Every finding on record at The Emeralds at St Paul LLC

Based on observation, interview, and document review, the facility failed to ensure repair recommendations from an outside pest control contractor were acted upon and completed timely to reduce the risk of rodent entry into the care center. In addition, the facility failed to follow Centers for Disease Control (CDC) recommended pest control procedures to ensure potential rodent entry points (i.e., holes in resident walls) were sealed, which had the potential to affect all 88 residents residing in the facility. This caused actual harm to R30 when a potential rodent sighting caused psychosocial distress (i.e., crying, moaning, restlessness, agitation).Findings include:A CDC Controlling Wild Rodent Infestations article dated 4/8/24, indicated rodents were known to carry various diseases which could be spread to a human population. These diseases included salmonellosis, monkeypox, and tularemia. Further, the article indicated it was important to seal gaps or holes in exterior walls, adding, mice can fit through a hole the width of a pencil (1/4 inch or 6 millimeters in diameter).A CDC How to Seal Up to Prevent Rodents article dated 4/8/24, indicated that it was important to check inside your home for gaps or holes such as around windows, doors, pipes leading to water heaters and furnaces, behind appliances, around the pipes under sinks, around all water and sewer lines, etc. The article indicated that any holes you find should be sealed to prevent rodents from entering and recommended that small holes be filled with steel wool and then caulked/spray-foamed in place. The article also indicated that if a larger hole was found, a lath (steel) screen, cement, hardware cloth, or metal sheeting should be used to cover/fill it.R30R30's significant change MDS dated [DATE], indicated R30 had admitted to the facility on [DATE] and had severely impaired cognition. The MDS indicated R30 was dependent on staff for all activities of daily living (ADLs) and was receiving hospice care and tracheostomy care. The MDS did not include a complete resident mood interview. The MDS did not include a diagnosis of anxiety. The MDS indicated R30 was admitted to the facility on [DATE] and resided in room [ROOM NUMBER].R30's care plan dated 8/12/26, indicated R30 was diagnosed with respiratory failure, malnutrition, and a stroke. The care plan also indicated that R30 had quadriplegia (affects a person's ability to deliberately control or move body parts from the neck down) and used a tracheostomy (a surgical hole in the front of the neck used to help with breathing) tube. The care plan's included diagnosis list did not reference anxiety. The care plan indicated R30 was completely dependent on a tube feeding for his nutrition and hydration support and was receiving no food by mouth. The care plan indicated that R30 was a categorically a vulnerable adult and staff were to monitor for signs of emotional distress or mood/behavior changes. The care plan indicated R30 had an alteration in socialization due to being unable to communicate, although the resident was able to say some words and shake head to yes or no questions. The care plan indicated R30 was signed on to hospice cares on 7/20/26 with an end-stage disease process of a cerebral infarction (stroke). The care plan indicated that R30 had an alteration in cognition, so staff were to document changes in orientation, provide cues, reorientation/supervision as needed, and provide/maintain a consistent environment.R30's medication and treatment administration record (MAR) dated 8/1/26 to 8/19/26 indicated the following:-on 7/21/26, 0.5 mg of lorazepam every four hours as needed. The as-needed lorazepam was given 14 times between 8/1/26 and 8/18/26.-on 8/11/20.5 mg of lorazepam every four hours was ordered for terminal agitation.-target behavior monitoring was completed three times a day, with behaviors noted 10 of the 19 days. Behaviors included pulling lines for 7 of the days with interventions of reposition and redirection. The other 3 days anxiety was noted with interventions of repositioning and redirection. R30's progress notes dated were reviewed. The note dated:-8/13/26 at 11:15 p.m., indicated that R30 had RR-A visit for the evening shift and R30 had been relaxed during the shift.-8/17/26 at 3:34 p.m., indicated R30 had no signs of pain, discomfort, or distress noted.-8/18/26 at 10:05 a.m., lorazepam was given for anxiety, pulling, and hitting out.-8/18/26 at 3:30 p.m., indicated that R30 was pleasant, calm and cooperative with cares.-8/18/26 at 6:07 p.m., the note indicated that RR-A had contacted the administrator related to a concern for a potential mouse. The note indicated that tangible solutions were discussed with RR-A. The note indicated that RR-A would like hourly checks to be completed through the evening and a room move tomorrow. The note indicated that a pest control company had been contacted to request a visit for tomorrow. The note indicated that a grievance form was completed and the administrator apologized for the inconvenience.-8/19/26 at 12:20 a.m., written by registered nurse (RN)-G, indicated that R30 was anxious and agitated due to his room condition. The note indicated that R30's tracheostomy was accidentally removed by R30, and a new tracheostomy set was placed. The note indicated that R30 was given his scheduled medications and then rested comfortably in bed. The note indicated that R30 was monitored every hour due to emotional distress.-8/19/26 at 7:26 a.m., indicated that the administrator had checked on R30 during morning rounds and R30 appeared to be sleeping comfortably in bed. The note indicated R30 had no anxiousness noted at the time of the visit. The note indicated that it was explained that a room move would be completed in the afternoon when R30 was up in his wheelchair, and R30 was agreeable to the plan.