Every finding on record at The Emeralds at Fairbault LLC

Based on interview and document review, the facility failed to ensure ongoing surveillance for infections, ongoing review of surveillance data, and documentation of follow-up activity and response. This practice had the potential to affect all 82 residents residing in the facility. Findings include:Review of the facility infection control binder provided 7/20/26, did not include line listing, mapping, or surveillance data for tracking and monitoring infections in the facility.During interview on 7/22/26 at 10:30 a.m., assistant director of nursing (ADON) stated she was new, had just started a few weeks ago, and was also hired to be the infection preventionist. ADON stated she had searched the prior infection preventionist's office, binders, and files and was unable to locate any infection control tracking, data, surveillance, or mapping documents. ADON stated she had to start from scratch and would need to implement a new program and start fresh.During interview on 7/22/26 at 1:32 p.m., interim director of nursing (IDON) stated the prior infection preventionist had left and they had just replaced her with ADON. IDON stated she was unable to find any evidence of surveillance or tracking of infections and ADON had been working on getting things up and running but things were not fully in place yet for infection prevention.Facility Infection Prevention and Control Program policy dated 11/2024, indicated the following:The Infection Control Program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. The major elements of the program are:Coordination/Oversight, Policies and Procedures, Surveillance, Data analysis, Antibiotic Stewardship, Outbreak Management, Prevention of Infection, Employee Health.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect all 82 residents residing in the facility.Findings include:Review of the facility infection control binder provided on 7/20/26, indicated no antibiotic tracking for correct indications, dosage, duration, resistance, and no 72-hour time-outs (a check that the resident is on the right antibiotic) to review cultures and verify correct antibiotics or resistance to prescribed antibiotics.During interview on 7/22/26 at 10:30 a.m., assistant director of nursing (ADON) stated she was new to the facility, had been hired to be the infection preventionist, and had just started working on an antibiotic stewardship program. ADON further stated she was unable to find any documents from the prior infection preventionist to show that antibiotic usage was being tracked and monitored. ADON stated she had started working backwards tracking antibiotics and had made it back a few months. ADON stated she did not think anything had been done with antibiotic stewardship or infection prevention for the year prior.During interview on 7/22/26 at 1:32 p.m., interim director of nursing (IDON) stated the prior employee in charge of antibiotic stewardship had left the facility. IDON was unable to find any evidence of tracking of antibiotic usage for correct dosage, duration, resistance, or that 72-hour time-outs were being completed to ensure proper antibiotic use. IDON stated she was aware this was a problem at the facility and ADON was working on antibiotic stewardship. IDON stated this was an area that needed improvement and that antibiotic usage should be monitored to ensure residents are getting the correct treatment and prevent worsening of symptoms.Facility Infection Prevention and Control Program policy dated 11/2024, indicated the following:Antibiotic Stewardship: Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. Antibiotic usage is evaluated and practitioners are provided feedback on reviews.

Based on interview and document review, the facility failed to ensure each resident or the resident's representative received education on pneumococcal immunization and failed to offer resident's the opportunity to receive or decline pneumococcal immunizations for 3 of 5 residents (R2, R35, R69) reviewed for immunizations.Findings include:R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, and diagnoses of cancer, high blood pressure, renal (kidney) failure, and diabetes mellitus.R35's quarterly MDS assessment dated [DATE], indicated intact cognition, and diagnoses of high blood pressure, malnutrition, renal (kidney) insufficiency, and chronic lung disease.R69's admission MDS dated [DATE], indicated intact cognition, and diagnoses of heart failure, fracture, and malnutrition.Review of R2's electronic health record (EHR) in Point Click Care (PCC) column titled Immunizations on 7/22/26 at 8:35 a.m., indicated no immunizations on file with the facility. Review of R2's facility form titled Resident Vaccine Administration Consent form dated 4/21/26, indicated no vaccines marked to be administered, and no vaccines marked as declined. No dates were listed for prior vaccines. No education provided. The form was signed by R2 but was not filled out by facility staff.Review of R35's EHR in PCC on 7/22/26 at 8:35 a.m., indicated past history of pneumococcal immunization (PCV 20) on 11/24/23. There was no facility form titled Resident Vaccine Administration Consent form on file for R35 to indicate she was educated on vaccines or given the opportunity to accept or decline any needed vaccines.Review of R69's EHR in PCC on 7/22/26 at 8:35 a.m., indicated she had no immunizations on file with the facility. Review of R69's facility form titled Resident Vaccine Administration Consent dated 6/25/26, indicated no vaccines marked to be administered, and no vaccines marked as declined. No dates were listed for prior vaccines. No education provided.Review of facility immunization records in the facility electronic health record (EHR) on 7/22/26 at 8:35 a.m., indicated no documentation that pneumococcal immunization education had been offered and further indicated pneumococcal vaccines were not offered to R2, R35, and R69.During interview on 7/22/26 at 10:30 a.m., assistant director of nursing (ADON) stated she was new to the facility and had just started a few weeks ago. ADON stated she recognized a concern with vaccines not being offered to residents when she was reviewing records. She verified that forms included in the admission documents were not filled out, and immunizations were not documented in the facilities electronic health record (EHR). ADON stated she would need to educated nurses about educating and offering vaccines to residents. ADON stated she had a plan to work with the pharmacy to get all residents who wanted vaccines up to date on their vaccines.Facility Infection Prevention and Control Program policy dated 11/2024, indicated the following:Prevention of Infection: Immunizing residents and staff to try to prevent illness.

Based on interview and document review, the facility failed to ensure each resident or the resident's representative received education on Covid-19 immunizations and boosters and failed to offer Covid-19 immunizations for 3 of 5 residents (R2, R35, R69) reviewed for immunizations.Findings include:R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, and diagnoses of cancer, high blood pressure, renal (kidney) failure, and diabetes mellitus.R35's quarterly MDS assessment dated [DATE], indicated intact cognition, and diagnoses of high blood pressure, malnutrition, renal (kidney) insufficiency, and chronic lung disease.R69's admission MDS dated [DATE], indicated intact cognition, and diagnoses of heart failure, fracture, and malnutrition.Review of R2's electronic health record (EHR) in Point Click Care (PCC) column titled Immunizations on 7/22/26 at 8:35 a.m., indicated no immunizations on file with the facility. Review of R2's facility form titled Resident Vaccine Administration Consent form dated 4/21/26, indicated no vaccines marked to be administered, and no vaccines marked as declined. No dates were listed for prior vaccines. No education provided. The form was signed by R2 but was not filled out by facility staff.Review of R35's EHR in PCC on 7/22/26 at 8:35 a.m., indicated no documentation of a Covid vaccine. There was no facility form titled Resident Vaccine Administration Consent form on file for R35 to indicate she was educated on vaccines or given the opportunity to accept or decline any needed vaccines.Review of R69's EHR in PCC on 7/22/26 at 8:35 a.m., indicated she had no immunizations on file with the facility. Review of R69's facility form titled Resident Vaccine Administration Consent dated 6/25/26, indicated no vaccines marked to be administered, and no vaccines marked as declined. No dates were listed for prior vaccines. No education provided.Review of facility immunization records in the facility EHR on 7/22/26 at 8:35 a.m., indicated no documentation that Covid immunization education had been offered and further indicated Covid vaccines were not offered to R2, R35, and R69.During interview on 7/22/26 at 10:30 a.m., assistant director of nursing (ADON) stated she was new to the facility and had just started a few weeks ago. ADON stated she recognized a concern with vaccines not being offered to residents when she was reviewing records. She verified that forms included in the admission documents were not filled out, and immunizations were not documented in the facilities electronic health record (EHR). ADON stated she would need to educated nurses about educating and offering vaccines to residents. ADON stated she had a plan to work with the pharmacy to get all residents who wanted vaccines up to date on their vaccines.Facility Infection Prevention and Control Program policy dated 11/2024, indicated the following:Prevention of Infection: Immunizing residents and staff to try to prevent illness.

Based on interview and document review, the facility failed to ensure bathing safety for 1 of 1 resident (R38) reviewed for activities of daily living (ADLs), when a safety seatbelt had not been applied during the bathing process. In addition, based on interview and document review, the facility failed to ensure safe electric wheelchair use for 1 of 1 resident (R73) reviewed for accidents, when a resident fell from her wheelchair on a community outing. Findings include: R38's diagnoses report dated 7/22/26, included diagnosis of non-traumatic intracerebral hemorrhage (bleeding in the brain not caused by injury and a type of hemorrhagic stroke). R38's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R38 was dependent upon staff for most activities of daily living and did not walk. R38's care plan dated 6/1/24, indicated a self-care deficit related to intracranial injury and impaired mobility; used a Hoyer (mechanical lift device) with assist of two for transfers, and required assistance with bathing. During an interview on 7/20/26 at 3:03 p.m., R38 stated there had been an incident about three weeks prior where he had been given a tub bath and staff did not apply a safety seatbelt and he slid down off the chair into the water. R38 stated he hollered and staff came to help. R38 did not know the nursing assistant (NA) who had put him in the tub; had not seen her prior to or since the incident. During an interview on 7/21/26 at 1:47 p.m., registered nurse (RN)-A who was also a nurse manager, stated she had been aware R38 had slipped down in the tub when an unknown agency NA had given him a bath. It had been the NA's first shift at the facility, and since she did not have an assignment, it had been determined she would be the bath aid on the long-term care unit. RN-A stated staff had not informed the NA where the safety seatbelt was for the tub, so she used a gait belt. RN-A had not informed the DON following the incident because R38 didn't think it was a big deal. RN-A could not recall the date of the incident or who was involved. During an interview and observation on 7/21/26 at 2:49 p.m. in the tub room, observed an [NAME] brand bathing system which included a chair that when a resident was seated on it, would be rolled into the tub, a door shut and then water added. NA-C demonstrated how a safety seatbelt would be applied to a resident and the tub chair. Observed multiple safety seatbelts hanging on the wall which were long white rubber straps with holes. NA-C stated the seatbelt went around the residents' belly, then attached to pegs on the back of the chair, stating the strap should be snug, but comfortable. NA-C stated a gait belt wouldn't do anything for a resident in the tub; they would just slide out of the chair. NA-C stated gait belts were only used for ambulating residents and that a safety seatbelt should always be used when bathing a resident. During an interview on 7/21/26 at 3:54 p.m., the interim director of nursing (IDON) stated she had not been made aware of the incident until informed by RN-A today. The IDON stated it should have been investigated and staff re-educated if necessary. The IDON stated she locked out/tagged out the tub (e.g., taken out of service) until the vendor could do a safety check. Manufacturer instructions for the [NAME] bathing system were requested and received; dated November 2017. During an interview on 7/22/26 at 10:24 a.m., both nursing assistants NA-A and NA-B stated they had been working the day of the incident and recalled the events. Both stated it had to have occurred the second or third week in June when a particular NA was on vacation and it had to have been on a Friday as that was R38's bath day. They were aware it was an agency NA and her first day at the facility. NA-A stated NA-D had radioed over her walkie talkie that she needed help in the tub room ASAP (as soon as possible). Both NA-A and NA-B rushed to help. NA-B stated R38 had a gait belt under his arms, not the safety seatbelt, and that R38 had not been under the water, but rather slid down off the chair with water up to chest. Both NA-A and NA-B stated R38 had not been at risk of drowning. They both reported the incident to RN-A and to licensed practical nurse (LPN)-A. During an interview on 7/22/26 at 10:32 a.m., based upon interviews from NA-A and NA-B, met with scheduling coordinator (SC)-B and was able to determine the date of the incident was 6/19/26, and was able to identify the agency NA by name. SC-B stated that had been NA-D's first and only shift at the facility. During a telephone interview on 7/22/26 at 10:41 a.m., LPN-A stated she had been working the day of the incident and recalled the events. LPN-A stated when she entered the tub room to help, she assisted R38 up onto the tub chair and had observed a gait belt around him. LPN-A stated at no time was R38 at risk of drowning. LPN-A stated she didn't tell anyone or document a progress note because R38 had not sustained an injury. During an interview on 7/22/26 at 12:58 p.m., the IDON stated there had been no orientation or training provided to NA-D prior to the start of her first shift. The current orientation packet for agency staff, provided by the IDON, did not include information about bathing, the [NAME] tub, chair or safety seatbelt. During a telephone interview on 7/22/26 at 7:28 p.m., NA-D stated she worked for an agency and when she saw the open shift at the facility on 6/19/26, she picked it up. NA-D stated she had not worked at the facility prior to this. When NA-D arrived, she stated staff were unaware she was coming and did not know where to assign her. After 30 minutes of staff trying to reach the IDON without success, they determined NA-D would be the bath aid on the long-term care unit. NA-D stated she had not received orientation/training prior to starting the shift. NA-D had asked the NA assigned to R38 if there was anything she should know about R38 but was given only general information. NA-D stated she had not been provided access to the electronic medical record (EMR) in order to review R38's care, adding, They just threw me into the position, so had to go off what residents and staff told her. The NA who had been assigned to R38 helped NA-D transfer R38 to the tub chair but said nothing about a safety seatbelt for the chair so she applied a gait belt to R38. When the water filled about halfway, NA-D stated R38 started to slide down off the tub chair. NA-D stated she quickly started draining the tub then called for help. NA-D stated staff came in right away and lifted R38. NA-D stated at no time had R38's head been close to the water. NA-D stated she was familiar with the brand of tub and had used it before and stated not all residents required the use of a safety seatbelt as they were strong enough to hold themselves up. NA-D stated typically staff would tell her if a resident needed a safety seatbelt or she would see it in their chart. NA-D stated no one at the facility had talked to her about the incident. During a telephone interview on 7/23/26, at 11:34 a.m., customer service (CS)-C at [NAME] Bath company stated instructions for use of the safety seatbelt were not included in the operating manual; those instructions came on a laminated document attached to the chair so that the chair/bathing system could not be used until the instructions were removed. CS-C provided the instructions titled Moving Resident to and from Bathing System, dated 10/17. Instructions included: before moving resident, fasten seatbelt (secure over white knobs on back of chair). Further, the instructions included a Warning indicating in part: only trained and authorized personnel conduct resident transfers with this system. Seatbelts are in good condition and secure snugly to the white knobs on the back of the chair. Facility policy on use of the tub, or a policy on safety measures when bathing residents was requested and not received. ELECTRIC WHEELCHAIR R73's quarterly MDS assessment dated [DATE], indicated intact cognition, use of wheelchair, setup assistance for eating, dependent for toileting hygiene, substantial assistance for personal hygiene, dependent for transfers, and diagnoses of debility due to cardiac (heart) and respiratory conditions, heart disease, heart failure, and diabetes mellitus. R73's care plan updated 5/23/26, indicated risk for injury related to decreased visibility, environmental hazards, and impaired judgment during evening outings. Risk for impaired physical mobility related to potential equipment malfunction or environmental barriers. Remain free from injury or falls during and after outings through the next review dated 8/26. Demonstrate understanding safety precautions for evening wheelchair use through next review date. During interview on 7/20/26 at 11:37 a.m., R73 stated she fell off her scooter a few days ago. R73 stated she was at bingo at a community establishment in her motorized wheelchair, missed the ramp, and fell down five stairs. R73 stated she had some scrapes and bruises and her daughters made her go to the emergency department to get checked out. R73 stated she was not admitted to the hospital and returned to the facility the same night. R73 further stated she was upset the facility had taken her motorized wheelchair away. Facility progress note dated 5/6/26, indicated R73 returned to facility at 11:00 p.m., accompanied by police officer due to darkness. Facility progress note dated 5/13/26, indicated R73 left the facility for bingo on her electric wheelchair at 4:45 p.m., writer was alerted by another staff member that emergency medical services and police were with resident because she got stuck on the sidewalk. Resident had minor skin tear on her right hand. Facility progress note dated 6/3/26, indicated R73 left facility at 4:32 p.m., electric wheelchair got caught in a rock on the sidewalk twice and got stuck. Staff pulled wheelchair and assisted R73. Facility progress note dated 7/11/26, indicated R73 choked on chicken nugget outside of gas station. R73 drove electric wheelchair to gas station, hit wood pile, and received a skin tear to right hand. Emergency medical services were called to the scene to complete wound care. Facility progress note dated 7/13/26, indicated R73 will be reevaluated with her electric wheelchair due to safety concerns on community outings. Therapy will conduct a new Community Assessment and SLUMS (cognitive test). Facility progress note dated 7/15/26, indicated social services spoke with R73 regarding her desire to attend bingo in the community that evening. R73 wanted to attend due to a special event. Risks of high temperatures reviewed. Ensure to fully charge phone. Facility progress note dated 7/15/26, indicated nursing received a call from a community establishment stating R73 drove her electric scooter off the steps instead of the ramp and fell on the ground. Emergency medical services arrived and R73 refused to go with them. Facility staff walked with her back to the facility. R73's daughters encouraged her to go the the emergency department and she agreed. R73 had bruises and abrasions and returned to the facility that night. Facility interdisciplinary team (IDT) note dated 7/16/26, indicated root cause analysis completed with cause determined to be decreased coordination with electric wheelchair. Immediate intervention included electric wheelchair removed from R73's possession, daughters in agreement. During interview on 7/21/26 at 1:34 p.m., assistant director of nursing (ADON) stated she was aware R73 was unsafe in her wheelchair but it was a tough situation. ADON further stated if it was her choice she would have taken the electric wheelchair away a long time ago. ADON stated the wheelchair should have been removed on 7/13/26, when it was determined a new community assessment was needed. ADON further stated R73's daughters had stated they thought R73 was a danger to herself and others in her wheelchair and supported the electric wheelchair being removed. During interview on 7/22/26 at 2:08 p.m., IDON stated R73 has had ongoing problems with her electric wheelchair, the ombudsman had been involved, and family was aware. IDON stated she is unsure why the electric wheelchair was not removed when it was discovered that a new community safety assessment was needed. IDON stated the electric wheelchair should have been removed on 7/13/26, until a new safety assessment could be completed. IDON stated this would have been important to ensure R73's safety. A facility policy on accidents was requested but not received.

Based on observation, interview, and record review the facility failed to maintain a safe environment for 2 of 2 residents (R4, R5) who were observed with wet floors and no indication that floor was wet while either residing in room or when returning to room. Findings include:R4R4's face sheet dated 6/12/26, identified diagnoses of left femur osteonecrosis (bone cell death), difficulty in walking, and urinary incontinence.R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 had no difficulties with hearing or speech. R4 had no cognition issues. R4 had behavioral issues directed at others one to three days. R4 required supervision/touch assist with transfers.R5R5's face sheet dated 6/12/26, identified diagnoses of unspecified dementia, and weakness.R5's admission MDS dated [DATE], identified R5 had minimal hearing difficulties and wore glasses. R5 had no cognition issues. R5 required supervision/touch assist with transfers.During a continuous observation on 6/9/26 from 11:50 a.m. through 12:22 p.m., the following was observed:11:50 a.m.- R4's room floor was visibly wet. No wet floor sign in front of room. R4 was not in the room. R5's room floor was also visibly wet. R5 was asleep in a recliner chair in room. No wet floor sign was noted in front of R5's room.11:53 a.m.- R4 had propelled herself to the entrance to her room with her walker, saw the floor was wet and did not enter the room.During an interview and observation on 6/9/26 at 11:54 a.m., registered nurse (RN)-A and R4 were present. RN-A stated she would expect the housekeeper to have a wet floor sign in front of R4 and R5's doors. R4 was verbally upset there was not a wet floor sign and no fan to dry her room. RN-A stated R5 did not know the floor was wet. RN-A explained to R5 the floor was wet and she should call if she wanted to move from the recliner. R5 stated understanding. R4 stated, Why doesn't this place have fans? That is a lawsuit waiting to happen. RN-A walked into R4's room and put R4's small personal fan on the floor and turned it on. RN-A asked R4 if she knew who the housekeeper was as she had not returned and the housekeeping cart was in the hallway. At 11:59 a.m., R4 wheeled into her room on her walker and called RN-A a, dumbass, picked up the fan and pointed it to the floor. I might as well just fucking sit here and dry it. A lot of useless assholes around here the government is paying them to be here. At 12:00 p.m., R4 stated it was, humid as hell, in here. R4 stood up without locking the brakes on the walker and walked to her window and opened it. The floor was still wet. R5's floor was also wet. At 12:02 p.m., physical therapist (PT)-A was by R4's room. R4 requested her room door be shut with her in the room and the floor still wet. At 12:13 p.m., Administrator in training came to R4's and R5's rooms and placed wet floor signs in front of them. At 12:14 p.m., RN-A stated R4's and R5's floors were still wet. R4 had been standing in her doorframe and shut the door on RN-A. At 12:22 p.m., R5's floor was dry. It is unknown if R4's floor was dry as her door was shut and she did not want to be disturbed again.During an interview on 6/9/26 at 12:04 p.m., PT-A stated it is a fall risk if the floors are wet and the residents are in the room with a wet floor. Rooms should have wet floor signs after being mopped. R4 and R5 are both at risk for falling if they would attempt to transfer on a wet floor.During an interview on 6/12/26 at 1:53 p.m., director of nursing (DON) stated she would expect housekeepers to place wet floor signs in front of wet floors so residents and staff were aware the floor was wet.The facility Walls and Floors policy dated 9/2012, identified Floors: sweep well, wash with hot water and non-sudsing cleaning solution, rinse well using mop, remove as much water as possible. Wipe with sanitizing solution, permit to air dry. Place wet floor signs to warn others of potential danger.

Based on observation, interview, and record review the facility failed to provide oral hygiene to 1 of 3 residents (R2) observed for oral hygiene cares. Findings include:R2's face sheet dated 6/11/26, identified diagnoses of displaced bicondylar fracture (break of both sides of tibia below knee which compromises knee weight bearing surface) of right tibia, displaced bicondylar fracture of left tibia, muscle weakness, and chronic pain.R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had some difficulty with understanding and wore glasses. R2 had moderate problems with thinking and memory. R2 had no behaviors. R2 had no natural teeth and was on a mechanically altered diet. R2 was dependent on staff for oral hygiene.R2's care plan dated 6/24/25, identified R2 had alteration in dental care related to edentulous (no natural teeth or tooth fragments) status. Interventions included dental visits as needed, monitor if R2 was tolerating current diet, oral cares a.m./h.s (hour of sleep) and per R2's request.During an observation on 6/11/26 at 7:52 a.m., nursing assistants (NA)-B and NA-C were providing morning cares for R2. NA-C put on gloves and took dentures from denture cup. NA-C went to the sink and rinsed dentures. NA-C handed R2 the bottom denture and placed in her mouth without denture paste. NA-C handed R2 the top denture and there was a translucent substance coming off the dentures hanging down in a glob that came off the dentures. NA-C took the top denture and denture cup back to the sink and rinsed it off. NA-C returned and put top denture in R2's mouth. NA-C did not clean R2's mouth prior to denture insertion.During an interview on 6/11/26 at 8:27 a.m. NA-B stated R2's gums should have been brushed prior to putting dentures in her mouth.During an interview on 6/11/26 at 8:36 a.m., NA-C stated R2's gums should have been brushed prior to putting dentures in her mouth.During an interview on 6/11/26 at 10:54 a.m., NA-D stated oral care for dentures included cleaning the dentures and providing gum care to the residents. A little sponge is used to clean overnight saliva and the mouth to freshen it before putting dentures in.During an interview on 6/12/26 at 1:53 p.m., director of nursing (DON) stated she expected staff to complete oral cares on residents in the morning and before bed, including cleaning the gums before inserting dentures.The facility Oral Care Assistance procedure undated, identified to assist the client with maintaining and promoting a healthy mouth environment, minimizing the change of tooth decay and bad breath. This included brushing teeth and tongue, brushing dentures, and assisting patients to use toothbrush or mouth swab to clean gums.

