/22 at 11:26 a.m., with the administrator identified she was unaware the RD wasn't doing face to faces with residents at the facility. She agreed R22 increased BS had a direct correlation between her not receiving her diet as ordered and agreed there was no current system for communication or oversight to ensure nursing and dietary were identifying root causes for resident concerns. She also identified there was no system to ensure there was oversight on the RD to ensure she was performing her contracted duties. Interview on 8/08/22 at 1:15 p.m., with the medical director identified he was unaware R22 had not been receiving her CHO diet as ordered, had a 32% weight increase, or had to be started on fast acting insulin ([MEDICATION(S)] SS) to try and keep her BS levels down. The MD agreed not following R22's diet contributed to her weight gain and increased need for extra insulin she had not required before. Review of the 10/4/21, Agreement to Provide Dietary Consultant Services in Long Term Care Facilities contract identified the RD was to: 1) Complete a kitchen sanitation regulation inspection and review with the dietary manager (DM) monthly. 2) Assist in resident nutrition screening, assessment and care planning for residents meeting MDS requirements upon Significant Change or decline in residents' nutritional status. 3) Provide consultation to residents. 4) Attend resident care conferences. 5) Provide a monthly written report to the DM and administrator.

Based on interview, observation, and document review, the facility failed to provide adequate supervision despite being a known elopement risk, for 1 of 1 residents (R1) who left the facility, self-propelling in a wheelchair with the intent of returning to his home, over a mile away, with an air temperature at 90 degrees Fahrenheit (F). A stranger subsequently picked up R1 a few blocks away from the facility and brought him to R1's home in the community. This resulted in an immediate jeopardy (IJ) for R1 when, after he was returned to the facility on [DATE], the facility failed to place interventions that would prevent reoccurrence, placing R1 at risk for serious harm, injury, or death if he should elope again. The IJ began on 6/18/22, when the facility failed to place interventions to prevent R1 from eloping again and was identified on 6/29/22. The administrator and director of nursing (DON), were notified of the IJ on 6/29/22, at 4:28 p.m. The IJ was removed on 6/30/22, at 1:53 p.m. when the facility implemented interventions to prevent further elopements, but noncompliance remained at the lower scope and severity level 2, D, isolated scope, and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's facesheet printed on 6/28/22, included a diagnoses of adjustment disorder with mixed disturbance of emotions and conduct, [CONDITION(S)], high blood pressure, heart failure (when the heart doesn't pump as well as it should), and depression. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had clear speech, was understood and could understand. R1 was independent in moving about on the unit in his wheelchair but required supervision off the unit. Walking occurred only once or twice during the MDS assessment period. In addition, the MDS indicated a wander/elopement alarm was not used. R1's plan of care printed on 6/28/22, did not identify elopement as a focus area of concern. R1's Elopement Risk Evaluation, dated 4/15/22, indicated R1 had a score of seven indicating he was at risk for elopement. The score was based upon the following seven parameters: 1. Ability to self-propel wheelchair 2. Habit/history of wandering or attempts to leave the building 3. Exhibited agitated behavior 4. Asked to go home 5. Had a psychiatric diagnosis 6. Family had voiced concerns that R1 may have a tendency to wander or elope 7. Taking medication which may cause confusion An intervention checked off on the elopement risk evaluation form included, exit alarm which, according to the director of nursing (DON) during an interview on 6/29/22, at 9:15 a.m., meant a WanderGuard bracelet (a device worn by residents, who when in the vicinity of an exit door, the door automatically locks preventing the resident from leaving unattended). According to the elopement risk evaluation form, a WanderGuard was in use at that time, 4/15/22. Discrepancies were noted in the facility documentation on whether R1 had or did not have a WanderGuard in place on 4/15/22. The MDS indicated he did not. Elopement Risk Evaluation indicated he did. The care plan did not mention a WanderGuard. Physician orders for June 2022, indicated R1 could go on pass and/or LOA (leave of absence) with responsible a party and his medication. A physician visit note dated 4/27/22, indicated R1 had been less agitated and understood he would be living at the facility long-term. R1 wanted to go out on pass and visit his wife and children. Family was concerned about his competency and his ability to make informed decisions. The physician indicated, he too, was very concerned about that as well. R1 had significant behaviors in the past including suicidal gesturing. The physician noted he would seek psychiatric input into his mental status. A psychiatry note dated 4/28/22, indicated R1 was impulsive and his lack of insight extended to his desire to go home. A psychiatry note dated 5/31/22, indicated R1 lacked safety awareness, had short term memory impairment and impairment in concentration. A progress note dated 6/17/22, indicated R1 was seen by a physician on routine rounds and R1 was upset and venting to the physician about wanting to go home and wanting all of his collections (coins and marbles) brought to the facility. The physician was informed that R1 never really slept and spent all day and night in his wheelchair with an occasional half hour in his recliner. The physician ordered [MEDICATION(S)] (medication to relieve anxiety) to be administered one half hour before bedtime. A progress note dated 6/18/22, at 6:33 p.m. indicated the facility received a call from family member (FM)-C who stated R1 arrived to his home in the community at 4:15 p.m. in his wheelchair. The DON was notified and staff were advised to call law enforcement to pick up R1 and return him to the facility. R1 returned at 4:50 p.m. and was assessed and no injuries were noted. An incident report completed on 6/18/22, at 5:00 p.m. by the DON read: On 6/18/22, at 4:15 PM, the charge nurse received a call from R1's wife. R1 had left the building in his wheelchair and gone home. Per the wife's explanation, he propelled his wheelchair part way and was picked up by a friend in a pick up [truck] and taken the rest of the way home. R1 informed staff, 'I wanted to go home.' 'I didn't do anything wrong.' The DON was called who advised charge nurse to immediately call 011 [911] and ask for police to go to the home address here in community and bring R1 back to the nursing home. No injuries. Alert and oriented. The incident report indicated there were no predisposing situational factors, including active exit seeker. R1 was upset because he wanted a young girl to give him a shower and was told she could not. He also just wanted to go home to get his marbles and coin collections. No witnesses were found. Following the incident, the DON, administrator, social services and R1's physician were notified. During an interview on 6/28/22, at 2:11 p.m. trained medication aide (TMA)-B stated she was on duty when R1 eloped. TMA-B stated at about 3:00 p.m. on 6/18/22, R1 had been upset because he wanted a certain employee to give him a bath and that employee could not. According to TMA-B, the next thing she knew, FM-C called the facility at approximately 4:15 p.m. to report R1 was at her house. TMA-B stated they were not aware R1 had left the building, adding that R1 had gone out an exit door between his room and the nurses station without telling anyone. TMA-B did not know if R1 was an elopement risk, stating it was not uncommon for R1 to self-propel outside in his wheelchair to sit for a bit. TMA-B stated R1 had a WanderGuard on his wheelchair for a while, but it had been removed and she did not know why. During a telephone interview on 6/28/22, at 2:14 p.m. FM-C recalled the shock she felt when, A guy showed up in the driveway in a black pick up. A guy got him [R1] out in his pick up and brought him up to the house in his wheelchair. FM-C stated she did know this man who told her R1 had been sitting on the road so he asked R1 if he needed help; R1 asked him to take him to his house. FM-C stated R1 was exhausted and it was hot that day, I think he pushed himself in the wheelchair, self-propelling, that wears him out. Hotter than heck that day. FM-C didn't know how far R1 got before the man picked him up, adding, we live clear across down. FM-C stated when she told the man R1 wasn't supposed to be here, he exited real quick. FM-C stated, R1, Flew in here and was looking for something. Money. He doesn't understand it's not safe to take everything valuable to the nursing home, that's mainly what he wanted when he came home, he wanted to look at his marble collection. FM-C stated she thought the time was about 6:00 p.m., but was not sure. FM-C stated R1 had lived at the facility since 2/3/22, and had not tried to go home before. When asked if R1 had an alarm bracelet on is body or wheelchair, FM-C stated no, they put one on and he cut it off, adding, if R1 wants something bad enough, he will do it. According to FM-C, she was at the facility the evening of 6/17/22, for beer and brat night when R1 told her he cut off his WanderGuard bracelet. FM-C stated she didn't know what to believe because R1 fibs a lot, so she didn't report this to the staff. According to website www.accuweather.com, the temperature in the community on the afternoon of 6/18/22, was 93 degrees F. During an interview on 6/28/22, at 3:38 p.m. the DON stated on 6/18/22, a Saturday afternoon, the charge nurse called her to report that FM-C called the facility to inform them R1 was at her home. The DON advised staff to call 911 to have law enforcement pick him up and return him to the facility. The DON then called the administrator and social services and called back to the facility to talk to staff. Fifteen minute checks were initiated. The DON stated the investigation started on Monday 6/20/22, when a regional consultant (RC)-D and vice president of clinical services (VPCS)-E arrived to the facility. The investigation included a care conference with R1, FM-C, and other family members. According to the DON, the family stated they were expecting it [elopement] to happen sooner because R1 called them and threaten it all the time. The DON stated R1 was not unhappy at the facility; he just wanted to go home and get his coin and marble collections. According to the DON, the investigation included talking to R1, the staff and a resident who R1 followed out the side door on the day of he elopement. The DON stated R1 had a WanderGuard bracelet on until 6/18/22, when unbeknownst to the facility, R1 cut it off. At that time, the facility was not conducting daily verification of WanderGuard bracelets on residents and therefore it went undetected. When asked if the facility had considered reapplying the WanderGuard bracelet following the elopement since R1 was assessed at being at risk for elopement, the DON stated they were told by RC-D and VPCS-E that R1's elopement was purposeful and this BIMS (brief interview for mental status) was 14 (indicating intact cognition), so a WanderGuard was not necessary. The DON stated following their investigation, RC-D and VPCS-E concluded the elopement was not a true elopement because R1 had a purpose and knew where he was going. During this interview, the administrator joined the conversation and stated she understood from the investigation that a WanderGuard was not necessary because R1 left the facility purposefully and knew where he was going, and for those reasons it was deemed not an elopement. During the same interview, at 4:00 p.m., the DON placed a phone call to VPCS-E who stated, We're not calling it an elopement. He knew what he was doing. He planned to leave. It was safe for him to leave the facility unsupervised - he's his own person and his BIMS is 14. VPCS-E stated a WanderGuard was not appropriate for R1, adding, He's a guy I would let sign out and go. He collects stuff and wanted to go home and see it. VPCS-E stated R1 had the capability to cut the WanderGuard bracelet off and therefore it would not be effective. VPCS-E stated the facility implemented one to one activities with R1 which was more proactive and they educated R1; He's his own person. VPCS-E stated they Reviewed R1's behaviors, he rolls away, gets mad, that's why we added impulsiveness to his care plan. The facility did not require residents to sign out when going outside to enjoy the weather. During an interview on 6/28/22, at 5:06 p.m., the DON stated WanderGuard's were implemented at the facility in April 2022 when they closed their secure unit. R1 had a WanderGuard bracelet placed on his wheelchair just prior to a 4/15/22, elopement risk evaluation, but according to the DON, the placement date was not documented. The DON identified the facility was not verifying placement of WanderGuard's on residents until after the elopement incident on 6/18/22. R1 cut the WanderGuard bracelet off his wheelchair around suppertime on 6/17/22, but staff were not aware of this. During an interview on 6/28/22, at 5:16 p.m., social services (SS)-A, stated one to one's were implemented with R1 following the elopement, adding R1 was welcomed to come in and visit; he talks when he wants to talk. According to SS-A, the sessions were proactive .more apt to see if R1 had a specific need .able to gauge his compulsive behaviors and mood .intervene if needed. During an interview on 6/28/22, at 5:20 p.m. activities director (AD)-A stated one to one sessions with R1 occurred with SS-A and staff in the activities department. These sessions were not scheduled, they were informal and the frequency was not defined. AD-A stated R1 participated in activities offered by the activity department on a daily basis, including weekends, adding R1 was out of his room often attending activities. During an interview and observation on 6/28/22, at 6:20 p.m. in his room, R1 stated, That day I was going to go home and I didn't tell anyone. I just left. R1 stated it was 90 degrees and he only went two or three blocks, traveling on the street before a man picked him up. I have no idea who it was. R1 stated he went home to get some of his collections [coins and marbles]. R1 stated he had a WanderGuard bracelet on his leg but cut it off, adding he borrowed a scissor from the cart they put the pills on, then put the bracelet in a drawer. R1 opened a drawer underneath a closet and said, It's gone, I gave it to them. R1 did not know what day it was when he cut off the bracelet, adding another one was put on, but later taken off by staff. During an interview on 6/29/22, at 9:54 a.m. the DON stated when R1 returned after his elopement on 6/18/22, social services director (SS)-A instructed staff to apply a WanderGuard bracelet to R1, however, when the investigation started on 6/20/22, they were instructed by RC-D and VPCS-E to remove it as R1 didn't need it. The DON stated she dragged her feet in removing it, adding, I didn't think it should be removed. On 6/23/22, RC-D saw the bracelet was still on R1 and again instructed her to remove it. The DON stated it was left on until 6/24/22. The DON stated R1 was still at risk for elopement risk, adding, He said he won't, but if he gets upset, his M.O. (modus operandi) is to leave. This was his first time; but it's a possibility. The DON stated R1 had child-like behaviors, and gave an examples of one day when he crawled under the bed because he was mad and another day when he faked a [CONDITION(S)] and was sent to the ER. He gets mad and has no impulse control. During a telephone interview on 6/29/22, at 10:07 a.m. (FM)-H and (FM)-I stated they were aware of the incident and had been concerned after hearing about the elopement. FM-I stated the facility should, get that WanderGuard back on R1's wheelchair. FM-I stated they were told by the facility that R1 was an adult and his own person, and could make decisions. In addition, FM-I stated the facility told them they couldn't imprison R1 and force him to do things. FM-H stated they did not know who picked up R1 and drove him to FM-C's home. The facility policy titled WanderGuard Policy dated 6/20/22, created in response to R1's elopement, indicated all staff would be aware of residents at risk of unsafe wandering and be aware of those who have a WanderGuard in place; staff would be educated on the use of WanderGuard's; nursing staff will check residents wearing a WanderGuard and document it on the TAR (treatment administration record). The policy provided guidance on want to do if the WanderGuard was not functioning properly. During a telephone interview on 6/29/22, at 3:07 p.m., medical doctor (MD)-G stated he R1 was probably cognitively intact, but lacked impulse control; He gets mad and holds a grudge and acts out. MD-G acknowledged R1 lacked safety awareness and stated it was not safe for him to leave the facility on his own without supervision as he did on 6/18/22. Interviews pertaining to R1's cognition and exit seeking behaviors: --6/28/22, at 3:30 p.m., (TMA)-A stated R1 had not eloped before, adding R1 was smart, but very impulsive. R1 got mad if he didn't get his way . it's almost like attention seeking behavior. --6/28/22, at 3:36 p.m., licensed practical nurse (LPN)-A stated R1 was a known elopement risk; he wanted to go home. 80% of the time, R1 makes good decisions and 20% of the time he did not. He gets mad and can't think clearly; makes poor decisions like leaving last weekend. --6/29/22, at 11:58 a.m., (TMA)-C stated R1 had exit seeking behaviors, adding we knew he wanted to go home. He liked to sit by the exit doors and watch the staff arrive to work. --6/29/22, at 3:20 p.m., SS-A described R1's cognition as intact, however very impulsive when frustrated or things did not go his way, causing him to make poor decisions. According to record review and interviews with the DON on 6/28/22, at 3:38 p.m. and on 6/29/22, at 9:54 a.m., and with SS-A on 6/28/22, at 5:16 p.m., the following actions were taken after R1's elopement: --A WanderGuard bracelet was immediately placed on his chair on 6/18/22, and removed on 6/24/22. --R1's elopement risk was reassessed on 6/20/22, and indicated a risk for elopement. The evaluation indicated a WanderGuard was not in use. --Provided R1 one to one opportunities with the activities department staff and the SS in order decrease R1's compulsive behaviors by gauging R1's mood and allow opportunities for him to express concerns. The frequency was not defined. During an interview on 6/29/22, at 5:58 p.m., the administrator stated she was out of town when R1 eloped. The DON made her aware of the elopement right away. The administrator directed her team to complete a vulnerable adult report to the State Agency, to put a WanderGuard on R1, and to start the investigation. Additionally, she informed her team that if they needed help, to reach out to the corporate nursing consultants. SS-A made the consultants aware of the elopement, As a heads up. On 6/20/22, the consultants arrived to the facility to conduct the investigation. When asked why RC-D and VPCS-E directed the staff to remove the WanderGuard from R1 on 6/20/22, the administrator stated it was her understanding RC-D and VPCS-E determined R1 leaving the facility did not constitute an elopement. In addition, the consultants determined R1 left purposefully and knew where he was going, and therefore did not require a WanderGuard. Facility policy titled WanderGuard Policy dated 6/20/22, created in response to R1's elopement, which indicated all staff would be aware of residents at risk of unsafe wandering and be aware of those who have a WanderGuard in place; staff would be educated on the use of WanderGuard's; nursing staff will check residents wearing a WanderGuard and document it on the TAR; and what to do if it's not functioning properly. Facility policy titled Wandering and Elopement, with revised date of March 2019, indicated the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as a risk for wandering or elopement, the residents care plan would include strategies and interventions to maintain the resident's safety. The policy did not include characteristics or behaviors to for staff to monitor that may indicate a resident had intent to leave the facility. This was verified by observation, interview and record review. The facility reassessed R1's elopement risk, provided R1 with a WanderGuard bracelet, added interventions to R1's care plan, implemented a policy of verifying placement of WanderGuard bracelets on residents twice a day and documenting it, implemented audits of WanderGuard's for all eight residents