-8/19/26 at 10:30 a.m., indicated that RR-A had found the administrator and stated that he would now like to go to the hospital related to R30's anxiety.An undated video shown by RR-A on 8/19/26 at 9:00 a.m., included a four-legged rodent that appeared to be anywhere from five to eight inches long (as a best estimate based on surrounding items) with a long tail. The rodent was observed walking down a hallway that at the end had a window, a baseboard heater, and a white foldable chair. In the video, the rodent was walking down the hallway towards the white chair, then along the bottom of the baseboard heater before the video ended.During an interview and observation on 8/19/26 at 9:00 a.m., RR-A was observed to take his phone out and show a video of a rodent in what appeared to be the fourth-floor hallway outside of R30's room. RR-A stated that the rat seen in the video had exited R30's room and entered the hallway last night. RR-A stated that he believed that a rat had been found in a trap in R30's room a few nights ago. RR-A stated that R30 had limited mobility and didn't keep any food in the room because R30 couldn't eat anything by mouth. RR-A stated that about a week and a half ago he saw a mouse in R30's room and he stepped on it and killed it. RR-A stated that last Thursday he had spent the night witnessed another mouse in the far-left corner of the exterior wall of R30's room. RR-A stated that last night a mouse had been observed in R30's bed and that had caused a lot of anxiety for R30. RR-A claimed that the repeated rodent sightings over the last couple of weeks in the facility had caused R30 emotional distress and they even had to make changes to his anxiety medication. RR-A stated the facility offered to move R30 to a new room after the incident last night. RR-A stated he had contacted the hospice company to see if he could get additional resources to bring R30 home with him. R30 stated that the facility had now started to put interventions in place but felt that these interventions should have been done prior to the repeated rodent sightings. RR-A stated he was going to admit R30 to the hospital due to R30's emotional distress from the rodent presence in the building.During an observation on 8/19/26 at 9:05 a.m., R30's fourth-floor room was observed with the baseboard heating unit pipes coming through the far wall on the left-hand side of the exterior wall of the room. A hole greater than the size of a quarter was observed around the pipe's entrance into the room, and a large sticky trap by it appeared new (no dust, build-up, debris). R30 was sitting in the dining room and appeared restless/agitated as he was loudly moaning, grunting, and his brow appeared furrowed/grimaced. R30's signs of restlessness/agitation were observed to stop when RR-A walked over to him. RR-A was then seen telling R30 he was going to load the car and then he was coming back. R30, in response, made loud moaning noises and tense, grimacing facial expressions, as if upset.During an interview on 8/19/26 at 10:40 a.m., NP-A stated she had gotten a report of a rodent in the building today and sometime last month. NP-A stated that if she got a report of a rodent in a resident's room or bed, she wasn't exactly sure what she would do but would start by seeing if the resident had any changes in condition or any bites. NP-A stated that although it depended on the person, a person most likely wouldn't want a rodent in their bed or room, and it could be a scary finding depending on the individual. NP-A stated that if a resident has a tracheostomy tube with anxiety and agitation, there could be a potential concern for the tracheostomy tube being pulled out. NP-A stated that for R30, he did have a recent history of anxiety and restlessness, and they had been having to make medication changes for him. NP-A stated that although R30 had this anxiety history, pulling out his tracheostomy tube was a change for him, as she was unaware of him doing this in the past. NP-A stated that in the past and when she visited him, he generally seemed relatively comfortable, and she had only seen him vocal related to possible agitation once or twice.During an interview on 8/19/26 at 10:54 a.m., RN-B stated she was R30's nurse for the day shift. RN-B stated R30 generally didn't have signs of anxiety or agitation for her, and she can tell when he is moaning and groaning. RN-B stated R30 did not have a history of pulling at his tracheostomy, and given his anxiety related to the mouse in his room last night, they were completing hourly checks on him today. RN-B stated she did notice anxiety in him this morning, but his anxiety seemed to escalate as the day went on and the partner was in the building.During an interview and observation on 11:02 a.m. with pest control service technician (PCST)-A and the DOM, a hole that was approximately two inches by approximately six inches around the pipes leading to the baseboard heating unit in the left-hand corner of R30's room was observed. PCST-A stated a rat could enter a resident room through a hole the size of a quarter and a mouse can get in through a hole the width of a pen. PCST-A stated that he believed this was where the rat had likely entered the resident's room last night. PCST-A stated he would use a powder in the hole as a poison for the rats and, for now, would leave the hole open with the now unoccupied room door closed so the rat didn't decide to enter a third-floor room instead or exit into the hallway. The DOM stated he had seen the video of a rat, and it appeared that the rat was in the fourth-floor hallway. PCST-A stated that the vines on the side of the building, even if they are treated and dead, could be used by the rats to climb and enter the building and suggested to the DOM that these be taken down.On 8/19/26 at 11:37 a.m., a call was made to the medical director with no answer and a message indicating his voicemail was full. A call was then placed at 11:38 to an office number provided by the facility, and a message was left asking for a call back. A call back was not received.During an interview on 8/19/26 at 12:01 p.m., nursing assistant (NA)-A stated she worked last evening with R30. NA-A stated that a family friend of R30 was in the room with R30 and had alerted her that they had seen a rodent in his room. NA-A stated she had then looked at R30, who was staring at the left-hand corner of the exterior wall of R30's room. NA-A stated she had then examined the area. NA-A stated the area had insulation