Based on observation, interview, and record review the facility failed to follow physician's orders for negative pressure wound therapy (wound vac) (device that applies gentle suction to help complex, large, or slow-healing wounds close) care for 1 of 2 residents (R1) who did not receive wound vac changes as scheduled. In addition, the facility failed to update the physician when attempt to reapply the wound vac failed for 1 of 2 residents (R1) reviewed for wound care and failed to update the physician for 1 of 1 residents (R2) who had a choking incident and required the Heimlich maneuver. Findings include:R1R1's face sheet dated 6/11/26, identified R1 had diagnoses of atherosclerosis of native arteries (progressive buildup of fatty plaque inside original, non-surgical arteries) of other extremities with ulceration, non-pressure chronic ulcer of other part of unspecified foot with unspecified severity, atherosclerosis of native arteries of extremities with intermittent claudication (muscle pain, cramping or fatigue that occurs during physical activity and resolves with rest) of right leg, peripheral vascular disease, and unspecified open wound right foot.R1's Perspective Payment System (PPS) Minimum Data Set (MDS) dated [DATE], identified R1did not have memory issues, and was able to communicate effectively. R1 required partial/moderate assistance with dressing and toileting. R1 was independent with rolling, lying to sitting on side of bed, and rolling left/right. R1 was dependent on staff to walk and move in wheelchair. R1 had surgical wounds.R1's care plan dated 6/1/26, identified alteration in skin integrity. Interventions included to document on skin condition and keep physician informed of changes.R1's hospital Discharge summary dated [DATE], identified R1 had been hospitalized from [DATE]-[DATE] for dehiscence (splitting or bursting open) of wound. R1 had a negative pressure wound vac system placed on the right groin and right lower extremity to improve healing time and increase compliance in dressing changes and wound management. Current wound measurements were right groin 7.0 centimeters (cm) length X 5.0 cm width X 1.5 cm depth and right lower extremity calf measured 11 cm X 3.0 cm X 0.5 cm depth. Instructions included: sponge to be placed in the wound and sealed with the plastic clear paper. The drain is to be set to low continuous suction at 125 millimeters of mercury (mmHg), wound vac system to be changed every 48 hours on a Monday, Wednesday, and Friday schedule, if the device becomes non-functional or cannot tolerate the wound vac system, moist to dry dressing changes should be performed. Kerlix should be used for wound packing. Kerlix to be soaked in normal saline and squeezed hard to remove most of moisture. Kerlix should be only slightly moist. Moist kerlix should be packed in the wound and covered with dry gauze. Dressing changes should be performed three times daily (TID). If the wound gets too moist and liquid is seen pooling in the wound, convert to dry dressing TID. The dry kerlix should also be packed in the wound. Wound vac is to continue until re-evaluation by surgical team and will most likely continue for many weeks, possibly up to a few months. Hospital surgical phone numbers for business hours and emergency situations were provided.R1's Admission/Initial Data Collection V-9 dated 5/26/26 at 12:29 p.m., identified Skin: groin and right inner ankle. No type or measurements identified. Narrative identified R1 had a surgical site present to the going area and lower portion of right leg above ankle. Surgical incision sites were assessed and monitored. No concerns noted. Staff will continue to monitor surgical sites for signs and symptoms of infection, drainage, increased redness, warmth, or swelling. R1 had a wound vac placed. Staff will update provider with any changes or concerns.R1's treatment administration record (TAR) for May 2026, identified:Wound care: right groin and thigh with wound vac. Change Monday, Wednesday, and Friday in the evening with a time of 4:00 p.m. Administration for 5/27/26, had a 9 and for 5/29/26, a checkmark for completed. R1's TAR chart code legend identified 9 as other/see nurse note.Wound vac: monitor for signs and symptoms of infection around wound vac site. Update provider as needed every shift. These correlated with check boxes for day, evening, and night to sign when completed. These were completed every shift.R1's default progress note for electronic medication record dated 5/27/26 at 3:20 p.m., identified wound care: right groin and thigh with wound vac. Change Monday, Wednesday, Friday in the evening. Wound care and wound vac dressing changed last night.During a phone interview on 6/10/26 at 3:15 p.m., registered nurse (RN)-C stated he had never changed R1's wound vac but was aware and had been taught how to change it. RN-C stated he consulted with the nurse manager on 5/27/26, as R1 had just returned from the hospital and had the wound vac placed. RN-C stated the nurse manager directed him to not change the wound vac on 5/27/26 as it was scheduled on the TAR.R1's TAR for June 2026, identified:Wound care: right groin and thigh with wound vac. Change Monday, Wednesday, and Friday in the evening with a time of 4:00 p.m. On 6/1/26, a 9 was marked, on 6/3/26, a checkmark for completed, and on 6/5/26, a 9 was marked.R1's default progress note for electronic medication record dated 6/1/26 at 7:42 p.m., identified wound care: right groin and thigh with wound vac. Change Monday, Wednesday, and Friday in the evening. Wound care and wound vac dressing to be changed tomorrow.During an interview on 6/11/26 at 1:17 p.m., licensed practical nurse (LPN)-A stated he worked 6/1/26. LPN-A consulted about changing the wound vac with RN-F who told him it would be changed on 6/2/26. The wound vac was working and had no leakage. Pressure was maintained at 125 [mmHg].R1's Wound Evaluation dated 6/3/26 at 7:06 p.m., identified RN-F completed the assessment. Wound measured 3.80 centimeters (cm) length by (x) 3.94 cm width on the right anterior (toward the front) groin. Tissue had exposed muscle. Yellow fibrin (shiny layer that forms during early phase of wound healing) present in wound, tissue temperature cool, tissue firmness was soft. Wound was blanchable (temporarily skin turns white when pressure applied), no evidence of infection, heavy serosanguineous (thin, watery fluid) drainage, wound edges not attached to base, no odor from wound. Non-pitting edema (swelling related to accumulation of fluid) > (greater than) 4 cm around wound. Anterior right lower leg wound measured 10.85 cm length x 4.86 cm depth. Tissue had exposed muscle. Periwound (surrounding) skin condition at risk. Yellow fibrin present in wound, tissue cool, blanchable, heavy serosanguineous drainage. Wound edges not attached to wound base. No odor. Skin color surrounding wound was bright red and blanches to touch. Non-pitting edema extends < (less than) 4 cm around wound. Interventions for both wounds were negative pressure wound therapy.R1's progress note dated 6/5/26 at 1:00 a.m., identified wound vac was changed early this morning by LPN-B and RN-D. During assessment, R1's leg was noted to be red, warm to the touch, and leaking fluid. R1 complained of pain during cares. Nurses attempted multiple times to reapply and troubleshoot the wound vac; however, the drape film would not adhere properly, causing a continuous leak. Due to inability to maintain suction, RN-D removed the wound vac, packed the wound and wrapped the leg until the morning shift could further assess and address the wound vac concerns.During an interview on 6/11/26 at 8:30 a.m., LPN-B stated R1's leg was red on 6/5/26 but thought it could have come from the film being taken off for the wound vac dressing.During a follow-up interview on 6/10/26 at 1:05 p.m., LPN-B stated RN-D was the other nurse who assisted with R1's wound vac change on 6/5/26. LPN-B could not recall if the physician was notified and could not find notification to physician in R1's record about the wound vac not being successfully changed on 6/5/26. LPN-B stated RN-D explained that the facility had 12 hours where they could pack the wound and not use the wound vac. LPN-B stated she left the facility after she assisted RN-D to remove the wound vac and gave the night nurse report. LPN-B stated she reported the incident to RN-F and director of nursing (DON).During an interview on 6/10/26 at 1:13 p.m., RN-D stated when he and LPN-B were unsuccessful getting the wound vac changed, he packed the wound with gauze. RN-D did not notify the physician that they were not able to apply the wound vac. RN-D notified the DON between 1:00 a.m. and 2:00 a.m. and was told LPN-B and RN-F would attempt to reapply in the morning. RN-D stated he followed the hospital discharge orders for dressing when wound vac could not be applied.During an interview on 6/11/26 at 11:20 a.m., RN-E stated on 6/5/26, at shift report it was reported the wound vac was off. Staff had tried to change it and could not get it to adhere so placed a dressing over it. RN-E notified medical doctor (MD)-A midmorning as MD-A was at the facility. RN-E had not observed R1's leg until after MD-A had examined him. RN-E thought someone was going to put the wound vac on but had wanted MD-A to examine it first. R1's wound on the groin looked red, and some irritation and slough. The leg wound was just red and irritated. RN-E did not think R1 had a lot of edema to his leg it, just looked like it was angry. RN-E stated MD-A was not happy the wound vac was off and had not been done on the proper schedule. RN-E did not notify the surgeon that the wound vac was off.During a phone interview on 6/11/26 at 11:21 a.m., RN-F stated she had been the nurse manager at facility. RN-G, another nurse manager, completes wound management on resident. The floor nurses are supposed to complete the Wednesday; Friday wound dressing changes and RN-G would complete Monday. On 5/29/26, RN-F completed wound vac change with RN-D. On 6/1/26, RN-F was given instructions that RN-G would complete wound vac change. RN-G told RN-F that wound care could not follow R1. RN-F reported the information to DON. DON informed RN-F that RN-G would look at the wound. RN-F stated she requested to get the wound care done and DON told her to wait until 6/2/26. RN-F stated RN-B was available and could help with dressing change on 6/1/26 but DON was insistent that it wait until 6/2/26 so RN-G could look at the wound. On 6/2/26, RN-F requested to DON that RN-D was available and could change the wound vac with her. DON stated to wait until 6/3/26, so RN-G could look at the wound as RN-G was not available on 6/2/26 and they could get pictures of the wounds. On 6/3/26, RN-F went in with initiative and changed the wound vac. R1 had a lot of drainage from the wounds. Drainage did not smell or look like an infection was present. R1 had edema and his leg was irritated from the dressing. On 6/5/26, LPN-B and RN-D attempted to change the wound vac. The vac was not suctioning so they applied a dressing. MD-A was onsite 6/5/26, and RN-F wanted MD-A to see R1's wound. RN-F stated she would expect the nurses to do their job and follow physician orders.During an interview on 6/11/26 at 1:46 p.m., RN-G stated she completed weekly wound rounds with the wound care provider. RN-G told RN-F on 6/1/26, that they could not look at R1's wounds because R1 did not meet the criteria as he was still followed by a surgeon so Medicare would not cover the facility wound care staff. RN-G told RN-F she could help her later with changing the wound vac but RN-F stated she was fine and did not need help. RN-G had not heard the wound vac had not been changed until 6/5/26 around 10:00 a.m. RN-G had never visualized R1's wounds. During a phone interview on 6/11/26 at 11:18 a.m., LPN-C stated he began work around 2-2:30 p.m. on 6/5/26. LPN-B had been informed in shift report by RN-E, something about wound dressing not changed, but was unsure of how many days or what the issue was. RN-F assisted LPN-C with removing the dressing that was applied during the evening shift on 6/4/26. LPN-C and RN-F put an abdominal pad (large, soft dressing) and wrapped the wound with gauze. LPN-C stated there was minimal drainage to the wounds. The groin was open and deep. The one on the leg looked superficial and not too deep. Drainage was pink and a little yellow in color from both.During an interview on 6/10/26 at 11:58 a.m., DON stated the wound vac did not get changed from 5/29/26-6/3/26. Nurse managers are expected to change the wound vacs. A follow-up interview on 6/12/26 at 1:53 p.m., DON expected physician to be notified when wound vac was not able to be changed as ordered.During an interview on 6/12/26 at 11:29 a.m., MD-A stated she would have expected a call from facility on 6/5/26 during normal business hours, at least by 7:00 a.m., that the wound vac was off R1. MD-A would expect the next shift to try and apply the wound vac and if that would not work to go to, plan C. If the wound would have been, goopy, yucky, or festering, she would have expected a phone call immediately.R2R2's face sheet dated 6/11/26, identified diagnoses of encounter for palliative care, non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity, and muscle weakness.R2's annual MDS dated [DATE], identified R2 had some difficulty with understanding others and wore glasses. R2 had some cognitive issues. R2 had no behaviors. R2 had no teeth and a mechanically altered diet. R2 had impairment on both sides of lower extremities and was dependent on staff for activities of daily living.R2's care plan dated 5/21/26, identified R2 had a texture modified diet due to choking incident. Interventions included R2 ate meals in the main dining room with direct supervision, staff to assist with cutting up meals, diet per physician order.R2's progress note dated 5/21/26 at 9:38 p.m., identified nursing assistant (NA) alerted RN-F that R2 was choking. RN-F performed CPR on R2 and cleared two big chunks of bread with peanut butter. Advised staff not administer food without consulting nurse first.R2's physician order dated 6/9/26 at 3:59 p.m., identified an order to start minced and moist diet with think liquids per facility starting on 5/28/26.During a phone interview on 6/11/26 at 1:10 p.m., RN-H stated on the evening of 5/21/26 between 8:30 p.m. and 9:00 p.m., she was told to come to the R4 who was unresponsive. R4 was in a Broda (specialized wheelchair designed for people who need advanced positioning, support and comfort) wheelchair. RN-H saw a small tray with peanut butter bread and assumed choking had started. RN-H lifted R4 up and used her legs to support her and began abdominal thrust with both hands folded on abdomen with R4's back to RN-H's chest. R4 vomited two boluses (round mass) of bread with peanut butter and a big lump of bread during the Heimlich. RN-H stated she called the DON and hospice provider but found out later she had the wrong contact information for the hospice provider, so they were not updated.During an interview on 6/12/26 at 10:24 a.m., team director for hospice (TD)-A reviewed hospice information. On 5/21/26, there was no record of a triage call. On 5/23/26, the facility reported an incident of choking from 5/21/26. On 5/28/26, hospice received an updated diet order for minced and moist. TD-A notified R4's family member of incident on 5/23/26. Hospice prefers to be notified immediately of any incidents that occur with residents in their care for continuity of care between hospice and providers.During an interview on 6/12/26 at 1:53 p.m., DON stated she would expect the physician to be notified immediately of a change of condition.The facility Notification of Changes policy dated 3/2024, identified changes in a residents condition or treatment be reported to attending physician or delegate.

Based on observation, interview, and record review the facility failed to follow infection prevention protocols including enhanced barrier precautions (EBP) when providing care to 2 of 3 residents (R2 and R4) observed during cares. Findings include: According to the Centers for Disease Control (CDC): EBP is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together with other high-contact activity, such as part of morning or evening care. This extended contact with the resident and their environment increases the risk of a MDRO (multi-drug resistant organism) (type of bacteria or microbe resistant to multiple antibiotics) spreading to staff hands and clothes. Outside the resident's rooms, Enhanced Barrier Precautions should be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. Hand hygiene is recommended before and after resident contact.R2R2's face sheet dated 6/11/26, identified diagnoses of non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity, displaced bicondylar fracture (break of both sides of tibia below knee which compromises knee weight bearing surface) of right tibia, and displaced bicondylar fracture of left tibia.R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had some difficulty with understanding and wore glasses. R4 had moderate problems with thinking and memory. R2 had no behaviors. R2 had impairment on both sides of lower extremities and was dependent on staff for activities of daily living.R2's treatment administration record (TAR) for 6/2026, identified follow EBP while providing wound cares and other high contact care activities every shift.During an observation and interview on 6/11/26 at 7:52 a.m., nursing assistants (NA)-B and NA-C went to R2's room and performed morning cares which included dressing, grooming, changing incontinent product, and transferring. NA-B and NA-C did not wear EBP while completing tasks.During an interview on 6/11/26 at 8:27 a.m., NA-B stated EBP is worn if a resident has a wound, catheter, or colostomy. NA-B stated EBP should have been worn while providing cares on R2 as she has wounds. During an interview on 6/11/26 at 8:36 a.m., NA-C stated EBP should have worn EBP during cares with R2 because she had wounds. R4R4's face sheet dated 6/12/26, identified diagnoses of left femur osteonecrosis (bone cell death), difficulty in walking, and urinary incontinence.R4's admission MDS dated [DATE], identified R4 had no difficulties with hearing or speech. R4 had intact cognition. R4 had behavioral issues directed at others one to three days. R4 required supervision/touch assist with transfers.R4's care plan dated 5/19/26, identified R4 was on EBP related to [left blank]. Interventions included staff to follow EBP; use appropriate communication to follow EBP; explain reason for use of EBP; staff to put on/remove EBP per enhanced barrier precautions when providing high contact cares.R4's physician order dated 6/3/26, identified negative pressure wound therapy (wound vac) in place for 14 days from surgery.R4's TAR for 6/2026, identified follow EBP while providing wound cares and other high contact care activities every shift.During an observation and interview on 6/10/26 at 7:55 a.m., registered nurse (RN)-B went to R4's room. R4 was sitting in her recliner watching television. RN-B applied a pair of gloves and assessed for edema, redness, and warmth on R4's legs. RN-B did not wear a gown while performing high contact care. RN-B removed gloves and left R4's room without sanitizing hands. RN-A walked out of a resident room with the vital sign machine, did not disinfect the machine, and RN-B took the machine to R4's room with an ipad to call the physician. RN-B did not apply EBP or disinfect vitals machine before placing blood pressure cuff, and oximeter on R4. While on the ipad video call with the physician, RN-B again checked R4's edema in legs, redness, and warmth. RN-B did not wear EBP. R4 ended the phone call, left R4's room with the vital sign machine, sanitized hands outside the door, and brought the vital sign machine to the medication cart at the nurses station. RN-B did not disinfect the machine. RN-B stated he should have worn EBP and disinfected the vital signs machine before and after using it for R4.During an observation on 6/10/26 at 8:23 a.m., director of nursing (DON) entered R4's room as R4 was screaming very loudly. DON sat on R4's bed while R4 was in the recliner and rubbed R4's back and hair to soothe R4. DON was not wearing EBP during this contact. DON stood up from the bed, walked to the door, removed a gown and gloves from the EBP station on the door, asked R4 if she could shut the door, and shut the door.During an interview on 6/10/26 at 9:49 a.m., DON stated she did not have to wear EBP when she was with R4 because she was just touching her. After reviewing CDC EBP recommendations with the DON, she stated, Oh, yeah, I would have to.During an observation on 6/10/26 at 10:05 a.m., hospital lab (HL)-A entered R4's room to draw blood. HL-A wore gloves but no gown. HL-A drew blood from R4's right arm. HL-A removed gloves, sanitized hands, and left room.During an interview on 6/10/26 at 10:16 a.m., HL-A stated she was told by the DON not to wear a gown today, because state was in the building and I can't wear gowns in the hallways. HL-A said technically she was supposed to have a lab coat because she is drawing blood. HL-A drew blood on approximately 20 residents this day and was very upset that she could not wear her lab coat. HL-A usually does not have to worry about EBP because she wears a gown for every patient. HL-A stated the DON was going to call HL-A's manager and talk about the issue.During an interview on 6/12/26 at 1:53 p.m., DON stated she would expect that staff followed EBP precautions when performing high contact cares on residents.The facility Enhanced Barrier Precautions policy dated 4/1/24, identified the facility implemented EBP for the prevention of transmission of multi-drug resistant organisms. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care: any skin opening requiring a dressing.

Based on interview and document review the facility failed to ensure care plan interventions related to anticoagulant therapy were effectively communicated to direct care staff responsible for observing and reporting changes in condition and failed to develop a comprehensive individualized care plan that addressed cardiac management for 1 of 3 residents (R2) reviewed for quality of care who had a significant cardiac history and administered blood thinning medications. Findings include:R2's face sheet identified the following diagnoses; acute diastolic congestive heart failure (sudden worsening of heart failure where the heart becomes stiff and cannot fill with blood properly, leading to fluid buildup), personal history of transient ischemic attack (TIA) temporary blockage of blood flow to the brain causing stroke-like symptoms), cerebral infarction without residual deficits (stroke with no lasting effects), atrial fibrillation (abnormal heartbeat that can cause blood clots or stroke), presence of aortocoronary bypass graft (heart bypass surgery to restore blood flow around blocked arteries), hypertension (high blood pressure), ischemic cardiomyopathy (weak heart muscle caused by poor blood flow from blocked heart arteries), atherosclerotic heart disease of native coronary artery without angina pectoris ( plaque buildup in the heart's own arteries, but not causing chest pain), and ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall ( heart attack in the lower part of the heart caused by a blocked artery and long term anticoagulation.R2's admission minimum data set (MDS) dated [DATE], identified R1's cognition was intact. R2 required staff to assist with activities of daily living (ADL)'s and used a wheelchair for mobility. R2's order summary dated 3/6/26 identified warfarin sodium 2 milligram (mg) tablet by mouth every evening for long term use of anticoagulants. On 2/13/26 monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath (SOB) and nose bleeds.R2's care plan was reviewed on 3/9/26 and lacked cardiac management related interventions and goals. Care plan dated 1/17/26, identified a problem-potential for alteration in blood formation and coagulation related to the use of anticoagulant medication. Diagnosis of coronary artery without angina pectoris. Interventions identified anticoagulant medication as ordered by MD, monitor and notify the MD of signs and symptoms of bleeding and monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath (SOB) and nose bleeds.Review of R2's undated Kardex and nursing assistant care guide sheets did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding or that R2 was on blood thinning medication.R2's ED note dated 2/9/26, identified a suspected GI source of anemia as R2 was told he was having some dark stools although he did not witness these. During an interview on 3/9/26 at 4:21 p.m., R2 stated he was hospitalized from [DATE] to 2/12/26 for gastrointestinal bleeding. R2 reported that a male staff member had informed him a couple of days prior to hospitalization that he was having dark stools. R2 stated he uses a bedpan for toileting and staff manage the bedpan, so he did not directly observe the stool. R2 reported he assumed staff were monitoring this condition since they informed him of the change.During an interview on 3/10/26 at 4:39 p.m., nursing assistant (NA)-A stated that she was not aware R2 was on blood thinning medication. She reported, I am not sure what signs and symptoms I would have to tell the nurse about if a resident received blood thinning medications. It doesn't say anything about that on our care sheets. That information should be on there. If you had to monitor for signs and symptoms of a bleed, I am not sure what that would be. Did When asked about specific symptoms, NA-A stated she was not familiar with what a tarry stool was and indicated that many residents have bruising and she does not report every bruise, as she believes nursing staff can observe them.During an interview on 3/11/26 at 8:48 a.m., NA-B stated she had no way of knowing which residents were on blood thinning medications. She indicated that while she would report visible blood in stool to the nurse, she was not aware of other signs and symptoms to monitor for bleeding. NA-B stated it would be helpful if this information was included on care sheets so staff would know what to observe and report. She further stated she was unaware that residents on blood thinners may bruise easily or experience weakness and indicated she may delay reporting such findings until the end of her shift if she did not recognize them as significant. NA-B reported she was unsure if she had access to the kardex. When asked about specific symptoms, NA-B was unable to describe what a tarry stool was and stated she does not report every bruise observed on a resident.During an interview on 3/11/26 at 10:32 a.m., NM-A confirmed that the kardex and care guides for direct care staff did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding for residents on anticoagulants. NM-A stated the care guide is intended to direct daily care and communication with staff. NM-A also confirmed that R2's care plan lacked individualized interventions for monitoring and responding to cardiac symptoms, including chest pain, shortness of breath, or other signs of cardiac distress.During an interview on 3/11/26 at 11:29 a.m., the DON confirmed that R2's care plan lacked individualized interventions for monitoring and responding to cardiac symptoms, including chest pain, shortness of breath, and other signs of cardiac distress. The DON also confirmed that the Kardex and care guides for direct care staff did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding for residents taking anticoagulants. He stated that the care guide serves as the primary tool for directing daily care and informing staff how to monitor and report resident needs.Facility policy, Care Planning, revised 11/24, outlines that each resident must have a person-centered, individualized care plan developed by the interdisciplinary team to address medical, physical, psychosocial, and functional needs. A baseline care plan is to be developed within 48 hours of admission to meet immediate needs, followed by a comprehensive care plan developed no later than the 21st day of admission. The comprehensive care plan is intended to derive interventions from a thorough assessment and be meaningful and targeted to the resident, used by staff to guide daily care, and updated as the resident's condition changes.