who have a WanderGuard and provided all staff with re-education on elopement. The immediate jeopardy that began on 6/18/22, was removed on 6/29/22, when R1 had a WanderGuard bracelet placed on his ankle; his plan of care was updated to reflect the use of the WanderGuard; staff were educated on R1's plan of care, and a comprehensive reassessment of R1's elopement risk was completed. Interventions to reduce the risk of elopement included: one to one opportunities with activities staff and social services to identify and decreased impulsive behavior to elope; group and individual outings would be offered to R1's twice weekly. The facility also conducted audits on residents with WanderGuard's daily for two weeks and verification would occur on the TAR for the charge nurse to check each shift. All nursing staff not yet educated on the use of WanderGuard's and the elopement policy were educated. Noncompliance remained at the lower scope and severity level of level, D, isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review the facility failed to provide a physician ordered mechanically ground diet of meat (pork roast) to 1 of 1 resident (R1). R1 subsequently began choking. Staff also failed to immediately perform the [MEDICATION(S)] maneuver, delaying potentially lifesaving treatment. This resulted in actual harm as R1 required a higher level of care after developing aspiration pneumonia (when food, saliva, or liquids are breathed into the lungs or airway instead of swallowed into the stomach) requiring medical intervention at the regional hospital. The survey resulted in an immediate jeopardy (IJ) that began on 3/7/22 at 12:25 p.m., at J-ISOLATED, when the facility failed to provide the appropriate physician ordered altered texture diet (mechanical ground), served R1 whole chunks of meat. Staff identified the meat was the incorrect consistency, however, they had left it within reach of R1, resulting in R1 eating the meat and choking. Staff saw R1 choking, but failed to immediately intervene and perform the [MEDICATION(S)] maneuver as staff waited for the director of nursing (DON) to arrive. R1 was later sent to the regional emergency department (ED) and was later admitted to the ICU for aspiration pneumonia. The administrator and DON were notified of the IJ on 3/29/22 at 2:00 p.m. The IJ was removed on 3/29/22 at 6:45 p.m., when it could be verified by interview and document review, the facility took steps to remove the immediacy by revising policies and procedures, educating nursing and dietary staff on ensuring diets were provided per physician order, and educated on how and when to provide the [MEDICATION(S)] maneuver. Non-compliance remained at the lower scope and severity level of D-isolated, potential for harm that is not immediate jeopardy. Findings include: R1's current, undated diagnoses list identified she experienced a stroke on 12/3/20, which resulted in dysphasia (difficulty swallowing), [CONDITION(S)] (paralysis of one side), [CONDITION(S)] (a language disorder that affects a person's ability to communicate), and anxiety disorder. R1's 2/7/22 Significant Change, Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and required supervision with eating. R1's current physician orders identified her diet was to be mechanical ground with nectar thickened liquids. Review of the 3/7/22 at 2:55 p.m., report to the State Agency (SA), identified R1 was reported to have choked on meat. Nursing assistants (NA)'s saw R1 choking and called the DON who was in her office across the hall from the dining room. R1 was noted to be cyanotic (blue in color from lack of oxygen) and stopped breathing for approximately 30 seconds. The DON performed the [MEDICATION(S)] Maneuver multiple times with good results. R1 pinked up and was responding as per her normal. R1 had some upper airway congestion. EMS was called and transported R1 to the local emergency department (ED) for evaluation. Review of the facility investigation documentation revealed on 3/7/22 at the noon meal, nurse aide (NA)-A retrieved R1's tray from the cart, and placed it in front of R1. When she removed the cover, she noted the meat and broccoli were not provided in the physician ordered mechanical ground texture. NA-A picked up the plate, scooped the meat into the cover, and set the cover in front of the food tray. NA-A instructed R1 (who was cognitively impaired) not to eat the meat, and left R1 unsupervised to obtain the correct textured meal. NA-A then spoke with the dietary manager (DM) who was in the hall, and explained R1 had received the incorrect textured meal. The DM went to obtain the correct meal, and NA-A returned to the dining room. NA-A observed R1 was actively coughing and choking. The director nursing (DON) was summoned and administered the [MEDICATION(S)] Maneuver multiple times to R1 before she was able to expel large chunks of unground meat. R1 became cyanotic and experienced a short period of apnea (absence of breathing), before the meat was able to be removed. R1 continued to cough and choke and the [MEDICATION(S)] Maneuver was repeated with more chunks of meat expelled. R1 was then transported to the local (ED) for evaluation at 12:20 p.m., and returned at 1:30 p.m. R1 was placed into bed with the head of her bed elevated and continued to experience increasing secretions and upper airway congestion in addition to cyanosis when coughing. MD-B was updated and provided orders to send to a regional hospital for evaluation and possible bronchoscope if the problems continued or it was felt she was declining. At 6:51 p.m., R1 was noted to have increased secretions and was unable to clear on her own. At times she did cough up thick phlegm but was not able to cough on command. R1 received oral suctioning multiple times with little relief. She was positioned on her side to allow the phlegm to drain from mouth, the ambulance was contacted and R1 was transferred to a regional hospital for further evaluation. On 3/7/22 at 7:22 p.m., the facility received a phone update that R1 had been admitted (ICU) on oxygen with a diagnosis of aspiration pneumonia. Observation and interview on 3/28/22 at 3:30 p.m., with Cook-B in the kitchen identified prior to the incident on 3/7/22 the facility had not utilized diet tray cards. Resident trays were dished up and placed onto the numbered shelves of the cart. There was a list of residents with the corresponding room number and diet posted on the inside of the cart door, but no identification on the tray which identified the specific resident the tray was for. Cook-B reported if staff had a question on a diet or food that was on a tray, the only way they had to verify the contents was to ask the cook or a nurse. Directly across from the steam table in the kitchen, notes were taped to the wall listing special diet types, resident allergies, and other reminders the cook would be able to reference if needed. R1's diet was not included in the notes. Cook-B reported R1 had been at the facility a long time and everyone knows her diet needs. Cook-B identified at the time new residents were admitted or there were changes in diet orders, they were posted by the entrance to the kitchen where staff were to review upon reporting for their shift. The notices remained on the board for a week or two and were then taken down and filed in a book that was on a shelf by the door. Following the incident on 3/7/22, the DM had implemented diet tray cards that were printed for each meal and contained the resident's name, room number, diet and choices in addition to any special orders, such as any altered texture, or thickened liquids. The cards were now used by the cook when plating food and immediately placed on the tray containing individual resident food items. It was the responsibility of the dietary aide (DA) to ensure all trays had a card before the cart was taken from the kitchen. Interview on 3/28/22 at 3:14 p.m., with the medical director (MD)-A identified he was in agreement if R1 had been served the appropriate mechanical therapeutic diet verses a regular diet, she would likely not have choked or aspirated. MD-A was unaware the facility did not have a system in place as a safeguard against this type of incident prior to the occurrence. He agreed the facility should have had measures in place, such as utilization of diet cards to ensure residents received their medically ordered diets to prevent choking. Interview on 3/28/22 at 4:00 p.m., with the DON identified she was in her office on 3/7/22 at 12:25 p.m. when NA-H knocked on the door and stated she was needed in the dining room right away. The DON reported she had immediately gone to the dining room and observed R1 seated at a table across the room. R1 was trying to cough and was choking. She rushed to R1 who appeared cyanotic. R1 had a pulse, and then stopped breathing for approximately 30 seconds. The DON told staff to call 911, and performed the [MEDICATION(S)] maneuver several times when a chunk of stringy-textured meat came out of R1's mouth. She began gasping and attempting to speak. R1 was wheeled from the dining room to the hall where she continued to cough, gag and choke. The DON performed the [MEDICATION(S)] several more times with more pieces of meat removed each time. R1 was breathing and able to talk, but sounded congested. Her color became [NAME], but she remained cyanotic around her mouth. EMS arrived and R1 was transported to the local hospital for further evaluation. R1 returned about 1.5 to 2 hours later, but her O2 sats remained in the upper 70's to low 80's. She required staff to suction her mouth frequently due to excessive phlegm that she was not able to cough out. The DON reported she was not comfortable with R1 remaining in the facility with her oxygen levels low, so she contacted R1's primary medical provider. The DON reported she had immediately telephoned MD-B and updated him on R1's condition. MD-B gave orders that R1 should be transferred to a larger regional hospital for further evaluation that was not available locally. The DON contacted the regional hospital and contacted EMS. Later that evening, she was updated R1 had received x-rays and had been admitted to ICU with aspiration pneumonia. The DON identified the cause of the incident as dietary staff served R1 the incorrect consistency meat. The error was not discovered until NA-A delivered and uncovered the meal tray. NA-A removed the meat from R1's plate, and put it in the plate cover which she set on the table in front of R1's meal tray. NA-A instructed R1 not to eat the meat and she would be right back. The DON agreed NA-A left R1 unsupervised with the plate cover containing the chunks of meat within reach, while she went to get the correct consistency meat. While NA-A was gone, R1 attempted to eat the meal and choked. The DON identified R1's cognition was coded as severe due to her inability to communicate. The DON identified her expectation would be for dietary to have plated the correct diet.and NA staff were not to leave incorrect consistency food on the table where a resident could attempt to eat it. The DON agreed there was a potential for harm and or death as a result of being served incorrect diets such as choking and airway obstruction. NA-A received verbal counseling following the incident, but no documentation of counseling and/or coaching was provided. Cook-A was suspended pending the investigation and was allowed to return following re-education on diets and the new system that was put into place. The DON made no mention the facility identified staff delay in administering the [MEDICATION(S)] maneuver to any resident could result in harm or death. R1's current, undated care plan identified R1 had a nutritional problem due to dysphasia. Staff were to ensure she had use of a lip plate, encourage R1 to feed herself as able, and provide assistance as needed. Per speech therapy, staff were to have R1 turn her head to the right with swallowing and instruct her to swallow twice with each bite. It was noted R1 may take up to 10 seconds for second swallowing effort. Staff were to sit with R1 for the first 5-10 minutes of each meal and provide reminders for swallowing, and continue to monitor and encourage R1 throughout the remainder of the meal. Review of the 3/7/22 at 12:16 p.m., local hospital ED report identified R1 was seen due to choking on a piece of meat that was removed after application of the [MEDICATION(S)] Maneuver. R1 was able to breathe but did have increased upper airway secretions. R1 had a weak cough and x-ray identified her lungs appeared clear with no acute infiltrates identified. Discharge instructions included to elevate the head of her bed at least 30 degrees, provide frequent suction to assist with secretions, and follow up with primary provider (MD)-B. If [CONDITION(S)] (low oxygen saturation level(O2 sat)) less than 90%, the ED recommended the facility consult with R1's physician and possibly return to ED for further evaluation. Review of the 3/7/22 at 7:55 p.m., regional hospital ED report identified R1 was able to respond to questions with occasional yes/no, responses but was not able to provide information on her condition. R1 had been transferred to the regional ED due to excessive respiratory tract secretions following a choking episode earlier that day. R1's oxygen level (SpO2) was reported as 82% (normal 92 - 100%) on room air at the time of arrival. Earlier that day, R1 had received a regular texture meal, choked, and required the [MEDICATION(S)] in an attempt to remove the obstruction. R1 was diagnosed with acute hypoxic (lack of oxygen) respiratory failure from the aspiration episode and aspiration pneumonia. The 3/9/22, hospital discharge summary identified R1 had a history of Barrette's esophagus (damage to the lower portion of the esophagus), stroke with [CONDITION(S)], and right sided weakness. R1 had received Speech Therapy since 2020 and was on a mechanical ground diet with thickened liquids. On 3/7/22, R1 had received the wrong meal and had choked with some aspiration. R1 was treated with antibiotics and high flow oxygen therapy and weaned back to room air at the time of discharge. The hospital speech therapy evaluated R1 prior to discharge and recommended a pureed texture diet with nectar thickened liquids. R1's progress notes identified on 3/7/22 at: 1) 12:00 p.m., R1 was in the dining room eating lunch and choked on meat. An unidentified NA ran to get the DON from her office and informed her that R1 was choking. R1 was cyanotic and did stop breathing for approximately 30 seconds. DON administered [MEDICATION(S)] maneuver multiple times with success. R1 continued to have upper airway congestion and coughing and required additional [MEDICATION(S)] attempts. 2) 12:20 p.m., R1 was transported to local ED via ambulance. 3) 1:45 p.m., R1 returned from the ED, a chest x-ray appeared to be clear, but her airway was likely inflamed. R1 was noted to be expected to have increased secretions and require suctioning as needed with the head of her bed elevated to 30 degrees. 4) 5:10 p.m. R1 was noted to be having increased secretions and upper airway congestion. R1 had couple episodes of turning blue. R1's physician (MD)-B was updated and directed staff if R1 continued to have problems, or worsened, she was to be sent to the regional hospital. 5) 6:51 p.m., R1 continued to have increased secretions. She was not able to clear her airway without assistance, and continued to have thick phlegm. She was unable to cough on command. R1 did become cyanotic at times with coughing and was suctioned multiple times with little relief. 6) 5:40 p.m., R1 was transferred to the regional hospital via ambulance. 7) 7:22 p.m., R1 was being admitted with a diagnosis of aspiration pneumonia. Interview on 3/29/22 at 8:30 a.m., with cook-A identified when a resident was admitted to the facility, the kitchen was notified via a paper form of the dietary order and/or any special type or consistency. The form was posted on the bulletin board for a 1-2 week period to allow all dietary staff to review the order. That form was then filed in a binder kept in the kitchen. Diet tray cards were now to be used by the cook as she plated food for the meal service. Cook-A served the noon meal on 3/7/22, and was aware R1's diet was supposed to be mechanical ground with thickened liquids. She stated she did not know what happened or how she had made the error, but she was not aware of the incident until she was telephoned prior to her return for the 3/7/22, evening shift. Following the incident, she had been suspended during an investigation from 3/7/22 until 3/12/22 when she returned to work. She had received education on the implementation of new diet tray cards and education on dietary requirements and acceptable foods allowed for altered diets. Interview on 3/29/22 at 8:40 a.m., with MD-B identified R1 should not have been served the improper diet, NA-A should not have left he plate near her, and immediate intervention should have occurred. The incident had the potential for harm and/or death. R1 had severely decreased cognition and in his opinion likely was not able to understand simple commands. Interview on 3/29/22 at 9:46 a.m., with NA-A identified she was working on 3/7/22. She retrieved R1's tray and placed it in front of R1 and removed the cover. NA-A recognized the diet was not correct, as the meat was cut into pieces and was not mechanically ground. NA-A stated she transferred the meat from R1's plate into the cover, which she placed on the table in front of R1's tray. She instructed R1 to not eat the meat and advised her she would be right back. NA-A left the dining room, and met the DM in the hall. She explained she needed a different meat for R1 that was ground and returned to the dining room where she discovered R1 choking. When she reached R1 she observed R1 had taken the pieces of meat from the cover and was choking. NA-A directed NA-H to get the DON and remained with R1 who she encouraged her to cough up the food. NA-A stated she did not know why she had not removed the meat from the table, but felt R1 would begin eating her other food items until she got back with the ground meat. NA-A realized she should have taken the meat with her and not risked R1, who could and did try to eat it. After the incident, diet tray cards had been implemented and included the resident name, diet, dislikes, and allergies. The card was placed on the tray at the time it was plated. The card remained on the tray with the resident's plate at the table. NA-A stated she had received training on identifying a resident choking and how to respond with the [MEDICATION(S)] maneuver on 3/29/22. NA-A reported Speech Therapy had also provided staff instruction on how to asssit R1 when she was eating following her readmission on 3/10/22. NA-A identified Nursing staff are in the hall passing medications during meals and were to be able to be reached by use of a walkie talkie if they are needed in the dining room for a concern. Interview on 3/29/22 at 11:43 a.m., with the dietary manager (DM) confirmed prior to the incident, orders were posted on the bulletin board for staff review upon entering the kitchen and remained posted for 2 weeks. After that, they were placed into a binder kept in the kitchen. When questioned about diet orders and how staff knew what a resident's diet was, she replied, staff knew the residents and their diets since they served them repeatedly in a small facility. New diet trays were implemented after the incident. The DM agreed there was no method in place at the time of the incident to prevent dietary from accidentally plating the incorrect meal. Review of the International Dysphasia Diet Standardization Initiative (IDDSI) Level 5 Minced and Moist diet identified ground mechanically altered meat to be served finely minced or chopped to 4 millimeter lump size served in a thick, smooth, non-pouring sauce or gravy. The size of the lump of meat was defined as the gap between the prongs of a standard fork. Review of the April 2007, Tray Identification policy identified the Food Services Department was to use appropriate identification to identify diets. The DM or supervisor was to have checked trays for correct diets before they are taken from the kitchen. Nursing staff were to check that each tray contained the correct diet before serving it to a resident. The dietary department was to be notified immediately if there was an error and dietary staff were to immediately provide the correct diet. The immediate jeopardy that began on 3/7/22 at 12:00 p.m. was removed on 3/29/22 at 6:45 p.m., when it was verified by interview and document review the facility reviewed and provided competency on dietary policies and procedures. Both nursing and dietary staff had received education on identifying resident diet cards for trays and ensure the appropriate diet was being provided. All staff also were educated to identify and respond to choking situations and how and when to perform the [MEDICATION(S)] maneuver if necessary.