on the floor that she hadn't noticed previously and it looked like something had come out of the wall. NA-A then stated that she believed that a rodent had exited the wall from that corner of the room and entered R30's room. NA-A stated she had seen anxiety in R30 before this incident but saw increased anxiety and agitation after this incident and thought R30 now looked fearful. NA-A stated that with R30's increased anxiety and agitation, R30 had pulled out his tracheostomy tube during the shift. NA-A stated she had elevated R30's bed high off the floor to try to help with his anxiety, and she checked on him often during her shift after the incident.During an interview on 8/19/26 at 12:24 p.m., RN-G stated that yesterday was her first day working with R30. RN-G stated that a family member of R30 had notified her that a rodent had been in R30's room and showed her a video of a rodent in the building. RN-G stated that when she entered R30's room, she had noticed insulation and what appeared to be pieces of wall on R30's floor that staff had to vacuum up. RN-G stated this had led her to believe that a rodent had entered R30's room. RN-G stated that after this incident, R30 became emotionally distressed and was moaning and crying. RN-G stated that R30 became agitated and pulled his tracheostomy tube out, and she had to insert a new one. RN-G stated she gave him his scheduled anxiety medication, completed more frequent checks on him, and after the medication had time to take effect, R30 calmed down.FacilityThe facility's consulted pest control company service report dated 6/30/26, indicated the following actions were required of the facility:-A continued recommendation from 4/28/25, there was a hole behind the toilet in room [ROOM NUMBER] that should be addressed by maintenance.-A continued recommendation from 6/12/25, there were holes in the bathroom in room [ROOM NUMBER] that should be patched, as it could lead to rodents entering the room.-A continued recommendation from 8/6/25, there were vines on the east side of the building that should be removed by staff, as rodents had been known to climb this in the past. The report included a picture of a brick building that appeared to be four stories with three windows, one above the other, noted. The picture included various brown vines on the building that climbed up to approximately the bottom of the second window that was visible (third-story window).-A continued recommendation from 8/6/25, there was a hole in the exterior of the building by the dumpster area, above a window to the left of a staircase. The recommendation indicated this was a potential rodent entry point, and it should be repaired as necessary.The facility's consulted pest control company service report dated 7/29/26, indicated the following action required of the facility:-A continued recommendation from 6/12/25, there was a hole in the 413 bathroom that should be patched and was too big for the consultant company to patch.The facility's consulted pest control company service report dated 8/13/26, indicated the following action required of the facility:-There were rodent concerns in room 415 and a big hole in the bathroom that needed to be filled with drywall.-There were rodent concerns in room 416 and a big hole under the sink that needed to be filled with drywall.-A continued recommendation from 8/4/26, there were major gaps around plumbing, with the recommendation to fill in the gap behind the toilet.The facility's consulted pest control company service report dated 8/17/26, indicated the following action required of the facility:-A continued recommendation from 8/4/26, there were major gaps around plumbing, with the recommendation to fill in the gap behind the toilet. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 admitted to the facility on [DATE], had intact cognition, and no delusions or hallucinations during the look back period (LBP). The resident resided in room [ROOM NUMBER].During an interview and observation on 8/19/26 at 8:42 a.m., R7 sat on the edge of his bed with oxygen tubing attached to himself (over the ears and inserted into the nose) with extra tubing lying on the floor. R7's bathroom was observed with a hole that was greater than the size of a quarter around each side of the pipes and was visible behind the toilet where the pipes entered the wall. R7 stated that he saw a mouse coming through the hole a week ago. R7 stated that the mouse got stuck in his oxygen tubing on his floor and he had to help it get out. R7 stated he saw mice every day in the facility but not always coming out of the hole in his bathroom.R16's quarterly MDS dated [DATE], indicated R16 admitted to the facility on [DATE], had intact cognition, and no delusions or hallucinations during the LBP. R16 resided in room [ROOM NUMBER].During an interview on 8/16/26 at 2:22 p.m., R16 stated there was a large hole in the plaster under the sink in their room, and they had seen mice in their room in the past. R16 stated that something had bitten him in bed last night and showed two pinpoint scabs approximately two centimeters apart on his lower calf.R58's quarterly MDS dated [DATE], indicated R58 admitted to the facility on [DATE], had intact cognition, and no delusions or hallucinations during the LBP. R58 resided in room [ROOM NUMBER].During an interview on 8/16/26 at 5:15 p.m., R58 stated that the facility had an issue with mice as she saw mice run across the floor in her room last month.R102's entry tracking MDS dated [DATE], indicated R102 admitted to the facility on [DATE]. An admission/comprehensive MDS with cognition data was not yet completed. R102 resided in room [ROOM NUMBER].During an interview on 8/16/26 at 1:56 p.m., R102 stated the facility was not well cared for, and nothing got fixed. R102 also expressed concern that there was ivy growing up the exterior wall outside their window. Multiple brown colored vines were observed covering R102's fourth-floor window.During an interview and observation on 8/18/26 at 2:42 p.m., the director of maintenance (DOM) stated he was the only maintenance personnel for the building, although occasionally the regional maintenance staff member would help. The DOM stated he