Based on observation, interview, and document review, the facility failed to ensure a timely comprehensive cardiac assessment and response when 1 of 3 residents (R2) exhibited acute cardiac symptoms and requested emergency medical evaluation, which resulted in delayed provider notification and emergent hospital transfer, reviewed for quality of care. Findings includeR2's face sheet identified the following diagnoses; acute diastolic congestive heart failure (sudden worsening of heart failure where the heart becomes stiff and cannot fill with blood properly, leading to fluid buildup), personal history of transient ischemic attack (TIA) temporary blockage of blood flow to the brain causing stroke-like symptoms), cerebral infarction without residual deficits (stroke with no lasting effects), atrial fibrillation (abnormal heartbeat that can cause blood clots or stroke), presence of aortocoronary bypass graft (heart bypass surgery to restore blood flow around blocked arteries), hypertension (high blood pressure), ischemic cardiomyopathy (weak heart muscle caused by poor blood flow from blocked heart arteries), atherosclerotic heart disease of native coronary artery without angina pectoris ( plaque buildup in the heart's own arteries, but not causing chest pain), and ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall ( heart attack in the lower part of the heart caused by a blocked artery, shown on the heart test (ECG).R2's admission minimum data set (MDS) dated [DATE], identified R1's cognition was intact. R2 required staff to assist with activities of daily living (ADL)'s and used a wheelchair for mobility. R2's care plan that was reviewed on [DATE] did not include a cardiac-focused problem and individualized interventions to guide staff in monitoring and responding to potential changes in cardiac status, despite the residents' extensive cardiac history.During an observation and interview on [DATE] at 4:21 p.m., R2 was lying on the left side of his bed with his back facing the wall. R2 stated that on [DATE], before 5:00 p.m. (suppertime) he experienced acute, severe left side chest pain radiating down the left arm, shortness of breath, nausea, and anxiety, consistent with possible cardiac distress. R2 reported a history of extensive cardiac disease including 13 stents, 3 prior heart attacks, open heart surgery (CABG), atrial fibrillation on warfarin, and a prior stroke. R2 stated he had put his call light on because he was having chest pain and initially a female staff answered his light, he told her he was having chest pain that felt like a heart attack, she said she would get the nurse. R2 explained a black male nurse came into his room asked him what was going on and he told the nurse he was having chest pain going down his left arm and thought he was having a heart attack and wanted to be sent to the ED. R2 stated the nurse refused to call an ambulance despite repeated requests, telling him that his vital signs were fine and he did not need to go. He described receiving only a blood pressure check, pulse oximetry, and temperature measurement, with no auscultation of the heart or lungs or other cardiac assessment performed. R2 stated that he was eventually taken to the hospital after family member (FM)-A intervened by contacting the administrator and was not sent to the ED until well after 6:00 p.m. R2 reported he tried to use his cell phone to dial 911 himself but it wasn't working. R2 expressed that he felt frantic and unsafe due to the delay in care and described the facility's response as negligent, noting that staff did not respond adequately to the severity of his symptoms. R2 stated, he called FM-A the first time when staff refused to send him and continued to call because the staff were not listening to him or taking him seriously. R2 stated, I truly thought I was having a heart attack, I was scared! R2 stated he could not figure out why staff would not send him, if it turned out to be nothing at least he was checked.During a phone interview on [DATE] at 11:21 a.m., FM-A stated on [DATE], R2 called him frantically four times, reporting chest pain radiating down his left arm and stating, I'm having a heart attack, but staff would not send him to the ED despite his requests. FM-A further stated that R2 told him the nurse checked his vitals and said they were within normal limits and did not require emergent treatment. The calls occurred at 4:53 p.m., 5:33 p.m., 5:41 p.m., and 5:49 p.m. FM-A explained that in between calls, he attempted to contact the administrator. He texted twice and called once, alerting her that staff were refusing to send R2 to the emergency department (ED). FM-A further explained the administrator responded in a text message that she would take care of it and that she was sending the director of nursing (DON) to handle it. FM-A stated, The facility staff should have listened to R2's urgent requests to be sent to the ED, and he should not have had to have me intervene for him to get emergent care promptly with his history of cardiac problems. He reported that from the onset of symptoms to the time 911 was called, over and hour had passed, and expressed concern given R2's history of heart attacks, stents, CABG, atrial fibrillation, and current GI bleeding with hemoglobin 5.7. FM-A further stated, I am not a medical person, but seeing as R2 was saying he was having a heart attack, and he wanted to be checked out at the ED, and he ended up with a low hemoglobin requiring 3 blood transfusions and all those stomach ulcers, I believe he would have died had I not intervened. He emphasized that staff should have called an ambulance when R2 complained of chest pain and requested it; he shouldn't have had to call me four times and for me to call the administrator to get him to the ED. FM-A stated with R2's previous heart attacks his vital signs were considered normal as well and FM-A believed that was not an indicator that ruled out a heart attack.R2's progress note dated [DATE] at 6:05 p.m., documented transfer to the hospital for chest pain rated 10/10. The hospital diagnosis listed was ST-elevation myocardial infarction (STEMI- which is not consistent with the hospital diagnosis of non-STEMI) involving the inferior wall of another coronary artery (heart attack in the lower part of the heart caused by a blocked artery). Vital signs at 6:03 p.m. were blood pressure 113/61, pulse 68 regular, respiratory rate 20 temperature 97.6 F, oxygen saturation 96% on room air. Pain was 10/10. R2 was alert and oriented, usual cognition intact. No behavioral concerns were noted.R2's ambulance report dated [DATE] indicated that EMS received an emergent call at 6:12 p.m. for chest pain and arrived on scene at 6:18 p.m. EMS found R2 lying in bed, alert and oriented x 4, reporting crushing chest pain radiating down his left arm for approximately 30 minutes, stating it felt like his previous heart attacks. He denied shortness of breath, dizziness, or recent illness. EMS performed vital signs monitoring, 12-lead ECG, and physical assessment, noting normal skin, head, neck, heart, neurological, and mental status, except for chest pain. EMS administered aspirin, sublingual nitroglycerin, and oxygen. R2 was transferred from bed to stretcher, transported in a position of comfort, and remained hemodynamically stable during transport. He was delivered to the ED, and care was transferred to hospital staff.R2's progress note dated [DATE] at 7:02 p.m., documented a hospital transfer for acute chest pain rated 10/10 with a hospital diagnosis of ST-elevation myocardial infarction (STEMI) involving the inferior wall of another coronary artery. At approximately 6:00 p.m., R2 reported sudden chest pain and shortness of breath. Vital signs were temperature 97.6 F, respiratory rate 20, pulse 68 regular, blood pressure 113/61, oxygen saturation 96% on room air. The resident was alert, oriented, and cognitively intact. Interventions offered included nitroglycerin, oxygen therapy, and head-of-bed elevation, all initially refused by the resident, who stated he wanted hospital transfer. The primary nurse notified the nurse practitioner (NP) at 6:03 p.m. and the facility RN at 6:10 p.m. Emergency Medical Services (EMS) was activated, and chewable aspirin was given after education. Chest pain decreased slightly to 8/10. EMS assessed R2, obtained repeat vital signs (BP 105/75), and offered nitroglycerin, which was eventually accepted. R2 was transported to the ED at 6:34 p.m., alert, verbal, and in stable condition, with all pertinent documentation sent with him.Review of R2's record reflected documentation of vital signs and pain assessment; however, there was no documentation of a comprehensive cardiac assessment or further clinical evaluation of the reported chest pain.R2's ED note dated [DATE], identified the R2 presented for evaluation of chest pain at 6:44 p.m. The record documented R2 had an extensive cardiac history including prior myocardial infarctions in 1997, 2004, 2009, and 2010, coronary artery disease (heart's arteries are narrowed or blocked, which can reduce blood flow and lead to heart problems), ischemic cardiomyopathy, atrial fibrillation, heart failure, and prior stroke in 2015. The record also identified a history of coronary artery bypass graft surgery in 2011 and multiple coronary artery stent placements and angioplasties (procedure to open a narrowed or blocked artery in the heart to improve blood flow). The ED note documented R2 presented from the facility with left-sided chest pain that began at approximately 5:00 p.m. on [DATE] and radiated to the left arm. R1 reported the pain felt similar to previous heart attacks. The record documented facility staff administered nitroglycerin and that R1 requested staff call emergency medical services but reported it took staff awhile to do so. The ED documentation identified diagnostic testing including an Electrocardiogram (ECG) which showed ST depressions and laboratory testing with an elevated Troponin Test of 50, raising concern for NSTEMI (A heart attack caused by a partially blocked artery that damages some heart muscle). Additional laboratory results revealed severe anemia with a hemoglobin level of 5.7, suspected to be related to a gastrointestinal hemorrhage (stomach bleed). The record further documented R1 was on chronic anticoagulation therapy and had an oxygen saturation of 87% on room air upon arrival at the ED. R2 received blood transfusions and was transferred to the hospital for further evaluation and treatment with diagnoses including NSTEMI, severe anemia (serious condition where the blood cannot carry enough oxygen because red blood cell levels are very low), gastrointestinal hemorrhage, atrial fibrillation, chronic anticoagulation (taking blood-thinning medication regularly to help prevent dangerous blood clots) and hypoxia (low oxygen in the blood that can make the body and organs not work properly).R2's Discharge summary dated [DATE] to [DATE], identified admission for chest pain, severe anemia, and gastrointestinal bleeding from gastritis and ulcers. Labs showed troponin 50 56 (heart muscle stress), hemoglobin 5.7, and EKG changes consistent with NSTEMI. He was transfused with 3 units of blood, which resolved his chest pain. Endoscopy identified bleeding ulcers that were treated, and hemoglobin stabilized to 9.3 at discharge. Warfarin therapy continued, and echocardiogram showed a small new area of reduced heart motion. The hospital recommended follow-up care for monitoring of heart and GI status.During an interview on [DATE] at 4:39 p.m., nursing assistant (NA)-A stated that R2 told her he might be having a heart attack, reporting severe pain in his left arm and noting his history of previous heart attacks. NA-A stated she immediately notified RN-A about R2's report. NA-A started her shift on [DATE] at 4:00 p.m., and estimated the incident had occurred around 5:00 p.m., before supper. She observed that it took a significant amount of time for R2 to be transported to the ambulance, which did not occur until after supper (around 6:00 p.m.). NA-A stated during that time R2 was visibly distressed, repeatedly pressing the call light at least three times, asking when the ambulance was coming. She reported that R2 looked very worried and upset, almost in tears, and that she was concerned about R2's safety. NA-A stated she did not know what to tell R2, as the nurses had not provided instructions, and she was not present when RN-A went into the room to speak with R2.During a phone interview on [DATE] at 4:59 p.m., registered nurse (RN)-A stated he was the nurse responsible for R2 on [DATE] during the evening shift. RN-A was unsure of exact times but stated a female aide informed him that R2 wanted to see him. The aide did not explain what R2 needed, and RN-A assumed the resident had fallen, so he brought equipment to check vital signs. RN-A stated that R2 was experiencing chest pain and appeared agitated. He reported he was unaware of R2's extensive cardiac history. When he attempted to assess the severity of R2's chest pain, R2 told him he just wanted to go to the ED. RN-A stated he was unaware of a specific facility policy or procedure for assessing cardiac symptoms. He indicated that he would consider blood pressure in the 150/90 range or pulse over 100 as a significant cardiac event. RN-A stated that he performed a full cardiac assessment, but he was unable to articulate what that included, and he did not document the cardiac assessment or R2's request to go to the ED in the resident's record. RN-A was unable to establish a clear timeline but thought that nurse manager (NM)-A had asked him around 5:50 p.m., when he was in the hallway outside of R2's room that FM-A had concerns that R2 was having heart attack symptoms and staff had refused to send to the ED. RN-A denied refusing care and stated NM-A got a set of vitals on R2 which were stable, called the provider and 911. R2 was then sent to the ED around 6:10 p.m.During an interview on [DATE] at 10:32 a.m., Nurse Manager (NM)-A stated he used to be the DON but was now a nurse manager. NM-A stated on [DATE], the administrator texted him at 5:46 p.m. reporting that FM-A indicated staff were refusing to send R2 to the hospital with symptoms of cardiac issues despite his request. NM-A went to the nursing station on R2's unit, asked RN-A if he refused a resident request to go to the hospital, and then proceeded to R2's room with vital signs equipment. NM-A observed R2 lying in bed and upset, reporting left-sided chest pain, a history of three heart attacks, stents, and open-heart surgery, and stating he wanted to go to the hospital immediately. R2 refused other interventions including oxygen and head-of-bed elevation. NM-A noted that vital signs were within normal limits but stated that vital signs can be normal during a heart attack. NM-A instructed RN-A to call 911 and contacted the NP just before 6:00 p.m. RN-A called EMS approximately five minutes later, and R2 was transported to the hospital, where he was found to have a GI bleed and ulcers. NM-A stated that as soon as R2 reported chest pain, he should have been sent to the ED immediately, a full cardiac assessment should have been performed, the provider notified, and all actions documented in the progress note. He further stated that a delay in care for a resident with extensive cardiac history experiencing cardiac symptoms could have resulted in a serious medical event.During an interview on [DATE] at 10:27 a.m., the administrator confirmed that FM-A attempted to call her on [DATE] but she had missed the call. She confirmed that FM-A texted her at 5:34 p.m., stating that R2 was having chest pain and arm pain, believed he was having a heart episode, and wanted to go to the hospital, but staff were refusing to send him. The administrator responded at 5:46 p.m., apologizing and stating that the DON was headed to the unit. FM-A clarified that R2 had a history of bypass surgery, two heart attacks, and 14 stents, emphasizing the seriousness of his complaints. In a follow-up text, FM-A stated that R2 called again, saying he could not wait, feared he was going to die, and wanted an ambulance called because his phone could not dial 911. The administrator stated that she followed through with FM-A's concerns and ensured that R2 was sent to the emergency department.During an interview on [DATE] at 11:39 a.m., DON stated he started at the facility on [DATE] and was familiar with R2. He reviewed the progress notes and confirmed that on [DATE], R2 reported chest pain rated 10/10 and shortness of breath. He stated that a comprehensive cardiac assessment should have been completed, including vital signs, pulse checks, evaluation for shortness of breath, chest pain, nausea, vomiting, diaphoresis, and dizziness, and documented in the progress note. He noted that no such cardiac assessment was documented. The DON stated that for residents with an extensive cardiac history and symptoms mimicking a heart attack such as R2, an immediate intervention would be to send the resident to the ED and notify the provider. DON confirmed that the administrator had messaged him on [DATE] about FM-A reported that a nurse refused to send R2 to the ED and that he verbally educated registered nurse (RN)-A that if a resident wants to go to the ED, staff should let them go; RN-A understood and agreed. The DON stated that no written education or competency testing on cardiac assessment and monitoring had been provided at that time to any of their staff.Facility document, undated Basic head to toe assessment, included a cardiovascular component, which required staff to assess apical pulse (rate and rhythm), peripheral pulses bilaterally (strength and equality), calf tenderness, edema (location, pitting or non-pitting), capillary refill and IV site condition and signs/symptoms of infection, including monitoring for antibiotic use.A comprehensive facility policy for cardiac assessment and monitoring was requested and not received.The policy should ensure timely recognition, evaluation, and intervention for residents experiencing acute or worsening cardiac symptoms, particularly those with a known cardiac history. The policy should require immediate assessment for symptoms such as chest pain, shortness of breath, palpitations, dizziness, diaphoresis, nausea, or pain radiating to the arm, jaw, or back, including a complete vital sign check (blood pressure, pulse, respiratory rate, temperature, oxygen saturation, and pain scale) and a systematic physical assessment of heart and lungs, peripheral pulses, edema, jugular venous distension, skin color, and capillary refill. It should specify continuous or frequent monitoring during acute events and routine monitoring for high-risk residents, with all findings documented in real time, including resident requests, refusals, and interventions. The policy must clearly outline notification and escalation procedures, requiring immediate provider notification and EMS activation whenever acute cardiac symptoms are present or a resident requests hospital evaluation, regardless of vital signs. In addition, staff education and competency verification on cardiac assessment, symptom recognition, and emergency response should be provided annually, including training for nursing assistants on prompt reporting changes in condition. Finally, the policy should include quality monitoring mechanisms, such as documentation audits and incident reviews, to ensure compliance and continuous improvement in the care of residents with potential cardiac events.

Based on interview and document review, the facility failed to ensure complete and accurate documentation in the medical record when a nurse failed to document a cardiac assessment and the residents request for hospital evaluation for 1 of 3 residents (R2), reviewed for quality of careFindings includeR2's face sheet identified the following diagnoses; acute diastolic congestive heart failure (sudden worsening of heart failure where the heart becomes stiff and cannot fill with blood properly, leading to fluid buildup), personal history of transient ischemic attack (TIA) temporary blockage of blood flow to the brain causing stroke-like symptoms), cerebral infarction without residual deficits (stroke with no lasting effects), atrial fibrillation (abnormal heartbeat that can cause blood clots or stroke), presence of aortocoronary bypass graft (heart bypass surgery to restore blood flow around blocked arteries), hypertension (high blood pressure), ischemic cardiomyopathy (weak heart muscle caused by poor blood flow from blocked heart arteries), atherosclerotic heart disease of native coronary artery without angina pectoris ( plaque buildup in the heart's own arteries, but not causing chest pain), and ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall ( heart attack in the lower part of the heart caused by a blocked artery, shown on the heart test (ECG).R2's admission minimum data set (MDS) dated [DATE], identified R1's cognition was intact. R2 required staff to assist with activities of daily living (ADL)'s and used a wheelchair for mobility. During an interview on 3/9/26 at 4:21 p.m., R2 stated that on 2/9/26 before supper he experienced acute left-sided chest pain radiating down his left arm with shortness of breath and nausea. R2 reported a history of extensive cardiac disease including multiple stents, prior heart attacks, open heart surgery (CABG), atrial fibrillation, and prior stroke. R2 stated he activated his call light and informed staff he believed he was having a heart attack and requested to be sent to the emergency department (ED). R2 reported the nurse checked his vital signs but refused to call an ambulance, stating his vital signs were fine. R2 stated he continued to request hospital evaluation and contacted family member (FM)-A because staff were not sending him to the hospital. R2 stated he felt frightened and believed he was having a heart attack. R2 further stated he was later hospitalized where bleeding stomach ulcers were identified and required treatment and blood transfusions.During a phone interview on 3/11/26 at 11:21 a.m., FM-A stated he was R2's son. FM-A reported that on 2/9/26 R2 called him four times stating he was having chest pain radiating down his left arm and believed he was having a heart attack but staff were refusing to send him to the ED. FM-A confirmed the calls occurred at 4:53 p.m., 5:33 p.m., 5:41 p.m., and 5:49 p.m. FM-A stated he contacted the administrator to report staff were refusing to send R2 to the hospital. FM-A reported more than an hour passed from the onset of symptoms until 911 was called and stated staff should have called an ambulance when R2 complained of chest pain and requested hospital evaluation.R2's progress note dated 2/9/26 at 6:05 p.m. documented transfer to the hospital for chest pain rated 10/10. Vital signs at 6:03 p.m. were blood pressure 113/61, pulse 68 regular, respiratory rate 20, temperature 97.6 F, oxygen saturation 96% on room air. R2 was alert and oriented.R2's progress note dated 2/9/26 at 7:02 p.m. documented hospital transfer for acute chest pain rated 10/10. The note documented vital signs, notification of the nurse practitioner at 6:03 p.m., activation of Emergency Medical Services (EMS), and transport to the emergency department at 6:34 p.m.Review of R2's medical record did not include documentation of a comprehensive cardiac assessment or documentation of R2's repeated requests to be sent to the hospital during the onset of chest pain symptoms.During an interview on 3/10/26 at 4:39 p.m., nursing assistant (NA)-A stated R2 told her he might be having a heart attack and reported severe pain in his left arm. NA-A stated she immediately notified RN-A. NA-A reported R2 appeared very worried and repeatedly used the call light asking when the ambulance was coming. NA-A estimated the incident occurred around 5:00 p.m. and that R2 was not transported until after supper around 6:00 p.m.During a phone interview on 3/10/26 at 4:59 p.m., registered nurse (RN)-A stated he was the nurse responsible for R2 on 2/9/26 during the evening shift. RN-A stated a nursing assistant informed him that R2 wanted to see him. RN-A stated R2 reported chest pain and appeared agitated. RN-A stated he was unaware of R2's cardiac history. RN-A reported he attempted to assess R2 but the resident stated he wanted to go to the ED. RN-A performed a cardiac assessment but was unable to describe what the assessment included and acknowledged he did not document the cardiac assessment or R2's request to go to the ED in the medical record. RN-A stated nurse manager (NM)-A later obtained vital signs and contacted the provider and EMS; R2 was sent to the ED around 6:10 p.m.During an interview on 3/11/26 at 10:32 a.m., nurse manager (NM)-A stated when R2 reported chest pain a full cardiac assessment should have been completed, the provider notified, and the resident sent to the ED without delay. NM-A confirmed that RN-A was instructed to document his findings and did not do so.During an interview on 3/11/26 at 11:39 a.m., the director of nursing (DON) confirmed RN-A did not document a cardiac assessment or R2's requests for emergent care on 2/9/26 and stated this information should have been documented in the resident's medical record.Policy requested for resident records-identifiable information was requested and not received. Facility policy should address complete, accurate, and timely documentation in the resident's medical record and clearly identify documentation expectations for assessments, resident complaints, provider notification, and emergent transfers.

Based on interview and document review, the facility failed to ensure four of five residents (R1, R4, R2, and R5) reviewed for financial exploitation were free from misappropriation of personal property and financial exploitation when facility staff stole resident credit/debit cards or card information and made unauthorized transactions totaling over $5,000. This had the potential to affect all residents residing at the facility. Findings include:R1R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderately impaired cognition and required partial to substantial assistance from staff for most activities of daily living (ADL's). R1's facesheet dated 7/9/25, indicated he was his own responsible party and his emergency contact was his spouse, R4. R1's diagnoses included unspecific dementia. R1's care plan dated 6/11/25, identified he was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R1's progress note dated 6/12/25, indicated the business office manager (BOM) alerted the social services direct (SDD) of suspicious activity on R1's banking statement and a large amount of missing money. R1 stated he had not given his banking information to anyone or made any new purchases. BOM and R2 called the bank and communicated there were many purchases on the account R1 didn't make. The bank put a stop on the account. Police were called and a report filed. Police spoke to the bank and stated a bank employee would come to the facility to assist R1 with filling out paperwork related to the fraudulent purchases. R1's bank form titled Cardholder Statement of Disputed Items dated 6/12/25, included a list of disputed transactions with dates, dollar amounts, and merchants for cardholder name of R1. Disputed transactions marked as unauthorized/counterfeit transactions (cardholder did not authorize or engage in the transaction) dated 5/19/25 through 6/11/25. There were 65 disputed transactions totaling $4,040.18. R1's bank statement dated 5/30/25, included the following transactions:- $279.61 on 5/23/25 to LULULEMONCOM- $136.56 on 5/27/25 to VALLEYFAIR ONLIN[E]- $168.00 on 5/27/25 to LULULEMONCOM R1's bank statement dated 6/30/25, included the following transactions:- $75.06 on 6/4/25 to eBay- $108.00 on 6/6/25 to Nike.com- $225.00 on 6/6/25 to Nike.com- $39.99 on 6/9/25 to SUGARBABYCARE- $69.80 on 6/9/25 to SUGARBABYCARE- $129.00 on 6/9/25 to LULULEMONCOM- $168.00 on 6/9/25 to LULULEMONCOM- $263.80 on 6/9/25 to Nike.com- $223.45 on 6/10/25 to VF Outdoor, LLC (a subsidiary of VF Corporation, an apparel, footwear, and accessories company that owns brands including Timberland)- $27.75 on 6/11/25 to TIKTOK SHOP- $35.94 on 6/11/25 to eBay- $168.00 on 6/11/25 to LULULEMONCOM- $198.00 on 6/11/25 to VF Outdoor, LLC- $198.00 on 6/11/25 to VF Outdoor, LLC a second time- $65.76 on 6/12/25 to eBay Nursing Home Incident Report submitted to the state agency (SA) dated 6/17/25, identified an allegation of financial exploitation for R1. Description of the incident included, On June 12, 2025, facility identified $4,047.67 in unauthorized transactions on resident [R1's] bank account, occurring between May 16 through June 12, 2025. [R1] did not approve these charges. Today, we confirmed the address linked to the transaction belongs to a facility employee. Alleged perpetrators identified in the report included one nursing assistant (NA), NA-A. Investigation follow-up report submitted to the SA dated 6/23/25, identified NA-A was interviewed after a Valley Fair (local amusement park) purchase made with R1's card was traced to NA-A's first name and a separate purchase from Sugar Baby Crush was linked to the same street address as NA-A's documented address, but with a one-digit difference in the apartment number. NA-A denied involvement in the transactions. NA-B was interviewed when online orders under his name were linked to the unauthorized use of another resident, R2's, financial information with shipments sent to NA-B's address on file. NA-B stated this was his previous address and he now lived at the address linked to the Sugar Baby Crush on R1's bank statement. NA-B denied involvement. Staff members with linked address were suspended pending further investigation. Investigation conclusion noted, the allegation was verified based on evidence collected during the investigation. During an interview on 7/1/25 at 11:16 a.m., R1 stated he was not sure of the exact amount, but people had taken his money without him knowing or authorizing this. His card was not taken, but money was taken out of his associated checking account some way or another. He previously kept his card in his wallet and wallet in his pocket or on the dresser. Now he kept it in a lockbox. R1 had worried this would continue to happen, but now had a new card. He was upset that his money was disappearing without him knowing and worried he might try to go shopping and have his card declined. He did not realize anyone was using the card prior to the BOM telling him about it, she ran the account statement and showed him. During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated she noted unusual transactions on R1's bank statement on 6/12/25. She saw purchases from that day and assisted R1 with cancelling his card immediately. The administrator in training (AIT) stated staff later noticed some of the purchases were related to an address of a staff member. The AIT stated NA-A was the name that appeared on one transaction and NA-B, who worked at the facility through a staffing agency, had an order shipped in his name from another transaction. Both were suspended. The facility called places where transactions occurred to get associated names and addresses. Staff were suspended as soon as they were identified. 14 or 15 people had been suspended pending investigation. Statements were taken from the suspended staff members who all denied involvement. The investigating police detective provided the facility with photographs of people at Valley Fair traced back to the Valley Fair transaction. The facility reviewed the images and identified three staff members. The facility was not sure how staff got access to R1's card because it was not missing, it could potentially have been added to Apple Pay as this is what R2's bank reported happened with his card. During an interview on 7/7/25 at 10:44 a.m., the administrator stated nursing assistant in training (NAIT)-B's employment was terminated because of the Valley Fair footage, the Valley Fair tickets being sent to his email address, and because his home address fit with other purchases made. That information came from the police detective (PD). NA-B was barred from working at the facility through the staffing agency because a purchase made on R1's account was sent to NA-B's address. NAIT-B did not respond when contacted for interview. During an interview on 7/8/25 at 2:44 p.m., NA-B stated he had picked up a few shifts at the facility through a staffing agency and his last shift was on 4/28/25. There was currently an investigation going on about fraud at the facility and he was now suspended from picking up shifts through the agency. NA-E stated a friend working at the facility, NAIT-B, had come around their friend group saying he had a way to get clothes and stuff like that and something had happened with a credit card. NAIT-B put card information into an application used to buy clothes from [NAME] gear on NA-B's cell phone. NA-B stated NAIT-B never told him he was not using his own money so NAIT-B made purchases not knowing the card belonged to someone else. NA-B used the card for transactions at [NAME], Nike Tech, and shoes and stated those were the three items he bought. NA-B was working with police and gave them the purchased items. NA-B stated police informed him the card belonged to a resident at the facility and he did make purchases with the card but was unaware the card belonged to a resident at the time. He endorsed making at least three purchases with the card for clothes and shoes from approximately June 12th through June 15th. R4R4's quarterly MDS assessment dated [DATE], indicated R4 had moderately impaired cognition and was dependent on staff or required substantial staff assistance for most ADL's. R4's facesheet dated 7/9/25, indicated her spouse, R1, was her responsible party and emergency contact. R4's diagnoses included unspecified dementia, disorientation, other signs and symptoms involving cognitive functions and awareness, and adjustment disorder with depressed mood. R4's care plan dated 5/5/25, identified she was at risk for abuse and or neglect and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R4's progress note dated 6/16/25, indicated the SSD followed up with R4 due to the [NAME][n]cial concern and she had no further questions or concerns. Bank statements for period ending 5/30/25 and 6/30/25 identified the statements were for an account under both R1 and R4's names. The account number was the same as the account number on R1's Cardholder Statement of Disputed Items. During an interview on 7/1/25 at 10:48 a.m., R4 stated a good amount of money was taken out of her and R1's account. She was not sure when or how this happened, but it was scary and overwhelming. She was tearful and concerned about her husband, she felt more sorry for him than herself. It bothered him and she worried about him. R1 was a veteran and had worked hard for his money, he went through hell and high water in the war. She had noticed him crying in his sleep and this hurt her to hear. R4 stated stealing was one of the lowest things a person could do and she hoped the people who took their money without authorization were kicked out of the facility. During a joint interview on 6/30/25 at 3:42 p.m. the AIT stated R4 was the spouse of R1 and R1 made financial decisions for her, though was not a power of attorney. The AIT stated the facility became aware R4's name was on the same account as R1's. The BOM stated the fraudulent charges linked to R1's debit card were on a checking account shared by both R1 and R4 and the money in the account belonged to them both. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of allegations of financial exploitation of R4 on 6/26/25 during a monthly billing-related review phone call with the corporate business office. R1 was discussed and the BOM brought up R4 and stated a hold needed to be placed on her collection to the facility until the fraudulent charges were reimbursed by the bank. The administrator stated she had not previously realized R1's bank account was shared with R4 and given that they were on the same account the financial exploitation affected R4 too. The administrator reviewed a copy of R1's bank statement dated 5/30/25 provided to the surveyor by the facility and confirmed both R1 and R4's names were listed on the account. R2R2's quarterly MDS assessment dated [DATE], indicated R2 had moderately impaired cognition and required supervision/touching assistance to no assistance from staff with most ADL's. R2's facesheet dated 7/9/25, indicated he had a financial power of attorney (POA). R2's diagnoses included Parkinson's disease. R2's care plan dated 5/20/25, identified he was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R2's progress note dated 6/20/25, indicated the AIT assisted R2 and POA with a meeting with the police regarding unauthorized transactions on R2's bank account. A police case was filed, bank card was cancelled, and bank initiated the refund process. R2's bank statement dated 5/16/25, identified transactions from the previous 30 days. Notations on the statement identified the following: on 5/4/25 the card was added to Apple Pay (mobile payment and digital wallet service), on 5/15/25 a Cash App (an application for peer-to-peer money transfers) transaction included NA-B's first name, on 5/15/25 the card was blocked by the bank, the bank would send a letter about fraud/amount reimbursed and a new debit card in 10 days, and fraudulent charges totaled $709.97. Cash App transactions listed as CASHAPP*[NA-B's first name]* included eight separate transactions on 5/15/25 for amounts of $10 and $15 totaling $110 in charges. Additional transactions included:- $82.18 on 5/7/25 to Nike.com- $50.80 on 5/12/25 to WAL-MART Investigation follow-up report submitted to the SA dated 6/23/25, was the follow-up report for the Nursing Home Incident Report about R1. It identified there was now an additional case regarding R2. NA-E was interviewed after online orders under his name were linked to the unauthorized use of R2's financial information with shipments sent to his address on file with the staffing agency. He denied involvement. R2's POA, POA-A, had confirmed there were purchases on R2's account that he did not authorize beginning around 5/15/25. Police were notified, bank contacted, and card cancelled. Nursing Home Incident Report submitted to the SA dated 6/25/25, identified an allegation of financial exploitation for R2. Description of the incident noted suspected fraudulent activity was identified on review of R2's bank statements. Alleged perpetrators identified in the report included seven NA's (NA-A, NA-C, NA-D, NA-E, NA-F, NA-G, and NA-H) and three NAIT's (NAIT-A, NAIT-B, and NAIT-C). During an interview on 7/1/25 at 2:10 p.m., R2 stated his debit card information was taken and someone took money out of his account. Someone used his card and a police report had been filed. The bank noticed some funny transactions and previously put a stop on his account. He was not sure how much money was taken, but thought it was around $740 in charges. He was told the suspected perpetrators worked at the facility and the police had a suspect, but he did not know who it was. R2 stated he had his wallet and checkbook at the facility, but did not recall getting any information about how to protect his valuables. He used to keep his wallet in his pocket or on his nightstand, but now kept it in a lock box. He did not like that his money was taken, felt a little upset, and felt the perpetrators invaded his personal space. During an interview on 7/3/25 at 1:41 p.m., R2's family member and POA, POA-C, stated fraudulent charges were identified on R2's card on 6/19/25 when she and R2's other power of attorney, POA-A, tried to use the card's information to obtain a storage unit for R2. The card was declined and marked as fraud. POA-A went to the facility the next day and notified the SSD of the fraud issue. POA-C stated R2's bank statement had a facility staff name on it and apparently the person used Apple Pay which could be done using a picture of the card without the card itself. The bank had previously texted a fraud alert to R2 but R2 did not text and never saw it. The fraudulent charges looked like they went from 5/5/25 through 5/16/25. POA-C's understanding was the charges were made by someone who worked at the facility. During an interview on 7/7/25 at 7:55 a.m., R2's friend and POA, POA-A, stated she identified the fraudulent activity on R2's card on 6/19/25 and notified the facility the next day on 6/20/25. At the time, she had no idea the fraudulent activity involved anyone at the facility. When she notified the facility, the SSD informed her there was an investigation as this had happened to other residents. POA-A gathered an employee was responsible for the fraudulent charges because you could see the name on the bank statement. Fraudulent activity was identified on the statement from 5/4/25 when Apple Pay was added through 5/15/25 when the bank shut off the card. R2 now had a lock box for his valuables but POA-A had taken his checkbooks and new debit card received from the bank because POA-C didn't want it there, lacked trust, and just didn't know what was going on. During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated the bank reported R2's card was put on Apple Pay. The SSD stated the facility found out about the fraudulent charges when POA-A stopped by her office and said they saw some suspicious activity on his bank statement. The SSD noted the card had been cancelled on the 15th by the bank due to unusual purchases. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility identified unauthorized charges on R1's account with transaction information linked to employees. Upon becoming aware of concerns of financial exploitation of R2 on 6/20/25, R2's bank statement was reviewed and the facility identified similar charges as those on R1's statement, such as transactions at the same merchants. Some staff were suspended because they were identified by name in bank statement transactions, were identified in footage provided by the police, or had an associated address. NA-B was barred from working at the facility through the staffing agency because Cash App payments were sent in his name on R2's account. During an interview on 7/8/25 at 2:44 p.m., NA-B stated he made transactions using Cash App with payment to himself. This was done utilizing a photo of a credit card sent to him by NAIT-B which NAIT-B said he found on the ground. NA-B used the photo to enter the card's information into Cash App on his phone and transferred $150 to himself. NA-B did not remember the name on the photographed card but noted it was not NAIT-B's name, the card was blue, and he no longer had the photo. He wasn't really thinking about the name on the card at the time he transferred the money, he just put the information in. He had already made other purchases using this card because NAIT-B entered the card information into NA-B's phone. NA-B stated NAIT-B had convinced him he had a place to buy good quality clothes and stuff for low prices and NA-B was blindsided by everything apart from the Cash App payments. NA-B denied awareness when he made fraudulent transactions of the misappropriation of resident property or financial exploitation of residents. The cops told him the card belonged to a resident, but he did not know who. NA-B stated he made transactions using card information from NAIT-B from approximately 6/12/25 to 6/15/25. R5R5's significant change MDS assessment dated [DATE], indicated R5 was cognitively intact, receiving hospice care, and was dependent on staff for most ADL's. R5's facesheet dated 7/9/25, indicated she had a financial POA. R5's diagnoses included encounter for palliative care, major depressive disorder, need for assistance with personal care, and dependence on enabling machines and devices. R5's care plan dated 7/8/25, indicated she was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R5's progress note dated 7/7/25, indicated her POA, POA-B, was called. POA-B stated she took R5's bills home and noticed charges that shouldn't be there on a bank statement. POA-B had only used the card for two medical rides for R5. POA-B stated the card went missing on 6/27/25 and she called the bank and had the card stopped. She was aware of $500 in fraudulent charges and took R5's valuables home. POA-B notified police and police stated the facility was aware of what was going on, so POA-B did not inform the facility at that time. POA-B had not made R5 aware of the situation as R5 was at the end of life and POA-B and family did not want R5 upset and thinking about who stole from her while she is here. R5's bank statement dated 5/21/25 through 6/19/25, included a list of 22 transactions with total purchases and charges of $651.95. Charges dated 5/29/25 and 6/12/25 were for $77 each to School Services. Additional transactions included:- $28.62 on 6/6/25 to Target- $7.49 on 6/6/25 to KWIK TRIP (a gas station)- $49.32 on 6/7/25 to SPEEDWAY (a gas station)- $1.60 on 6/7/25 to KWIK TRIP- $5.99 on 6/7/25 to KWIK TRIP- $47.05 on 6/10/25 to CASEY'S (a gas station)- $37.30 on 6/10/25 to CASEY'S- $45.00 on 6/10/25 to FAMS BARBERSHOP AND A Faribault- $52.84 on 6/11/25 to KWIK TRIP Nursing Home Incident Report submitted to the SA dated 7/7/25, identified an allegation of financial exploitation for R5. Description noted the police detective (PD) informed the facility R5's family member reported a missing credit card that went missing on 6/27/25 with approximately $500 in unauthorized charges. The facility followed up with the family member, POA-B who noted she had previously reported the incident to the police and planned to submit the bank statement to the facility the following day. There were no identified alleged perpetrators. During an interview on 7/7/25 at 3:26 p.m., the AIT stated he spoke to the PD handling the financial exploitation investigations that morning. The PD notified the facility of another resident, R5, who was a potential victim of financial exploitation as R5's family notified the PD she had a missing bank card. The SSD followed up with R5's family who confirmed her credit card was missing. During an interview on 7/9/25 at 7:50 a.m., the administrator stated she had met with POA-B who provided a copy of R5's bank statement. POA-B indicated the charges from School Services were authorized charges for medical rides, but did not identify any other authorized charges on the statement. Total unauthorized charges were $497.95. The administrator reviewed the bank statement and transactions and noted merchants were the same or similar as those seen on the statements for R1, R2, and R4's accounts. The transactions were also from the same time frame at the beginning of June and ended when the facility identified concerns about R1's card. Charges made to a gas station and two fast food restaurants were especially similar, and the administrator thought the same people made the purchases with R5's card as did so with R1 and R2's cards. During an interview on 7/8/25 at 1:42 p.m., R5's family member and POA, POA-B stated R5's credit card was missing and there were fraudulent charges on the account. POA-B had taken R5's bills home to review and looked through the credit card statement and saw all this fraud. On 6/28/25 she cancelled the card, went to the facility and noted the card was missing from R5's wallet, and reported it to the police. She did not know when the card went missing, but the fraudulent charges were between 6/5/25 and 6/11/25, totaling $497.95. There were two legitimate charges on the card from medical rides with a transport company that showed as School Services. There were no further fraudulent charges on the account after the date on the statement. She guessed the card was stolen around 6/5/25. The detective, PD, had informed POA-B on 7/2/25 she was already working on an investigation and working with the facility, so POA-B did not notify the facility because she thought they knew about R5. The PD reported the suspects had already been suspended from the facility and were going to be charged and the police had video footage of a suspect. POA-B noted R5 was not aware of the financial exploitation concern. POA-B and R5's significant other had decided not to tell R5 because she was declining, in the end days of life, and would be so upset and was starting to get confused. They did not want her to know and POA-B was sure she would be upset thinking someone in the facility that was there to care for her was actually stealing from her. She used to keep her purse with checkbook and credit cards in it on the nightstand which POA-B had removed from the facility. POA-B thought R5's sense of trust would probably be impacted by the events and she would always be wondering if whatever aide came in to help her was the person that stole from her. R5 would expect her valuables to be safe and it would be upsetting because she trusts people and someone violated her personal belongings. During an interview on 7/7/25 at 8:33 a.m., police detective (PD) stated she was the detective handling the investigation into financial exploitation cases at the facility. PD stated that, due to the open nature of the investigation, she could not share victim or suspect names at this time. The PD stated she had two suspects, the facility had suspended multiple staff members, and she was confident the suspects were not currently working at the facility. She had three victims. The first victim was reported to the police on 6/12/25 by the facility, second victim reported on 6/20/25 by the facility, and third victim reported by their POA on 6/28/25. The PD stated she had more than enough evidence and would be filing charges against the two suspects. The fraudulent charges for all three victims stopped on either 6/11/25 or 6/12/25. All the fraudulent charges were made in May and June. The first and second victims had photos taken of their cards, whereas the third victim's physical card was taken. It was undetermined who had taken the card, but she thought it was one of the suspects who shared the card and card information with a bunch of people. The PD identified the two suspects as facility staff. So far, she had determined one suspect was connected to all three victims' cases and the second suspect was connected to two victims' cases. During a follow-up interview on 7/17/25 at 10:52 a.m., PD stated she had completed her suspect interviews and would be closing the case and filing charges. There were three victims, R1, R2, and R5. PD was not aware R1's card used for fraudulent charges was linked to a bank account shared with R4. Estimated totals in fraudulent transactions for the victims were approximately $4,000 for R1, $550 for R2, and $497 for R5. The PD identified three suspects, two of whom were facility employees, NAIT-B and NA-B. The PD had interviewed both NAIT-B and NA-B multiple times. During the interviews, NAIT-B informed the PD of the following: NAIT-B took a picture of a card identified by the PD as belonging to R1; NAIT-B used the card for purchases of [NAME] Lemon, sweatshirts, Valley Fair tickets, and ordering food with NA-B and the third suspect. NAIT-B reported the third suspect used the card for eBay purchases; NAIT-B took a picture of a card identified by the PD as belonging to R2. NAIT-B put the card into Apple Pay and used it at Walmart; NAIT-B took a picture of and took a card identified by the PD as belonging to R5. The card was used to buy stuff at gas stations and NAIT-B confirmed his identity in video footage the PD obtained from Kwik Trip associated with the transactions. NAIT-B also used the card at Target and a barbershop; NAIT-B sent pictures of R1 and R5's cards to NA-B, and of R1's card to the third suspect. During interviews, NA-B informed the PD of the following: NA-B received pictures of cards from NAIT-B identified by the PD as belonging to R1 and R2; NA-B used R1's card for multiple purchases including Sugar Baby Care, [NAME] Lemon, Nike, Timberland shoes, and TikTok. NA-B stated NAIT-B purchased and sent him a ticket for Valley Fair; NA-B used R2's card for Cash App transactions made to himself of about $250; NA-B stated he did not have information about a third card. The PD stated she had no suspicions that anyone else was knowingly involved and did not think anyone else spent money on R1, R2, and R5's cards other than the three suspects. Both NAIT-B and NA-B were to be charged with felony level financial transaction card fraud. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 2/2023, identified the purpose included to protect residents against abuse by anyone including but not limited to facility staff and staff of other agencies serving the individual. Incidents to be reported to the state agency noted a list including mistreatment - inappropriate treatment or exploitation of a resident, misappropriation of resident property, and financial exploitation including but not limited to residents providing gifts to staff or volunteers, residents or families providing any payment in cash or checks to staff or volunteers, and having residents sign over POA to staff. Facility policy titled Resident Right Policy dated 1/2024, identified it was the practice of the facility to uphold the rights of all residents. Residents had access to these rights including via a copy of the Combined Federal and State [NAME] of Rights provided in the admission process. Facility document titled Combined Federal and State [NAME] of Rights with State Agency logo dated 6/18/19, included The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and document review, the facility failed to implement its policy to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property when pre-employment background screening procedures were not completed for one of 11 staff members reviewed for background screening. This had the potential to affect all 71 residents residing in the facility as the staff member worked on all units. Findings include:Findings include:Untitled undated facility personnel document, identified nursing assistant in training (NAIT)-A was a new hire for position of NAIT with start date of 1/29/25. NAIT-A's employee status was full time.Criminal Background Study Information form undated, contained personal and demographic information required to complete a criminal background study for NAIT-A. A box on the form labeled office use only contained date results received space for date to be written in. This space was blank.Review of NAIT-A's employee file did not identify a completed pre-employment background screening.Review of NAIT-A's timesheets indicated she worked shifts at the facility from 1/29/25 through 6/24/25.During an interview on 7/8/25 at 11:26 a.m., NAIT-A stated she began working at the facility at the end of January as an NAIT. She stated she worked everywhere including the facility's unit on the second floor and both units on the first floor. During an interview on 7/1/25 at 1:26 p.m., the director of nursing (DON) stated keeping residents safe included the hiring process. Background screening was done and references checked to ensure whoever was brought into the facility to care for residents was cleared. This was part of the hiring process for everyone in the facility.During an interview on 7/7/25 at 2:33 p.m., the administrator stated the requested background clearance for NAIT-A could not be located. She noted NAIT-A had completed a background study form online but never went for fingerprinting, so there was no background clearance in NAIT-A's file. The administrator was not previously aware NAIT-A's background screening procedure was not completed, and facility procedure was to complete this prior to an employee starting work. This needed to be done to ensure the facility brought in individuals who were competent, safe, and allowed to work in healthcare.Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy included protecting residents against abuse by anyone, including facility staff. The Prevention section included employee screening and noted, The Minnesota Department of Health requires Criminal Background Studies to be completed on all facility employees (Sections 144.40 to 144.58). Potential employees are screened for a history of abuse, neglect, or mistreating residents. Licensing verification checks, and Nursing Assistant Registry checks are completed on facility employees when indicated.Facility policy titled Background Study Policy dated 12/2016, identified it was the facility's policy to complete criminal background studies on all employees. Upon hire or facility transfer, employees completed a facility background study form. The Human Resources Director would verify the information was correct and submit an online background study request. Further, The employee may not begin working until the results of the request are received and indicate the applicant is not disqualified or may work unsupervised while a study is being completed. If an employee was not disqualified, the applicant could then be scheduled to work and results were filed in employee personnel file. Staff personnel files containing study results were maintained by the [NAME] President of Human Resources.