Based on interview and document review the facility failed to provide a physician ordered mechanically ground diet of meat (pork roast) to 1 of 1 resident (R1). R1 subsequently began choking. Staff also failed to immediately perform the Heimlich maneuver, delaying potentially lifesaving treatment. This resulted in actual harm as R1 required a higher level of care after developing aspiration pneumonia (when food, saliva, or liquids are breathed into the lungs or airway instead of swallowed into the stomach) requiring medical intervention at the regional hospital. The immediate jeopardy (IJ) that began on 3/7/22 at 12:25 p.m., at J-ISOLATED, when the facility failed to provide the appropriate physician ordered altered texture diet (mechanical ground), served R1 whole chunks of meat. Staff identified the meat was the incorrect consistency, however, they had left it within reach of R1, resulting in R1 eating the meat and choking. Staff saw R1 choking, but failed to immediately intervene and perform the Heimlich maneuver as staff waited for the director of nursing (DON) to arrive. R1 was later sent to the regional emergency department (ED) and was later admitted to the ICU for aspiration pneumonia. The administrator and DON were notified of the IJ on 3/29/22 at 2:00 p.m. The facility had implemented immediate corrective action on 3/10/22 to prevent recurrence, therefore, the IJ was issued at PAST NON-COMPLIANCE. Findings include: R1's current, undated diagnoses list identified she experienced a stroke on 12/3/20, which resulted in dysphasia (difficulty swallowing), hemiplegia (paralysis of one side), aphasia (a language disorder that affects a person's ability to communicate), and anxiety disorder. R1's 2/7/22 Significant Change, Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and required supervision with eating. R1's current physician orders identified her diet was to be mechanical ground with nectar thickened liquids. Review of the 3/7/22 at 2:55 p.m., report to the State Agency (SA), identified R1 was reported to have choked on meat. Nursing assistants (NA)'s saw R1 choking and called the DON who was in her office across the hall from the dining room. R1 was noted to be cyanotic (blue in color from lack of oxygen) and stopped breathing for approximately 30 seconds. The DON performed the Heimlich Maneuver multiple times with good results. R1 pinked up and was responding as per her normal. R1 had some upper airway congestion. EMS was called and transported R1 to the local emergency department (ED) for evaluation. Review of the facility investigation documentation revealed on 3/7/22 at the noon meal, nurse aide (NA)-A retrieved R1's tray from the cart, and placed it in front of R1. When she removed the cover, she noted the meat and broccoli were not provided in the physician ordered mechanical ground texture. NA-A picked up the plate, scooped the meat into the cover, and set the cover in front of the food tray. NA-A instructed R1 (who was cognitively impaired) not to eat the meat, and left R1 unsupervised to obtain the correct textured meal. NA-A then spoke with the dietary manager (DM) who was in the hall, and explained R1 had received the incorrect textured meal. The DM went to obtain the correct meal, and NA-A returned to the dining room. NA-A observed R1 was actively coughing and choking. The director nursing (DON) was summoned and administered the Heimlich Maneuver multiple times to R1 before she was able to expel large chunks of non-ground meat. R1 became cyanotic and experienced a short period of apnea (absence of breathing), before the meat was able to be removed. R1 continued to cough and choke and the Heimlich Maneuver was repeated with more chunks of meat expelled. R1 was then transported to the local (ED) for evaluation at 12:20 p.m., and returned at 1:30 p.m. R1 was placed into bed with the head of her bed elevated and continued to experience increasing secretions and upper airway congestion in addition to cyanosis when coughing. MD-B was updated and provided orders to send to a regional hospital for evaluation and possible bronchoscope if the problems continued or it was felt she was declining. At 6:51 p.m., R1 was noted to have increased secretions and was unable to clear on her own. At times she did cough up thick phlegm but was not able to cough on command. R1 received oral suctioning multiple times with little relief. She was positioned on her side to allow the phlegm to drain from mouth, the ambulance was contacted and R1 was transferred to a regional hospital for further evaluation. On 3/7/22 at 7:22 p.m., the facility received a phone update that R1 had been admitted (ICU) on oxygen with a diagnosis of aspiration pneumonia. Observation and interview on 3/28/22 at 3:30 p.m., with Cook-B in the kitchen identified prior to the incident on 3/7/22 the facility had not utilized diet tray cards. Resident trays were dished up and placed onto the numbered shelves of the cart. There was a list of residents with the corresponding room number and diet posted on the inside of the cart door, but no identification on the tray which identified the specific resident the tray was for. Cook-B reported if staff had a question on a diet or food that was on a tray, the only way they had to verify the contents was to ask the cook or a nurse. Directly across from the steam table in the kitchen, notes were taped to the wall listing special diet types, resident allergies, and other reminders the cook would be able to reference if needed. R1's diet was not included in the notes. Cook-B reported R1 had been at the facility a long time and everyone knows her diet needs. Cook-B identified at the time new residents were admitted or there were changes in diet orders, they were posted by the entrance to the kitchen where staff were to review upon reporting for their shift. The notices remained on the board for a week or two and were then taken down and filed in a book that was on a shelf by the door. Following the incident on 3/7/22, the DM had implemented diet tray cards that were printed for each meal and contained the resident's name, room number, diet and choices in addition to any special orders, such as any altered texture, or thickened liquids. The cards were now used by the cook when plating food and immediately placed on the tray containing individual resident food items. It was the responsibility of the dietary aide (DA) to ensure all trays had a card before the cart was taken from the kitchen. Interview on 3/28/22 at 3:14 p.m., with the medical director (MD)-A identified he was in agreement if R1 had been served the appropriate mechanical therapeutic diet verses a regular diet, she would likely not have choked or aspirated. MD-A was unaware the facility did not have a system in place as a safeguard against this type of incident prior to the occurrence. He agreed the facility should have had measures in place, such as utilization of diet cards to ensure residents received their medically ordered diets to prevent choking. Interview on 3/28/22 at 4:00 p.m., with the DON identified she was in her office on 3/7/22 at 12:25 p.m. when NA-H knocked on the door and stated she was needed in the dining room right away. The DON reported she had immediately gone to the dining room and observed R1 seated at a table across the room. R1 was trying to cough and was choking. She rushed to R1 who appeared cyanotic. R1 had a pulse, and then stopped breathing for approximately 30 seconds. The DON told staff to call 911, and performed the Heimlich maneuver several times when a chunk of stringy-textured meat came out of R1's mouth. She began gasping and attempting to speak. R1 was wheeled from the dining room to the hall where she continued to cough, gag and choke. The DON performed the Heimlich several more times with more pieces of meat removed each time. R1 was breathing and able to talk, but sounded congested. Her color became [NAME], but she remained cyanotic around her mouth. EMS arrived and R1 was transported to the local hospital for further evaluation. R1 returned about 1.5 to 2 hours later, but her O2 sats remained in the upper 70's to low 80's. She required staff to suction her mouth frequently due to excessive phlegm that she was not able to cough out. The DON reported she was not comfortable with R1 remaining in the facility with her oxygen levels low, so she contacted R1's primary medical provider. The DON reported she had immediately telephoned MD-B and updated him on R1's condition. MD-B gave orders that R1 should be transferred to a larger regional hospital for further evaluation that was not available locally. The DON contacted the regional hospital and contacted EMS. Later that evening, she was updated R1 had received x-rays and had been admitted to ICU with aspiration pneumonia. The DON identified the cause of the incident as dietary staff served R1 the incorrect consistency meat. The error was not discovered until NA-A delivered and uncovered the meal tray. NA-A removed the meat from R1's plate, and put it in the plate cover which she set on the table in front of R1's meal tray. NA-A instructed R1 not to eat the meat and she would be right back. The DON agreed NA-A left R1 unsupervised with the plate cover containing the chunks of meat within reach, while she went to get the correct consistency meat. While NA-A was gone, R1 attempted to eat the meal and choked. The DON identified R1's cognition was coded as severe due to her inability to communicate. The DON identified her expectation would be for dietary to have plated the correct diet. NA staff were not to leave incorrect consistency food on the table where a resident could attempt to eat it. The DON agreed there was a potential for harm and or death as a result of being served incorrect diets such as choking and airway obstruction. NA-A received verbal counseling following the incident, but no documentation of counseling and/or coaching was provided. Cook-A was suspended pending the investigation and was allowed to return following re-education on diets and the new system that was put into place. The DON made no mention the facility identified staff delay in administering the Heimlich maneuver to any resident could result in harm or death. R1's current, undated care plan identified R1 had a nutritional problem due to dysphasia. Staff were to ensure she had use of a lip plate, encourage R1 to feed herself as able, and provide assistance as needed. Per speech therapy, staff were to have R1 turn her head to the right with swallowing and instruct her to swallow twice with each bite. It was noted R1 may take up to 10 seconds for second swallowing effort. Staff were to sit with R1 for the first 5-10 minutes of each meal and provide reminders for swallowing, and continue to monitor and encourage R1 throughout the remainder of the meal. Review of the 3/7/22 at 12:16 p.m., local hospital ED report identified R1 was seen due to choking on a piece of meat that was removed after application of the Heimlich Maneuver. R1 was able to breathe but did have increased upper airway secretions. R1 had a weak cough and x-ray identified her lungs appeared clear with no acute infiltrates identified. Discharge instructions included to elevate the head of her bed at least 30 degrees, provide frequent suction to assist with secretions, and follow up with primary provider (MD)-B. If hypoxia (low oxygen saturation level(O2 sat)) less than 90%, the ED recommended the facility consult with R1's physician and possibly return to ED for further evaluation. Review of the 3/7/22 at 7:55 p.m., regional hospital ED report identified R1 was able to respond to questions with occasional yes/no, responses but was not able to provide information on her condition. R1 had been transferred to the regional ED due to excessive respiratory tract secretions following a choking episode earlier that day. R1's oxygen level (SpO2) was reported as 82% (normal 92 - 100%) on room air at the time of arrival. Earlier that day, R1 had received a regular texture meal, choked, and required the Heimlich in an attempt to remove the obstruction. R1 was diagnosed with acute hypoxic (lack of oxygen) respiratory failure from the aspiration episode and aspiration pneumonia. The 3/9/22, hospital discharge summary identified R1 had a history of Barrette's esophagus (damage to the lower portion of the esophagus), stroke with aphasia, and right sided weakness. R1 had received Speech Therapy since 2020 and was on a mechanical ground diet with thickened liquids. On 3/7/22, R1 had received the wrong meal and had choked with some aspiration. R1 was treated with antibiotics and high flow oxygen therapy and weaned back to room air at the time of discharge. The hospital speech therapy evaluated R1 prior to discharge and recommended a pureed texture diet with nectar thickened liquids. R1's progress notes identified on 3/7/22 at: 1) 12:00 p.m., R1 was in the dining room eating lunch and choked on meat. An unidentified NA ran to get the DON from her office and informed her that R1 was choking. R1 was cyanotic and did stop breathing for approximately 30 seconds. DON administered Heimlich maneuver multiple times with success. R1 continued to have upper airway congestion and coughing and required additional Heimlich attempts. 2) 12:20 p.m., R1 was transported to local ED via ambulance. 3) 1:45 p.m., R1 returned from the ED, a chest x-ray appeared to be clear, but her airway was likely inflamed. R1 was noted to be expected to have increased secretions and require suctioning as needed with the head of her bed elevated to 30 degrees. 4) 5:10 p.m. R1 was noted to be having increased secretions and upper airway congestion. R1 had couple episodes of turning blue. R1's physician (MD)-B was updated and directed staff if R1 continued to have problems, or worsened, she was to be sent to the regional hospital. 5) 6:51 p.m., R1 continued to have increased secretions. She was not able to clear her airway without assistance, and continued to have thick phlegm. She was unable to cough on command. R1 did become cyanotic at times with coughing and was suctioned multiple times with little relief. 6) 5:40 p.m., R1 was transferred to the regional hospital via ambulance. 