had started working at the facility approximately six months ago and stated that the building was in terrible shape. The DOM stated it was only him for the most part to complete all the maintenance for the building, and he felt that he didn't have enough time to complete all the tasks that were assigned to him. R16's room was observed with a hole surrounding the sink pipes that was approximately one foot by one foot. Multiple brown vines were observed adhered to the exterior of R102's window. The DOM stated that he thought the hole had been that way for a while and it was on his list to fix, but he didn't have enough time to finish everything.During an observation and interview on 8/19/26 at 9:14 a.m. with the DOM,-brown vines were observed as described in the 6/30/26 consultant pest control report but seemed to have expanded a couple of feet and now covered a resident window. The DOM stated he had treated the vines but thought that since they were thought to be dead, the rats would be unable to climb the vines, and it would also be a lot of work to take them down.-A hole in the exterior of the building by the dumpster area was observed, above a window to the left of a staircase, and was approximately 1.5 inches in diameter. The maintenance director stated he had been unaware of this hole, but it looked like the area needed to be filled.-An approximately inch gap around the outside of the 413-bathroom (shared with 411) toilet pipes was observed.-In 414 (shared with 412) bathroom, a hole that was at least three inches by one inch was observed behind the toilet where the pipes enter the wall.-In 415's (shared with 417) bathroom, a hole that was greater than the size of a quarter around each side of the pipes was visible behind the toilet where the pipes entered the wall. The DOM stated that he did believe that rats or mice would be able to enter the holes observed in the 413, 414, and 415 bathrooms. The DOM stated he believed that these holes had been present since at least when he started six months ago. The DOM stated that the facility had made fixes in the main kitchen as they had previously had issues with rodents entering this area. The DOM stated that, as it was mainly only him working on these fixes, he was unable to get to fixing the holes in the resident rooms due to time constraints.During an interview on 8/19/26 at 2:23 p.m., the administrator stated the building previously didn't have a great maintenance structure. The administrator stated that since the current DOM took over, he had been patching holes, they completed maintenance on the kitchen, were completing monthly building plant tours, and redid a walkway. The administrator stated the facility had a lot of things that still needed to be done, but the facility had made a lot of improvements since the DOM started. The administrator stated the DOM had been the sole person completing the maintenance on the building with occasional help from the regional maintenance staff member. The DOM stated the facility depended on corporate approval for getting additional resources such as staff for completing maintenance projects. The administrator stated she had been made aware of a potential rodent from RR-A and had ensured more frequent monitoring was completed on R30. The administrator stated she had gone up today to check on R30 and felt that R30 was not showing any anxiety or agitation at that time. The administrator stated she had offered a room change to RR-A. The administrator stated that at first RR-A was agreeable to this, but then RR-A's anxiety was out of control and R30 ended up transferring to the hospital. The administrator stated she felt like RR-A's anxiety led to an increase in R30's anxiety. The administrator stated that she felt that R30's anxiety was caused by multiple factors and did not feel it could be attributed to the rodents in the building.A Policy regarding pest control was requested and not received.

Based on interview and document review, the facility failed to ensure notification was sent to the Office of the State Long-Term Care Ombudsman(OOLTC) for 1 of 2 residents (R99) reviewed for discharge and 1 of 2 residents reviewed for hospitalization (R11). Findings include: R99 R99's face sheet printed 8/18/26, indicated diagnosis of saddle pulmonary embolus (blood clot straddles the main fork of the heart affecting blood flow to the lungs). R99's censes sheet printed 8/18/26, indicated admit on 5/9/26 and billing stopped on 6/16/26. A facility report titled Admission/Discharge To/From Report dated 5/1/26 to 7/31/26, indicated R99 was discharged on 6/16/26. R99's electronic medical records (EMR) lacked evidence of OOLTC notification of discharge. R11 R11's quarterly MDS dated [DATE], indicated R11 was admitted to the facility on [DATE] and had moderately impaired cognition. The MDS indicated R11's most recent re-entry was on 7/16/26 from a short-term general hospital. R11's Census data dated 8/15/26, indicated R11 was in hospital status on 7/10/26 before a change back to active status on 7/16/26. R11's medical record was reviewed, and an indication that the ombudsman was notified of her transfer to the hospital was not found. An email from the [NAME] Ombudsman (RO) received on 8/19/26, indicated facility discharge notifications had not been received for 6/2026 and 7/2026. During interview on 8/19/26 at 11:12 a.m., administrator stated Social Services Director (SSD) would be the person to upload and submit (currently on leave). SSD did upload reports for discharge, transfer and hospitalization but went to OOLTC in different district. This resulted in the facility's OOLTC not being notified of discharges, transfers, or hospitalizations from this facility for June and July. Administrator expected that the report titled Admission/Discharge To/From Report would be run and sent in the first 10 business days for the previous month. A Facility policy titled Ombudsman Hospital Transfer Report, updated 8/2025, directed staff to run a report in PointClickCare (electronic health record) monthly. The report would include transfers to hospital, discharge date and discharge/transfer to new facility. The report will be printed and faxed to the Ombudsman.