Based on interview and document review, the facility failed to ensure allegations of financial exploitation were reported to the State Agency (SA) within 24 hours for four of five residents (R1, R2, R3, and R4) reviewed for allegations of financial exploitation. Findings include:Findings include:R1R1's facesheet dated 7/9/25, indicated he admitted to the facility on [DATE] and was his own responsible party. R1's emergency contact was his spouse, R4.R1's care plan dated 6/11/25, identified he was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Nursing Home Incident Report #360867 was submitted to the SA on 6/17/25 at 2:57 p.m. The report identified an allegation of financial exploitation for resident R1. The business officer manager (BOM) was the initial reporter and became aware of the incident on 6/17/25 at 2:00 p.m. Details included, facility found out that resident's bank statement has unauthorizes purchases which is linked to employee's address. Description included, On June 12, 2025, facility identified $4,047.67 in unauthorized transactions on resident [R1's] bank account, occurring between May 16 through June 12, 2025. [R1] did not approve these charges. Today, we confirmed the address linked to the transaction belongs to a facility employee.During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated she assisted R1 monthly to check his bank account and print the statement. She noticed unusual activity on R1's bank statement on 6/12/25 and notified administration right away. The administrator in training (AIT) stated he filed a Minnesota Adult Abuse Reporting Center (MAARC) report initially and then when the facility later noticed that some of the transactions were linked to employee names, an Office of Health Facility Complaints (OHFC)/State Agency (SA) report was filed.During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility first became aware of concerns regarding suspicious activity on R1's bank account on 6/12/25 when the facility identified $4,047.67 in unauthorized charges. A police report and MAARC report were filed on 6/12/25 but the report to the SA was not filed until 6/17/25 when addresses linked to the transactions were identified as belonging to employees. She was not present on 6/12/25 and did not know why it was not reported to the SA at that time, she would expect the allegations to have been reported to the SA on 6/12/25. The administrator stated alleged financial exploitation should be reported to the SA within 24 hours. R2R2's facesheet dated 7/9/25, indicated he admitted to the facility on [DATE] and had a financial power of attorney.R2's care plan dated 5/20/25, identified he was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Investigation Report with submission date 6/23/25 at 4:06 p.m., was submitted to the SA as the follow-up for Nursing Home Incident Report #360867 regarding R1. The investigation report noted similar incidents had been identified including a case involving R2. Unauthorized transactions had been discovered on R2's bank account beginning around 5/15/25. The BOM had confirmed this with R2's power of attorney (POA), POA-A. Police were notified and investigation ongoing.Nursing Home Incident Report #360946 was submitted to the SA on 6/25/25 at 11:48 a.m. The report identified an allegation of financial exploitation for resident R2. The BOM was the initial reporter and became aware of the incident on 6/20/25 at 1:30 p.m. Description included, upon review/investigation of an open OHFC [report] relating to financial exploitation, business office manager reviewed resident's bank statement and discovered suspected fraudulent activity.During an interview on 7/1/25 at 1:07 p.m., the BOM stated she became aware of the concerns when POA-A spoke to the social services director (SSD) who came and got her. The SSD told her POA-A noticed some things on R2's bank statement. The BOM reviewed the bank statement with POA-A and identified concerns for fraudulent activity like that seen on R1's account.During an interview on 7/7/25 at 7:55 a.m., POA-A stated she identified concerns with R2's credit card on 6/19/25 when she tried to use the card to obtain a storage unit for R2 and it was declined due to fraudulent activity. POA-A went to the facility the next day on 6/20/25 and mentioned this to the SSD. R2 had his bank statements, which POA-A reviewed with facility staff who stated there was an investigation going on and this had happened to another resident. The facility notified the police, who came and spoke with R2 regarding the fraudulent activity. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of concerns about financial exploitation related to R2 on 6/20/25 when his bank statement was reviewed with the BOM and suspected fraudulent activity identified. This was reported to the SA on 6/23/25 when it was included in the investigation report submitted as follow-up on the allegations of financial exploitation of R1. A separate report specific to R2 was then submitted to the SA on 6/25/25. The administrator stated the facility was aware of the allegations regarding financial exploitation of R2 on 6/20/25 and she would expect this to have been reported to the SA within 24 hours. She confirmed this should have been reported right away and should have been filed as a separate report, not included in the follow-up investigation report for R1. R3R3's facesheet dated 7/9/25, indicated she admitted to the facility on [DATE] and was her own responsible party.R3's care plan focus dated 6/17/25, identified she was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Investigation Report with submission date 6/23/25 at 4:06 p.m., was submitted to the SA as the follow-up for Nursing Home Incident Report #360867 regarding R1. The investigation report identified similar incidents had been identified including a case involving R3. R3 reported a missing bank card but experienced no financial loss and had cancelled the card.Nursing Home Incident Report #360948 was submitted to the SA on 6/25/25 at 12:17 p.m. The report identified an allegation of financial exploitation for resident R3. The report identified the social services designee (SS) was the initial reporter and became aware of the incident on 6/24/25 at 12:00 p.m. Description of the incident included, during facility investigation of open OHFC relating to financial exploitation, resident informed social services of missing debit card 6/16/25. Debit card found 6/24/25 and resident confirmed there was no fraudulent activity on the account.Untitled facility resident interview document dated 6/18/25, indicated an interview was conducted with R3 by facility staff with note that R3 admitted to the facility on [DATE]. Question Have you noticed any unusual transactions on your bank account recently? had answer No. Froze card. Question Have you noticed any missing valuables, money, checks, credit cards, or debit cards recently? had answer Debit card is missing - lost since first day here. Froze Card. [Bank name] - blue debit card. Had it when she left hospital. Says son doesn't have it. R3's progress note dated 6/18/25, indicated the AIT followed up with R3 regarding her missing card. R3 stated she cancelled the card and there were no unauthorized charges.During an interview on 7/7/25 at 10:44 a.m., the administrator stated she became aware of concerns regarding financial exploitation of R3 on 6/20/25 when she received an email for R3's son stating her debit card had gone missing but then it showed up the following morning on 6/21/25 and there were no fraudulent charges on the account. R3 was included in the investigation report for R1 submitted 6/23/25 and then filed as a separate report with the SA on 6/25/25. The administrator then reviewed R3's progress notes and confirmed the facility was aware of R3's missing debit card on 6/18/25, stated this should have been reported to the SA within 24 hours, and confirmed it had not been reported within that time frame.R4R4's facesheet dated 7/9/25, identified she admitted to the facility on [DATE], and her spouse R1 was her responsible party and emergency contact.R4's care plan dated 5/5/25, identified she was at risk for abuse and or neglect. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.During a joint interview on 6/30/25 at 3:42 p.m. the AIT stated R4 was R1's spouse and R1 made financial decisions for her, though was not her power of attorney. The AIT stated the facility became aware R4's name was on the same account as R1's so they filed a MAARC report as part of the process of trying to obtain a financial conservator for them both. The BOM stated the fraudulent charges linked to R1's debit card were on a checking account shared by both R1 and R4 and the money in the account belonged to them both.During an interview on 7/1/25 at 9:11 a.m., the SSD stated she submitted a MAARC report regarding R4 after the facility found out R1's account was shared with R4. She was made aware of this and submitted the report on 6/26/25. The SSD confirmed the concern for R4 was an allegation of financial exploitation as the money in the account belonged to both R1 and R4 who were financially independent. The SSD stated she only knew how to file MAARC reports, and the administrators were responsible for filing reports to the SA.During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of allegations of financial exploitation of R4 on 6/26/25 during a monthly billing-related review phone call with the corporate business office. R1 was discussed and the BOM brought up R4 and stated a hold needed to be placed on her collection to the facility until the fraudulent charges from R1's card were reimbursed by the bank. The administrator had not previously realized R1's bank account was shared with R4 and given that they were on the same account the financial exploitation affected R4 too. The administrator reviewed a copy of R1's bank statement dated 5/30/25 provided to the surveyor by the facility and confirmed both R1 and R4's names were listed. The administrator stated R4's name was clearly on the account and she would expect allegations of financial exploitation of R4 to have been identified and reported to the SA on 6/12/25 when the facility identified fraudulent activity on the account. The administrator confirmed allegations of financial exploitation were also not reported within 24 hours of the facility becoming aware of the allegations for R1, R2, and R3. The allegations needed to be reported because all residents were vulnerable adults and any alleged or confirmed abuse or any sort needed to be reported to the SA within two hours if there was physical harm or 24 hours for all others.Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy included to promptly report, document, and investigate all incidents of alleged or suspected abuse/neglect. All staff were responsible for reporting any situation that was considered abuse or neglect. The policy identified incidents that must be reported to the State Agency including: mistreatment (inappropriate treatment or exploitation of a resident), misappropriation of resident property, and financial exploitation (including but not limited to: residents provide gifts to staff or volunteers, residents or families provide any payment in cash or checks to staff or volunteers, having residents sign over POA to staff). Section titled How and when to report to the Minnesota Department of Health (MDH)/ Office of Health Facility Complaints (OHFC) included, 2.) Suspicion of Neglect, Exploitation, or Misappropriation of resident property must be reported to OHFC online reporting process not later than 2 hours if the incident resulted in serious bodily injury. 3.) If the suspected Neglect, Exploitation, or Misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours. 6.) Notify the Minnesota Department of Health (MDH) on the notification website immediately after discovery of incident. Additional direction included Utilizing the Minnesota Adult Abuse Reporting Center (MAARC). The policy directed the following scenarios should be reported directly to MAARC: a.) If the Vulnerable Adult is not a facility resident. b.) The Vulnerable Adult discharges from facility against medical advice, including residents who do not return from a Leave of Absence. *All discharges that are against medical advice need to be reported to MAARC within 24 hours. c.) The alleged maltreatment occurred prior to facility admission.

Based on interview and document review, the facility failed to identify and protect all residents at risk of financial exploitation during investigations into 4 of 4 residents (R1, R2, R3, R4) reviewed who made allegations of financial exploitation. This had the potential to affect all 67 other residents who were residing in the facility, including R5, whose representative subsequently identified and reported additional allegations of financial exploitation. Findings include:Untitled resident questionnaire documents dated 6/17/25 and 6/18/25, included dates, resident names, interviewer signatures, and three questions. Questions included: have you noticed any unusual transactions on your bank account recently; Have you noticed any missing valuables, money, checks, credit cards or debit cards recently; and do you know how to report facility concerns, lost, missing, or damaged items. Questionnaires were completed for 29 residents. One questionnaire had a resident name written down and crossed out with no further information, and one questionnaire had a resident name, R5, date of 6/17/25, and note at the bottom indicating R5 was hospitalized /on a leave of absence. Facility document titled Attendance Record dated 6/18/25, identified it was for resident education on storing valuable items. The record included resident names/signatures or staff signatures on behalf of residents unable to sign and resident room numbers. The record identified education was completed with 47 residents, per listed room numbers. Facility document titled Resident Education Regarding Valuables in the Facility undated, was a one-sheet page with printed information. The information included, It is important to be aware that while residing in the facility, there will be multiple staff that frequently enter and exit residents' private living spaces. Checkbooks, cash, credit cards, and valuable jewelry should not be left unsecured in residents' private living space. Residents may wish to obtain a lockbox to secure items should they decide to keep these items at the facility. It is recommended that valuables be kept with family if possible. It is important to be aware that physical credit cards do not need to be taken, thieves have taken pictures of credit cards and used the images to permit theft. You should never share your financial PIN [personal identification number] numbers or passwords with anyone. If you suspect a crime has occurred, report it immediately to staff. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility first became aware of allegations of financial exploitation on 6/12/25 when the facility identified $4,047.67 in unauthorized charges/suspicious activity on R1's bank account statement reviewed by the business office manager (BOM). On 6/17/25, the facility identified addresses linked to the transactions belonged to employees. The facility became aware of concerns regarding financial exploitation of R3 on 6/18/25, when an interview was conducted with R3 who reported her debit card was missing but had no fraudulent transactions because she had cancelled the card. The facility became aware of concerns about financial exploitation related to R2 on 6/20/25 when his bank statement was reviewed with facility staff and suspected fraudulent activity identified. The facility became aware of concerns about financial exploitation related to R4 on 6/26/25 when they realized R1's bank account was shared with R4, her spouse. The administrator would expect the allegations of financial exploitation of R4 to have been identified on 6/12/25 when the facility identified the fraudulent activity on the account because R4's name was clearly on the bank statement/account. In a follow-up interview at 3:32 p.m., the administrator stated the fraudulent charges on R2's account totaled $709.97. During a joint interview on 6/30/25 at 3:42 p.m., the administrator in training (AIT) stated after the facility identified potential financial exploitation of R1 was linked to employee addresses and names via transactions, identified staff members were suspended. In addition, the facility checked in with other residents who managed their own finances to see if they had issues. The social services director (SSD) stated she completed this along with the social services designee and the receptionist. This was a list of questions, a safety questionnaire, she discussed with about 20 to 30 residents. The AIT stated this was when R3 notified the facility she had a missing bank card. During an interview on 7/1/25 at 9:11 a.m., the SSD stated after the BOM noticed fraudulent activity on R1's bank account, staff including herself completed questionnaires with residents and asked them if they had noticed anything similar. Education was provided that if they wished to purchase a lock box they could. She stated secure storage for resident valuables was not offered to residents unless they asked for it, and the admission contract contained information about storage of valuables. During a follow-up interview on 7/7/25 at 12:11 p.m., she confirmed safety questionnaires were completed on 6/17/25 and 6/18/25. She was advised to complete them only with residents who oversaw their own finances. Staff also rounded with an educational paper given to all residents about lock boxes and keeping personal items safe. It did not notify residents of the financial exploitation concerns or need to check their finances for potential fraudulent charges. The SSD stated all residents were probably not capable of understanding this education and she had not followed up with any families or representatives of the residents educated. She did not know of other actions taken to notify all residents and representatives of the concerns. During an interview on 7/7/25 at 10:44 a.m., the administrator stated she was aware of concerns related to financial exploitation for four residents, R1, R2, R3, and R4. An all-staff meeting was held on 6/30/25 with education about the facility's abuse prohibition and vulnerable adult policy but was not mandatory. She was unable to articulate what was done to follow up with staff not present at the meeting. Staff rounded with residents on 6/17/25 and 6/18/25 to complete safety questionnaires. She thought this should have been done with every resident. Questionnaire papers indicated rounding was done with 31 residents and she did not know how they were selected. She identified one completed with a resident with dementia who might not understand the questions and whose family should have been notified, and one with a resident (R5) who was in the hospital at the time. The administrator was not aware of follow-up completed with these residents and their representatives. She stated there were at least 40 residents (those who did not get questionnaires) who were not talked to about concerns for financial exploitation or were talked to but not documented. She was unable to articulate what was done to protect these residents from potential financial exploitation. To protect residents, she would expect every resident in the building and their family/representatives to have been notified of the concerns as soon as the facility found out there was a second resident involved in the alleged financial exploitation. The administrator stated all residents should have been followed up with because even if someone had a POA (did not manage their own finances) they could still have something (such as a credit or debit card) at the facility that could be utilized to make unauthorized purchases. She had not yet notified all families of the potential financial exploitation and did not see evidence all residents had been informed. She would expect safety interviews with residents, meetings with residents if they wanted assistance reviewing bank statements, and communication with families and POA's to see if they had noticed fraudulent activity for all residents. Additionally, staff interviews and all staff education. During a follow-up interview on 7/7/25 at 12:20 p.m., the administrator stated the education sheet provided to all residents communicated it was important to be aware of personal items, but it did not say the facility had something like this happen. Further, all residents were not capable of understanding the information as presented and regardless of if a resident was their own representative, the facility should have followed up with every resident to ensure they understood. Residents would not be aware of the risk of potential financial exploitation if the facility did not explain it. During an interview on 7/7/25 at 3:26 p.m., the AIT stated he had spoken to the police detective (PD) handling the financial exploitation investigations that morning. The PD notified the facility of another resident, R5, who was a potential victim of financial exploitation as R5's family had notified the PD she had a missing bank card. The SSD followed up with R5's family who confirmed her credit card was missing. During a joint interview on 7/8/25 at 8:22 a.m., the administrator stated R5's POA, POA-B, indicated R5's credit card went missing on 6/27/25 and there were about $500 in fraudulent charges. The administrator confirmed the safety questionnaire for R5 completed on 6/17/25 indicated she was in the hospital at the time. The administrator did not see any follow-up completed with R5 or her family/representatives to provide the information in the questionnaire. The regional director of operations (RDO) stated the facility had initially determined to notify only residents who managed their own credit cards of the concerns. He confirmed residents who did not manage their own finances could also have cards in the facility. He confirmed every resident was not able to understand and follow up on the information presented in the resident education sheet and facility would have followed up with POA's for these residents. He was not able to identify evidence of this follow up. During an interview on 7/8/25 at 1:42 p.m. POA-B stated she was R5's family member and POA. POA-B stated R5's credit card was missing and had fraudulent charges on the account. She identified this on 6/28/25 when reviewing R5's credit card statement. She cancelled the card right away, went to the facility and noted the card was missing from R5's wallet, and reported it to the police. She did not know when the card went missing, but the fraudulent charges were between 6/5/25 and 6/11/25, totaling $497.95. The detective, PD, had informed POA-B on 7/2/25 that she was already working on an investigation and working with the facility, so POA-B did not notify the facility because she thought they knew about R5. POA-B stated she spoke to facility staff yesterday and they had not known about R5. POA-B stated she received an automated voice message from the facility that morning regarding financial fraudulent activity in the facility, but had not received previous communication from the facility notifying her about potential concerns. POA-B stated she did not know when the facility became aware of the concerns, but thought they should have let people know sooner if they knew sooner. During an interview on 7/3/25 at 1:41 pm., POA-C stated she was R2's family member and one of his POA's. Fraudulent charges were identified on R2's card on 6/19/25 when she and R2's other POA, POA-A, tried to use the card's information for a transaction and it was declined and marked fraud. POA-C stated she thought the facility was going to send out a letter or communication to all guardians or individuals this financial exploitation pertained to, and she had received nothing. This was concerning. There were vulnerable people at the facility who didn't have someone like herself or POA-A watching their backs and some didn't have the capacity to do so on their own. This made her sick as there was nothing sicker in her mind than elder abuse and what happened was criminal. During an interview on 7/7/25 at 7:55 a.m., POA-A stated she identified the fraudulent activity on R2's card on 6/19/25 and notified the facility on 6/20/25. At the time, she had no idea the fraudulent activity involved anyone at the facility. When she notified the facility, the SSD informed her there was an investigation as this had happened to other residents. POA-A gathered an employee was responsible for the fraud. POA-A was informed the facility would send a letter to all residents that these activities were going on. POA-A had not received such communication. POA-A stated people needed to know this was happening so they could check their funds and be aware. It has been two weeks since she first notified the facility of the activity on R2's account and she thought this communication should have gone out. POA-A was concerned this may have happened to other residents and thought the facility should notify every resident because, otherwise, how would residents and guardians know to look at bank statements. POA-A stated if she had not stopped by the facility on 6/20/25 and mentioned the fraudulent activity on R2's card to staff, she would never have known it was connected to the facility, no one had contacted her. POA-A stated she was upset and felt very strongly about this as she would still have no idea what was going on if she hadn't happened to mention it to the SSD on 6/20/25. During an interview on 7/7/25 at 8:33 a.m., the police detective (PD) handling the investigation into multiple reports of financial exploitation at the facility stated the investigation was on-going. The first case was reported to the police by the facility on 6/12/25. The PD had enough evidence to file charges against two employees of the facility related to the financial exploitation. She stated there were currently three residents who were victims but felt there could be more cases. She thought it would be good for the facility to get something out to notify people to make sure they were checking their bank accounts often in case there were additional victims. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy, including To protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse, to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect, and to identify and remedy any potentially abusive situations. Policy interpretation and implementation section indicated all staff were responsible for reporting any situation considered abuse, neglect, injuries of unknown origin, misappropriation of resident property, or involuntary seclusion. Further, A supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated. Investigation/protection section included, Staff will take immediate and appropriate actions to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and The facility will provider proper follow up communication related to the incident across all shifts and to practitioners and resident representatives as applicable.