7) 7:22 p.m., R1 was being admitted with a diagnosis of aspiration pneumonia. Interview on 3/29/22 at 8:30 a.m., with cook-A identified when a resident was admitted to the facility, the kitchen was notified via a paper form of the dietary order and/or any special type or consistency. The form was posted on the bulletin board for a 1-2 week period to allow all dietary staff to review the order. That form was then filed in a binder kept in the kitchen. Diet tray cards were now to be used by the cook as she plated food for the meal service. Cook-A served the noon meal on 3/7/22, and was aware R1's diet was supposed to be mechanical ground with thickened liquids. She stated she did not know what happened or how she had made the error, but she was not aware of the incident until she was telephoned prior to her return for the 3/7/22, evening shift. Following the incident, she had been suspended during an investigation from 3/7/22 until 3/12/22 when she returned to work. She had received education on the implementation of new diet tray cards and education on dietary requirements and acceptable foods allowed for altered diets. Interview on 3/29/22 at 8:40 a.m., with MD-B identified R1 should not have been served the improper diet, NA-A should not have left he plate near her, and immediate intervention should have occurred. The incident had the potential for harm and/or death. R1 had severely decreased cognition and in his opinion likely was not able to understand simple commands. Interview on 3/29/22 at 9:46 a.m., with NA-A identified she was working on 3/7/22. She retrieved R1's tray and placed it in front of R1 and removed the cover. NA-A recognized the diet was not correct, as the meat was cut into pieces and was not mechanically ground. NA-A stated she transferred the meat from R1's plate into the cover, which she placed on the table in front of R1's tray. She instructed R1 to not eat the meat and advised her she would be right back. NA-A left the dining room, and met the DM in the hall. She explained she needed a different meat for R1 that was ground and returned to the dining room where she discovered R1 choking. When she reached R1 she observed R1 had taken the pieces of meat from the cover and was choking. NA-A directed NA-H to get the DON and remained with R1 who she encouraged her to cough up the food. NA-A stated she did not know why she had not removed the meat from the table, but felt R1 would begin eating her other food items until she got back with the ground meat. NA-A realized she should have taken the meat with her and not risked R1, who could and did try to eat it. After the incident, diet tray cards had been implemented and included the resident name, diet, dislikes, and allergies. The card was placed on the tray at the time it was plated. The card remained on the tray with the resident's plate at the table. NA-A stated she had received training on identifying a resident choking and how to respond with the Heimlich maneuver on 3/29/22. NA-A reported Speech Therapy had also provided staff instruction on how to assist R1 when she was eating following her readmission on 3/10/22. NA-A identified Nursing staff are in the hall passing medications during meals and were to be able to be reached by use of a Walkie-Talkie if they are needed in the dining room for a concern. Interview on 3/29/22 at 11:43 a.m., with the dietary manager (DM) confirmed prior to the incident, orders were posted on the bulletin board for staff review upon entering the kitchen and remained posted for 2 weeks. After that, they were placed into a binder kept in the kitchen. When questioned about diet orders and how staff knew what a resident's diet was, she replied, staff knew the residents and their diets since they served them repeatedly in a small facility. New diet trays were implemented after the incident. The DM agreed there was no method in place at the time of the incident to prevent dietary from accidentally plating the incorrect meal. Review of the International Dysphasia Diet Standardization Initiative (IDDSI) Level 5 Minced and Moist diet identified ground mechanically altered meat to be served finely minced or chopped to 4 millimeter lump size served in a thick, smooth, non-pouring sauce or gravy. The size of the lump of meat was defined as the gap between the prongs of a standard fork. Review of the April 2007, Tray Identification policy identified the Food Services Department was to use appropriate identification to identify diets. The DM or supervisor was to have checked trays for correct diets before they are taken from the kitchen. Nursing staff were to check that each tray contained the correct diet before serving it to a resident. The dietary department was to be notified immediately if there was an error and dietary staff were to immediately provide the correct diet. The immediate jeopardy that began on 3/7/22 at 12:00 p.m. was removed on 3/10/22 when it could be verified by interview and document review the facility reviewed policies, provided staff education and competency on dietary policies and procedures and audited their corrective action.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident's (R4) care plan was followed when staff failed to implement the intervention of use of body pillows beside R4 prior to her fall. This caused actual harm when R4 sustained a nasal fracture and facial sutures. Findings include: R4's 2/26/20, quarterly Minimum Data Set (MDS) identified R4 had severe cognitive impairment. R4 required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. R4's [DIAGNOSES REDACTED]. R2 had 1 fall with major injury on 2/18/20 since the last assessment and was at risk for falls. R4's 6/5/19, Care Area Assessment (CAA) identified R4 was at risk for falls. R4's 2/19/20, report filed to the State Agency (SA) identified R2 was found in her room on the floor next to her bed on 2/18/20. R4 was bleeding from her nose. R4 was transported to the emergency department (ED) for evaluation. R4 was in bed sleeping prior to being found. R4's 2/18/20, ED note identified R2 had a small contusion to the left forehead above the eyebrow, and a small 0.5 centimeter (cm) V-shaped laceration to the bridge of the nose with mild swelling and bruising. A CT scan of her facial bones identified bilateral nasal bone fractures and a non-displaced nasal fracture. R4's laceration on her nose was cleansed and sutured closed. R4's 2/19/20, incident report identified nursing assistant (NA)-A walked past R4's room at 10:30 p.m. on 2/18/20, and found R4 lying on floor next to the bed. R4 was bleeding profusely from her nose, and her nose was turning purple and was swollen. R4 also had a quarter-sized raised area above her left eye. R4's neurological status was assessed. R4 was transferred to the ED for evaluation. There were no witnesses identified. R4's bed was higher then it usually was. A request was made for the facility's investigation notes but no facilty investigation reports were available. R4's 2/24/20, 5-day investigation report submitted to the SA identified R4's care plan and the facilty abuse and neglect policy were reviewed. Interviews with staff identified R4 was assisted to bed at 8:30 p.m. Staff last observed R4 sleeping in bed at 10:10 p.m. At 10:30 p.m., NA-A found R4 on the floor next to her bed. R4 sustained a nasal fracture as a result of the fall. NA-A had not placed R4's body pillows next to the resident in the bed as R4's care plan directed. NA-A was suspended on 2/20/20, until completion of assigned training and education. R4's care plan was updated to increase R4's safety, and the staff education occurred on 2/21/20, regarding R4's care plan. Staff were to keep R4's bed placed next to the wall. Staff were to ensure R4's bed was locked in the lowest position when in bed. Staff also were to place a floor mat next to the bed. Review of R4's 2/24/20, Fall Risk assessment identified R4 was found to be at high risk for falls Review of R4's 2/18/20, incident report identified the interdisciplinary team (IDT) reviewed R4's fall. R4 was found on the floor next to her bed on 2/18/20, at 11:30 p.m. R4's 3/4/20, current care plan identified R4 required total assistance of 2 staff for bed mobility. R4 had fluctuating cognition. R4 required staff to use 2 body pillows to position her body in bed. R4 was at moderate risk for falls. Staff were to ensure the call light was within reach and the bed was to be locked and in lowest position and placed against the wall. Staff were to ensure the body pillows were placed and a floor mat lying on the floor next to the bed. R4 was to use a hip plate call light when in bed. R4's use of body pillows while in bed for movement and positioning had a created on date of 5/16/19 and was a current intervention at the time R4 fell on [DATE]. Review of the undated, nursing assistant care plan included R4 staff were to ensure use of a body pillow, floor mat and were to check R4 every 2 hours. Interview on 3/4/20, at 2:00 p.m. with NA-A identified she was one of the NAs on duty when R4 was found on the floor. R4 fell during change of shift rounding. NA-C was the staff who found R20 lying on the floor when responding to call lights. R4 was not aware of any recent falls out of bed prior to her most recent fall. R4 was not mobile and required assistance of 2 staff to position her in bed. Prior to her fall, staff were required to place pillows on her side to prevent her from rolling out of bed. R4 tended to roll out of bed. NA-A confirmed R4 did not have body pillows placed on her side at the time of fall. Review of the 2/26/20, nurse meeting notes identified staff education was provided regarding R4's fall out of bed. A power point slide was provided and included the fall investigation found R4's pillows were not placed next to her in bed. The pillows could have prevented R4's fall had that intervention been followed. All staff were expected to follow resident care plans. Additionally, the facilty abuse prevention policy was reviewed. Review of the 2/26/20, staff meeting attendance roster identified 12 of 33 staff were not in attendance at the meeting. Interview on 3/5/20, with the director of nursing (DON) identified R4's care plan was not followed at the time R4 fell out of bed. R4 was to have had body pillows on both sides while in bed. After her fall on 2/18/20, her care plan was changed to have the bed placed with one side against the wall. The DON expected staff to follow the care plan. The DON verified 12 staff had not completed the education as described in the nurses meeting note from 2/26/20. 5 of the 12 remaining staff had worked since 2/26/20, who were not present at the meeting and had not been educated prior to thier next shift. Review of the undated, Assessing Falls and Their Causes policy identified the purpose of the policy was to provide guidelines for assessing resident falls to assist staff in identifying causes of falls. Equipment and environmental factors that may have contributed to falls were to be addressed promptly. NA-C was unavailable for interview at the time of the survey.

Based on interview and document review, the facility failed to appropriately assess, and monitor 1 of 1 resident (R1) who had a fall with a head injury resulting in subsequent mental and physical decline leading to his death. The survey resulted in an immediate jeopardy (IJ) that began on 12/9/19, when the facility failed to appropriately assess, monitor, intervene, and notify physician and family after a fall with known head injury with decreased mental status, resulting in the death of R1. The administrator, and DON were notified of the IJ for R1 on 12/24/19 at 12:35 p.m. The IJ was removed on 12/26/19 p.m. at 12:40 p.m., when it could be verified by interview and document review, the facility took steps to remove the immediacy by revising policies and procedures, and educating licensed nursing staff in the event change of condition were to occur with any hospice residents residing at the facility. Non-compliance remained at the scope and severity of G, isolated-actual harm that is not immediate jeopardy. Findings include: Review of the 12/20/19, report filed to the State Agency (SA) identified on 12/09/2019, between 3:00 a.m. and 4:00 a.m., staff heard R1 fall in his room. R1 was found on floor and placed back in bed. R1 hit his head on left side receiving a bruise which was red in color approximately two inches in diameter. R1's family had been notified around 9:30 a.m Upon arrival at the facility, the family found R1 unresponsive, never regained consciousness. R1 passed away on 12/10/2019, at 9:55 pm. The complainant was aware R1 was on hospice care and had orders to do not resuscitate (DNR). The complainant identified had R1 not fallen, he would have not passed away at that time. Interview on 12/23/19 3:10 p.m., with the complainant (C)-A identified she was made aware of the incident until hours later. When family arrived at about 9:00 a.m., R1 was comatose. Family member (FM)-A asked her R1 if ok and never responded. Staff advised family R1 had fallen while self-toileting. R1 had been using urinal, spilled some, and slipped hitting his head. C-A was upset staff took so long to contact family. R1 was receiving hospice care for [MEDICAL CONDITIONS]. The family was not notified by hospice or facility staff of the incident immediately after it occurred. R1 had been cognitive the day and evening before, and had called his family member A (FM)-A to wish her goodnight as he advised her he was going to get ready for bed. C-A was unsure of the events surrounding R1's fall. C-A reported FM-A had asked staff why R1 was never taken to the emergency room (ER). An unidentified nurse stated, He was going downhill for several days anyway. Review of R1's 12/9/19, Incident Report identified R1 fell on [DATE] at 3:15 a.m. while using his urinal. A nursing assistant (NA) heard a loud noise coming from his room. Staff found him lying next to his bed. R1 had hit his head. Neurological (neuro) checks were started. Immediately R1 was assessed to have decreased level of consciousness (L[NAME]). R1 was lethargic and responded slowly to verbal stimuli, and his pupils were sluggish to react (normal is brisk). R1 sustained scrapes and bruising under his right eye, bruising on his left ear, and skin tears to his elbow and left upper arm. R1 was very short of breath (SOB). Immediately after the fall, his oxygen saturation (SpO2) was 46%. Staff took initial set of vitals BP 155/82, HR 110, RR 28. (R1's normal SpO2 were averaging 86-96% prior to his fall.) R1 was very slow to respond and confused. He was able to move all extremities without difficulty. R1 advised staff he had been using his urinal, spilled it and slipped and fell on to the floor. Hospice nurse (RN)-A was notified R1 had fallen. RN-A advised staff to continue with nebulizer treatments to open R1's airways, continue to monitor, and keep the head of the bed elevated. Staff were to urge R1 to use his call light when he needed toileting. There was no mention RN-A was notified of R1's abnormal neuro signs or known head injury. R1 was not taken to the emergency room (ER). R1 was noted to be lethargic, have labored breathing. His mental status was documented as alert but confused. Staff check-marked no injuries post incident. Staff identified predisposing factors to the fall were a wet floor, confusion, incontinence, recent changes to medications or new sedative medication. The report noted the director of nursing (DON) was called on 12/9/19 at 5:55 a.m., FM-A was documented as having been notified at 7:18 a.m., RN-A at 5:55 a.m., and R1's medical doctor (MD)-B was notified at 5:54 a.m. Review of R1's 12/9/19 at 3:15 a.m., SBAR-Change of Condition note identified R1 fell on [DATE] at 3:15 a.m. while using his urinal. A NA heard a loud noise coming from his room. Staff found him lying next to his bed. R1 had hit his head. R1 was on hospice care and his condition had declined with increased SOB. Nursing assessment identified R1 was lethargic and slow to respond to staff and more confused. Staff documented they were awaiting a response from MD-B as they had faxed him regarding R1's fall but had not heard back yet. They would continue to do neuro checks and monitor his condition. Staff documented no level of urgency on the form as they were indicated to do. There was no mention R1's family had been called to identify if they wanted R1 sent to the ER immediately after the incident. Review of the time-stamped 12/9/19, fax to R1's primary care physician (MD)-B was 8:08 a.m., almost 5 hours after the incident occurred. Interview on 12/23/19 at 3:10 p.m., with FM-A identified she had not been called at the time of the incident and was not notified until over 4 hrs. later. She unaware R1 had declined. When she arrived at the facility at approximately 9:00 a.m., R1 was completely non-responsive. FM-A felt she should have been notified of R1's fall immediately. She would have like him to have been evaluated at the ER. This was not a result of the [MEDICAL CONDITION], but a direct result of the fall. He could have lived longer. R1's 11/29/19, admission Minimum Data Set (MDS), identified R1 had intact cognition, only required supervision with oversight or cueing for transfers, walking in his room and toileting. R1 was always continent of urine. R1 was administered antianxiety medication, antidepressants, and diuretics (water pills to assist with urination). R1 was receiving hospice, and had desires and expectations to return to the community. R1's Care Area Assessment (CAA) identified he triggered for falls. R1 had [DIAGNOSES REDACTED]. R1 required O2 therapy via continuous positive airway pressure ([MEDICAL CONDITION]). Review of R1's Medication Administration Record [REDACTED] 1) Duloxetine (antidepressant) related to pain in his lower leg. 2) [MEDICATION NAME] (water pill) for [MEDICAL CONDITION]. 3) [MEDICATION NAME] (water pill) for [MEDICAL CONDITION]. 4) [MEDICATION NAME] (antianxiety) twice daily. 5) [MEDICATION NAME] (inhaler medication) for [MEDICAL CONDITION], [MEDICATION NAME] (neuroleptic used to treat pain), 6) Duo-neb ([MEDICATION NAME]/[MEDICATION NAME]) inhaled nebulizer (neb) treatments 4 x daily for [MEDICAL CONDITION]. 