Based on observation, interview, and document review, the facility failed to provide ordered palm protectors and restorative interventions intended to maintain range of motion for 1 of 1 residents (R25) reviewed for restorative services and assistive devices.Findings include:R25's comprehensive Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact, requiring maximum assistance with activities of daily living (ADLs), and having functional limitations in the range of motion of the upper and lower extremities. R25 was also dependent on staff for transfers, dressing, and personal hygiene.R25's care plan, dated 8/13/26, indicated that the resident required total assistance with ADLs, was non-ambulatory, required maximum assistance with bed mobility and transfers, and had severe contractures and spasms of the upper and lower extremities. The care plan further indicated that R25 received restorative therapy, including the use of palm protectors to prevent further contractures and muscle weakness.R25 had a provider order for bilateral palm protectors to be worn at all times, with removal permitted for hand hygiene each shift and washing as needed. R25's treatment administration record (TAR), dated 8/17/26, indicated that the palm protectors had been applied.During an observation on 8/17/26 at 11:31 a.m., R25 was observed in the dining room seated in a wheelchair in a reclined position. A wedge was positioned between the resident's contracted legs. R25 did not have palm protectors in place on either hand. Both hands were contracted, and the wrists and elbows were curled toward the resident's body.During an observation on 8/18/26 from 7:30 a.m. to 8:22 a.m., R25 again did not have palm protectors in place.During an interview on 8/18/26 at 8:53 a.m., RN-C stated that the facility did not have a restorative rehabilitation department or restorative rehabilitation staff. RN-C stated that the physical and occupational therapy departments provided education and training related to ordered therapies. RN-C further stated that physician orders and the care plan were important and needed to be followed to ensure accurate care was provided to each resident.During an interview on 8/18/26 at 9:08 a.m., RN-D stated that residents were expected to receive restorative care and use assistive devices as ordered. RN-D stated that these interventions were important for maintaining alignment and decreasing contractures.During an interview on 8/18/26 at 9:36 a.m., LPN-A confirmed that R25 did not have the ordered palm protectors in place. LPN-A stated that R25 should have had the palm protectors due to the resident's contractures and that the palm protectors were intended to maintain strength and joint mobility.During an interview on 8/18/26 at 11:42 a.m., the Director of Rehabilitation (DOR) stated that therapists received orders to evaluate and treat residents and implemented a functional maintenance program based on their assessments and the residents' individual needs. DOR stated that the plan was placed in a folder, physical and occupational therapy staff completed the plan and trained facility staff, staff signed the training documentation, and each department head received a copy. DOR further stated that instructions were placed in the resident's room and hung on the wall. DOR confirmed that R25 had a written functional maintenance plan and hand protector education and that staff sign-off had been completed.During an interview on 8/18/26 at 2:44 p.m., the Director of Nursing (DON) stated that the expectation for the functional maintenance program and assistive devices was for staff to be properly trained on each resident's individual plan and to follow the care plan and physician orders to prevent contractures and maintain the resident's function and mobility.Document review and interviews further revealed that the facility did not have a policy addressing functional maintenance programs, assistive devices, or restorative rehabilitation services.