Based on observation and interview, the facility failed to post accurate data reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care on a daily basis. This had the potential to affect all 71 residents residing in the facility and their visitors who may wish to review the information. Findings include:On 7/9/25 at 8:50 a.m., the facility's nurse staff posting form dated 7/9/25, was located on top of a chest of drawers by the front desk. The posting included the daily resident census, total number of nursing staff hours, and sections for the facility's three units and section labelled agency. Each section was further broken down into sections of day shift, evening shift, overnight shift, and adjustments with spaces in each for registered nurse (RN), licensed practical nurse (LPN), trained medication aide (TMA), certified nursing assistant (NA), and nursing assistant in training (NAIT). Information written on the paper indicated the number of staff working in each role on each shift on each unit with corresponding number of total staff hours worked per role per shift per unit (i.e. one RN and eight hours or two LPN's and 16 hours). The sheet did not identify the actual hours worked for any of the identified nursing staff roles. During an interview on 7/9/25 at 8:50 a.m., the director of nursing (DON) reviewed the nurse staff posting form dated 7/9/25. The DON indicated the posting was written to show how many people were working in each role for the shift and then the total hours worked by those people. The DON stated the actual hours worked by nursing staff were reflected in the schedules for staff posted at the nursing stations. He acknowledged those schedules were not the facility's nurse staff posting. He confirmed the actual hours worked by nursing staff were not included in the facility's daily nurse staff posting. Facility policy titled Nursing Hours Posting dated 10/2/2022, identified it was facility policy to post nursing staffing data on a daily basis at the beginning of each shift. The posting was to include facility name, current date, resident census, and the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Categories included registered nurses, licensed practical nurses or licensed vocational nurses, and certified nursing assistants. Policy interpretation and implementation identified federal law required Medicare and Medicaid certified nursing homes to post the number of staff who are directly responsible for resident care in the facility on each shift.

Based on observation, interview, and document review, the facility failed to ensure the three-compartment dish sink was of proper sanitization parts per million (ppm) which had the potential to affect all 76 residents who received meals from the main kitchen. Furthermore, the facility failed ensure employees wore beard restraints to prevent hair from contacting food. Findings Include: A report titled Diet/consistency Rollup printed on 4/30/25, categorized each diet and had total meals served out of the main kitchen as 76. During the initial kitchen walk through conducted on 4/28/25 at 1:22 p.m., an area over the three-compartment sink had logs for documentation of water sanitization for April 2025, completed for April 1-24th. Above the sink were two large bottles held by a wire rack with two tubes that ran down into the three compartment sink, both were empty. The bottle on the left was labeled quaternary sanitizer and the one on the right was labeled pot/pan detergent and sanitizer. A large bottle of Dawn dishwashing detergent sat on the far right of the three-compartment sink. A cook was wearing a navy-blue baseball cap and had a beard that extended from the chin approximately 1. During an interview on 4/28/25 at 2:11 p.m., culinary services director (DOC)-A confirmed hair nets were available for employees and donned one himself. DOC-A stated employees needed to either wear a hat or a hairnet. DOC-A then stated if a beard was too big they need to wear a cover or shave it, and after a couple of days beards should be shaved or covered or else it could fall into the resident's food. DOC-A could not recall a facility policy on beards in the kitchen, but said employees would be written up if they didn't wear a beard restraint. DOC-A confirmed beard restraints were not available for employees at the kitchen entrance or in the office on 4/28/25. During an observation on 4/29/25 at 11:43 a.m., The pots/pan detergent and sanitizer bottle above the three compartment sink had approximately 1 inch of a blue bubbly solution. On the right hand of the three-compartment sink was a large bottle of Dawn dish detergent. During an observation and interview on 4/29/25 at 12:07 p.m., cook (C)-A removed a puree mixer lid and blade from the drying rack located on the left of the three-compartment sink. C-A stated the puree mixer was hand washed with Dawn and often Dawn detergent was added to the pots/pans bottle above the sink. Dawn and water were then mixed and the sink was filled to wash pots, pans, and kitchen utensils. During an interview on 4/29/25 at 2:08 p.m., dietary aid (DA)-A stated the three-compartment sink area was used for pots and pans. The pots and pans were scrubbed with Dawn and then used to cook. All resident dishware was put through dishwasher. During an observation on 4/30/25 at 12:41 p.m., Dawn dish detergent was used to wash a clear/gray plastic top to the puree mixer. The top was rinsed off and set on the side of the sink to dry. These items were rinsed less than 30 seconds. During an interview on 4/30/25 at 12:43 p.m. C-A stated no thermometer was available to check the water coming out of the sink and confirmed a puree blender top were hand washed with Dawn and other kitchen utensils. During an observation on 5/1/25 at 9:44 a.m., a three-compartment sink had a large bottle of Dawn dish soap. During an interview on 5/1/25 at 10:31 a.m., DOC-B stated the facility policy allowed for manually washing dishes in the three-compartment sink, but all dishes needed to be sent through the dishwasher to be sanitized. DOC-B stated he was not aware the cooks were manually washing and reusing the items without sending the items through the dishwasher and replied, oh no, they can't do that to which the nearby DOC-A responded, yes we talked about that. DOC-B also confirmed beards should be no longer than a 1/2 for all Monarch facilities and that C-A should wear a beard cover. Facility Policy titled Sanitization, revised October 2008, #9 Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing. C: Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solution may consist of: Chlorine, Iodine, Quaternary ammonium. Facility Policy titled Cleaning and Disinfection, revised September 2012, Mixer bowls, beaters, grinders, pots, pans, roasters, electric knife, blades, food thermometers, etc. 1. Wash in 3 compartment sink or dishwasher: a. 1st compartment-soap and water (110-120 degrees Fahrenheit). B. 2nd compartment-clear water for rinsing (120 degrees Fahrenheit). c. 3rd compartment-Detergent/disinfectant (170 degrees Fahrenheit for 2 minutes). 2. Allow to remain wet for 10 minutes to air dry. Facility Policy titled Food Preparation and Service, revised April 2019, Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food

Based on observation, interview, and document review, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms and 2 of 2 units (70's, 90's) reviewed. This had potential to affect all 75 residents within the care center. Findings include: On 4/29/25 at 7:57 a.m., the campus' main laundry washroom was toured with housekeeper (HSK)-A present. HSK-A explained they were the primary person who completed laundry for the care center, and they then provided a tour of the laundry process and the machines used. The soiled linen receiving area and washroom were located on one side of the hallway and folding area (clean) on the opposite. However, in the hallway between these areas were a series of mobile, off-white colored hard plastic bins including one labeled, Soiled Linen Only, in black paint. The bin was covered with a light-blue colored cloth covering which was lifted exposing it's contents which was soiled white linens and personal clothing, much of which was not bagged but rather loose in the bin causing articles to touch. HSK-A verified the items were not bagged and expressed they should have been prior to transport. HSK-A stated the bin was likely brought down last evening by the nursing assistant (NA) staff. HSK-A stated they had, at times, noticed soiled laundry items to be coming down to the main washroom not bagged adding aloud on occasion, yes. HSK-A stated they had talked about the issue with the care center administrator in the past, however, added, But not as frequently as maybe I should have, to be honest. HSK-A then verified they had not collected any soiled linen from the units today yet. A tour of the '70's Unit' was then completed. The soiled utility room was opened with HSK-A present which, inside, had three mobile, off-white containers similar to the one observed by the washroom. HSK-A stated two were used for trash and one was used for soiled linens and personal clothing. The laundry container had a balled-up light-blue cloth cover inside the corner of the container and, again, nearly all of the soiled laundry inside was not bagged. HSK-A stated they items should be bagged at the point-of-use and not transported loosely like it appeared had happened adding aloud, [They should be] bagging in, bagging out. HSK-A stated most of the personal laundry and linens were laundered by the care center adding, Pretty much [yes]. HSK-A stated the soiled linen should be bagged to help prevent cross contamination between the garments. Following, a tour of the '90's Unit' was then completed. The soiled utility room was opened with HSK-A present which, inside, had multiple mobile, off-white containers similar to the one observed by the washroom and '70's unit.' The container for soiled linens and laundry was uncovered and, inside, nearly all of the garments and linens were not bagged. Further, sitting on top of the soiled laundry was two yellow-colored bags which had markings on them to indicate potential bio-hazard (i.e., isolation room, active infection). HSK-A verified the items were not covered or bagged and stated aloud, That will be addressed today. HSK-A stated they did complete audits of laundry care which included walking around with the administrator and observing general cleanliness. HSK-A stated they would provide these for review. A series of three Monthly Facility Tour Form(s), dated 12/27/24 to 3/28/25, were provided. These outlined various areas of the care center and provided spacing to record a score (0 to 10) of cleanliness of the corresponding area. A section was listed, Laundry/Linen, which outlined three specific areas to review including linen closets, personals, and laundry room. The spacing provided to write-out any comments was left blank and no concerns were written. However, the provided audits all lacked evidence the soiled utility rooms (where soiled linens were kept until transport to the washroom) were included in the review or audit process. On 4/30/25 at 10:01 a.m., the interim director of nursing (DON) was interviewed, and they verified they were the campus' infection preventionist (IP). DON explained they have educated staff through staff meetings and such about the need to bag soiled items where collected, and he verified soiled laundry and linens should be bagged prior to transport. This was important to do as staff could spread infections from one place to another. DON added, We will continue to do staff education and follow-up with the staff. A facility-provided Infection Prevention and Control Program policy, dated 11/2024, identified the facility would establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment. The policy outlined several steps taken with this program including infection surveillance, antibiotic stewardship and data analysis; however, the policy lacked information on soiled linen handling or transportation. A separate, facility-provided Skill 6. Gown, Glove, and Bag Linen protocol, undated, identified a checklist for staff to implement with gown removal and soiled item collection in an isolation room. This identified, 5. Remove the soiled linen. Keep the linen contained during removal and place in the appropriate bag/receptacle. A facility' policy on soiled laundry handling and transportation was not provided.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R54, R74) who utilized urinary catheters. Findings include: R54 R54's annual Minimum Data Set (MDS) dated [DATE] identified R54 with intact cognition, impairment of both lower extremities, dependent on staff for toileting hygiene and lower body dressing and had an indwelling catheter (tube for urine collection from bladder to a bag outside of the body). During observation on 4/28/25 at 1:42 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. During observation on 4/28/25 at 2:39 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. Two staff walked past the room. At 5:13 p.m., a staff member pushed a meal cart past R74's room. At 5:15 p.m., one staff member was observed inside the room speaking to R74 and left the room. During observation and interview with R74 on 4/28/25 at 6:35 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of the bed visible to the hallway. R74 stated, staff have never asked me if I wanted a cover on my urine bag. And I imagine other people would not feel comfortable looking at my urine in this bag. I guess I would not like to see anyone else's urine in their bag if I think about it. During observation and interview on 4/29/25 at 8:39 a.m., registered nurse (RN)-B was obtaining medications from the medication cart which was located across the hall from R54. RN-B observed the uncovered partially filled large urine drainage bag from hall and stated, catheter bag should be covered for dignity and decency. R74 R74's admissions MDS dated [DATE] identified R74 with intact cognition, required substantial to maximal assist with toileting hygiene and lower body dressing, and had an indwelling catheter. During observation on 4/29/25 at 8:03 a.m., R74 wheeled self around hallway seated in wheelchair with large urine drainage bag attached to underside of wheelchair. R74 wheeled self to nursing station where four residents were eating a meal at tables adjacent to the nursing station. The urine bag was visible and uncovered. During observation and interview on 4/29/25 at 8:31 a.m., licensed practical nurse (LPN)-A observed R74 wheel past her as she was obtaining medications from medication cart and stated, that [urine bag] should be covered for dignity. During interview with R74 on 4/30/25 at 10:04 a.m., R74 stated, It [catheter drainage bag] was never covered until yesterday when they [staff] came in and put one[sic] cover on it. I don't want to see another person's pee[urine]. I should be more respectful. During interview with director of nursing (DON) on 4/30/25 at 10:48 a.m., DON stated, Foley [catheter] need to be covered and stated the uncovered catheter bags were a concern for infection control and dignity. Facility policy for dignity was requested and not received. 51567

Based on interview and document review the facility failed to ensure comprehensive assessments and monitoring, follow physican orders for monitoring and reporting changes in skin condition and provide subsequent required wound care for 1 of 3 residents (R1) reviewed for surgical wounds. The facilities failures resulted in actual harm to R1 when R1 developed an infection in the wound and transferred to the hospital for surgical debridement and required extended follow-up medical care. Findings include R1's hospital discharge summary dated 7/12/22, documented R1 was hospitalized for nonoperative posterior tibial plateau fracture and a medial (nearer the middle of leg) thigh hematoma. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission/Initial Data Collection assessment dated [DATE], indicated R1 was admitted to the facility on [DATE], with a blister on his left thigh measuring 3 x 1.4 and bruising measuring 14 x 10. Registered nurse (RN)-A documented on the admission assessment that R1 had bruising from the front to back (of the thigh) related to a fall with a fracture. An admission note dated 7/12/22, at 3:47 p.m. documented R1 was admitted to the facility due to a left tibia plateau fracture and that his left leg was in a soft brace. R1's Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderate cognitive impairment; required extensive assistance with bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene; and documented R1 did not have skin issues. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed to assess circulation, sensation, movement, odor, pain, and skin around immobilizer. R1's care plan dated 7/13/22, indicated R1 had impaired skin integrity, associated goal included R1 would remain free from skin breakdown. Specific interventions included monitor skin integrity daily during cares and weekly skin inspection by nurse; monitor for skin breakdown and for signs and symptoms of infection and report signs and symptoms to provider; and document skin condition and keep provider informed of changes. R1's medical record did not include and/or identify monitoring and comprehensive assessments were completed in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's record only identified a progress note dated 7/18/22, in which wound care had been provided with no other information provided, and a Weekly Skin Evaluation dated 7/19/22, in which a comprehensive assessment was not evident. However, the following day on 7/20/22, physician documented eschar (dead tissue) covered 100% of the wound bed and required sharp surgical debridement. R1's record did not include and or identify when the wound had started deteriorating. R1's skilled progress note dated 7/18/22, indicated wound care was provided but does not identify location of wound or the care that was provided. R1's Weekly Skin Inspection dated 7/19/22 documented by licensed practical nurse (LPN)-D indicated R1's visible skin was warm, dry and intact; left thigh bruising and blister from fall and fracture pre-admission; and no new skin alterations noted. The inspection note did not identify the status (improving/worsening and/or measurements) and did not indicate that the soft brace was removed so the hematoma could be assessed. Attempts were made and messages left to LPN-D who had completed the skin evaluation on 7/19/22, however the call was not returned. A progress note by nurse practitioner (NP)-A/certified wound specialist (CWS) dated 7/20/22, documented R1 was seen by NP-A for a left distal thigh hematoma that was community acquired. Patient stated he had a fall in the community resulting in a contusion of the left knee and wore a knee immobilizer. Physical exam of wound included: ecchymosis (bruising) and generalized [CONDITION(S)] to left lower extremity, hematoma measured 13 x 4.5 x 0.1 cm. small amount of serosanguinous (drainage that is thin, like water and usually pink tinged) drainage, surface area was 58.5 cm, 100% eschar. NP-A documented the following bedside procedure completed on 7/20/22: debridement: conservative sharp (cutting away of debris of infected or dead tissue from a wound), with resulting small serosanguinous discharge. NP gave order dated 7/20/22, indicated to clean wound with normal saline, apply a nickel sized amount of Santyl to wound bed, cover with island dressing, change every other day if saturated and continue to wear knee immobilizer. R1's treatment administration record (TAR) identified the NP's order given on 7/20/22 was not implemented by nursing until 7/23/22. Between 7/20/22 to 7/23/22 the record continued to lack evidence the wound was treated/monitored/or assessed as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R1's record did not have any other subsequent wound monitoring/assessments between 7/22/22 to 7/26/22. A progress note dated 7/26/22, at 10:25 a.m. documented physical therapy requested R1's dressing be changed due to the dressing was saturated with bright red blood. Upon removal of the dressing there was a very strong order to wound area (indicative of decaying tissue) and the wound is warm to touch (indicative of an infection). A telephone order dated 7/26/22, received from medical doctor (MD)-A directed staff to send R1 to the emergency department for wound assessment and possible surgical debridement. R1 was discharged from the facility on 7/26/22 to hospital. R1's resident representative (RR)-1 provided surveyor with a picture of R1's wound that was taken on 7/26/22. The picture showed an irregular shaped very large wound that extended from R1's knee to lower thigh and an ABD dressing that was lifted away but still touching the top of the wound. The dressing had a substantial amount of serosanguinous drainage on the top half. The periphery of the wound was reddened. The wound bed was mostly covered with thick black eschar and the top left corner had a small area where the eschar appeared thinner and/or open. During an interview on 8/7/22, at 11:20 a.m. R1's resident representative (RR)-1 stated they visited R1 daily and asked staff each day how the hematoma was healing. Staff consistently informed RR-1 the wound was healing fine. RR-1 stated the leg was always in the immobilizer and never observed the wound. RR-1 further stated, R1 had to be admitted to the hospital for a two-hour surgery to debride the dead tissue on R1's thigh and had a wound vacuum pump placed to help the wound heal. Additionally, R1 is in a lot of pain due to the infection and surgery on his thigh. During an interview on 8/10/22, at 1:37 p.m. RN-A stated she observed a blister and large hematoma on R1's front right thigh during the admission/intake to the facility. It was noted to be large, puffy, and intact. RN-A stated it was not a responsibility of the admitting nurse to complete the care plan and that the unit manager or DON created care plans. RN-A further stated since there was no unit manager at that time, the responsibility would go to the DON. RN-A stated R1's wound should have been assessed every day and it was not assessed. During an interview on 8/10/22, at 8:40 a.m. DON stated she did not observe R1's wound at any time. She also did not enter a directive in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON further stated whoever completes the care plan must enter the directive in TAR/MAR. DON stated she is not sure if anyone ever assessed the hematoma. When asked where the documentation in the medical record of R1's wound observations and assessments were, DON indicated there was no documentation. During an interview on 8/10/22, at 10:15 a.m. LPN-A if there was no unit manager, the management of the unit and included care planning and it would be completed by the DON. LPN-A further stated nursing staff would have been responsible to assess R1's wound and it should have been completed per the care plan. During an interview on 8/12/22, at 9:57 a.m. MD-A stated the facility staff should have followed R1's care plan and should have assessed R1's wound on a daily basis. During a return telephone call interview on 8/18/22, at 3:10 p.m. LPN-C stated upon entering R1's room on 7/26/22, the soft splint was open, and the thigh dressing was observed to be blood soaked. When the dressing was opened there was a horrible smell. R1 stated this was the first time she would be caring for R1, so she conducted a medical record review to understand what cares R1 required. During the medical record review LPN-C noted R1's wound was directed to be assessed daily. LPN-C further stated after reading the care plan she reviewed the TAR, but there was no directive for staff to complete the task. LPN-C was also unable to find that any assessments had been performed in the previous days. The facility, Skin Assessment & Wound Management policy last revised 5/27/22, directed staff to perform routine skin inspections with residents daily care, and nurses are to be notified if skin changes are identified; skin problems also included large bruising