7) [MEDICATION NAME] (pain medication) 0.5 milliliters (ml) by mouth every 4 hours for pain and comfort care (given in the overnight hours of midnight and again at 4 am). 8) [MEDICATION NAME] neb every 2 hours as needed for SOB. R1 received a neb treatment on 12/8/19 at 6:30 p.m. prior to his fall, and had not received any additional treatment until 12/9/19 at 9:35 a.m., even though staff reported R1 was SOB after his fall. Review of R1's printed 12/24/19, care plan active at the time of his admission, identified he used [MEDICAL CONDITION] medications related to an end stage disease process ([MEDICAL CONDITION]) as evidenced by air hunger. R1 received hospice services and preferred to spend his day visiting with his spouse who was there much of each day. Staff were to call hospice when new medication was needed or R1's condition changed. There was no mention staff were to call R1's family or physician with changes. Review of R1's 12/9/19, Neurological Flow Sheet identified staff began neurological (neuro) checks at 3:15 a.m. The neuro checks showed: 1) Between 3:15 a.m. and 4:00 a.m., R1 was lethargic and responded slowly to staff. His pupils were sluggish to respond. At 3:15 a.m., R1's vital signs (blood pressure (BP), heart rate (HR) and SpO2 were abnormal. His BP ranged 136/75 to 155/82 millimeters of mercury (mm/hg) (normal 120/80), HR ranged from 95 beats per minute (bpm) to 110 bpm (normal 60-100), and his SpO2 ranged from 46% to 53% (R1's normal was 88-96%) during that time. 2) On 12/9/19 from 4:15 a.m. on through 12/10/19 at 5:15 p.m., R1 was reported to vary from conscious and awake to lethargic and responding slowly, then asleep during the last 2 entries of 9:15 p.m. and 1:15 a.m., where staff had not woken R1 to assess his neuro status. His BP ranged from 146/73 mm/hg trending down to 124/56 mm/hg. His SpO2 had increased from 67% up to 93% with oxygen via [MEDICAL CONDITION] during that time. The flow sheet denoted on the top right corner staff were to notify the medical doctor (MD) immediately if there were signs or symptoms of intracranial pressure, such as difficulty speaking or a change in the level of alertness. R1's progress notes identified on: 1) 12/8/19 at 4:06 p.m., RN-A had been to the facility to visit R1. R1's wife was in attendance. R1 had increasing periods of SOB, with some relief from nebulizer treatments. There was no indication R1 had any L[NAME] changes at that time. 2) 12/9/19 at 3:15 a.m., R1 fell next to bed. A NA heard R1 fall and found him lying on his left side on the floor next to his bed. R1 had hit his head. Neuros were started. R1 had been sitting up in bed using his urinal, spilled the urinal and slipped on urine on the floor. R1 was on hospice and had been declining with increased SOB. R1's vitals at the time of the fall were BP 155/72 mm/hg, HR 100 bpm, and SpO2 46% on 4 liters of oxygen via [MEDICAL CONDITION]. R1 hit his head and neuros were started. R1 had a small abrasion and bruise under his right eye and bruising on his left. R1 was lethargic and slow to respond and was more confused. MD-B was faxed regarding the fall and RN-A was called. Staff were told by RN-A to elevate R1's head of his bed and to continue to give nebulizer treatments while awake. Staff were to remind R1 to use his call light when needing assistance with his urinal and to keep his gripper socks on when in bed. There was no mention family or the ER was called, nor had staff identified abnormal vitals as potential head injury complications. 3) 12/09/19 at 6:30 a.m., R1 was sitting on the edge of his bed using his urinal, unable to sit up on his own. R1 had voided a large amount of urine. His color was dusky (dark) and his SpO2 was 72% with O2 at 4 liters per minute, per nasal cannula. R1 refused breakfast. Staff applied his [MEDICAL CONDITION] mask and his SpO2 rose to 92%. At 10:00 a.m., RN-A was notified of R1's condition and his wife was called and updated. At 10:00 a.m., RN-A was at the facility and FM-A was there to visit. R1 refused lunch, had difficulty swallowing, and confusion was noted. R1 had been in bed all day and repositioned per staff. 4) 12/10/19 at 6:27 a.m., Post fall: R1 had been quiet all night. He received [MEDICATION NAME] per order. SpO2's were 90% via mask. 12/10/19 at 7:48 p.m., R1 had been resting comfortably in bed all day. Non- responsive. R1 had been taking nothing by mouth (food or medication). Staff were unable to insert a urinary catheter after multiple attempts that day. R1 had moderate amounts of secretions coming out of his mouth and nose several times that day. Staff started Tylenol for pain and were to continue to monitor. There was no mention what the secretions were or if staff had identified if they were related to his head injury. 5) 12/10/19 at 10:08 p.m., R1's vital signs ceased at 9:55 p.m A call was placed to family and hospice. There was no mention MD-B had been notified of R1's decline after his fall up to the point of his death. Interview on 12/24/19 at 8:20 a.m., with MD-B's clinic registered nurse (RN)-B identified if a resident fell the facility would normally send a fax alerting whichever clinic provider had oversight of the resident, notifying them of a fall with no injury. The clinic's after-hours number was answered by the local hospital ER, and was to be used for any incidents or injuries after hours or urgent needs by residents. The faxed notifications were to be used only to notify the physician for routine concerns. RN-B remembered the fax received regarding R1. There was no indication R1 had sustained any injuries after his fall. The facility's expected process was to call the after-hours number for a fall with a head injury. MD-B was unavailable for interview at that time as he would not be resuming work until after the holidays. A message was left requesting MD-B to call back. No call was received after the survey from MD-B. Interview and document review, on 12/24/19 at 9:00 a.m., with licensed practical nurse (LPN)-A identified she had worked the day shift on 12/10/19, and began her shift at 6:00 a.m. that day. She was made aware of R1's fall and had reviewed the assessment data on the neuro sheet. She notified family via telephone after report, sometime around 7:30 a.m. on 12/9/19. LPN-A had also sent a fax to R1's primary physician, MD-B. She verified the time on the fax to be the time she had sent the faxed notification. LPN-A had reviewed R1's neuros recorded on the flow sheet that morning at the beginning of her shift and had contributed to the assessments thereafter. She identified R1 had abnormal neuro check data. She agreed looking back at the neuro flow sheet, his neuro data was consistent with a head injury and signs and symptoms of head trauma. LPN-A verified there was no call made to the after-hours clinic for MD-B, which was forwarded to the ER, to identify if R1 should be seen for treatment for [REDACTED]. FM-A was not notified of R1's change of condition until approximately 7:18 am, per documentation when LPN-A called. MD-B was never updated to R1's declining condition after fax notification had been sent. LPN-A identified she had not felt R1's mental status changes or level of alertness would be urgent to intervene because he was on hospice. The hospice nurse made all the decisions. Hospice drives the care. They tell us what to do. LPN-A identified the facility procedure for a patient on hospice was to notify hospice for anything that happened with a hospice resident. Hospice was to call the MD and family at their discretion and advise facility staff what steps to take. LPN-A identified she had not called theER on ce she was made aware of his abnormal neuros, as hospice already knew about the situation. The night nurse (LPN-B) had advised her she called hospice and they dictated to facility staff what measures were to be taken. LPN-A knew R1 was on hospice for [MEDICAL CONDITION]. He fell after he slipped in his urine. When LPN-A was asked if the fall would be related to [MEDICAL CONDITION] exacerbation, she replied No. He fell because he slipped. LPN-A stated, had R1 not been on hospice, she would have called the after-hours number to see what direction staff should take with a R1's care. Interview and document review on 12/24/19 at 9:38 a.m., with the hospice nurse (RN-A) identified she was notified of R1's fall approximately ½ hr. after the incident. The incident report identified staff had documented she was not notified until 5:55 a.m RN-A thought that may be when staff documented the notification into the electronic form and was not accurate. She was advised R1 had fallen but not of his head injury. She was advised R1 had slipped on urine and fell . RN-A advised LPN-B to make R1 comfortable, provide oxygen and elevate the head of his bed. Staff were to notify her with any new changes. RN-A expected the facility to call the family and physician. Not knowing details of an incident, RN-A stated it would be impossible to accurately depict the events surrounding R1's fall. RN-A had no idea R1 had hit his head and was not informed of that by LPN-B. Had she been informed, she would have come to the facility right away to assess R1. She was not allowed access to facility incident reports on a routine basis to assist with root cause analysis for appropriate care planning and treatment. She was unaware of the neuro assessments that had been performed. RN-A agreed R1 had changes in his level of consciousness that could be contributed to head trauma. She agreed there was no indication in R1's medical record to support his fall and subsequent death was related to a sudden exacerbation of R1's [MEDICAL CONDITION]. Review of the (MONTH) (YEAR), Hospice Services agreement, identified hospice was to assume full responsibility for professional management of terminal care. The facility was to provide care to each hospice resident to keep him reasonably protected from accident or injury. Facility staff were to call hospice immediately if they observed a significant change to the resident's physical and mental status, or clinical complications that suggest a need to alter the plan of care, a life threatening condition, or the need to transfer the resident. Interview and document review, on 12/24/19 at 11:04 a.m., with the director of nursing (DON) identified if a resident is on hospice care, hospice decides what care that resident was to receive. She was unaware of R1's neuro changes and immediately after the fall. R1 had been slowly declining related to his [MEDICAL CONDITION]. She agreed his SpO2's immediately leading up to the fall were 88-96% and fell to 46% after the fall. Nursing staff's assessment of changes in neuros were consistent with head injury. She was aware of the notation on the Neuro Flow Sheet directing staff to immediately call the physician with signs and symptoms of L[NAME] changes. In R1's case, he was a hospice patient so she had expected staff to call hospice to identify what measures were to be taken. Nursing was to contact the after-hours number linked to the ER for all other patients. She was not aware the family had not been called, nor that hospice had not been advised of R1's head injury. She was unaware MD-B had not been called as indicated, but had been faxed hours later at 8:-08 a.m., per timestamp from the fax machine. After review of the information, the DON agreed she would expect staff to follow facility policies for non-hospice related incidents, such as falling after slipping on urine. The DON and interdisciplinary team reviewed all falls daily and bi-weekly. That information was to have been brought to Quality Assurance Performance Improvement (QAPI) during the last meeting on 12/12/19. She cannot recall if R1's fall had been discussed in depth. In review of the QAPI meeting minutes, she could not identify R1's fall had been documented as discussed. She could not recall any measures formulated by QAPI regarding R1. Interview on 12/24/19 at 11:30 a.m., with the medical director (MD)-A identified he had no knowledge of R1's fall. To his knowledge, that was not discussed at the QAPI meeting on 12/12/19, nor was he notified after the fall. No falls were discussed at QAPI related to R1 that either he, or his wife, who attends meetings with him, had any knowledge of. The MD agreed a fall related to slipping on urine on the floor with no documented decline in L[NAME] or [MEDICAL CONDITION] exacerbation symptoms hours before the incident, would lead him to believe the fall was not caused by R1's [MEDICAL CONDITION] hospice diagnosis. R1's immediate L[NAME] changes and decline could be contributed to the fall itself related to head injury. His expectation was staff should have followed all policies and procedures and sent R1 to the ER for evaluation for head injury with L[NAME] changes. Review of the 12/12/19, QAPI Meeting Agenda identified MD-A, the DON, and the administrator were present as well as other members. Discussion of falls identified 8 of 20 falls happened with 1 repeat fall upon waking or going to bed. 4 falls were with a repeat fall who has been declining. Medications were reviewed and changes were made for that resident. 3 falls were isolated incidents. 2 falls were from 1 resident self-transferring from a recliner to the wheelchair. There was no mention of R1's fall or subsequent death identified in the QAPI meeting minutes as a fall for R1 who slipped on urine resulting in head injury and subsequent death. Interview on 12/24/19 at 2:38 p.m., with LPN-B identified she was working the night R1 had fallen. A nursing assistant (NA) heard R1 fall. R1 had toilet himself using a urinal and had slipped and fell on spilt urine hitting his head. R1 was able to use the urinal himself. Staff only emptied it after he was finished. LPN-A indicated R1's L[NAME] earlier that evening before he went to bed, was normal. She agreed he had L[NAME] changes after the fall consistent with documented assessment. LPN-B believed she advised RN-A R1 had received a head injury, but had not documented what RN-A had been notified of in her notes. R1 was on hospice, so any injuries or changes of condition were to be handled by hospice to drive care. Normally, for non-hospice patients, she would have called the after-hours number to alert medical staff at the hospital of the events surrounding an incident. LPN-B had not called MD-B. She thought staff had sent a fax. She agreed L[NAME] changes directly after a fall were indicative of potential head trauma. Facility procedure identified hospice was to identify what measures were to be taken, if any. Hospice was responsible to call family and the provider. She was aware of the notation to call the provider on the Neuro Flow Sheet for signs and symptoms of abnormal neurological status. LPN-B perceived this to not apply to any hospice patients. The IJ was removed on 12/26/19 p.m. at 12:40 p.m., when it could be verified by interview and document review on 12/26/19 between 10:00 a.m. and 12:40 p.m. the facility revised policies and procedures, educated licensed nursing staff on how to identify a change in condition and whom to contact when this occurs. The immediacy was removed and non-compliance remained at the scope and severity of G, isolated-actual harm that is not immediate jeopardy. Review of the current undated, current Falls Clinical Protocol policy identified nursing shall assess, document and report vital signs, recent injury especially a head injury, change of condition (COD) or L[NAME], and neuro status. Staff with physician guidance, were to follow up on any fall associated fall with injury until the resident was stable and delayed complications, such as fracture or brain bleed had been ruled out or resolved. Review of the current undated, Change in a Resident's Condition or Status policy identified the nurse supervisor or charge nurse were to notify the physician or on-call physician when there had been an accident or incident involving the resident, a significant change in a resident's physical and mental condition, and the need to alter treatment or transfer to the hospital. Unless instructed by the resident, the nursing supervisor or charge nurse were to notify the resident's family of any incident that results in injury, when there was a significant change in physical or mental status, or if it was necessary to transfer the resident to the hospital.