Based on observation, interview, and document review the facility failed to ensure water was available and/or offered for 1 of 2 residents (R13) reviewed for hydration.Findings include: R13 R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact, dependent on staff for transfers to wheelchair and mobility in wheelchair. R13's diagnoses included chronic respiratory failure with hypoxia (low blood oxygen), diabetes, osteoarthritis of both knees, and mild protein/calorie malnutrition. R13's care plan dated 7/6/26 indicated R13 was at risk for malnutrition with a goal of being free from signs and symptoms of dehydration. Interventions included to provide food and beverages between meals. During interview and observation on 8/16/2026 at 11:29 a.m., R13 was lying in bed, hospital gown on that was not covering their shoulders or upper chest area, R13 stated they asked for water frequently and staff returned with it maybe 50% of the time. R13 stated this occurred on a daily basis. R13 stated they asked for water this morning, however no water was observed near resident. R13 stated they were frequently warm in their room and stated their fan was on most of the time. During observation on 8/17/2026 at 10:14 a.m., R13 observed lying in bed with bare shoulders and upper chest, box fan on floor blowing toward bed. A small plastic disposable cup noted on breakfast tray with approximately 60 milliliters (ml) clear liquid. R13 was observed to have dry lips as they applied lip moisturizer. During interview and observation on 8/17/2026 at 11:53 a.m., a plastic disposable cup with clear liquid was on R13's lunch tray, R13 stated it was the same water from her breakfast tray. R13 stated they used to have mugs staff would bring with ice water but have not been brought in a while; days at least, probably weeks. Not noted to have larger container of water in room. During interview and observation on 8/18/2026 at 11:54 a.m., R13 stated they did get a mug of ice water last evening, however no mug was seen in the room. R13 stated they requested more water this morning, but they probably forgot again. During observation on 8/18/2026 2:36 at p.m., R13 was observed lying in their bed sleeping with bare shoulders and upper chest, fan on, and no containers with water were noted in room. During interview and observation on 8/19/2026 at 9:15 a.m., no containers of water were noted in R13's room. R13 stated they asked for the water container to be replaced last evening. R13 was brought a small disposable cup of water with their medications, but no other fluids were provided. R17 R17's quarterly minimum data set (MDS) dated indicated R17 was cognitively intact. R17's diagnoses included quadriplegia (paralysis of the body below the neck), neurogenic bladder (bladder control problem), high blood pressure. During resident council interview on 8/18/2026 at 1:26 p.m., R17 stated their number one concern in facility was the staff do not pass water on shifts or ask residents if they want water. R17 stated they have had more urinary tract infections at this facility than in previous stays at other facilities. During interview on 8/18/26 at 11:45 a.m., nursing assistant (NA-B) stated staff brought the residents' water; all staff, nursing assistants, nurses, whoever the residents ask and that water was passed with breakfast, lunch, and dinner on meal trays; a cup of water each time. During interview on 8/18/26 at 11:49 a.m., NA-C stated they usually had water bottles that staff filled up and nursing assistants were responsible for getting residents water in the morning, and those who worked in the afternoon refilled the bottles if residents asked, or some residents could get it themselves. NA-C stated the facility recently ran out of bottles. When that happens, staff notify the manager and they tell the administrator who orders more. During interview on 8/18/26 at 2:43 p.m., registered nurse (RN)-D stated most residents had their own bottle and staff got fresh water for them every morning. RN-D also stated all staff were responsible for getting water for residents and it was passed when residents asked for it. During interview on 8/18/26 at 2:47 p.m., licensed practical nurse (LPN)-D stated all staff were responsible for passing water to the residents. LPN-D also stated water was passed at mealtimes, at the beginning of the shift, and as needed; it should be available all the time, and some residents will ask for it. During interview on 8/19/26 at 1:35 p.m., director of nursing (DON) expected water to be available and that staff should bring water to residents in the morning, at meals, and at nighttime; water should be passed at shift change. DON also stated if residents were to lack access to water it could result in dehydration and increase in urinary tract infections. A facility policy titled hydration program policy dated 6/2026, directed staff to ensure equipment and supplies were provided, and water was passed as directed between meals, and as requested, for residents.

F695 Based on observation, interview and document review, the facility failed to ensure necessary emergency suction equipment was readily available and accessible at the bedside during a hypoxic event for 1 of 1 resident (R2) reviewed for respiratory care. R2's quarterly minimum data set (MDS) dated [DATE], severely cognitively impaired, diagnoses of acute and chronic respiratory failure with hypoxia (low blood oxygen), ventilator dependent (needs a machine to assist with breathing) and had a tracheostomy (surgical airway in the neck). R2 was dependent for all cares and required maximum assistance with activities of daily living (ADL's).R2's provider orders instructed to suction as needed every shift for excessive secretions/respiratory distress to maintain airway. Lavage (flush) with 3cc of normal saline with suctioning as needed for thick secretions. R2's orders instructed Volera (a system that expands lungs and airway and loosens secretions and dislodges mucus) for oscillation and nebulization treatment in-line (continuous) suction with trach for airway clearance three times a day. R2's care plan dated 8/1/26, indicated R2 required a ventilator due to acute and chronic respiratory failure. Interventions