Based on observation, interview, and document review the facility failed to immediately implement appropriate interventions to protect residents from sexual abuse from R1 who had sexual behaviors that were inflicted on 5 residents (R4, R2, R3, R5, and R6) in the facility which resulted in a potential risk of serious harm identifying immediate jeopardy. The immediate jeopardy began on 1/22/22 when R1 touched R4's breast under her shirt and the director of nursing (DON) was notified. R1 touched R4's breasts a second time on 1/25/22. The administrator, and director of nursing (DON) were notified of the IJ on 2/3/22 at 1:00 p.m and the facility implemented corrective action on 1/26/22 prior to the start of the survey and was issued at Past Noncompliance. Findings include R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment and did not have behaviors. The MDS identified R1 was independent with locomotion on and off he unit. R1's mood care plan dated 10/21/21, included Resident has an alteration in mood and behavior related to Alzheimer's dx [diagnosis] loss of independence. Has also has a hx [history] of making sexually inappropriate comments towards staff and residents. Associated interventions dated 10/21/21 included, be alert to mood and behavioral changes, medications per physician order, redirect as needed (added 11/1/21), social services to assist resident (added 11/1/21) and monitor and document on mood state (added 11/1/21). The care plan also identified R1 watched pornography in his room. The care plan did not specifically identify or address level of supervision and/or while around female residents and/or individualized interventions to prevent R1 from voicing inappropriate comments to female residents. R1's behavior progress note dated 12/7/21 indicated R1 attempted to go into R2's room, staff had to remind him he was not allowed in R2's room. He stated Oh I forgot. He then left and went to the common area on the unit where he sat and talked with resident [R3]. He asked this resident what room number she is staying. R1 followed her to her room and started to go in. TMA [trained medication assistant] had to remind him once again that he is to not go into anyone's room. R1's social services note dated 12/8/21, included Staff have been reporting that resident has been flirting with other residents and attempting to go into other residents' rooms. Resident does have a history of sexual behaviors towards staff at his previous facility. Staff have concerns that resident will begin to display sexual behaviors towards residents. The note indicated the social worker notified R1's power of attorney who would have a conversation with R1 and social worker encouraged resident to continue being social and making new friends but it needs to remain appropriate and can be done in common areas within the building. Resident thanked writer and said he understood. Staff will continue to monitor and report any further behaviors. R1's social services note dated 12/9/21, included Activities staff reported to writer that she found resident in [R2's] room. Resident was asked again to visit with residents in common areas. Writer later chatted with [R2] who reported that she did not invite [sic] him in he had just showed up and came into her room There was no indication of inapposite behavior between R1 and R2. R1's physician visit note dated 1/17/2022 indicated nursing notes that he is frequently looking at porn on his phone The physician note did not address the sexual behaviors identified in the progress note and did not identify the plan for behavioral management. R1's quarterly MDS dated [DATE], identified R1 did not have cognitive impairment and did not have behaviors. R1's progress note dated 1/22/22, at 7:22 p.m. included Resident [R1] seen in the hall at 70's with one of 70's resident [R4]. Resident wanted to touch other resident's breast. When I heard conversation, I warned him not to do anything, and told him they should be 6 feet apart. I continued to watch his behaviors. Resident did not listen and start to touch the other resident's breast under her shirt. Resident taken into his room and immediately informed the DON. The DON called and told us to tell him that he is not allowed to come out from his room for the rest of the night. Resident stated that he did not care outcomes. Resident will be monitored and he will not be out his room for the rest of the night. R1's late entry progress note created on 1/25/22 by the administrator for effective date of 1/24/22 at 4:33 p.m. included [Staff member] was working on 1/24/22 and noticed the resident was in a female resident's room alone. [Staff] immediately went to the room that he was in and told him that he couldn't be in there. [Staff] noticed that resident near the females' residents' bed while she was laying in her bed. [Staff] immediately reported it to the administrator. Later on, the shift [Staff] noticed that resident was in another female's room, [Staff] immediately went over there to let resident know that he cannot be in another resident's room alone. [Staff] notified the administrator right away. R1's behavior note dated 1/25/22, at 11:46 a.m. included Patient has been behaving inappropriately to other female residents. This morning he was caught touching [R4's] her breasts by [certified nursing assistant and [housekeeper] in the 70s common area. Nurse talked to the resident about his behavior and notified that if this behavior continues he will be reported as he is taking advantage of the vulnerable old female residents. Resident was also told to stay 3 to 4 feets [sic] away from the other female residents and no more visiting with the female resident no matter where in the building. Will keep to monitor and update as needed. During an observation and interview on 1/31/22, at 2:49 p.m. R1 sat in his wheelchair in his room and stated he was going home soon. R1 stated he was recently caught by the nurse rubbing R4's boobs and stated R4 liked it when he did that. R1 stated he had only touched R4's breasts once and had not touched any other residents. R1 denied touching other residents inappropriately. R1 indicated he shouldn't have done that because he knew it was against the law. R1 stated when staff had seen him touching R4, he was removed from the area, and staff were watching him really close now. R1 stated he was not to go into other female resident rooms and was no allowed to have female residents in his room. During an interview on 2/1/22, at 8:10 a.m. police officer (PO)-1 stated he was the responding officer to a call he had received on 1/25/22 after the incident with R4. PO-1 stated he had interviewed the staff who were witnesses to R1 touching R4's breasts. PO-1 stated from his interviews from staff, staff had been aware of R1's behaviors and had been going on for quite some time. PO-1 stated staff reported he would probably not be able to interview R4 because she probably would not remember the event and she had emotional distress after the incident. PO-1 stated he did not interview R4 for those reasons and did not want to cause any further distress. PO-1 indicated he asked staff to talk to R1, however when PO-1 got to R1's room he was not there. PO-1 stated he had observed R1 down the hallway with 3 other female residents without staff supervision. PO-1 stated when staff approached R1 to remove him away from the women, R1 refused and directed them to call the police. PO-1 indicated that's when he approached R1 to make his police presence known. PO-1 stated R1 denied touching R4's breast and only touched her hand on 1/25/22 but had R1 told him he touched R4's breast on 1/22/22, and R1 Had told him R4 liked her breasts being touched. Interviews were conducted on 1/31/22, at 11:47 a.m. with facility staff who had knowledge of R1's sexual behaviors and witnessed R1 inappropriately touching residents which included - Registered nurse (RN)-A stated she had worked on 1/22/22, however was not assigned to R1's hallway. RN-A stated when she looked down R1's hallway she observed R4 sitting in her wheelchair with R1's hand down R4's shirt; R1 was clearly grabbing R4's breasts. RN-A stated she ran down the hallway and told him to stop immediately. RN-A stated R4 did not display any behaviors and was not reactionary. RN-A stated she removed R4 and brought her up to the nurse's station, called the administrator who then called the director of nursing, and then the director of nursing (DON) called her to get report of the incident. RN-A indicated no further care plan interventions were implemented. RN-A stated DON had a conversation with R1 via phone and directed and informed him he could not touch other residents. Administrator and director of nursing confirmed they had received the call from RN-A and the allegation was not reported to the state agency nor was an investigation initiated because they had not received all the details that R1 had physically touched R4's breast, and at the time had thought R4 had the capacity to consent. -Nursing assistant (NA)-A stated she was aware of R1's inappropriate behaviors towards residents and indicated it had been going on almost since R1 was admitted to the facility. NA-A stated a couple of months ago she had responded to R2's call light, R2 was lying in bed crying, R1 was rubbing her legs up and down her leg. NA-A indicated although it seemed R2 sought R1 out, R2 did not want R1 touching her at that time. NA-A stated another aide removed R1 from the room, NA-A stated with R2, was able to console her, R2 then called a family member who arrived at the facility about an hour later. NA-A stated she thought she had reported to the charge nurse at the time, however, could not recall who the nurse was. NA-A stated when R1 was out in common areas he would watch female staff and residents and would rub himself through his pants. NA-A stated it made her feel uncomfortable and would no provide cares to him by herself. NA-A stated on 1/25/22, she had witnessed R1 rubbing R4's left breast and heard R4 telling R1 to stop. NA-A stated she told R1 to stop, NA-A told him to stop and saw RN-B. DON and administrator stated that had not been aware of the incident that involved R2. -RN-B stated on 1/25/22, he saw R1 walk up to R4 and asked her if she had any boyfriends that came to visit. RN-B stated he redirected R1 and told him to stay away. RN-B stated he then went into someone else's room and a few minutes later he came out, when I heard NA-A telling R1 to stop. RN-B stated they removed R1 and educated him on staying away from the ladies. RN-B stated the administrator was immediately notified. RN-B stated R1 returned to his room and came out again later, RN-B indicated he then observed R1 asking R5 if she had any boyfriends and if they came to visit while rubbing her thigh. RN-B indicated an awareness if the incident that involved R5 was reported to the administrator. RN-B indicated after the incident R1 was supposed to be directly supervised. RN-B stated it seemed as though R1 would seek out the most vulnerable residents and that R1 was masturbating out in public areas and not that his urinary catheter was bothersome because there was no irritation and was consistent with his behavior. Administrator stated the incident between R1 and R4 was immediately reported to the state agency and to the DON; and was not aware of the incident with R5. Director of nursing indicated she had received a call from the administrator pertaining to the incident that had occurred between R1 and R4. DON stated 1:1 supervision and behavior monitoring was implemented, physician was made aware, medication changes were ordered, a cognition test was completed for R1 along with revision to care plan interventions, and mood symptoms screener was completed for R4. In addition, involved families were contacted and notified, and social services started working on R1's discharge plan. DON also indicated the facility developed and provided immediate re-education to staff members on abuse prevention and reporting procedures. Administrator stated she also was provided direct education by her supervisor pertaining to capacity to consent and reporting procedures. DON and human resource director provided and verified staff were all educated on 1/26/21. During an interview on 1/31/22, at 3:45 p.m. NA-B stated a familiarity of R1 and his behaviors. NA-B stated upon admission to the transitional care unit (TCU) R1 did not have any behaviors and recently had gotten really bad and sexually inappropriate behaviors such as rubbing female resident thighs, asking inappropriate questions, and touching himself, in addition to sexually harassing female aides had been happening for about two months. NA-B stated R1 was cognitively intact and knew what he was doing, stated she heard him on the telephone telling someone about what he was doing and how they liked it. NA-B stated he was going into demented female resident rooms while they laid in bed, pull up their night gown and touch their thigh or rub their arms and tell them he loved them. NA-B stated we [NAs] we would walk past rooms, find him doing these things, and remove him from their room. NA-B stated a while ago she had been walking past R3's room when she found R3 sitting up in bed talking to R1 while he massaged her thigh. NA-B stated she had redirected R1 out of R3's room and reminded him he was not supposed to be there. NA-B thought she had reported the incident to the nurse, however, could not recall who the nurse was but thought she remembered documenting a behavior note. NA-B stated R6 had also reported to her that R1 made her feel uncomfortable because he would touch her legs and could not recall if she had reported to the nurse. NA-B stated the incidents with R3 and R6 occurred prior to 1/25/22. NA-B indicated for a while there was a sign with instructions for R1 posted in the nurse's station that directed staff what R1 could and could not do. For a while he could not go into any female residents' rooms and he could not have female visitors in his room, however that changed to he could only go into cognitive females room without supervision. NA-B could not recall the dates of implementation of these interventions. NA-B stated up until the incident with R1, R1 had general supervision then and not the 1:1 supervision R1 was getting now. During an interview on 1/31/22 at 4:15 p.m. administrator and DON stated an unawareness of the abuse allegations that involved R3 and R6 that happened prior to 1/25/22; there for a report was not made to the state agency, a thorough investigation was not implemented, and interventions were not implemented to prevent further abuse. During an interview on 2/1/22 at 10:30 a.m. DON indicated when staff become aware of allegation of abuse, the administrator is supposed to be immediately notified, then administrator notifies her. DON stated once she is notified, she calls the nurse that reported to get the details, directs the staff of what assessments to complete, and the immediate interventions to implement. DON stated the nurse is supposed to complete the assessments and implements the interventions, monitors and documents the interventions for effectiveness; if the interventions are not effective, then the nurse was supposed to call her back. DON stated had staff followed the appropriate reporting procedures, assessments, and appropriate interventions would have been correctly completed and implemented at the time of occurrence. R4 R4's admission MDS dated [DATE] identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R4 required extensive assistance from one staff for bed mobility and locomotion on and off the unit, two or more staff for transfers, and extensive assistance from one staff for dressing. During an interview on 2/1/22, at 8:45 a.m. R4 laid in her bed. R4 stated an awareness of who R1 was. R4 stated, He touched my breasts and it seemed he liked it. R4 stated she did no like R1 touching her and told him to stop. When asked how many different times R1 had touched her, R4 stated R1 had touched her several times. When R4 was asked if staff helped her when she was being touched, R4 lowered her head and did not respond. R2 R2's quarterly MDS dated [DATE], indicated R2 did not have cognitive impairment, identified primary medical condition category as progressive neurological. The MDS also identified R2 required limited assistance from staff for transfers, did not walk, and one-person physical assistance for locomotion on and off the unit. During an interview on 1/31/22, at 4:45 p.m. R2 stated a familiarity of R1 and his behaviors. R2 stated once he came into my room a while ago (R2 was unable to articulate a date), I didn't have the tray table in front of me. R1 kept trying to touch my breast and I didn't want him to, he then tried to touch my crotch. R2 stated she kept trying to prevent him from touching her breast but couldn't totally prevent it. R2 waived her hands/arms in the air scissoring across her breasts (R2 demonstrated the motion) so he couldn't touch my breasts. R2 stated she did not want him to do that and felt violated. R2 stated staff came to help and removed R1 from her room. R2 indicated after the incident R1 continued to come into her room, however put the tray table across her chest to prevent R1 from touching her. R2 stated staff would notice R1 in her room and ask her if it was ok for him to be in there. R2 stated it was ok for him to be in her room as they were friends but did not want him touching her. R2 indicated staff would not stay in her room to supervise R1. R2 indicated R1 moved back down to the other hallway and had not been in her room lately. R3 R3's quarterly MDS dated [DATE], identified R3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R3 required supervision during transfers and walking, and for dressing required supervision after set-up. During an interview on 1/31/21, at 4:40 p.m. R3 stated she was not aware of who R1 was and indicated she had not been inappropriately touched by staff or other residents. R5 R5's quarterly MDS dated [DATE], identified R5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R5 had moderate cognitive impairment and required extensive assistance from two or more staff for bed mobility, extensive assist from one staff for transfers, dressing, and locomotion. R6 R6's quarterly MDS dated [DATE], identified R6 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R6 required one staff limited assistance for bed mobility, and extensive assistance from one staff for dressing. Facility policy Sexual Allegations Procedure dated 6/18/2019 included 1) The charge nurse of the unit where the alleged victim resides will verify that an allegation of criminal sexual conduct has been made. The charge nurse will then conduct an assessment of the alleged victim, initiate an Incident Report and immediately call the administrator and/or director of nursing to determine if 911 should be called. The charge nurse will ensure that no potential evidence is touched, so as to protect against contamination. 2) The charge nurse will take immediate steps appropriate to the situation to endure the protection and safety of the resident. 3) The administrator, director of nursing, or social worker will notify Minnesota Department of Health immediately. 6) The Nurse or Nurse manager will notify the physician and family regarding the facts of the situation. The immediate jeopardy that was removed on 1/26/22, after it was verified the facility completed the following actions before the abbreviated survey: -The allegation of abuse that occurred on 1/25/22 was reported timely in accordance with facility reporting procedures and the regulation. -The facility immediately reassessed R1 and put appropriate interventions in place that included 1:1 supervision in order to immediately protect residents and prevent reoccurrence until appropriate placement and discharge from the facility. -The facility provided re-education on abuse and reporting to procedures for direct care staff and ancillary staff. -The facility assessed staff knowledge by providing quizzes of the education and determined staff were competent. -The facility developed and implemented a monitoring system of the areas that had been identified as deficient.

Based on interview and document review the facility failed to conduct appropriate nursing assessments and interventions for 1 of 1 residents (R1) who had a [CONDITION(S)] was found in an unresponsive state. This resulted in actual harm when the registered nurse did not complete a comprehensive nursing assessment, to identify why the resident was unable to breath which resulted in respiratory distress and hospitalization . Findings include: R1's face sheet indicated R1 was admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Because R1 was a new admit there was not a completed Minimum Data Set (MDS) assessment or an initial care plan. When interviewed on 2/3/21, at 11:19 a.m. and 2/4/21, at 12:14 p.m. registered nurse (RN)-A verified she had gone into R1's room around 6:30 a.m. to give R1 her morning medications with nursing assistant (NA)-A. RN-A stated she noticed R1's breathing kind of seemed different and it did sound like she could have used a suction. R1's oxygen saturations (O2 sats) were at 92% (a normal level of oxygen is usually 95% or higher). R1 was a pink color and kind of clammy and R1 looked like she was sleeping but she just wasn't the same. RN-A tried to move R1 to see if she would wake up, as [R1's] eyes seemed open, but she wasn't alert. RN-A spoke loudly to R1, turned on R1's overhead lights, nudged R1, and attempted a sternal rub, but R1 did not respond. RN-A had NA-A stay with R1 while RN-A called 911 and went to find the automated external defibrillator (AED). RN-A stated when emergency medical technicians (EMT) arrived, they told RN-A she should have suctioned R1 more. RN-A stated, they made me feel like I didn't do enough. RN-A stated she had suctioning equipment ready and the EMT's suctioned R1 using EMS equipment. RN-A stated she did not suction R1 when she found her unresponsive and called 911 because she felt it was an emergency, and she didn't want R1's O2 sats to drop. RN-A verified she did not have another nurse assess R1 and stated, it was in the middle of shift change and my nurse was running late to relieve me. RN-A verified she did not stay with R1 and attempt interventions, rather she went to call 911. RN-A verified NA-A could have gone to call 911 and get the AED for her and stated, I have had an aid call 911 for me before, I just wanted to call myself because I had been working with her night before and wanted to give them up-to-date, accurate information. RN-A verified there were no other residents on vents in the facility at that time and there was a policy and procedure book for the vents on the unit that she and the interim director of nursing (DON) had reviewed earlier that day. RN-A was visibly upset during interview and stated, I assumed she was ok, there were no signs of distress. When interviewed on 2/4/21, at 8:55 a.m. NA-A verified she was in R1's room with RN-A that morning, as RN-A wanted to do something with R1 but needed help. When RN-A and NA-A walked into the room, R1 did not respond to anything. Per NA-A, [R1] was breathing, but to be honest with you she looked like she was going to pass right there. NA-A stated R1 didn't have color, and looked more white. R1 did not move and didn't respond to any stimulation. RN-A shook R1, lifted R1's head and stated it just fell to the other side like there was nothing there. NA-A stated RN-A was baffled what to do. NA-A described R1's breathing patterns as rapid and stated, it sounded like she was trying to catch her breath, but she couldn't, then she would stop, almost like she was trying to take a deep breath, but she couldn't. NA-A verified RN-A asked me to stay with the patient and she went to get the paddles, she came back and placed them in the room, and then she went to call 911, RN-A was gone approximately 4-5 minutes. NA-A stated RN-A returned to R1's room just a hair before the paramedics arrived. NA-A verified RN-A didn't try to suction her and stated, it was obvious that she was having trouble breathing. NA-A verified RN-A did not have another nurse come into R1's room to assess or stay with R1 while NA-A was present. When interviewed on 2/3/21, at 2:18 p.m. the director of nursing (DON) verified R1 arrived at the facility on 1/28/21, via ambulance and was suctioned about every 30 minutes while transported from the hospital to the nursing home. DON stated RN-A suctioned R1 a few times upon R1's admission to the facility, and placed R1 on the ventilator (device that supports or takes over the breathing process, pumping air into the lungs).R1 came off of the ventilator later that afternoon. DON verified the facility was told by the admitting hospital that discharged R1 that R1 was on the ventilator overnight and when she napped for proper ventilation and oxygen exchange. When interviewed on 2/4/21, at 10:57 a.m. family member (FM)-A verified on 1/29/21, at approximately 6:30 a.m. to 6:45 a.m. RN-A called and said she had to call 911 because R1's O2 sats dropped and she had trouble with the ventilator. FM-A verified R1 had [CONDITION(S)] and stated, with the [CONDITION(S)] if the vent isn't working properly, she gets loaded up with [MEDICATION(S)], she basically passes out and she becomes unresponsive. FM-A stated in November, R1 had a similar occurrence at home and had to be intubated and hospitalized as R1's [MEDICATION(S)] level got too high. When interviewed on 2/5/21, at 2:53 p.m. emergency medical technician (EMT)-A verified he responded to R1's medical emergency on 1/29/21, at about 6:40 a.m. and stated, we brought in all of our equipment, suctioning and everything. EMT-A stated when he arrived, R1 was cyanotic (blue / ash gray in color) and described R1's breathing pattern as guppy breathing or gasping for air. EMT-A stated R1's eyes were open but not tracking and stated, a change in mental status is a number one indicator for [CONDITION(S)] (lack of oxygen). The pulse oximeter R1 had in place indicated R1's O2 sats were at 79 percent on three liters of oxygen. EMT-A stated he couldn't hear any internal air movement and believed R1 had a [MEDICATION(S)] plug. EMT-A asked RN-A if she had done suctioning, RN-A indicated she had not, and had suctioned at 11:00 p.m. the night before and 2:00 a.m. EMT-A placed a bag valve mask (BVM) (device used to manually ventilate a patient whose respirations are absent or inadequate) over R1's [CONDITION(S)]. EMT-A verbalized the BVM didn't even fill back up with air because R1 had a [MEDICATION(S)] plug that blocked her [CONDITION(S)] tube. EMT-A stated he put about 3 milliliters of saline down R1's [CONDITION(S)] tube and removed about 10 ml - 15 ml of [MEDICATION(S)], a substantial amount. EMT-A measured R1 [MEDICATION(S)] (CO2) level and was found to be 131. EMT-A verbalized a normal CO2 level is between 35-45 and a lethal level is about 100 - 110. EMT-A stated, that number told me that she had not ben breathing for a while. EMT-A stated RN-A should have put a bag value mask on and have been bagging the patient to assist her in breathing. EMT-A stated the suction machine was in R1's room at the time of his arrival. EMT-A further stated there were saline bulbs present in R1's room and RN-A could have tried to get the [MEDICATION(S)] plug out by flushing the [CONDITION(S)] with the saline. R1's progress note, dated 1/29/21, indicated, at approximately 6:30 a.m. RN-A went to administer R1's medications. When RN-A attempted to wake R1, she did not respond to light or sound. RN-A tried to wake R1 with a gentle shoulder rub and sternal rub with no response. RN-A called 911 at 6:35 a.m. EMT's arrived on site at 6:40 a.m. and left the facility at 6:55 a.m. with R1 in route to the hospital. RN-A notified R1's husband of the situation. North Memorial Ambulance Service, dated 1/29/21, indicated [AGE] year-old female found unresponsive lying-in bed with agonal respirations (abnormal breathing pattern characterized by labored breaths, gasping, contractions, and grunting). Pt [Patient] was found to be cyanotic (blue) and hypoxic. She was trying to gasp for air but wasn't passing air. We were unable to ventilate the pt. we put 2 ml (milliliters) of NS (normal saline) down her tube and they started suctioning. We were able to get some [MEDICATION(S)] up but when we repeated with the NS and more suctioning, we were able to clear her airway and we started to ventilate her with high flow O2. We found her to have a very high level of CO2. The physical examination performed reveals mental status unresponsive. Eyes: R: 4-mm (millimeters); L: 8 mm or > [greater]. Skin cyanotic, diaphoretic (sweaty), warm. Breath sounds decreased on L [left] and R [right]. we continued to ventilate using the BVM with high flow O2. She remained to have a high CO2. We needed to resuction one more time to clear out more [MEDICATION(S)]. We found that her L eye was very filtrated and her lung sounds were very diminished. R1's emergency department (ED) triage notes, dated 1/29/21, indicated, upon the ED physical exam [R1] had no purposeful movement or response and had agonal respirations with minimal to no air movement. R1's initial labs were consistent with likely respiratory acidosis (a condition that occurs when the lungs cannot remove all of the [MEDICATION(S)] the body produces). Upon arrival to ED, staff performed deep suctioning and were able to get the O2 sats up to 100% with this. Facility policy titled change in resident condition, dated 6/2019, stated, If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted and The nurse will make detailed observations and gather relevant and pertinent information for the provider.

Based on observation, interview and document review, the facility failed to assess falls and implement interventions to reduce the risk of falling for 2 of 3 residents (R1 and R2) reviewed for falls. This resulted in actual harm for R1 when R1 fell from the bed resulting in a cervical (neck) fracture. Findings Include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and required supervision with transfers. The MDS indicated R1 had no falls since the previous assessment. R1's care plan revised on 1/3/21, indicated a risk for falls related to impaired mobility, medication management, disease process, and assistive device, with a goal to have zero falls within the next 90 days. R1's care plan directed staff to keep room clean and free from clutter dated 3/7/20, keep call light within reach dated 3/7/20, low bed dated 11/30/20, and non-skid mat taped to the floor next to the bed dated 3/8/20. R1's Incident Review and Analysis dated 12/10/20, identified R1 had been found on the floor at 7:55 a.m. The incident analysis identified R1 had fallen asleep on the edge of the bed. The form did not identify if the bed had been in the low position as care planned when R1 had fallen or not. R1's progress note dated 12/10/20, identified R1 complained of hip pain and pain on right foot and was sent to the emergency department. R1's progress note dated 12/13/20, identified, Monitor area on right foot just above toes. Area is red and measures 6 x 3. R1's Incident Review and Analysis form dated 1/4/21, indicated R1 was found on the floor/fall from bed with causal factor of the incident, Aide called this nurse to the residents room. This resident was found on the floor in a sitting position next to her bed. This nurse did not see any bleeding or bumps at first glance but resident stated that her head and right knee hurt. When asked how she fell , resident stated that she did not remember how she fell . She stated that she hit her head but could not remember how she hit her head. Contributing factors included, Decline in cognition is playing a part in resident forgetting she needs to ask for help for transfers. The form did not identify if R1's care planned approach to have bed in the low position was implemented or not, however, included, ensure low bed is care planned. The form did not identify if R1 had an unmet need pertaining to the fall, such as assessing toileting schedule/continence status, when she was last seen, or if medications had been assessed. R1's physician televisit dated 1/8/21, identified, History of falling, this is multifactorial and at least in part due to not remembering she needs assistance. There are also significant staffing constraints during COVID-19 outbreak. Her bed has been lowered and I noticed during our visit today that the top of the mattress falls below the knee of the examining nurse. May need to consider discontinuing anticoagulant. R1's Incident Review and Analysis form dated 1/9/21, included R1 had been found on the floor with a fall from the bed again. Resident was found by two aids laying on the floor next to the bed, around 0720 am. She was in a sitting position with hands covering her face. Resident was bleeding from scalp, it appears that she got more than one open areas on scalp. Resident stated she was trying to get to the bathroom, but do [sic] not remember what happened or how she end [sic] up on the floor. Resident was conscious all the time. Contributing factors included, Cognition, resident is supposed to be assist of 1 but often will [sic]. R1's progress note dated 1/9/21, identified R1 had been sent to the emergency room via ambulance around 8:00 a.m. and was subsequently hospitalized . There was no indication if the current care planned interventions were implemented or not, or if there were other contributing factors that led to R1's fall. R1's Abbott Northwestern Emergency Department (ED) report dated 1/12/21, indicated [R1]'s CAT (CT) scan (a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body) revealed a C2 fracture (a fracture in the second bone down from the skull in the cervical (neck) vertebrae) after sustaining a fall at the skilled nursing facility (SNF). R1 was placed in a neck collar and admitted to the hospital. R1's discharge plan was to be admitted to a hospice with family concerns about lack of supervision at this facility. R1's investigative file dated 1/9/21, identified, Resident was found on her floor in her room by the CNAS [certified nursing assistant]. Resident had a significant head injury with blood all over. Staff sent resident out to ER. Family and MD were notified. Care plan was being followed. Bed was in low position and call light was in reach, but resident did not pull the call light. A typed statement dated 1/9/21, at 6:25 p.m. nursing assistant (NA)-B stated [R1] was last checked on at 5:00 a.m. and was sleeping. When interviewed on 1/13/21, at 11:34 a.m. licensed practical nurse (LPN)-A stated when entering [R1]'s room after the fall on 1/9/21, the bed was noted in the medium position and [R1] was sitting on the floor. R1's call light was attached to the bed but was not turned on. Additionally, LPN-A stated [R1] usually turns on the call light when [R1] needed something however, did not that morning. LPN-A verified [R1]'s bed should have been in the lowest position according to the care plan but did not know why is wasn't in the lowest position. When interviewed on 1/13/21, at 11:47 a.m. NA-C stated they had entered [R1]'s room with NA-D at 7:20 a.m. for the first time that morning and found [R1] sitting on the floor with legs stretched out under the wheelchair that was sitting next to the bed. The bed was mid-way up and was not in the lowest position. NA-C demonstrated the bed could be lowered further and lowered the bed to it's lowest position. NA-C did not know why the bed wasn't in the lowest position since it was the first time going into [R1]'s room the morning of the fall. NA-C verified [R1]'s bed should have been in the lowest position according to the care plan. When interviewed on 1/13/21, at 1:44 p.m. family member (FM)-A stated she had come to the facility when R1 had been transferred to the hospital and found R1's bed was not in the lowest position, the call light was was clipped to the outside part of the bed rail, where it would have been difficult to reach. When interviewed on 1/13/21, at 2:36 p.m. the director of nursing (DON) stated a care plan directing staff for a low bed means the bed should be in the lowest position possible. DON verified [R1]'s care plan required a low bed. The DON was unable to find an analysis of the falls R1 had from bed on 12/10/20 and 1/4/21, and verified no new interventions were placed to prevent R1 from falling from bed again. R1 remained in the hospital with a broken neck and may not survive. R2's Hospital Discharge Summary dated 11/19/20, identified R2 was being discharged from the hospital following gall bladder surgery and subsequent difficulty voiding and urinary catheter placement. The hospital discharge summary included under the section of Functional Limitations R2 had, Decreased bed mobility, decreased cognition, impaired ADL's [activities of daily living], difficult transfers, decreased activity tolerance, impaired ambulation, impaired balance at 11/18/2020. R2's admission MDS dated [DATE], included, severe cognitive impairment and required extensive assistance with activities of daily living, including with bed transfers and ambulation. R2's care area assessment (CAA) dated 11/30/20, documented R2 triggered for activities of daily living (ADL) functional needs related to assistance needed with ADLs and severe cognitive impairment. The CAA also documented R2 had a recent decline in mobility related to his recent long hospitalization . R2's care plan revised on 1/3/21, documented in the Focus section, Fall risk related to history of falls, impaired mobility, date initiated: 11/27/20. The section, Interventions, documented, Low bed, date initiated 1/3/21. and Monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. date initiated: 12/4/20. R2's progress note dated 12/21/20, indicated R2 had a fall out of bed resulting in an abrasion to the left elbow. R2's Incident Review and Analysis V-3 dated 12/22/20, reviewed the fall from bed on 12/21/20. The section Incident Analysis documented, resident rolled out of bed. The section Follow-up/Interventions documented under interventions, Bed in lowest position. The form failed to evaluate the reason for, rolled out of bed. R2's progress note dated 1/4/21, indicated R2 had a fall in his room and was found on the floor without injury. R2's Incident Review and Analysis V-3 dated dated 1/5/21, reviewed the fall from bed on 1/4/21. The section Incident Analysis under the section, Incident Analysis, documented, Resident was last seen resting in bed, CNA went into room to check on resident and found him sitting on the floor in front of his recliner. His breakfast tray was spilled all over the floor. Under the section Incident Analysis, there was no further documentation of a causal factor and the section contributing factors had nothing listed. Under the section, Possible Interventions, the facility listed, proper footwear/gripper socks and Bring resident out to dining room table for meals, ensure resident has proper footwear on. The form did not indicate any assessment of this fall had been completed. R2's progress note dated 1/13/21, indicated R2 had a witnessed fall in the commons area while self ambulating without assistance resulting in an abrasion to the left elbow. On 1/13/21, at 2:06 p.m. R2 was observed in his room sleeping in a low bed that was in a partially raised position, approximately two feet above the bed's lowest position. On 1/13/21, at 2:11 p.m. nursing assistant (NA)-A, stated she was working with R2 and was familiar with his cares. NA-A confirmed R2 was sleeping in his bed and it was not in the low position. NA-A demonstrated the bed could be lowered further and lowered the bed to it's low position. On 1/13/21, at 2:25 p.m. registered nurse (RN)-A stated she was working with R2 and was familiar with his cares. RN-A stated R2 should always have his bed in the lowest position while in bed. On 1/13/21, at 2:36 p.m. director of nursing (DON) stated the expectation with a low bed is to have the bed in the lowest position while a resident is in bed. A Fall Prevention and Management policy dated 2/2020 was provided. This identified a purpose of identifying residents at risk for falls, implementing interventions to help prevent falls, and providing guidelines for assessing a resident post-fall. A section labeled, Managing Falls and Fall Risk directed the following Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent falls and minimize complications from falling. Further, indicated if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Additionally, indicated staff may also identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 when the facility failed to separate COVID positive residents from COVID negative residents resulting in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19 for 2 of 3 residents (R1, R2) reviewed for infection control practices. The IJ began on 11/22/20, when the facility failed to separate roommates, when other rooms were available and R1 was COVID-19 positive and R2 was negative, the IJ was identified on 11/24/20. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 3:27 p.m. on 11/24/20. The immediate jeopardy was removed on 11/25/20, when the facility implemented corrective actions, but noncompliance remained at the lower scope and severity level of a D - isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Current CDC guidance last updated 11/20/20, indicated nursing home residents are at high risk of being affected by respiratory pathogens like COVID-19 due to older age and underlying chronic medical conditions. Residents with known or suspected COVID-19 should be placed in a private room with their own bathroom. Residents with COVID-19 should, be cared for in a dedicated unit or section of the facility with dedicated staff. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively impaired and had [DIAGNOSES REDACTED]. R1's COVID-19 polymerase chain reaction (PCR) test result dated 11/16/20, indicated R1 was positive for COVID-19. R2's admission MDS dated [DATE], indicated R2 had a Brief Inventory of Mental Status (BIMS) score of 13, was alert and oriented and had [DIAGNOSES REDACTED]. R2's COVID-19 PCR test result dated 11/16/20, indicated R2 was negative for COVID-19. These comorbidities placed R2 at significant risk for complications if R2 were to contract COVID-19. During interview on 11/24/20, at 9:20 a.m. nursing assistant (NA)-A stated she cared for R1 and R2. R1 tested positive for the [MEDICAL CONDITION] on 11/16/20. R2 tested negative for the [MEDICAL CONDITION] on 11/16/20. R1 was asymptomatic. NA-A stated that because R1 and R2 were roommates when COVID testing took place, they continued to reside in the same room. During interview on 11/24/20, at 9:20 a.m. NA-A stated the bathroom was designed to be shared between two rooms. The bathroom was currently only used by R2. R1 needed complete physical care and did not use the bathroom or a commode. The resident in the adjacent room used a commode and did not use the bathroom. During interview on 11/24/20, at 10:44 a.m. licensed practical nurse (LPN)-A stated as far as she knew, R1 and R2 would continue to be roommates since they have been asymptomatic (without symptoms), even though R1 was COVID-19 positive and R2 was COVID-19 negative. During interview on 11/24/20, at 11:23 a.m. the DON and administrator stated they had part of the facility that was not occupied and would be a designated COVID-19 unit. They did not plan to move R1 at this time, nor separate R1 and R2, but instead would wait until they had multiple residents with positive COVID-19 [DIAGNOSES REDACTED]. During observation on 11/24/20, at 12:10 p.m. surveyor entered room for R1 and R2. The curtain for R1's side of the room was pulled completely around the bed. R1's bed was against the wall that faced the hallway. There was a space of about 4 feet between the curtain and the door that led to the bathroom. The bathroom door was closed. There was a linen hamper on the left side of the bathroom door and a trash hamper on the right side of the bathroom door. R2's bed was against the wall. The head of the bed was toward the windows. A commode was located by the windows. During interview with R2 on 11/24/20, at 12:15 p.m. R2 stated that she was very unhappy to be in the room. R2 stated that until the morning of 11/24/20, she was allowed to use the bathroom but now must use a commode. R2 stated this was unsanitary. R2 stated, This room is not ventilated. It is hot, smelly, and cramped. If I use the commode, it smells worse. During interview with R2 on 11/24/20, at 12:15 p.m. R2 stated, I do not understand why I have to be in a room with a person who is sick with COVID. I am afraid that I will get sick with COVID and if I catch COVID, I will die. Attempt to interview R1 on 11/24/20, at 12:25 p.m. was not successful, R1 did not respond when asked questions due to cognitive ability. During interview on 11/24/20, at 1:28 p.m. the DON stated they went by their Monarch corporate policy titled Coronavirus (COVID-19) dated 10/8/20. The COVID-19 policy indicated it was generally not recommended to separate symptomatic positive residents and their roommates. DON stated R1 and R2 had both been asymptomatic. The DON confirmed the COVID-19 policy also indicated COVID-19 positive residents ideally would be moved to a private room with a private bathroom. DON stated even with the COVID-19 policy, the plan was not to separate R1 and R2. DON stated they had 6 potential rooms that were available as private room with private bathrooms. The CDC People with Certain Medical Conditions, revised November 2, 2020, identified adults with certain underlying medical conditions such as kidney disease, diabetes, or lung disease, are at increased risk from [MEDICAL CONDITION] that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. During interview on 11/24/20, at 2:28 p.m. the administrator stated they did an [MEDICATION NAME] test, (diagnostic test designed for rapid detection of [MEDICAL CONDITION] that causes COVID-19. [MEDICATION NAME] tests are very specific for [MEDICAL CONDITION], but are not as sensitive as molecular PCR tests) on R2 shortly before the interview, and the results were negative. Administrator stated they consulted with their corporate offices on 11/24/20 (prior to the notification of the IJ), and decided as a group to move R1 to the COVID-19 unit. Going forward from today, 11/24/20, the practice would be to move residents with positive [DIAGNOSES REDACTED]. The IJ that began on 11/24/20, was removed and the deficient practice corrected on 11/25/20 at 2:30 p.m. when it could be verified by observation, interview and document review that R1 was moved to a private room with own bathroom. Also, the policy titled Coronavirus (COVID-19) was updated 11/24/20, to include how residents with known or suspected COVID-19 should ideally be in private room with own bathroom. Exposed residents are ok to cohort with other exposed. The facility could consult with public health officials on decisions about resident placement. Next, education was provided on 11/24/20, to all staff involved in receiving diagnostic test results and facilitating room changes, that positive and negative residents were not to be cohorted. Instead, positive residents were to be moved to a private room with private bathroom to keep the roommate and other residents safe from COVID-19. Lastly, a policy compliance audit tool was developed. The tool would track the date of any positive diagnoses, date isolation started and if a private room with private bathroom was available. If private room was not available, the audit tool indicated to note the other accommodations that were made.