Based on interview and document review, the facility failed to ensure a system to identify a residents's physician orders [REDACTED]. The facility's lack of ensuring accurate advanced directives resulted in an Immediate Jeopardy (IJ) placing potential for serious harm, injury or death for R6 in the event their heart stopped beating and breathing ceased and had not received emergency life sustaining treatment. In addition the facility identified R5 and was also at risk by inaccurate information in each resident's medical record related to inaccurate advanced CPR directives. The Immediate Jeopardy (IJ) began on [DATE], when R6 changed his wishes from do not resuscitate DNR to CPR on his POLST. These changes were not updated in the EMR nor were they addressed on R6's care plan, orders, or face sheet. The administrator and director of nurses (DON) were informed of the IJ at the level J (isolated) on [DATE] at 3:04 p.m The IJ was removed on [DATE], at 3:00 p.m., but non-compliance remained at an isolated level of no actual harm with potential for more than minimal harm (Level D). Findings include: R6's face sheet, undated, identified R6 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. R6's quarterly Minimum Data Set ((MDS) dated [DATE], identified cognitive assessment could not be performed as R6 was non-verbal. R6's physician documentation dated [DATE], identified R6 as being able to indicate through shaking his head or hand gestures, or yes or no answers. R6's POLST dated [DATE], was signed by the court appointed guardian and the nurse practitioner on [DATE], indicating their agreement of R6 wanting to change his code status from DNR to CPR. R6's physician orders [REDACTED]. R6's current care plan ----date---- made no mention of current or past advanced directives. During interview on [DATE], at 6:31 p.m., licensed practical nurse (LPN)-D identified if a resident require life-threatening intervention, staff would review information identified in the dashboard section of their EMR, auto-populated by staff updating the EMR when orders were inputted into the EMR upon admission or if there were changes to code status. During interview on [DATE], at 6:33 p.m., with trained medication aide (TMA)-B revealed if a resident coded I would alert licensed staff by looking up code status on the resident's EMR face sheet. She felt confident in saying, I know who is and who is not full code without verifying the information, however. During interview on [DATE], at 7:10 p.m., with LPN-A revealed a resident current code status would be identified in the dashboard of their EMR. LPN-A reviewed R6's code status and stated he was a DNR. That was the quickest and easiest way staff could find a resident's code status. After reviewing the discrepancies of R6's POLST and EMR, LPN-A agreed R6 was in fact CPR status, not DNR, and R6 would have not received CPR if a life-threatening emergency arose. During interview on [DATE], at 7:17 p.m., with registered nurse (RN)-A revealed she would check code status on Dashboard or under the residents orders in case of an emergency. During interview on [DATE], at 7:42 p.m., with SW-designee indicated if a resident requests a change in Advance Directives she is the person responsible for obtaining the corrected POLST. Nursing was responsible for making changes to the medical record (orders, face sheet, dashboard). Furthermore, she identified the MDS nurse was present at care conferences and would be aware of any changes in advanced directives. During interview on [DATE], at 8:13 p.m., the director of nursing (DON) stated it was her expectation staff were to reference code status in the EMR or the POLST in the residents chart to determine advance directive status. The POLST should match the EMR and should be updated promptly at the time a POLST was changed. At 8:15 p.m. the DON updated R6's EMR but did not update R6's face sheet in the paper record. During interview on [DATE], at 10:52 a.m., with R6 was unable to verbalize his answers due to his [MEDICAL CONDITION] but could nod his head up and down indicating yes when asked if he remembered when he changed his code status, and if he wanted CPR in case of a life-threatening emergency. During interview on [DATE], at 11:48 a.m., with R6's court-appointed guardian (CAG) stated while at a care conferences R6 was able to make his needs known regarding advanced directive status. R6 decided he wanted to change his DNR status to CPR. Although R6 was not verbal, he is in a good frame of mind I agreed with the change and signed the POLST. The CAG identified Tribal Court also reviewed the change and the judge agreed with R6's decision to have CPR. During interview on [DATE], at 11:12 a.m., the administrator identified the facility looked through other resident's charts and identified 2 other residents found to be at risk to not receive CPR. The administrator agreed the following residents records were inaccurate and could cause CPR not to be performed: R5's face sheet, undated, revealed she was admitted in (MONTH) (YEAR), with a [DIAGNOSES REDACTED]. A new POLST was signed by NP-I on [DATE] identifying CPR was to be performed in case of an emergency. R5's current care plan made no mention of current or past advanced directives. During interview on [DATE], at 10:49 a.m., DON stated if there were medical changes, the nurse would be expected to make the changes to the EMR. The DON indicated there was no follow up plan to ensure this had taken place. The medical director and nurse practitioners NP-I were contacted on [DATE], but did not return a call. The IJ was removed on [DATE], at 3:00 p.m., when it could be verified through observations, document review and staff interview, the facility had educated all staff on advanced directives. Review of the advanced directives policy, dated [DATE], revealed all directives can be changed per resident choice and chart, EMR, and (the resident's) face sheet must all be updated. Nursing is to contact the attending physician to obtain appropriate orders for all advanced directives. Review of the facility undated Emergency Procedure- CPR revealed if an individual/resident/visitor or staff member is found unresponsive and not breathing, a licensed staff member certified in CPR/Basic Life support (BLS) shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external Defibrillation (shock) exists for that individual or there are obvious signs of irreversible death.

Based on observation, interview and document review, the facility failed to provide adequate supervision and interventions to prevent verbal and physical altercations between residents resulting in potential for serious harm and injury for 1 of 1 resident (R50) reviewed for intrusive wandering behaviors which resulted in escalating resident to resident altercations in the facility's locked South Dementia Unit The immediate jeopardy (IJ) began on 02/08/17 related to 13 separate incidents of resident-to-resident verbal and physical aggression, and one incident of visitor physical aggression which occurred to R50 while residing on the facility locked South Dementia Unit. The incident reports from 1/20/17 to 5/14/17 identified verbal and multiple instances of physical aggression occurred between other residents and R50, which resulted in R50 being struck by a housekeeping wet floor sign, PVC pipe game piece and received a skin tear from other resident who resided on the locked South Dementia Unit. At 5/25/17 at 5:25 p.m., the administrator, director of nursing (DON), social services, and nurse consultant (NC) were informed of the IJ for R50. The immediate jeopardy was removed on 5/26/17. The facility will remain in non-compliance at a lower scope and severity level, of no more than minimal harm and isolated scope, level D. Findings include: R50's medical [DIAGNOSES REDACTED]. R50's significant change Minimum Data Set ((MDS) dated [DATE] identified R50 had severe cognitive impairment and continuous behaviors of disorganized thinking and inattention, with behaviors identified as not directed towards others (pacing, disrobing in public, rummaging, etc ). The assessment identified these behaviors did not occur daily, but 4 to 6 times during the assessment period. The impact was not identified as having placed the resident at significant risk for illness or injury. The behavior was not identified as placing others at a significant risk for physical injury, nor was it identified as intruding on the activities or privacy of others. R50 was dependent upon staff for all activities of daily living. During observation on 5/23/17, at 8:26 a.m. R50 was noted to be down on all four extremities, crawling on his hands and knees and picking at items on the carpet. The resident was not wearing shoes and socks at this time. Staff who were in the area just walked by and did not encourage or direct resident to place his shoes or sock on. During interview, at this time, trained medical assistant (TMA)-A stated R50 will remove shoes and socks if staff attempt to replace them, so they do not make any attempts to do this anymore. During observation on 5/23/17, at 2:01 p.m. R50 was walking up and about the hallway of the locked unit on South, pacing back and forth between other resident room, the housecleaning cart, and the exit door. R50 entered another residents room, R14, where housekeeping was cleaning and exited again. R50 then proceeded to the housekeeping cart and began to fidget with the locked lid, and then proceed to wander about the facility. During interview on 5/23/17, at 2:06 p.m. housekeeping staff (HK)-A stated they were unaware of what should be done for R50 who wandered the locked dementia unit, and stated, they were a new employee. On 5/24/17, at 11:31 a.m. R50 was brought to the table by TMA-A and immediately started removing milk and dessert from other residents places at the table. TMA-attempted to get R50 to sit down at the table and eat but R50 continued to take others food. R50 was provided with a cheese stick and sandwich for ease in eating and exited the dining room, began walking down the hallway with food in his hand. On 5/24/17, at 12:11 p.m. R50 was observed ambulating about in the dining room, and proceeded to move R31's walker away from the table. R31, who had been seated at the table, stood by the table, moved the walker away from R50 and placed dinner plates and beverage out of R50's reach. R31 was speaking to R50, with brows furrowed, and eyes glaring. TMA-A intervened at this time and escorted R50 out of the dining room. While out in the hall at 12:18 p.m. with TMA-A. R50 went to R47 and attempted to smooth her sweater by touching her shoulders. R47 began yelling out loudly and harshly, Don't take my clothes off! TMA-A intervened and redirected R50 to the dining room and assisted R47 to her room. During interview on 5/25/17, at 9:09 a.m. registered nurse (RN)-A reviewed recent medication usage of resident and noted resident had received an injection of Haldol 10 mg (a tranquilizer used to calm anxiety and behaviors) on both 5/15/17 and 5/19/17. R50 had received Haldol 2 mg by mouth on 5/23/17 and 5/24/17. RN-A stated R50 has been sleeping better at night and eating better but the largest concern was R50's behavior of being intrusive with other residents. RN-A stated R50 will take juice and other items from residents seated in the dining room, and attempt to intervene when this occurs. The activity level in the afternoon seems to correlate with R50's increased agitation and does not respond well to loud noises. During this conversation, R50 wandered into another residents room at 9:26 a.m Staff entered and redirected R50 out of room. R50 promptly ambulated to the next resident room and staff again entered and escorted R50 out of the other residents room. During observation on 5/25/17 at approximately 9:30 a.m., R50 walked into the dining room where other residents were finishing their breakfast meal. He suddenly stopped in the middle of the room, knelt down, and sat on his knees. Staff entered the room, and walked around R50, along with other residents while R50 remained sitting on the floor. NA-F gave R50 a glass of water while he sat on the floor. NA-F did not encourage him to stand up even though he was in the middle of the floor. After a few minutes, NA-F asked R50 to stand up, and after a few requests R50 complied, stood up and continued walking out of the dining room. During interview on 5/25/17, at 1:06 p.m. with R50's primary care provider medical doctor (MD)-A stated the resident exhibited pacing behaviors and was enrolled in Rice Hospice. MD-A thought the behaviors were better managed at this time, but was unaware of R50's behavior of kneeling on floor or sitting on the floor. MD-A stated at the present time the Hospice and nursing home staff were working on medication and other interventions. During interview on 5/25/17, at 1:29 p.m. the activities director (AD) stated R50 has been known to enter other's space, hanging near them, holding onto their chairs, etc . The AD stated at times, other residents will yell at him. Staff monitor for this and intervene when needed. The AD identified interventions include one to one interactions, offering of foods, diversion of attention. The other residents will sometimes speak negatively towards R50, for example; Knock it off!, Stay away! and That's not yours!. During interview on 5/25/17, at 1:38 p.m. NA-A identified R50 can get aggressive and will try to grab the tables and move/adjust them. When R50 grabs the tables, chairs, and other's walkers other residents will often yell at R50. At times, R50 will cease the behavior, but other times he continues. NA-A stated other residents get upset if R50 wanders into their room, They get after him. The other residents will yell Get out! or Get that man out!. NA-A stated R50 does react, at times by holding the hand rails, and at other times he has nonsensical verbalization towards others. NA-A stated some female residents have raised their arm and fist towards him and wanders into the area where they are seated. R31 has moved her walker towards him in attempts to hit R50 with her walker. NA-A stated R50 exhibits continual wandering behaviors, and may enter other residents rooms when staff are assisting other residents and are unavailable to redirect. NA-A stated resident R28, has raised her fist to R50, and commented, I'll get you! I'll knock your nose when R50 was wandering near the table where R28 was seated. During interview on 5/25/17, at 1:49 p.m. RN-B stated R50 has auditory and visual hallucinations because he frequently picks up items unseen by others and moves them around. RN-B stated medication changes were reviewed and discussed the benefit of change in Seroquel versus utilizing Haldol to benefit the hallucinations. R50 was started on Haldol 1 mg as needed twice daily for delusional disorders on 2/9/17. R50's Seroquel was changed on 3/29/17. R50's current Haldol orders, effective 5/9/17, was 10 mg injection as needed for uncontrolled behavior which does not cease. The physician is to be notified when used. R50 also has a current order for Haldol 2 mg sublingually (under the tongue) every hour as needed for agitation. The order identified R50 is to receive no more than 10 mg per 24 hour period. RN-B stated the most notable distressing behavior R50 has displayed was removal of clothing. Staff try to meet his needs and offer gentle guidance. Other residents see R50 approach and they start to yell at him and his behaviors wind up. RN-B stated everyone is used to R50's exhibiting behaviors They kind of feel this is the normal. Moving the tables and rearranging the furniture throughout the night was not normal behavior of residents. R50 will also suddenly kneel on the floor, and then crawl around on all four extremities. RN-B stated staff try to interact with him but R50 is generally set in what he is doing. As long as he is not intrusive to others or endangering others, or himself, we kind of let him be. Review of the facility incident reports from 1/20/17 to 5/14/17 identified the following: 1/20/17: Time of incident 1845 (6:45 p.m.). R31 was observed yelling at R50 and swinging a sweatshirt at R50. R50 began to swing his fists at R31 and made contact with forearms. There was no noted injury with their altercation. Causal factors identified was R50's cognitive impairment. Interventions implemented included Residents separated. Continue to follow current care plan for both residents. Continue to engage residents with activities. Redirect those during verbal altercations to avoid physical altercations. The document provided recommendations/interventions taken to prevent recurrence: Activities, redirection, one to one interactions. 2/8/17: Time of incident: 0730 (7:30 a.m.). R50 was moving the table R46 was sitting at. R46 Yelled at (R50) to stop. Dietary staff witnessed R46 and R50 hitting each other in the torso with their fists. No injury noted to either resident. Causal factors included; resident restless, pacing, moving furniture. Recommendations: R50 was redirected out to the hallway, away from other residents. 2/8/17: Time of incident; 1600 (4:00 p.m.). R50 entered the room of R36 and was instructed by R36's visitor to leave the room. R50 proceeded forward, swinging at the visitor, striking him 3-4 times. The visitor defended themselves and made contact with his closed fist to R50's abdomen. R50 then walked away. Causal factors identified R50 had a history of [REDACTED]. R50 had severe cognitive impairment and wandered within the unit. Recommendations to prevent reoccurrence were to send R50 to ER (emergency room ) for evaluation. The interventions currently in place are identified as follows: *Explain what you are going to be doing before providing care. *Please don't have me near others that I disturb. *Help me to avoid situations or people that are upsetting to me. *Let my physician know if my behaviors are interfering with my daily living. Plan to prevent reoccurrence included to continue with care plan for resident. The emergency room (ER) provider notes from Renville County ER dated 2/8/17 identified R50 was seen in ER for aggressive behavior on two occasions. Upon evaluation in ER, resident was given a Haldol 10 mg injection and remained in the ER while awaiting transfer to Meeker Memorial Hospital Behavioral Health Unit. On the morning of 2/9/17, R50 was cooperative and returned to the nursing home instead of being admitted to the behavior health unit. Discharge instructions identified : Continue present medication. Haldol 1 mg BID (twice daily) PRN (as needed) for agitation. Follow up with PCP (primary care provider) this week. There was no indication, in the record the facility had contacted the primary physician to follow up after the 2/8/17 emergency room visit. Review of the medication administration record identified R50 received 2 oral doses and 2 intra muscular injections of Haldol in May 2017, for agitation and pacing behaviors which were effective. The facility had not completed an assessment of R50's behaviors, to determine appropriate interventions, and rational for the continued use of the Haldol medication. 2/15/17: Time of incident: 0330 (3:30 a.m.). R50 was up at this time and wandered into the room of R25. R25 yelled at R50 to get out. No injury or physical altercation at this time. R50 was redirected from room of R25. Causal factors identified R50 had the [DIAGNOSES REDACTED]. Recommendations to prevent reoccurrence included to redirect R50 as needed if wandering into other's rooms. 