included staff to ensure suction equipment, bag-valve mask and artificial airway are functional and present at bedside.During observation on 8/17/26 at 10:11 a.m., R2 had copious amounts of thick, light yellow, sputum out of nose and mouth. R2 was on continuous oxygen (O2) saturation monitoring. The monitor started to alarm. At 10:13 a.m., R2's O2 saturations read 79% (normal was above 90%). Registered nurse (RN)-A entered the room and started gathering supplies. RN-A yelled down the hallway for someone to bring in sterile water and yelled for someone to call for the respiratory therapist (RT). O2 saturations dropped to 65%. At 10:16 a.m., RN-A yelled from bedside, requesting trach suction assistance, while using Ambu bag (bag to blow oxygen into the airway) to stabilize R2. Two unidentified staff entered room at 10:17 a.m. and found no sterile suction catheter in room. Unidentified staff left room to obtain in supply closet. RN-A asked for suction, while continuing to bag R2. At 10:18 a.m., O2 sats 83% while RN-A continued using the Ambu bag. At 10:19 a.m., O2 sats 79%, sterile suction catheter was brought to R2's room by staff member. RN-A suctioned R2 three times. At 10:23 am., R2's O2 saturations were at 96% and R2 was placed back on ventilator. During an interview on 8/17/26 at 12:06 p.m., RN-A stated R2 had a recent increase in secretions recently. R2 had required increased suctioning for the past few days. RN-A verified there was no sterile water or suction available in R2's room, so RN-A started bagging R2 to maintain O2 levels. RN-A stated respiratory therapy (RT) and nurses were responsible for stocking the emergency respiratory supplies at bedside. Nurses were expected to suction immediately when residents were having respiratory distress. During an interview on 8/17/26 at 12:33 p.m., RN-B stated she suctioned R2 approximately 3 times before 10:13 a.m., additionally, did a Volara treatment. When a nurse sees secretions, suction should be performed immediately. RT and RN manager were responsible for stocking emergency respiratory supplies in room. RN-B stated she used the last of the sterile suctions and sterile water earlier in the day but did not restock the supplies. During an interview on 8/17/26 at 12:54 p.m., RT stated she rounds and stocks 2-3 times a week. There were no other audits or reviews on supplies performed. The emergency respiratory supplies should be at bedside. During an interview on 8/17/26 at 2:42 p.m., R2's NP stated she was aware of the recently increased secretions and was attempting to manage it. The expectation was to have emergency respiratory supplies at bedside. NP further stated she would be concerned about the oxygenation of the organs and R2's brain function with an episode of hypoxia that lasted six minutes. During an interview on 8/17/26 at 3:07 p.m., the director of nursing (DON) stated the expectation was to have emergency respiratory supplies at bedside. However, there wasn't a policy maintaining on trach suctioning or respiratory emergencies. A policy on Tracheal Suctioning, Respiratory Emergency Supplies and/or Suctioning Supplies policies were requested, however, the facility lacked these policies.

Based on observation, interview, and document review, the facility failed to ensure dental needs were evaluated and, if needed, acted upon or addressed timely to promote oral health for 1 of 1 residents (R58) reviewed for dental care. Findings include:R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58 admitted to the facility on [DATE], had intact cognition, and no delusions or hallucinations during the look-back period (LBP). The MDS indicated R58 had no broken or loosely fitting full/partial dentures and did not have mouth/facial pain, discomfort, or difficulty chewing.R58's care conference note dated 12/19/25, included a section titled Exams that included a blank for last dental exam that was left empty and comments that indicated no data.R58's care conference note dated 12/29/25, included a section titled Exams that included a blank for last dental exam that was left empty and comments that indicated see doc tab.R58's care conference note dated 6/8/26, included a section titled Exams that included a blank for last dental exam and comments that were both left empty.R58's Census data dated 8/15/26, indicated R58's primary payment source was Medicaid.R58's medical record was reviewed and did not indicate R58 had been offered, refused, or had received dental services while at the facility.During an interview and observation on 8/16/26 at 5:18 p.m., R58 was observed sitting on her bed with three front upper teeth that appeared shorter than the rest and slightly jagged. R58 stated that she used to have caps on her three now shorter front teeth but thought they had fallen off at least six months ago. R58 stated that she had not seen a dentist since she got here and didn't recall anyone offering to help her make an appointment. R58 stated that it bothered her the way her teeth looked without the caps and wished someone would help her get them fixed. R58 stated she couldn't recall if she had told anyone the caps had fallen off.During an interview on 8/18/26 at 1:45 p.m., licensed practical nurse (LPN)-A, the care coordinator for the unit, stated dental services should be offered to residents on admission. LPN-A stated that a document should be added related to offering this, but all he could find was related to vision services. LPN-A stated he would look further into the matter and get back to the surveyor.During an interview on 8/19/26 at 11:51 a.m. with the director of nursing (DON) and LPN-A, the DON stated that dental services were offered on admission or as requested. The DON confirmed she had reviewed R58's medical record and did not find a record that dental services were offered. The DON also stated that dental services should be discussed at care conferences.A policy regarding dental services was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure maintenance services were provided in a timely manner to ensure a homelike living space was provided for 3 of 3 residents (R16, R58, R102) reviewed with room maintenance needs. Findings include: R58 R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58 