Based on interview and document review, the facility failed to follow resident wishes and physician orders [REDACTED]. This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found without a pulse or respirations and CPR was not initiated for 45 minutes due to confusion over resident code status and R1 died . In addition, R2 was found without a pulse or respirations and CPR was initiated immediately although R2's resuscitation order was DNR (do not resuscitate). The facility immediately implemented interventions and corrected the deficient practice on [DATE]. This is issued as past noncompliance at Immediate Jeopardy (IJ). The IJ that began on [DATE] was corrected on [DATE] when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on [DATE], at 2:14 p.m., as a result of the immediate corrective action taken by the facility. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively impaired and had [DIAGNOSES REDACTED]. R1's hospital discharge orders to facility dated [DATE], indicated R1's resuscitation status was full code. R1's physician order [REDACTED]. R1's paper chart or electronic medical record (EMR) lacked a Physician order [REDACTED]. R1's care plan dated [DATE], indicated Advance directive in place and will be honored during the review period. R1's care plan interventions included Arrange medical doctor (MD) consultation as necessary and Review resident's Advance Directive PRN (as needed) per resident and/or family request. R1's code status was not indicated on the care plan. When interviewed on [DATE], at 9:49 a.m. family member (FM)-A stated, The doctor looked at (R1) when there (the hospital) and asked if he wanted to be resuscitated and he said yes. FM-A further stated LPN-A called her requesting R1's DNR paperwork on [DATE]. FM-A stated, If there was any hope we wanted to be resuscitated not on machines. FM-A further stated that R1 was not on hospice and there had been no conversation about entering hospice. (R1) wanted to get up and moving. When interviewed on [DATE], at 11:47 a.m. activity assistant (A)-A stated being on the unit to assist with the dinner tray delivery when she overheard LPN-A yell from R1's room for someone to grab a crash cart and call 911. So the aides came with the crash cart and I am on the phone with 911 giving them all the details then (LPN-A) said hang up the phone he is hospice DNR we do not need anyone. A-A stated the staff did not do any CPR because they thought R1 was DNR. When interviewed on [DATE], at 2:06 p.m. DON stated the expectation was the admitting nurse should review the POLST with the new resident or the resident's family on the day of admission or as soon as possible thereafter. DON further stated the resident would come to the facility with a signed resuscitation order from the hospital. DON further stated the signed order was to be followed and that order was what drove the code status to display in the resident header in the EMR. DON further stated the expectation was when someone was found unresponsive, staff would confirm the code status from the POLST in the paper chart. If the POLST was not available, staff should check in the EMR resident header or active orders. Staff were not expected to initiate CPR until code status was determined. Once CPR was initiated it should not be stopped until paramedics arrive. DON confirmed R1 had a resuscitation order of full code upon admission. When interviewed on [DATE], at 2:35 p.m. nurse practitioner (NP)-A stated she previously took care of R1 in a different care facility and that he was a full code there and that it remained the same in this facility. NP-A recalled previous conversations with FM-A and FM-A would have wanted R1 to be full code. NP-A further stated the Genevieve (a provider group) triage note from [DATE], at 1:15 p.m. and 1:21 p.m. indicated R1 was a full code. When interviewed on [DATE], at 3:20 p.m. LPN-A stated someone from Genevieve called to speak with her about R1 but she was too busy to take the call and instructed nursing assistant (NA)-A to tell them she would call them back. When she called them back she thought they said they were Genevieve hospice. LPN-A further stated when she found R1 unresponsive she thought R1 was on hospice. LPN-A further stated she looked for hospice and code status in R1's paper chart and in the EMR but could not locate it. LPN-A stated after she found R1 without a pulse, she spoke with DON several times over a ,[DATE] minute period and the last conversation the DON confirmed R1 was a full code. When interviewed on [DATE], at 3:44 p.m. NA-A confirm he answered the first phone call from Genevieve who called on [DATE], to check the status of R1. I thought it was hospice and so did the nurse. NA-A could not recall a name of the person who called. When interviewed on [DATE], at 9:33 a.m. registered nurse (RN)-A stated worked on a different unit and was called to help try to find a heartbeat on R1. RN-A stated she did not know the code status of R1 at that time and looked in the paper chart and the EMR and could not find a POLST and the code status field in the resident header was blank. The code status field displayed in the resident header should have indicated either CPR (for full code) or DNR. The code status in the resident header was used for quick identification of resident code status upon opening the resident's electronic chart. RN-A confirmed the DON finally called back and informed LPN-A that R1 was a full code. RN-A then started CPR on R1. When interviewed on [DATE], at 10:03 a.m. RN-B stated she spoke to the triage nurse from Genevieve at 1:30 p.m. during that day ([DATE]) but did not know R1's code status. It was discussed with triage, I looked in (the EMR) and the chart and could not find it. RN-B confirmed R1's code status on the resident header was blank. RN-B stated recalling the Genevieve triage nurse saying that NP-A had jotted it down that (R1) was a full code. RN-B further stated she would look for the POLST in the paper chart and if it was not there, she would look in the resident header in the EMR. RN-B confirmed she did not think to look at R1's orders. When interviewed on [DATE], at 11:50 a.m. DON stated staff should look for the POLST first in the paper chart and if the POLST was unavailable they should look at the code status in the resident header or the orders in the EMR. DON confirmed there were two different orders available in the EMR to enter the resuscitation order but only one of them would cause the code status to appear in the resident header. DON did not know why the two different code status orders existed, but discovered that R1's code status had been entered under the wrong one. DON confirmed that on [DATE], an audit was completed on all resident's charts to make sure the code status was ordered with the correct order and displayed in the resident header and that all residents had a POLST completed and scanned into the EMR. R2's admission record [DATE], indicated [DIAGNOSES REDACTED]. R2's hospital records on [DATE], from Mayo Clinic stated R2's resuscitation status was do not resuscitate (DNR). R2's facility admission orders [REDACTED] R2's progress notes dated, [DATE], at 12:30 a.m. included, resident was found in the room with food tray in front of her at 7:02 p.m. Resident was pulseless, removed patient from wheelchair and started CPR. Reviewed POLST (Physician order [REDACTED]. 911 dispatch stated that writer was to continue CPR until police/paramedics arrived even though resident was DNR/DNI. CPR was stopped once police arrived and resident was pronounced dead at 1912 (7:12 p.m.). When interviewed on [DATE], at 12:19 p.m. director of nursing (DON) stated when staff found R2, they started CPR immediately even before they checked the POLST. Once the nurse found out that R2 was DNR, she stopped CPR but the paramedics told her to keep doing until they arrived. DON said the nurse started panicked and started CPR. She confirmed that it was not the facility policy to start CPR before confirmation of the code status. DON stated she believed that she talked to the nursing staff and educated them about facility policy after the incident, but nothing was written down. The facility policy Cardiopulmonary Resuscitation dated ,[DATE], indicated a POLST form should be completed upon admission by the nurse manager or designee and reviewed upon readmission, quarterly and as needed. A POLST form is a medial order, which means it must be signed by a medical provider to be valid. During an emergency, the nurse will provide care according to the resident preference as indicated on the physician's orders [REDACTED]. The facility provided document titled Admission Steps dated ,[DATE], indicated the admission packet was to be reviewed with the resident or resident representative upon admission to include advanced directives. The past noncompliance immediate jeopardy began on [DATE] and was corrected on [DATE]. Verification of corrective action was confirmed on [DATE], by interviews with licensed and unlicensed staff. The facility audited all resident charts for presence and accuracy of the POLST and confirmed consistency with the EMR and code status in resident header. The facility developed and implemented staff education regarding CPR and code status and all facility staff and agency staff were educated. The facility revised their orientation of agency staff to include code status and CPR initiation.

Based on interview and document review, the facility failed to comprehensively assess and monitor 1 of 3 residents (R10) reviewed whom had a change of condition. This resulted in actual harm when R10 had 23.13% weight loss within 19 days of their stay, and was hospitalized [MEDICAL CONDITION], and severe dehydration. Findings include: R10's admission Minimum Data Set ((MDS) dated [DATE], indicated moderate impairment in cognition based on Brief Inventory of Mental Status (BIMS) score of 8. R10 had not rejected care. R10 required extensive assistance from one staff in bed mobility, locomotion on/off unit, dressing, toileting and hygiene. R10 required total assist from 2 staff for transfers. R10 was independent with eating. R10's face sheet dated 8/21/20, indicated admission [DIAGNOSES REDACTED]. R10's hospital discharge summary dated 8/21/20, indicated R10's weight at discharge was 134 pounds (lbs). R10's facility admission recorded weight, dated 8/21/20, also indicated R10's weight was 134 lbs. R10's facility admission orders [REDACTED]. Nurses were to document activities of daily living (ADLs), continence, behaviors, intake, assistance level, ambulation/transferring etc. Additionally, R10 had an order from 8/21/20 for daily weights due to admission, on every day shift for three days with a start date of 8/22/20. The medical record lacked documentation or refusal of those daily weights. R10 had an order for [REDACTED]. R10's care plan dated 8/24/20, indicated R10 had a nutritional problem or potential nutritional problem. The care plan directed staff to monitor intake and record every meal per protocol. R10's dietary PN dated 8/24/20, at 11:29 a.m. indicated R10 was able to feed herself and denied difficulty chewing or swallowing. R10 had moderate protein calorie malnutrition and a potential for weight change due to diuretic use. On 8/27/20, R10 was started Med Pass (a fortified nutritional shake) 4 ounces three times daily. The intake was documented on the medication administration record (MAR) with staff initials and a checkmark, but not a percentage of how much was consumed. R10's social services PN dated 9/3/20, at 1:09 p.m. indicated R10 had a care conference. R10 and their spouse, therapy department and social services attended. R10's plan was to continue with therapy. R10 had minimal progress and was improving. The PN from 9/4/20 to 9/7/20, lacked documentation of R10's status and lacked documentation of any refusal to eat or drink. The MAR from 8/21/20 to 9/8/20, lacked documentation of R10's refusal to eat or drink. R10's Med Pass supplement scheduled for three times a day was initialed with a check mark but not a percentage of how much was consumed. R10's dietician PN 9/8/20, at 3:19 p.m. indicated per interdisciplinary team (IDT) R10 had been refusing the majority of meals. Weight history is variable: 107 lbs lbs. (9/8), 135 lbs. (9/3), 115 lbs. (9/1), 134 lbs. (8/21). R10 had been refusing therapy and refusing to get out of bed. Recommendation to increase Med Pass to four times daily. Will request reweigh to determine accuracy. The MAR on 9/9/20 showed a new order for Med Pass 120 cubic centimeters (cc) four times daily. The MAR from 9/9/20 to 9/10/20, showed Med Pass intake with staff initials and the number 9 which indicates other/see nurses notes. R10's nursing PN dated 9/9/20, at 1:55 p.m. indicated R10 was pocketing medications (storing in cheek), and had decrease in responsiveness and participation. R10 had poor intake at meals. R10 required total assist for cares today. Nurse practitioner (NP) had been updated. R10 was to be reweigh and NP updated in the morning. NP also ordered speech therapy evaluation. A nursing order was added to check vital signs every shift. R10's MAR dated 9/9/20, indicated R10's reweigh was 103 lbs. This was a 31 lbs. (23.13%) weight loss from admission, 8/21/20, 19 days ago. R10's care plan dated 9/9/20, indicated R10 was at risk for dehydration. Staff were to encourage adequate fluid intake and monitor resident for signs and symptoms of dehydration. R10's daily flood/fluid intake logs were requested, and the only ones found were 9/8/20-9/11/20. Review of these intakes indicated: -9/8/20, R10 had refused breakfast and fluids, took one bite of food and had zero fluids for lunch and had refused dinner and fluids. The medical record lacked documentation on 9/8/20, for comprehensive assessment related to decreased to no intake, ongoing monitoring for dehydration related to intake refusal or that other food/fluids were provided/encouraged. -9/9/20 R10 had refused breakfast, lunch, dinner and no fluids were documented. -9/10/20 R10 had zero intake recorded for lunch and dinner. R10's nursing PN dated 9/10/20, at 12:00 p.m. indicated on night shift, R10 had pocketed (stored in cheek) pills. R10 was unable to swallow and continues to decline meals. R10 was unresponsive at this time. NP had been notified. The NP ordered x-ray to R10's knee due to the knee looking displaced and swollen. The PN lacked documentation of any additional information the NP may have said to the nurse, lacked what type of stimulus R10 was unresponsive to, and lacked why R10 was not sent to the ER at this time due to unresponsiveness. R10's speech therapy PN dated 9/10/20, at 3:19 p.m. indicated speech therapist attempted to assess R10's swallow function with medication due to reports of pocketing medications. R10 could not be roused. Speech therapist provided nurse on cart with recommendation for order to crush medications. The PN lacked documentation of how crushed medications would be administered to a resident that was unresponsive. There was no indication this was a change of condition for R10's. R10's PN dated 9/10/20, at 4:00 p.m. indicated NP gave orders to send R10 to emergency department (ED) for further evaluation if family wishes. R10's ambulance run report dated 9/10/20, dispatched at 3:57 p.m. indicated staff reported to emergency medical staff (EMS) that R10 was normally alert and talkative, however, had been unresponsive since at least 8:00 a.m. today, 9/10/20. In the ambulance R10 was noted to have [MEDICAL CONDITIONS] tachypnea and [MEDICAL CONDITION] (low blood pressure, high heart rate, high respiratory rate and low oxygen levels, respectively). R10 had an altered mental status with Glascow Coma Scale (GCS) of 8 (the initial GCS score correlates with the severity of [MEDICAL CONDITION] and prognosis. Patients with scores of 3-8 are usually said to be in a coma). R10's vital signs (VS) at 4:14 p.m. were: blood pressure 87/61, heart rate 111, respiratory rate 44 and pulse Oximetry 88%. R10 was administered supplemental oxygen and intravenous (IV) fluids in the ambulance. R10's ED provider notes dated 9/10/20, indicated R10 arrived to the ED with decreased level of consciousness. R10 wasn't responding to catheter or intravenous sticks. R10's urine was very strong and malodorous. R10 was diagnosed in the ED with [MEDICAL CONDITION] (worsening brain function), [MEDICAL CONDITION] (too much sodium in the blood), dehydration [MEDICAL CONDITION]. R10 was transferred to a different hospital for further treatment and evaluation. R10's hospital weight on 9/10/20, following intravenous (IV) fluid administration was 108 lbs. R10's hospital admission notes dated 9/11/20, indicated R10 arrived and was critically ill. R10's severe high blood sodium levels were thought to be related to significant dehydration [MEDICAL CONDITION]. During interview by phone on 9/15/20, at 9:31 a.m. family member (FM)-A stated was concerned how R10 had been admitted at 134 lbs., which was close to her normal weight, and then 13 days later at the care conference, FM-A was told R10's weight was 115 lbs. FM-A stated there did not seem to be a concern level at the facility about the weight loss. FM-A stated the facility had been updating family when family called, but probably not with the level of concern that should have been applied. FM-A stated had known R10 was not eating well, but was not aware it was to the extent of starving to death. FM-A stated R10 had malnutrition in the past, related to depression but not to the extent that was seen upon discharge from the Emeralds. FM-A stated R10's normal weight was around 145 lbs. During interview by phone on 9/15/20, at 11:06 a.m. hospital physician (MD)-A, stated had seen R10 upon their arrival to the hospital on [DATE]. MD-A was concerned because R10 was noted to have altered mental status for up to 9 hours that day and was delayed in being brought to the ED. MD-A stated R10's lab values were consistent with severe dehydration. MD-A stated R10 had a free water deficit. This occurs in primarily in older adults but is preventable if they are provided with water to drink. MD-A stated this condition does not come on acutely. Rather it would take some time possibly several days for someone to get to this level. MD-A stated for R10 to get to this level at a skilled nursing facility was concerning. MD-A stated today, 4 days after admission, R10 was in the intensive care unit (ICU). During interview on 9/15/20, at 12:39 p.m. licensed practical nurse (LPN)-A stated had worked with R10 once. LPN-A stated R10 was in bed all shift and was not sure what R10's intake had been. LPN-A had access to the medical record to review. LPN-A stated sufficient intake could not be found in the medical record. LPN-A stated if a resident was not eating or drinking, especially if a resident was taking a diuretic like R10, nursing should be assessing further and monitoring hydration more closely. LPN-A stated supplements were checked off on the MAR once they were given to residents. LPN-A was unable to remember if they had watched R10 consume the entire supplement. During interview on 9/15/20, at 12:53 p.m. registered nurse (RN)-A stated had worked with R10 before and had updated NP of R10's change in condition on 9/9/20. RN-A stated previously R10 would talk and would respond and took medications. On 9/9/20 R10 was not responding and not taking medications. During interview by phone on 9/15/20, at 2:38 p.m., nurse practitioner (NP)-A stated had seen R10 via telemedicine while a resident at the Emeralds of Faribault. NP-A had access to documentation during phone call and reviewed the record. NP-A stated had seen R10 via telemedicine on 8/27/20. R10 was noted to be alert and pleasant that day, in no distress and able to answer questions. NP-A was notified on 9/9/20, at 12:45 p.m., that R10 had poor appetite, was not eating, not participating and was pocketing their medications. NP-A was told R10 had a 30 pound weight loss in 5 days. NP-A stated staff were instructed to re-weigh R10. NP-A stated R10 was not full of fluid and was not expected to have a significant weight loss like this. NP-A stated if R10 wasn't eating well for a couple days maybe a 5-7 lb. weight loss would be expected. For a 20-30 lb. weight loss, R10 would have to had not been eating during their entire admission. NP-A stated gave orders for speech evaluation on 9/9/20. NP-A stated would expect the nurses to follow their protocol for status change. NP-A would expect the nurses to use clinical judgement and monitor vital signs more often, assess over all status, and push fluids or food. NP-A stated pharmacy could do an assessment to see if any meds should be held that would be contributing to lethargy. On 9/10/20, NP-A stated had completed an acute telemedicine visit. R10 was noted to be very unresponsive at 8:52 a.m. R10 also had a swollen right knee. NP-A gave order for x-ray to the right knee and would do telemedicine visit later in the morning. NP-A stated saw R10 about 11:00 a.m. NP-A stated nursing staff reported R10 was unresponsive, not eating and not taking meds. NP-A stated, in comparison to their 8/27/20 televisit, today R10 had a significant change. NP-A stated if R10 stayed in the facility it would be for comfort cares. If R10 wanted more aggressive treatment they should be sent to the ER. During phone interview on 9/15/20, at 3:26 p.m. nursing assistant (NA)-B stated had worked routinely with R10. NA-B recalled on 9/10/20, R10 was real tired and did not eat. NA-B stated had known R10 was not eating or responding as well prior to 9/10/20, but was not sure for how long. NA-B stated had reported the change to the nurse. NA-B stated was unsure if nursing was doing anything different due to R10's change. NA-B could not recall if different food and drink options had been offered to R10 due to her decrease in intake. During phone interview on 9/15/20, at 3:30 p.m. nursing assistant (NA)-A stated had worked with R10 upon admission then again on 9/9/20. NA-A stated upon admission R10 was coherent, would talk and would even do some teasing. NA-A stated came back to work and on 9/8/20, R10 was totally different. NA-A stated was told R10 was now too weak to transfer and they were to reposition in bed. NA-A stated had obtained a weight on R10 and the result was 103 lbs., which NA-A knew to be a significant change. NA-A stated gave the weight information to the nurse. During phone interview on 9/15/20, at 3:36 p.m. nursing assistant (NA)-C stated had worked with R10 routinely during their stay at the Emeralds of Faribault. NA-C recalled noticing a steady decline from their admission to the end of their stay. NA-C stated when first working with R10, they would eat and drink. NA-C stated over the course of R10's stay, R10 would no longer drink water and was not eating at all. NA-C stated they would record R10 was not eating on a paper intake form in the nursing assistant hand book for the unit. NA-C was unsure of the dates, but stated had reported to the nurse a couple times that R10 wasn't doing well. NA-C stated it was pool nurses and did not remember exactly who they had reported the change to. On 9/16/20, at 9:00 a.m. registered dietician (RD) stated had followed R10 while residing at the facility. RD stated R10 had been accepting supplements. Initially R10 was initially accepting intake but on 9/8/20, had not. On 9/8/20, RD did a chart review but had not seen R10 so was unable to comment on their status. RD stated had not looked at R10's free water intake and typically does. RD stated would expect intake tracking to be consistent and for nursing to be monitoring for dehydration related to decreased intake. RD stated due to the 115 lbs weight that was recorded, would expect nursing to look at trends and re-weigh within the next day for a significant change such as that. On 9/16/20, at 11:15 a.m. regional nurse consultant (RN-B) and DON stated residents are brought water each shift and that should be recorded. They were unsure who was monitoring intakes other than the dietician on their monthly rounds. DON stated it was hard to tell because there were not good records available. DON stated the expectation is to monitor intake for all residents with every meal. On 9/16/20, at 11:30 a.m. social services director stated R10 had been admitted for rehabilitation and skilled nursing with a goal to go home. The facility policy Monitoring Food and Fluid Consumption, dated 9/2012, directed staff to maintain adequate nutritional intake and hydration for all residents. Further, staff are to determine the amount of food consumed at each meal and assess the need for additional snacks and appropriate intervention as necessary to maintain weight, optimal nutrition and hydration. All residents, including those who receive trays, will be monitored for dietary intake during each meal.