2/15/17: Time of incident: 1500 (3:00 p.m.). R50 was walking with the wet floor housekeeping sign and R31 took the sign away from R50 and struck R50 on the back. No injuries were noted. Causal factors identified: dementia, delusional, depression. Specific recommendations identified included: *Redirection *Activities No incidents were noted in the month of March 2017 4/15/17: Time of incident: 1400 (2:00 p.m.). Staff heard R44 yelling at R50 to stay away from her. R50 was holding R44's right arm, and pulling on it. R44 received a skin tear to her right arm. Skin tear measurements were not identified. Causal factors were R44 was seated near the independent activities supplies which R50 enjoys. Staff proceeded to separate residents. Care plan interventions outlined: *Please re-direct me when I wander into other rooms or areas that are unsafe for me. *Help to avoid situations or people that are upsetting to me. *Allow resident to walk throughout the secure unit at will. *Provide normalized programming based on patient assessment and interests. *Resident likes to fix things. *Staff will assure safety and allow resident to work on things. *Will sit at times to watch TV in the day room (Price is Right, Let's Make a Deal, and westerns). *At times will stand next to a group but just likes to observe. *At times will walk with his snack. Finger foods work best. *Staff training is on going. *Residents were separated immediately. *Residents continued on with their every day activity. *No further injury or behavior noted. The first nine interventions identified listed above were previously outlined on care plan developed on 8/16. The intervention regarding assurance of safety was denoted above but was not identified on current care plan. 4/15/17: Time of Incident: 1630 (2:30 p.m.). Residents R50 and R44 had an altercation, but neither was able to provide background information due to dementia. R44 was found standing up in front of her (R44's) wheelchair (w/c). R50 attempted to push the w/c forward and bumped into R44's legs. R44 began yelling and struck R50 on R50's back with her open hand. R50 received a skin tear just above the elbow, measuring 2.2 cm in diameter, roughly the size of a nickel. Causal factor was R44's w/c being in the pathway when R50 attempted to pass. The recommendations were made to place R44's w/c in an area outside of traffic and position away from the area where independent activities are kept. No other interventions were identified 5/3/17: Time of incident: 1345 (1:45 p.m.). R50 and R47 were yelling at one another. Upon approaching residents, they were both pulling a side of a dining room chair. R47 was yelling for R50 to let go of the chair. R50 did release the chair after a few tugs. R47 was noted to have a skin tear on top of the right hand. Causal factors: R50 trying to move a chair and R47 protesting. Staff identified intervention of separating residents. No additional changes noted to the care plan. 5/4/17: Time of incident: 1830 (6:30 p.m.). Staff heard residents hollering in the common area on the South Unit. R50 was sitting on the floor with R31's walker laying on it's side on the floor in front of him. R31 was standing in front of R50 yelling at him. The causal factors were noted to be: dementia with behavioral disturbances, delusional disorder, hallucinations, history of wandering. The recommendations/interventions to prevent reoccurrence were identified by writer as: Closer supervision of residents on So.(South) No other interventions were identified 5/13/17: Time of incident: 1345 (1:35 p.m.). R31 was heard yelling at R50 about walking around without pants on, wearing only an undergarment. R50 was carrying a newspaper under their arm. R31 pulled the paper out from under R50's arms and struck R50 with the newspaper. The causal factors include; dementia, delusions, traumatic brain injury (TBI), and depression. Recommendations identified by staff to prevent reoccurrence included the use of coveralls, pants/shorts/ redirect, and activities. No other interventions were identified. 5/13/17: Time of incident: 1830 (6:30 p.m.). Staff heard R31 and R50 yelling in the hallway. R31 and R50 were fighting over another residents w/c. Both residents were instructed to let go, however, only R31 did. R50 proceeded to go down the hallway, passing R31 while pushing the w/c. At that time, R31 turned and pushed R50 by the shoulders. R50 did stumble, but did not fall. Causal factors include; dementia, delusions, TBI, and major depression. Staff recommendations to prevent reoccurrences include; keep unoccupied w/c's out of the hallway. Encourage resident participation in activities. No other interventions were identified. 5/14/17: Time of Incident: 0930 (9:30 a.m.). R28 was seated by the table with her walker next to her. R50 was walking by the table where R28 was seated by and grabbed R28's walker with both hands. R28 yelled at R50 to leg go and struck R50 with her open hand. Staff instructed R28 not to strike others, to which R28 responded I will hit him whenever I want!. Causal factors including dementia, depression, TBI, major depression, delusions, wandering, and intrusive passively. No injuries were noted for either resident. Staff recommendations/interventions to prevent reoccurrence included: redirect and activities. No other interventions were identified. 5/14/17: Time of Incident; 1300 (1:00 p.m.). R50 was standing by the table in the dining room. R44 was telling R50 to go away, trying to get him to leave the table. R50 went along the table and he placed his hand in front of R44, at which time R44 hit R50's hand with her open hand. No injuries were noted for either resident. Causal factor to be that R50 wanted coffee and was no longer able to communicate wish for coffee and lacked awareness that it was unacceptable to take another's coffee. Staff intervention was to provide R50 with coffee, which he sat quietly and consumed. No other interventions were identified. 5/14/17: Time of Incident: 2100 (9:00 p.m.). R50 was wandering around the unit. doing usual activities. R50 approached R46 with an activity board and attempted to place it on the table near R46. R46 then began to scream at R50, picking up a piece of PVC pipe used for an activity game and began striking R50 several times before staff could intervene. No injuries were noted with this altercation. Causal factors for R50 was that he has the [DIAGNOSES REDACTED]. Recommendations were made staff to provide with redirection and encourage activities. No new interventions were identified for R50. Upon review of the above altercations involving R50, it is identified that 13 of the 14 altercations have risen to the point of physical aggression, with only one event involving a verbal altercation. The time frames of the altercations identified 11 of the 14 events occurred in the afternoon and evening hours. R50's care plan, initially developed at the time of admission in 8/16 identified: My safety is at risk and there is a potential for abuse due to : Decreased cognitive ability, inability to communicate, Wandering. The following interventions were implemented on 8/30/16: *Explain what you are going to do before providing care. *Please don't have me near others that I disturb. *Please don't have me near others who disturb me. *Please explain my environment to me if I don't understand what is going on around me. *Please keep others out of my room that don't belong there. *Please re-direct me when I wander into other rooms or areas that are unsafe for me. *Please remove me from potentially dangerous situations. Additionally, R50's care plan initiated on 8/30/16 identified: I sometimes have behaviors which include wandering, exit seeking, taking things apart, refusing cares, and refusing medications. The following interventions were initiated on 8/30/16: *Attempt interventions before my behaviors begin. (identified as revision of 3/9/17 but no specific details outlined) *Do not seat me near others that disturb. *Give me my medications as my doctor has ordered. *Help me maintain my favorite place to sit. *Help me to avoid situations or people that are upsetting to me. *Let my physician know if my activities are interfering with my daily living. *Make sure that I am not in pain or uncomfortable. *Offer me something as a diversion. *Please refer me to my psychologist/psychiatrist as needed. *Please tell me what you are going to do before you begin. *Speak to me unhurriedly and in a calm voice. Although the care plan had the interventions identified, the care plan was generic and not specific as to where R50's favorite place to sit and what diversions were to be done for R50. R50's care plan, initiated 8/30/16, also identified: Resident has [DIAGNOSES REDACTED]. Due to cognitive loss, diminished decision making capabilities, and safety and security issues, placement in the secure unit with programs designed for this population. Interventions include; *Allow resident to walk throughout the secure unit at will. *Provide environmental cues throughout the secure unit to minimize effects of cognitive deficit. *Provide normalized programming based on patient assessment and interests. R50's care plan initiated on 9/2/16, identified; Due to a cognitive loss, diminished decision making capability, and safety and security issues, placement in the secured unit with programs designed for this population. Interventions included; *Activity staff provide one to one visits. Resident does smile and make eye contact and will wave. Verbal interactions are very limited, and are hard to understand. Resident likes to walk with his head down and look out the doors. *Allow resident to walk throughout the secure unit at will. *Provide normalized programming based on patient assessment and interests. Resident likes to fix things. R50's care plan was updated on 2/27/17 with the concern: The resident has a behavior AEB (as evidenced by) undressing, uncooperative with cares at times, and be uneasy (sic)to redirect. The interventions are as follows: *Administer meds as ordered. *Anticipate the resident needs. *Caregivers to provide with opportunity for positive interaction, attention. Stop and talk with him/her as passing by. *Intervene as necessary to protect the rights and safety of others. Approach, speak in a calm manger. Divert attention. Remove from situation and take to alternate location as needed. *May use one piece jumpsuit: (Removed from care plan on 4/12/17). *Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. *Provide a program of activities that is of interest and comates residents status. The facility's monthly Behavior Monitoring sheets are completed on each shift for R50 for target behaviors Rejection of cares, wandering and exit seeking, taking things apart, physical aggression, urinating in a public area, and undressing in public areas. The interventions identified included: redirect, one to one interactions, refer to nurse's notes, activity, return to room, toilet, give food, give fluids, change position, adjust room temperature, backrub, education (to be specified on back of monitoring form, and medication (noting it should not be first intervention). R50's monthly Behavior Monitoring sheets from 1/1/17 to 5/25/17 identified the following: January 2017 DAY SHIFT: R50 had behaviors of wandering/exit seeking and taking things apart. R50 had wandering/exit behavior every day shift and took things apart on 28 days of 31. The resident refused cares on two occasions on the day shift, and undressed in public on 16 shifts. EVENING SHIFT: R50 reject cares or medication on 24 occasions, and had 29 shifts of wandering/exit seeking behaviors. He had physical aggressiveness on 5 evening shifts, undressed in public on 6 shifts and urinated in public areas during 5 evening shifts. NIGHT SHIFT: R50 exhibited no behaviors on 7 nights, and had behaviors of wandering/exit seeking and taking things apart on 19 shifts. R50 had rejection of care/medications on 9 night shifts, urinated in public on 4 occasions, undressed in public 6 times, with only ones of the undressing that correlated with urinating in public. Staff interventions attempted included: redirection,one to one interaction, activities, return to room, toilet, and giving of food and fluids. The outcome to these behavior interventions were not consistently identified or reflective of what interventions were beneficial. An improvement was noted following interventions on one shift during the day, on six occasions during the evening shift, and one occasion at night. There was no indication on the form to determine which of the interventions were effective for which specific behavior. February 2017 DAY SHIFT: R50 had wandering/exit seeking behaviors which occurred daily. He had rejection of cares on two occasions and was taking things apart on 10 shifts. R50 was physically aggressive on one day shift and undressed in public on 7 occasions. EVENING SHIFT: R50 had rejection of cares/medication on 9 occasions, and wandering/exit seeking on a daily basis. He was physically aggressive on 5 occasions, undressed in public and urinate in public areas 10 times, though not always occurring at the same time. NIGHT SHIFT: R50 exhibited behaviors of wandering and exit seeking on 18 shifts, undressed in public areas on 6 occasions and took things apart on 7 occasions. R50 did not have any behaviors on 7 of 31 shifts. The interventions to these behaviors identified redirection, activities, return to room, toileting, give food and fluids, and one on one interventions, which identified 17 episodes of interventions implemented. There were no changes in R50's behavior after interventions on the day shift, and had improvement with 6 behaviors during the evening shift, and no improvement in behavior with interventions on the night shift. The outcome does not specifically identify which intervention was of benefit. There was no indication on the form to determine which of the interventions were effective for which specific behavior. March 2017 DAY SHIFT: R50 had wandering/exit seeking behaviors which occurred daily. R50 was physically aggressive on 2 shifts and undressed in public on 6 occasions. EVENING SHIFT: R50 had wandering/exit seeking on a daily basis, and had rejection of cares/medication on 3 occasions. He undressed in public on 1 occasion and noted to fix things on four occasions. NIGHT SHIFT: R50 exhibited behaviors of wandering and exit seeking and refusal of care on 5 shifts, and on 8 shifts there were no concerns. The interventions to these behaviors identified redirection, activities, return to room, toileting, give food and fluids, and one on one interventions, which identified no changes in R50's behavior after interventions on the day shift, and had improvement with 6 occasions during the evening shift. There was no indication on the form to determine which of the interventions were effective for which specific behavior. April 2017 DAY SHIFT: R50 had wandering/exit seeking behaviors which occurred daily. R50 was identified as having 14 episodes of disrobing in public, which was an increased behavior from previous months, however, the target behavior identifier has changed and the identifier previously used for taking things apart is now used for disrobing in public. The previous identifier for disrobing in public is now used for urinating in public areas, which identified one episode of this behavior. EVENING SHIFT: R50 had behaviors of wandering/exit seeking behavior daily, occurrence of fixing behavior only once on the evening shift, and disrobing in public on one occasion. He also exhibited rejection of cares on two occasions and had physical aggression on three shifts. NIGHT SHIFT: R50 was identified as no incidence of behaviors on 18 shifts. R50 exhibited wander/exit seeking behaviors on 5 shifts, rejection of cares/medication on one episode, urinating in public area on 2 occasions, and taking things apart on 2 occasions. The interventions attempted included redirection, activities, return to room, toileting, give food and fluids, and one on one interventions. Improvement in behaviors was noted on 15 occasion of the evening shift and two occasions on the night shift. The documentation for day shifts identified no change/worsening in behaviors with interventions provided. May 2017: . DAY SHIFT: R50 exhibits constant wandering/exit seeking behaviors daily, disrobing in public 17 occasions which was an increase from the previous months. R50 had rejection of cares/medications on 4 occasions, and physical aggression on 1 occasion. EVENING SHIFT: R50 was consistently wandering and exit seeking behavior every evening shift, 8 occurrences of disrobing in public and physical aggression on 4 occasions. NIGHT SHIFT: R50 exhibited rejection of cares,/medication on seven occasions, as well as wandering/exit seeking behavior on 13 occasions. R50 had 12 episodes with taking things apart, 4 episodes of disrobing in public, and 1 episode of urinating in public. The interventions attempted included redirection, activities, return to room, toileting, give food and fluids, and one on one interventions. R50 was noted to have an improvement in behavior on two occasions on the day shift, on 20 occasions on the evening shift, and on two occasions on the night shift. There was no indication on the form to determine which of the interventions were effective for which specific behavior. During interview on 5/25/17, at 3:38 p.m., reviewed R50's increased prevalence of altercations with other residents with the director of nursing (DON), and identified there were 11 out of 14 altercations that occurred during the afternoon and evenings hours. The DON stated the plan of care is developed to meet the identified needs of the resident. R50's care plan was reviewed and noted the primary interventions were put into place upon residents admission in 8/16, with few changes noted. The DON stated in the consultant pharmacist reviewed the clients medication profile monthly, and R50 was seen in routine follow up by the medical doctor. The interdisciplinary team reviewed recommendations, evaluated the current interventions/activities for resident response and update as needed. The DON stated they were working in conjunction with hospice to meet the residents best i