Based on interview and document review, the facility failed to thoroughly assess and monitor 1 of 3 residents (R1) who were reviewed for change in condition. This resulted in actual harm when a resident was admitted to the hospital intensive care unit (ICU) and diagnosed with [REDACTED]. Findings include: The Mayo Clinic [MEDICAL CONDITION] as a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection.[MEDICAL CONDITION] occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically. This may lead to death.[MEDICAL CONDITION] is most dangerous in older adults and people with chronic conditions. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition. R1 had not rejected cares. Further, R1 required extensive assist from staff with bed mobility, transfers, dressing, eating and toileting. R1 had [DIAGNOSES REDACTED]. R1's care plan at the time of survey (9/9/20 -9/10/20) did not identify a focus problem area for risk of infection. R1's care plan dated 10/15/18, indicated R1 had a [DIAGNOSES REDACTED]. R1 would like to remain free from unforeseen complications due to medical history. The care plan directed staff to observe for changes in condition or abilities, further evaluate, and report pertinent information to the medical doctor or nurse practitioner for follow up. R1's progress note (PN) dated 7/31/20, at 11:06 p.m. indicated R1 had declined lunch and supper. R1 had multiple bouts of diarrhea and vomiting. The doctor recommended to send resident to emergency room (ER) if condition worsens or per resident's request. R1's PN's lacked documentation of comprehensive assessment at that time to include vital signs (VS) such as blood pressure, pulse, temperature or oxygen (O2) sats. R1's PN dated 8/1/20 - 8/2/20 lacked further evaluation such as documentation of ongoing assessment or monitoring of R1's condition during their illness. The PN also lacked documentation of R1 being sent to the hospital. R1's hospital discharge summary dated 8/12/20, indicated R1 was admitted to the hospital on [DATE], and discharged on [DATE]. R1's principal [DIAGNOSES REDACTED].coli urinary tract infection [MEDICAL CONDITION]. R1 went from the ER and was admitted to the ICU. During interview on 9/9/20, at 10:09 a.m., R1 stated was in the hospital but was really sick and did not remember why. R1 stated had lived at this nursing facility for over two years. During interview on 9/9/20, at 11:43 a.m. family member (FM)-A stated was talking to R1 on the phone on 8/2/20, and recognized increased confusion. FM-A was aware R1 had diarrhea, vomiting and was tired. FM-A then called the facility nursing station and spoke to the charge nurse. After that phone call, R1 was transferred to the ER, then to ICU then to a medical surgical unit over the course of the 10 day hospital stay. FM-A stated the ER doctor said R1 had [MEDICAL CONDITION] and dehydration. FM-A stated R1 has a history of UTI's and the facility should have pushed fluids and done more to prevent the progression of the illness [MEDICAL CONDITION]. During phone interview on 9/9/20, at 1:20 p.m. nursing assistant (NA)-A recalled working with R1 on 7/31/20, and R1 had not felt well and had diarrhea. NA-A reported it to the nurse. During phone interview on 9/9/20, at 1:51 p.m. R1's primary care physician (PCP) was aware of R1's hospitalization and illness from 8/2/20 - 8/12/20. PCP stated R1 was frail. Septic shock would take a couple days to progress, it would not have a sudden onset. PCP stated would expect nursing to monitor more frequently and to check vitals more often in a resident with acute illness. PCP further stated the picture was unclear what [MEDICAL CONDITION] originated from and if hospitalization could have been prevented had there been early monitoring in place. During interview on 9/9/20, at 2:36 p.m. the director of nursing and facility administrator were not sure which day R1 had been sent to the ER or what R1's condition was like on 8/1 - 8/2/20 during the illness. There were no progress notes to review in the chart. They stated the documentation lacked assessments and monitoring. DON said the expectation was if something happened the nurses should document it. During interview on 9/10/20, at 9:05 a.m. licensed practical nurse (LPN)-A stated had worked as charge nurse and nurse on the floor on 8/1/20. LPN-A stated was not made aware that R1 was ill. LPN-A stated would have ensured more monitoring was in place. Furthermore, the expectation was to enter a progress note when there was a change so other staff are aware. LPN-A reviewed the medical record and stated it lacked information on R1's status while ill and of their later transfer out. During interview on 9/10/20, at 9:24 a.m. registered nurse (RN)-A recalled working with R1 on 7/31/20. RN-A had notified the doctor via phone that R1 had multiple emesis and diarrhea. RN-A administered [MEDICATION NAME] (anti-diarrhea medication) and [MEDICATION NAME] (anti-nausea medication). RN-A stated had thought R1's VS were stable at this time, however, the VS are not documented so RN-A did not know the specifics. RN-A stated had verbally passed the information on to the night shift that R1 was ill. RN-A said a resident ill with vomiting and diarrhea the expectation would be to notify the charge nurse, update family and doctor. Additionally, using nursing judgement, would next check VS more often, document VS in the medical record, ask resident how they are feeling more often, monitor intake and output (I&O). RN-A looked up in the medical record and agreed VS, I&O or increased monitoring were not documented. During phone interview on 9/10/10, at 9:53 a.m. registered nurse (RN)-B recalled having sent R1 to theER on [DATE] in the afternoon or evening. RN-B stated had gone into R1's room at the beginning of the shift. RN-B observed R1 was not able to find words and was confused so R1 was sent to the ER. RN-B stated was not sure if R1 had a change in condition when receiving nurse to nurse report at the beginning of the shift, since this is not documented. RN-B also stated the medical record was lacking documentation of R1's condition before being sent out to the ER. RN-B said typically VS are taken before paramedics arrive. RN-B was unsure if had taken VS as it was not documented in the medical record, but remembered R1's condition was concerning. R1's ambulance run report dated 8/2/20, dispatched at 12:52 p.m., indicated staff reported to emergency medical services staff (EMS) that R1 had history of frequent UTI's dementia and one previous stroke. Ambulance run report also indicated staff reported to EMS that R1 had been acting altered all day compared to baseline and had an episode of slurred speech. While in the ambulance the heart monitor showed [MEDICAL CONDITION] and VS within normal range. Oxygen saturations decreased to 86% and supplemental oxygen was applied. R1's hospital admission paperwork dated 8/3/20, indicated, in theER on [DATE], R1 required increase in supplemental oxygen from 2 to 4 liters and mental status fluctuated. The ER consulted with the physician intensivist (physician who provides special care for critically ill patients) and had been recommended R1 transfer to progressive care unit. Facility policy titled Change in Condition, undated, indicated the nurse will record in the residents' medical record information relative to changes in the resident's medical/mental condition or status. A policy on Nursing Standards of Care was requested, however, the facility stated they did not have one.

Based on interview and document review, the facility failed to assess and monitor for change of condition after a resident on an anticoagulant fell with head injury/laceration and bleeding and four days later was hospitalized with subdural hematoma, bilateral cranial bleeding, pain, and a T11 back fracture resulting in an immediate jeopardy situation for 1 of 3 residents (R1) reviewed for falls. R1 sustained actual harm with subdural hematoma, bilateral cranial bleeding, and a T11 back fracture. The immediate jeopardy began on 2/3/20, when R1, who was on an anticoagulant therapy medication, fell and hit her head, the physician and family were not notified and the facility failed to assess and monitor a change in condition, identified on 2/28/20. The interim administrator, director of nursing, and regional nurse consultant were notified of the immediate jeopardy at 5:30 p.m. on 2/28/20. The immediate jeopardy was removed on 2/29/20, but noncompliance remained at the lower scope and severity level of G which indicated actual harm that is not immediate jeopardy. Findings include: R1's Details of Hospital Stay dated 2/10/20, indicated R1 presented to the emergency department (ED) 4 days after fall with pain and nausea and was on [MEDICATION NAME] (blood thinner) for [MEDICAL CONDITION] (irregular heartbeat). A head CT (scan) was obtained which revealed scattered areas of subarachnoid (fluid-filled space around brain) hemorrhage (bleeding) along the left frontoparietal and right frontal and temporal lobes. Lumbar spine CT revealed an acute obliquely oriented fracture through the T11 vertebrae as well as a chronic L1 compression fracture. Her INR (blood clotting time test) blood level was 3.6 (normal range 2.0 to 3.0) and she was administered Kcentra, vitamin K, and 1 unit FFP (fresh frozen plasma) for reversal. R1 was interviewed on 2/28/20, at 1:50 p.m. sitting in her recliner in her room alone, walker near her chair. R1 stated she had fallen a year ago and broke her elbow. R1 stated the same thing happened when she fell on [DATE], and broke her back and hit her head and bled. R1 stated on 2/3/20, she realized she was late for lunch, was in a hurry, and her right foot turned in and she fell to the floor and hit her head. R1's annual Minimum Data Set ((MDS) dated [DATE], indicated R1's cognition was impaired, included a [DIAGNOSES REDACTED]. R1's MDS indicated R1 needed extensive assist of one staff, with bed mobility, transfers, dressing, toileting and personal hygiene. R1's MDS indicated R1 walked with a walker and was independent with ambulation in her room and off unit. R1's Care Area assessment dated [DATE], indicated R1's cognition was impaired and R1 was not steady when moved from a seated to upright position and only able to stabilize with staff assistance. Assistant Director of Nursing (ADON) stated on 2/28/20, at 12:05 p.m. the dietary manager (DM) had reported in morning report in interdisciplinary team (IDT) meeting on 2/4/20, that she had seen steri strips and dried blood in the back of R1's head when R1 was in the dining room. ADON said the nurse manager (NM) was responsible to check the risk management system after a resident fell to make sure the fall was noted and the nurse manager would identify fall interventions. ADON stated she did not know if this had been completed for R1's fall on 2/3/20, as NM registered nurse (RN)-F's last day of employment had been 2/3/20, and a new NM had not yet started in her place. ADON stated RN-C should have automatically sent R1 to the emergency room for a CT scan since R1 was on an anticoagulant medication and had had a head injury with her fall on 2/3/20, and was at increased risk for bleeding. ADON stated RN-D had said she had asked R1 if she wanted to go to the hospital and R1 declined. R1 was not provided education about the risks of increased bleeding when on an anticoagulant medication and a fall. ADON stated she had not re-educated RN-C nor any other nurses other than licensed practical nurse (LPN)-A about notification to the physician after a resident, who is on an anticoagulant, falls and received a head injury. ADON confirmed no fall intervention had been put in place after R1's fall on 2/3/20. ADON verified R1's neurological (neuro's) checks and vital signs had not been completed per protocol from 2/3/20 to 2/4/20, and verified there were no other neuro checks and/or vital signs documented in R1's medical record up to the hospitalization on [DATE]. ADON confirmed the nurses should have followed protocol and followed the guidelines and completed as guided. LPN-B stated on 2/28/20, at 2:00 p.m. she was called in R1's room on 2/3/20, around lunchtime, and saw R1 on the floor with moderate amount of blood on the floor and on R1's head. LPN-B stated RN-C came into the room and asked R1 if she wanted to go to the hospital and R1 told RN-C no. LPN-B stated she would have sent R1 into the ED because of R1's age and that she had fallen. LPN-B stated she did not know if it made a difference or not of R1 being on an anticoagulant but reiterated she would have sent R1 to the hospital because of her age. ADON verified on 2/28/20, at 1:15 p.m. the facility's fall policy lacked any information about residents who are on an anticoagulant and would be at risk to bleed if they fell and hit their head. ADON stated she verbally educated nurses upon orientation and annually about residents on anticoagulants and risk of bleeding if they fell . ADON stated she did not have any written documentation to support her verbalization to the nurses. Trained medication assistant (TMA)-B stated on 2/28/20, at 2:10 p.m. she had taken R1's vitals later in the day on 2/3/20, but had not looked at R1's head wound and was unaware of whether R1 had steri strips on her head. RN-F stated on 2/28/20, at 2:18 p.m. she had not been made aware of R1's fall on 2/3/20. RN-F stated R1 had fallen about a month previously, received a bruise on her face, had not broken anything; however, did not remember what fall intervention had been put in place after the fall. RN-F stated R1 was independent with ambulation, walked with a walker to meals. RN-F stated she would have expected RN-C to have notified her of R1's fall on 2/3/20. RN-F stated she tried to re-educate staff and provide on the spot training when needed but did not always document it. Regional nurse consultant (RNC) stated on 2/28/20, at 2:30 p.m. she had spoken with RN-C and RN-C told her she had not notified the physician or R1's family after her fall on 2/3/20, but had passed the fall information along to the next shift nurse coming in. RN-C was unavailable for surveyor to interview. RNC stated R1 had asked for an x-ray on 2/7/20, because of back pain radiating to her abdomen from her fall and had been sent to the hospital on [DATE], for an x-ray of her back and ribs. R1 was observed on 3/2/20, at 10:16 a.m. in her recliner in her room with a distressed look on her face. R1 stated she had pain across her abdomen to her right side and explained she broke one of her bones in her back when she fell and also had a brain bleed. R1 stated she has had pain since the fall and stated she felt less pain when she stood versus when she sat. R1 stated she did not feel she could get out of her chair alone and had asked staff earlier for something for her pain. R1 stated she had had two falls since she was admitted and both occurred in her room. ADON stated on 3/2/20, at 10:49 a.m. IDT would change would discuss resident falls more in. ADON stated she had talked to RN-C later on 2/28/20, and reeducated her about the importance to call the physician, family, DON and a progress note, incident report and risk management needed to be completed after all falls. ADON explained she told RN-C when a resident on an anticoagulant medication and falls and hits their head they are to be sent to the ER for evaluation. Transition Care Unit NM RN-J stated on 3/2/20, at 11:04 a.m. when a resident falls and had a head injury she expected the nurse to control the bleeding, render first aide, notify the provider, DON, family and follow the provider instructions. RN-F stated neuro checks were to be started with unwitnessed fall and resident hits head, complete vitals, range of motion, access pain, and cognition changes, put an order in to monitor injury every shift and put in a progress note where everybody could find it. The Nurse Practitioner (NP) stated on 3/2/20, at 11:45 a.m. she expected the nurse to call her right away whenever a resident fell and was surprised to find out she had not been notified on 2/3/20, when R1 fell and injured her head. NP stated she would have wanted R1 immediately sent to the ED on 2/3/20, and stated R1's fall was traumatic because she hit her head on the dresser. NP explained the provider at the ED would have decided R1's plan of care and could have diagnosed earlier an intervention for the brain bleed and an intervention with the x-ray for her broken back. NP stated she thought R1's quality of life had been affected when R1 was not walking to the dining room and sequestered herself in her room to eat. The medical director (MD) stated on 3/2/20, at 11:51 a.m. the physician should have been notified right away after R1 fell on [DATE], especially because R1 was on an anticoagulant and sustained a head injury. MD noted she noticed at the quality assurance performance improvement (QAPI) meeting, falls in the facility had increased and QAPI would now look at all resident falls. NM RN-F verified on 3/2/20, at 1:49 p.m. there was no fall assessment completed for R1's fall on 2/3/20, and no incident review and analysis completed until 3/1/20, when DON completed it. RN-F stated IDT had talked about R1's fall on 2/3/20, and how R1 had stumbled in her room and now therapy would complete an evaluation. RN-F stated she had not reviewed R1's neuro's sheet completed after her fall but confirmed neuro's and vitals were missing on the 24 hour report sheet. The medical physician (MP) stated on 3/2/20, at 2:05 p.m. she nor the NP been notified regarding R1's fall on 2/3/20. MP was alarmed at the lack of notification to a medical provider when R1 fell and hit her head. LPN-A stated on 3/2/20, at 3:01 p.m. she came in to work the evening shift on 2/3/20, the day R1 had fallen in her room. RN-C reported to her R1 had hit her head on the television stand, steri-strips were applied, and neuro checks were started. LPN-A stated she had not known an incident form and risk management form had not been completed. She also was not aware the physician or the family had not been notified. LPN-A stated four days later when she worked on Friday 2/7/20, R1 complained of stomach pain in the morning and RN-J had sent R1 to the hospital as R1 wanted an x-ray for pain in her back and abdomen from her fall on Monday. LPN-A stated the hospital had called her and when LPN-A could not find anything in R1's medical record about the fall she had on 2/3/20, she had called the DON to notify her. LPN-A stated the hospital staff had told her they were transferring R1 to the Rochester hospital because of R1's brain bleed and back fracture. R1's family member (FM)-B stated on 3/4/20, at 8:25 a.m. he had not been notified of R1's fall on 2/3/20, did not know R1 hit her head until FM-B visited two days after her fall and at that time still did not know she fell . The facility had not notified him about the fall until four days later when she was transferred to the hospital for an x-ray because of back and abdominal pain. FM-B stated after hospitalization R1 now had therapy, got tired easily, needed therapy to build her strength back up and had pain. FM-B stated R1 used to go independently to the dining room with her walker and now does not go to the dining room and preferred to eat in her room. FM-B stated the hospital had told him R1 had two spots on the brain with intracranial bleeding. FM-B stated the hospital had told him the back fracture would take R1 three months to heal. The DON stated on 2/28/20, at 11:05 a.m. the IDT met daily Monday through Friday discussed resident falls, chose a fall intervention which the nurse manager updated on the resident care plan and implemented with staff. DON stated she had not been called on 2/3/20, regarding R1's fall but would have wanted to be notified. DON verified no fall incident report, fall assessment or progress note was completed after the fall. The physician or R1's family was notified, and the fall had not been put on the 24 hour report. DON stated R1 had been complaining of back and rib pain on 2/7/20, and went to the hospital with a [DIAGNOSES REDACTED]. R1's Neurological Flow Sheet revealed 7 of the 24 neuro checks and 3 of the 24 vital signs on 2/3-2/4/20, were not completed for R1. R1's medical record revealed no evidence of any vital signs and/or neuro checks completed from 2/4/20, until R1 was hosptalized on [DATE]. R1's progress note dated 2/7/20, indicated R1 had pain that wrapped around lower back and abdomen and R1 wanted an x-ay to rule out fracture from fall earlier this week. Facility provided [MEDICATION NAME] Medicine Information sheet dated January 1, 2020, indicated [MEDICATION NAME] may cause very bad and sometimes deadly bleeding and to call the doctor right away with any signs of bleeding. Policy on change of condition and/or monitoring requested and not made available. The immediate jeopardy that began on 2/28/20, was removed on 2/29/20, when the facility educated all residents/families of the risk regarding anticoagulant therapy and falls and care plans of these residents were updated to include the risk of anticoagulant therapy and falls. All licensed staff were educated immediately on fall prevention and management, IDT was reeducated on fall management, and daily audits around falls were started. Policies and procedures were reviewed and updated. Fall intervention guidelines were posted at each nursing station and updated neurological flow sheet with direction were implemented. The noncompliance remained at the lower scope and severity level which indicated actual harm that is not immediate jeopardy, Level G. R1 sustained actual harm after a fall in which R1, who was on an anticoagulant medication, fell and hit her head, was not adequately monitored and was hospitalized four days after the fall with a subdural hematoma, bilateral cranial bleeding, and a T11 back fracture

Based on interview and document review, the facility failed to ensure 4 of 11 residents (R26 R21, R16, R108) whose medications were reviewed were free from significant medication errors. R26 suffered actual harm, a [MEDICAL CONDITION] with hospitalization , when a significant medication, [MEDICATION NAME] (anticoagulant/blood thinner) was not administered for 51 days. Findings include: R26 did not receive prescribed [MEDICATION NAME] for 51 days and was subsequently hospitalized with bilateral [MEDICAL CONDITION] (blood clot). The resident's hospital history and physical (H&P) at the time of the resident's admission to the facility in 5/12 noted the resident had a [MEDICAL CONDITION] with surgical repair and had long-standing anticoagulant use for a history of [MEDICAL CONDITION] embolism (obstruction of blood vessel) and [MEDICAL CONDITIONS]. According to the American Heart Association Patient's Guide to Taking [MEDICATION NAME]/[MEDICATION NAME], "The effect of [MEDICATION NAME] ([MEDICATION NAME]) must be monitored carefully with blood testing. On the basis of the results of the blood test, your daily dose of [MEDICATION NAME] will be adjusted to keep your clotting time within a target range." Review of R26's record indicated a physician's telephone order had been received on 3/26/13, for a change in [MEDICATION NAME] based on an international normalized value of blood clotting time (INR) of 2.64. (The laboratory's therapeutic INR range was identified between 2.0 to 3.0). The order was for 2.5 milligrams (mg) Tuesday and Thursday and 5 mg all other days, with a repeat INR in two weeks. The repeat INR was completed on 4/9/13 with results recorded as 3.1 and the [MEDICATION NAME] order was changed to 2.5 mg on Monday, Wednesday and Friday, with 5 mg on all other days and an order to repeat an INR in one week. However, the INR level was not repeated after one week (due 4/16/13) as ordered. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Physician orders [REDACTED]. In addition, the NP had ordered [MEDICATION NAME] 5 mg at bedtime beginning 6/5/13 with a follow up INR to be drawn on 6/8/13. According to an Investigative Report related to the medication omission error, the resident's son had been notified of the medication error, and he had requested further evaluation bassed on her history. On 6/6/13, at 4:10 p.m. the NP gave orders for [MEDICATION NAME] (for acute [MEDICAL CONDITION] treatment) 90 mg subcutaneous injection every 12 hours until the resident's INR level was between 2.0 and 3.0 at which time the [MEDICATION NAME] was to be discontinued. At 4:30 p.m. on 6/6/13, the NP also ordered a bilateral lower extremity Doppler (an ultrasound study which measures blood flow) for potential [MEDICAL CONDITION]. The Investigative Report indicated that the Doppler test had been completed at 7:02 p.m. on 6/6/13, and results had been received at 10:17 p.m. that same day. The Doppler test results indicated there was "[MEDICAL CONDITION] to bilateral lower extremities." At 10:30 p.m. on 6/6/13, the NP ordered R26 to be sent to the hospital by ambulance for evaluation. A medication error report initiated on 6/5/13, indicated the NP had ordered, "Draw INR on 4/16/13. [MEDICATION NAME] based on INR." According to the medication error report the error had occurred because the INR order had not been entered into the lab book. On 6/26/13, at 9:33 a.m. a registered nurse (RN)-E stated during interview, that R26's [MEDICATION NAME] medication error was discovered on 6/5/13, during a quarterly Minimum Data Set assessment. RN-E stated, "The MDS asks if the resident had received anticoagulants so I looked at the physician orders." RN-E said that when she had reviewed the physician orders, she had noticed [MEDICATION NAME] had previously been ordered, and orders had included to "redraw an INR around 4/19/13." RN-E stated that after reviewing the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN-E stated she had informed the administrator, director of nursing (DON) and NP immediately and had left a message for the resident's son, completed an incident report, and had reported the incident to the designated State agency (SA). As a result of the facility's identified issues with the anticoagulant medication error, they implemented staff training and modifications to their medication transcription/reconciliation system. However, they did not address the medication system as a whole to address all medications, and therefore continued to be at risk of significant medications errors. According to review of two Medication Error Reports for R108 dated 6/6/13, R108 did not receive the correct dosage of [MEDICATION NAME]. A medication error report dated 6/6/13 revealed R108 had not received the correct physician ordered dosage of [MEDICATION NAME] from 5/28/13 to 6/6/13. According to the medication error report R108 was to receive [MEDICATION NAME] 3 mg on Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday, and no [MEDICATION NAME] on Mondays. Instead of receiving [MEDICATION NAME] as ordered, the medication error report revealed a higher dose of [MEDICATION NAME], 6 mg on Mondays and Fridays; and 4 mg all other days, was administered. A second medication error report dated 6/6/13, revealed R108's INR level of 2.7 had not been called to the [MEDICATION NAME] physician or nurse practitioner, and R108 continued to receive the higher dose of [MEDICATION NAME] until 6/6/13, when the error was reported to the nurse practitioner. After receiving INR report, indicating 2.7, on 6/6/13, the nurse practitioner ordered [MEDICATION NAME] 3 mg every day, with a repeat INR level to be drawn on 6/10/13. The acting administrator and DON were interviewed on 6/27/13, at 3:17 p.m. regarding the medication errors and omitted medications. The DON explained that after R26's [MEDICATION NAME] error was discovered and reported to the State agency, the facility had instituted two-person checks of the medication orders against MARs for all residents. An audit tool was implemented and a tracking book for each resident who received [MEDICATION NAME] was initiated. The DON and administrator said staff had been educated, and a flow sheet developed, for placing orders in the computer and on the lab calendar. When asked what else had been done to ensure medication errors did not continue, the DON said the errors had occurred all around the same time frame. Record review revealed R16 did not receive [MEDICATION NAME] 40 mg (to reduce elevations in total blood cholesterol and/or to reduce risk of [MEDICAL CONDITION]/failure) as ordered, from 6/1/13 to 6/26/13 when the omission was discovered by the surveyor. R16 was admitted to the facility in 8/12 and had [DIAGNOSES REDACTED]. [MEDICATION NAME] 40 mg was ordered by the physician on 5/22/13 and although it had not been discontinued, the June 2013 MAR indicated [REDACTED]. The medication was ordered following laboratory results for R16 on 5/22/13 that revealed a total cholesterol level of 306, triglycerides of 258, and low-density lipoprotein (LDL) 42, and non high-density lipoproteins (HDL) cholesterol 264, as well as a cholesterol/HDL ratio of 7.29 which was noted as high. According to the American Heart Association, normal levels for total cholesterol are less than 200 mg, LDL less than 100 mg, HDL over 60 mg, triglycerides less than 150 mg, and the optimal ratio 3.5:1. A registered nurse-E (RN-E) was interviewed on 6/26/13 at 2:00 p.m. and stated she assumed the [MEDICATION NAME] had not been administered for the entire month of June, as it was not listed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The medication cart was checked on 6/26/13, at 4:04 p.m. with RN-F. The medication card containing [MEDICATION NAME] issued on 5/22/13 had only five pills removed from the card. RN-F verified that there had been 30 pills for June, and 25 pills remained in the card that had not been administered to the resident. R21 had a [DIAGNOSES REDACTED]. R21's physician orders [REDACTED]. The May 2013 MAR indicated [REDACTED]. Documentation by staff was inconsistent regarding whether or not the resident had received the medication from 5/13-5/28/13. Staff had initialed and coded the MAR indicated Drug ordered/Not received" on 5/14, 5/16, 5/20, 5/21 and 5/25. Staff had initialed and coded as "Administered" on 5/17, 5/18, 5/19, 5/22, 5/23, 5/24, 5/26, 5/27 and 5/28/13. There was nothing coded for the dates of 5/29, 5/30 or 5/31/13. The medication had been omitted from the June MAR until the facility had discovered the error on 6/21/13, when the [MEDICATION NAME] had been re-added to the medication sheet and the drug had been reinitiated on 6/22/13. The medication cart was checked with a trained medication aide (TMA)-A on 6/27/13, at 7:48 a.m., and it was noted that the card of [MEDICATION NAME] medication had first been delivered to the facility on [DATE]. TMA-A verified four pills were gone from the card. RN-A was interviewed on 6/27/13 at 12:03 p.m. At that time, RN-A called the pharmacy to see if any other cards of [MEDICATION NAME] had been sent to the facility. The pharmacy verified that they had only sent out one card of 30 pills on 5/25/13, and confirmed that was the first they had received the order for the [MEDICATION NAME]. RN-A and RN-E stated on 6/27/13 at 12:09 p.m., that they did not know when R21 had received the four pills that were missing from the [MEDICATION NAME] card, as it was difficult to tell from the MAR. They verified the [MEDICATION NAME] was not included on the MAR from 6/1 to 6/21/13. They reiterated that only one card had been sent out by the pharmacy on 5/25/13 which contained 30 pills. RN-A and RN-E stated they were unaware why the pharmacy had not received the order for the [MEDICATION NAME] on 5/13/13 when the physician had first ordered the medication. The director of nursing (DON) was interviewed on 6/27/13 at 12:30 p.m. She verified that R16 did not receive [MEDICATION NAME] from 5/29/13 to 6/26/13 nor did R21 receive [MEDICATION NAME] from 5/29/13 to 6/21/13 and that these would have been considered significant medication errors. The acting administrator and DON were interviewed on 6/27/13, at 3:17 p.m. regarding the medication errors and omitted medications. Although the DON had previously explained that they had instituted two-person checks of the medication orders against MARs for all residents following the [MEDICATION NAME] errors, the DON verified errors found by the surveyors for R16 and R21 had not been noted by staff completing the checks. The DON explained that the nurses were still checking physician orders [REDACTED]. The nurse managers were responsible for checking their units. The DON said they just started a new electronic medical record (EMR) system for medications that "went live" on 5/29/13. She said they had just realized "last week" that "in the turmoil and putting those orders in" they had not gone through the June 2013 order sheets, and they needed to do another review for the month of June. The DON said it had just come to her attention last week, and they were now looking back two to three weeks and "these errors are popping up."