Based on observation, interview, and document review, the facility failed to comprehensively reassess and/or implement effective interventions to reduce the risk of falls and injury for 2 of 5 residents (R51, R64) who experienced falls. This resulted in actual harm for R51 who sustained head lacerations requiring emergent medical care. Findings include: R51's quarterly Minimum Data Set ((MDS) dated [DATE], identified R51 had moderate cognitive impairment, required staff assistance for ambulation and transfers, was frequently incontinent of bladder, and had sustained two or more falls with injury since the previous assessment. R51's progress note dated 4/15/15, identified R51 had been assessed to be alert with confusion and forgetfulness, does not remember to use his call light due to his confusion, and was unsteady with transfers. Further, the note identified R51 had sustained 10 falls since the previous assessment period. R51's at risk for falls care plan dated 11/21/14, included a goal of no fall related injuries and instructed staff to toilet R51 per his request, rug by recliner and therapy referral. The physical functioning care plan instructed staff to supervise R51 and remind him to take the walker with him when ambulating. The elimination care plan instructed staff to toilet R51 at 3:00 a.m. but indicated he toilets himself during the day. During observation on 6/04/2015, at 12:40 p.m. R51 was in bed with his eyes closed and sleeping. His left foot was hanging off the bed touching the floor, and his four-wheeled walker was approximately 6 ft away from the bed. A soft bedside mat was folded up at the end of his bed and propped up against the foot board of the bed. R51's bed control was hung on the bedside grab bar and within his reach, along with a rug being positioned in front of his recliner chair, however the edges had several areas of lifting up from the floor creating an uneven surface and a potential tripping hazard for R51. When observed on 6/4/15, at 2:25 p.m. nursing assistant (NA)-C provided R51 his four-wheeled walker in the dining room and R51 ambulate unsupervised to his room. Upon entering his room, R51 set his walker aside, and leaned over to unplug his television from the wall plug that was approximately 18 inches from the floor. R51 proceeded to walk to his recliner and transferred himself into the chair without reaching back to find the arms first, and sat down with his buttocks seated halfway on the armrest of the chair. R51 attempted to reposition himself in the chair, but was unable to do so independently. The facility's Minnesota Incident Reports for R51 dated 2/1/15, through 5/26/15, were reviewed with the director of nursing (DON) on 6/4/15, at 11:30 a.m. and identified R51 had sustained the following falls: February 2015, five falls including: 2/1/15, at 8:00 a.m.; 2/5/15, at 4:50 a.m.; 2/23/15, at 6:45 a.m.; 2/27/15, at 6:00 p.m.; and 2/28/15, at 11:00 p.m. Four of the falls occurred in his room and one fall occurred in the dining room. Details of each documented fall indicated R51 had been attempting to self- transfer. There was no evidence the falls were comprehensively assessed to determine causative factors in order to develop/implement appropriate interventions. Documentation of Interdisciplinary Team (IDT) review of falls included the following interventions had been developed following the falls in February 2015: continuing therapy, continuing to offer assistance as needed, pharmacy review of medications, appointment with the physician, continue talk therapy with house psychologist, and continue with current care plan. Documentation revealed the fall R51 had sustained on 2/28/15, resulted in a laceration to his head which had required a visit to the local hospital's emergency department, and staples were needed to close the wound. A physician's progress note dated 3/3/15, indicated R51's primary physician was aware of the fall but had made no recommendations for modification of interventions. Although R51 had sustained five falls in February 2015, there was no indication the facility had identified any pattern of R51 falling while attempting to self- transfer in his room, nor was there evidence that R51 was evaluated for the need for increased assistance with activities of daily living. March 2015, also identified five falls: 3/19/15, at 1:30 p.m.; 3/21/15, at 4:10 a.m.; 3/26/15, at 6:50 a.m.; 3/28/15, at 12:15 a.m.; and 3/28/15, at 2:10 a.m. The incident reports indicated four of the falls had occurred in the resident's room when R51 was attempting to self transfer, and one fall had occurred in the shower room. However, there was no evidence the facility attempted to identify the reason R51 continued to attempt self-transfers. In addition, there was no evidence the falls had been comprehensively assessed to determine causative factors in order to develop/implement appropriate interventions. The IDT review of the falls for March 2015, had resulted in the following interventions: contact the provider regarding jerky spells, occupational therapy evaluation, and to place a sign on his walker reminding him to use it. The DON stated at 11:45 a.m. on 6/4/15, that interventions identified for February 2015, falls included: offer assistance as resident will allow, and pharmacist review of medications. The DON stated the pharmacist had recommended to discontinue oxybutynin (a bladder medication known to increase risk for falls) however, the physician had declined and had directed staff to continue with R51's current care plan. Regarding the March falls, the DON stated interventions included: continue with the current plan of care, keep bed remote out of reach, urology consult appointment, place a sign on his (R51's) walker to remind him to use it, and to continue to verbally remind R51 to use his walker at all times. In addition, the DON stated staff were supposed to be doing more one to ones and close monitoring, however, she was unable to define what staff were monitoring or for how long. April 2015, included eight falls, all of which occurred in the resident's room: 4/6/15, at 12:00 p.m.; 4/7/15, at 3:30 p.m.; 4/15/15, at 3:50 a.m.; 4/16/15, at 7:30 p.m.; 4/18/15, at 11:00 a.m.; 4/21/15, at 11:30 p.m.; 4/22/15, at 3:00 a.m.; and 4/25/15, at 11:00 a.m. There was no evidence the falls were comprehensively assessed to determine causative factors in order to develop/implement appropriate interventions. An IDT review of the falls for April 2015, indicated the following interventions should be implemented: continue current plan of care and provide more assistance as resident will allow, offer toileting assistance during the day, physical therapy to evaluate and treat, and treat for a urinary tract infection. R51's fall on 4/25/15, resulted in a head injury with decreased level of consciousness. R51 had been sent to the emergency room and received 3 staples and 9 stitches. The DON stated R51 had again been started on an antibiotic at that time, for treatment of [REDACTED]. May 2015, included one fall: 5/25/15, at 8:05 p.m. while attempting to use the toilet. The DON stated interventions were to continue his current plan of care. During an interview on 6/4/15, at 10:04 a.m. NA-C stated sometimes R51 needs help, he will toilet himself independently. Most of the time he is not a fall risk, sometimes he is. NA-C stated R51's fall interventions included, If he is unsteady we give him a wheel chair. During an interview on 6/4/15, at 10:08 a.m. registered nurse (RN)-A stated that R51 was a fall risk, had angry spells, was prone to tremors and would become unsteady on his feet. RN-A stated R51's fall interventions included a mat in front of his recliner, a low bed, and a wheel chair for use when unsteady. She stated there were no other fall interventions that she was aware of. RN-A further stated that the nursing assistants had care sheets that listed R51's fall interventions as well as his required level of care. A review of the South Aide Sheet (used by the nursing assistants to direct resident care) undated, indicated R51 was incontinent and directed staff to encourage assist with toileting during the day, but lacked directions regarding frequency and level of assistance. The Aide Sheet further indicated R51 used assist rails and had a rug placed by his chair, used a walker for transfers and ambulation and had a wheel chair available for use when needed. The Aide Sheet did not include staff directions regarding the level of assistance required for transfers, ambulation or cares, nor did it indicate when staff should utilize the wheel chair for R51. During an interview on 6/4/15, at 10:18 a.m. RN-B stated she was aware of R51's fall history and that the facility had tried toileting, tried eating, talked to the doctor about meds, and consulted house psychiatry. She further stated R51's falls were put on an incident report and were discussed at a daily stand up meeting. RN-B said interventions are put in place for all falls, and stated that interventions should be added to R51's care plan and any changes to the care plan should be put on the nurse aide's sheet. RN-B further stated she does not do any fall analysis, but lists what falls have occurred on the MDS (Minimum Data Set) progress note. During an interview on 6/4/15, at 11:06 a.m. the DON stated that following each fall, the nurses would review when R51 was last toileted and the last time he was seen by staff. The DON said the incident report was then filled out, family was notified, and the incident report was brought to the IDT meeting on the next business day. The IDT looked at previous falls and tracked the date, the time and the last intervention, including the outcome of each intervention and whether the intervention was appropriate. The DON stated that following the IDT review, interventions were implemented and any changes would be added to the care plan, and the nurse aide's care sheet. She stated, Every intervention should be on care plan and care sheets and that should be done immediately. She stated that R51's family member (FM)-A wanted him to remain as independent as possible and had been educated a few times about the risks and benefits of R51's fall history. The DON further stated that documentation of such education should be noted in the facility progress notes. A review of the facility progress notes from 2/1/15 to 6/4/15, lacked evidence that R51's FM-A had received any education regarding the risk and benefit of R51's independence as it related to falls. During an interview on 6/4/15, at 12:45 p.m. licensed practical nurse (LPN)-A stated she was aware that R51 was at risk for falls. She stated that R51 had a low bed but that the bed was not always in the lowest position. She stated staff kept the bed low at night but not during the day. (LPN)-A further stated, I believe therapy placed a piece of tape on wall to indicate the appropriate bed height. During observation of R51's room on 6/4/15, 12:48 p.m. there was no tape observed on R51's wall to indicate appropriate bed height. During an interview on 6/4/15, at 12:52 p.m. the director of rehab stated that R51 had been on caseload with therapy in January of 2015, due to a functional decline related to a [DIAGNOSES REDACTED]. The director of rehab further stated that she'd received an order to evaluate R51 again on 3/19/15, due to falls, but felt that R51's falls were related to behaviors and not functional mobility so he was not appropriate for therapy at that time. During an interview on 6/4/15, at 1:52 p.m. FM-A stated, They will call me when he falls. FM-A stated she was not really sure why R51 had the falls but stated that he was getting worse. She stated she thought he was losing his balance. FM-A further stated R51 won't call for help, he thinks he can do everything on his own and they (the facility) know that. She further stated that the facility tells R51 to use his call light and that he can have the call light right next to him but won't use it. FM-A stated she felt the sign on his walker reminding him to use it is was doing some good, but stated she didn't think there was anything the facility could do. FM-A said R51 will just get up, not have his breaks on, or will be unsteady, and he will lose his balance and fall. She stated the facility knows that R51 wants to maintain his independence but they haven't really educated me on the risks of him falling. During an interview on 6/4/15, at 2:25 p.m. R51 stated, I think I have fallen twice, I remember going to the hospital and they stapled my head. The staples hurt, it was sore for a couple of days and again after they pulled them out. R51 further stated he was unsure how long ago he'd fallen but thought it had been about a month. Regarding staff assistance R51 stated, We got it fixed up so I can get to the chair and they (NA)'s, lean into me so I'm straight in the chair. He stated, The staff watches me to make sure I have my walker. Although the facility staff did conduct reviews of R51's falls, a review of the facility progress notes dated 2/1/15 to 6/4/15, lacked evidence that a comprehensive analysis of R51's falls had been completed. The intervention: Continue plan of care was initiated multiple times after the IDT review of falls, and other interventions including: occupational therapy, sign on the walker, treatment of [REDACTED]. R51's care plan lacked evidence of any new interventions after 1/13/15. R51's progress notes indicated he had frequent episodes of shakiness and jerky movements, impaired balance and gait problems and required supervision while ambulating. His care plan dated 7/29/14, indicated R51 required supervision with ambulation but facility progress notes indicated R51 ambulated independently on the unit frequently. While R51 was assessed to be incontinent of bladder and had multiple falls attempting to self transfer to the toilet, there was no indication the facility addressed R51's toileting plan after 1/13/15, even though R51 had an increase to his Lasix (a diuretic that increases frequency of urination and is attributed to falls) dose on 2/25/15. The facility progress notes and R51's care plan also lacked consistent evidence that measures were taken to reduce the risk of injury related to falls. As a result, R51 had sustained two lacerations 2/28/15 and 4/25/15, which required medical treatment that resulted in actual harm for R51. A facility policy labeled Falls Change of Condition Guidelines for Completion dated 11/13/14 directed staff to: assess individual condition after a fall occurs and to identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls. The policy further directed staff to implement new recommendations and record them on the plan of care. R64's admission MDS dated [DATE], identified R64 had severe cognitive impairment, and had sustained falls in the previous months prior to her admission to the facility. R64's care plan dated 5/19/15, identified R64 was at risk for falls, and directed staff to have her bed in low position with mat on floor as an intervention to reduce her risk of injury if she fell . Review of the facility's Minnesota Incident Report dated 5/23/15, identified R64's audible alarm was sounding, and staff found her sitting on the floor on the left of her bed. Further, the report provided a space for staff to specify recommendations/interventions taken to prevent reoccurrence, and staff identified an intervention which included, .bed in the low position. R64's Post Fall Analysis / Plan dated 5/26/15, identified R64 had roll/slid out of bed, and identified an intervention to reduce the risk of further injury to R64 as, IDT (inter-disciplinary team) - put bed in low position + (and) mat on floor. During observation of R64 on 6/1/15, at 6:07 p.m. she was laying in bed with the room lights on, but her eyes closed. R64's bed was raised up from the floor approximately 6 inches, and she had a large mat at the bedside. On 6/2/15, at 1:18 p.m. R64 was again observed in bed. Her eyes were closed, and her feet were hanging off the side of the bed, dangling towards the floor. The bed was raised up from the floor approximately 18-24 inches, and there was a mat in place on the floor. Nursing assistant (NA)-A was notified by the surveyor to R64's bed being raised up, and her feet hanging over the edge dangling towards the floor on 6/2/15, at 1:21 p.m. NA-A stated she helped R64 to bed following the lunch meal, and should have put her bed in the lowest position adding it should have been lowered down. When interviewed on 6/2/15, at 1:30 p.m. registered nurse (RN)-A stated R64 had slipped out of bed before, and added R64 should have her bed kept in the lowest position to reduce her risk of injury if she would fall out of bed. During interview on 6/2/15, at 3:34 p.m. the director of nursing (DON) stated R64's bed should have been in the lowest position, Definitely should be in low position.

Based on observations, facility documentation review and interviews, the facility failed to ensure that 1 of 3 residents (#1) reviewed remained free of accident hazards. Resident #1 sustained a second degree burn after he was found out of bed and lying against the radiator and boiler pipe next to his bed. Findings include: Record review conducted on February 27, 2012, at 5:15 p.m. revealed Resident #1 was admitted to the facility on [DATE], for short term rehab following a hospitalization . He has [DIAGNOSES REDACTED]. Nursing progress documentation of February 16, 2012, at 10:21 a.m. notes he requires two staff assistance with bed mobility and transfers with two staff assistance and a mechanical lift. He has long and short term memory problems with variable levels of alertness. Nursing documentation also notes on February 17, 2012, of 3:24 a.m. that at approximately 11:30 p.m. staff heard Resident #1 call out and staff found him lying on the floor next to his bed and the radiator. His left arm was slightly reddened and swollen but after a couple of minutes this was resolved. The incident report has additional documentation added February 17, 2012, at 10:30 a.m. that indicates staff noted three blisters on his left hand. The facility staff contacted the physician. The physician orders dated February 17, 2012, noted to wrap the left hand with gauze daily and once the blisters break open staff are to make an appointment for the resident to be seen at the clinic for debridement. Resident #1 was evaluated by a physician at the clinic on February 23, 2012. The physician ordered a treatment to clean the blisters gently and apply silvadene, telfa and kerlix every two days. Resident #1 was to be seen by the physician for a follow up appointment two weeks later. There was no documentation indicating Resident #1 requires his bed next to the wall. Observations conducted on 2/27/2012 at 4:56 p.m. revealed two second degree burns on Resident #1's left thumb and second digit. On his left thumb was a 3.1 centimeter by 1.6 centimeter absorbed blister. On the left second digit there was a 2.1 centimeter by 1.6 centimeter broken blister. This was measured and verified by Employee D/nurse. Employee D treated and dressed the blistered areas as ordered by the physician. An interview conducted with Employee (A)/administration on February 28, 2012, at 9:05 a.m. revealed Resident #1's incident was investigated on 2/17/2012. Facility staff found blisters on his left hand and which they felt to be caused from the exposed pipe approximately six inches from the floor to the radiator. The following interventions were put into place after blisters were noted on Resident #1's left hand: The air mattress on the bed was replaced with another style of pressure reducing mattress. A body pillow was placed in the bed. Resident #1 was transferred to the room next door so he was near the door and not by a radiator. Staff contacted Resident #1's physician who ordered to wrap the blistered area and later on February 23, 2012, gave an order for [REDACTED]. The exposed pipe on the radiator was covered to prevent anyone else from touching the exposed pipe. Maintenance staff examined all of the radiator and pipes at the ends of radiators to the walls and extending below radiators down to the floor in the facility. Maintenance covered them to prevent any potential burns from touching the pipes. An interview was conducted with Employee E/nurse who stated on February 16, 2012, at approximately 11:30 p.m. staff heard Resident #1 call out. They responded immediately and found him lying on the floor next to his bed against the radiator. He was lying on his left side with his arm tucked under his body and the upper part of his body to his waist was against the radiator. His left arm was swollen and reddened but resolved within a couple of minutes. He was holding his head up. Employee E stated Resident #1's bed was against the wall and radiator. Observations conducted on 2/27/2011 at 3:10 p.m. with Employee (B)/maintenance revealed 24 of 65 resident beds were less than 3 feet from the radiators, including 18 resident beds which were positioned against the wall. Employee (B) stated that according to the facility policy, beds are to be no less than 3 feet from a radiator. Employee B verified beds were less than 3 feet from the radiator in 24 resident rooms. Eighteen beds were pushed up against the radiator. The room Resident #1 resided in at the time of the incident was the only room with a radiator on the wall at the head and side of the bed. Radiator temperatures were tested and all were within acceptable parameters. Review of the facility policy and procedure for Baseboard Heater/Radiator Temperatures and Bed Placement Safety, revised last on 4/1/2010, states "Resident beds will never be placed against a heat source (radiator/baseboard heater). No bed will be placed within 3 feet of wall unless: Documentation exists that bed placement is required to be against wall for residents safety."