admitted to the facility on [DATE], had intact cognition, and no delusions or hallucinations during the look-back period (LBP). During an interview and observation on 8/16/26 at 1:56 p.m., R58 was observed sitting on her bed in her room. R58's room was observed with a space from the floor extending up to approximately six inches above the floor across all visible walls (did not have things covering the wall such as baseboard heating unit, closet, etc.) that appeared as if the room had previously had a baseboard and now did not. The remaining wall (the six-inch space extending from the floor) was in some areas: peeling back, blackish in color, or a tan color that was different from the wall that was above the six-inch space. R58 stated she believed that the wall had been like that since she had moved in last year, and she didn't like the way it looked. R102 R102's entry Minimum Data Set (MDS) dated [DATE], did not include a cognition assessment. During an interview on 8/16/26 at 1:56 p.m., R102 stated, this place is a dump and nothing gets fixed. R102 pointed at damage on their windowsill and their wall. R102 also expressed concern that there was ivy growing up the exterior wall outside their window. During an observation on 8/16/26 at 1:56 p.m., R102's windowsill was missing a triangular piece of wood in the center, approximately 5 inches long and 2 inches deep with a sharp edge, their wall was patched with plaster but not painted, approximately 2 feet by 2 feet, and brown vines were around the exterior of R102's window. R16 R16's quarterly MDS dated [DATE], identified R16 was cognitively intact. During an interview on 8/16/26 at 2:22 p.m., R16 stated there was a large hole in the plaster under the sink in their room and they had seen mice in the past. During an observation on 8/16/26 at 2:22 p.m., there was a hole surrounding the sink pipes in R16's room, approximately 1 foot by 1 foot, which appeared to be cut out. There were also unpainted plaster patches on the wall behind R16's bed, approximately 4 feet long. During an interview and observation on 8/18/26 at 2:42 p.m., the director of maintenance (DOM) stated he was the only maintenance staff member for the building, although occasionally the regional maintenance staff member would help out. The DOM stated he had started working at the facility approximately six months ago and stated that the building was in terrible shape. The DOM stated it was only him for the most part to complete all of the maintenance for the building, and he felt that he didn't have enough time to complete all of the tasks that were assigned to him. Third floor: R58's room was observed with a space from the floor extending up to approximately six inches above the floor across all visible walls (did not have things covering the wall such as baseboard heating unit, closet, etc.) that appeared as if the room had previously had a baseboard and now did not. The remaining wall (the six-inch space extending from the floor) was in some areas: peeling back, blackish in color, or a tan color that was different from the wall that was above the six-inch space. The DOM stated he was unaware of how long the wall had been like this. The DOM stated it was unlikely that the resident had removed the trim herself and felt it was most likely unfinished work from prior to when he started. Fourth floor: R16's room was observed with a hole surrounding the sink pipes that was approximately one foot by one foot. There was also an unpainted white patched area on the wall behind R16's bed that was approximately four feet long, with a varied height, with one foot at the tallest point. R102's windowsill was observed to be missing a triangular piece of wood in the center that was approximately five inches long and two inches deep with a sharp edge. R102's wall had an area that appeared to have been patched and left unpainted and was approximately two feet by two feet. Multiple brown vines were observed adhered to the exterior of R102's window. The hole and unpainted patch in R16's wall, the unpainted area, and damaged windowsill were reviewed with the DOM. The DOM stated that he thought the hole and unpainted areas had been that way for a while and it was on his list to fix, but he didn't have enough time to finish everything. A policy regarding building maintenance was requested and received.

Based on observation, interview, and document review the facility failed to ensure proper cleaning of snack/nourishment refrigerators maintained with food items are dated and labeled to prevent the potential for foodborne illness for 3 of 3-unit refrigerators. Findings include: During observation on 7/27/25 at 12:50 p.m., the refrigerator for residents on the 4th floor had an open gallon jug of milk, expiration date 7/9/25 no label on the container stating when milk was opened. A clear Tupperware container wrapped in a Macy's bag without a label. A Menards's bag with food container inside, had a resident's name, no date on item. A drawer contained: one open unlabeled package of saltine crackers, open bag of carrots and a peach. In the door of refrigerator there was an opened unlabeled chocolate pudding, a yogurt no label, expiration date 6/25, a bag with no label, open containers of Pace hot sauce, ketchup, Jalapenos, strawberry jam, Core Power beverage, Top of the Tator dip, expiration date 5/25, all items unlabeled. The bottom of the refrigerator, under the drawers had a red, dried liquid substance on it. The freezer had a [NAME] jar with a grayish substance in it, labeled with date 4/31/25 no name. An unlabeled open container of glycerin swabs sticks. A frozen unlabeled loaf of bread used by date 5/29/25. An unlabeled frozen bag of long grain white rice expiration 5/24. A bag from Culver's with resident's name, no date on it. Lastly, a frozen [NAME] frozen deluxe pizza expiration date 3/22/25 no label on item. Observed nursing assistant (CNA)-D removed a plaid thermos from refrigerator and placed it on top of refrigerator. During observation on 7/27/25 at 1:41 p.m., the refrigerator for residents on the 3rd floor contained an open package of hot dogs with white, green and brown fuzzy coating on them, unlabeled, expiration 6/25. A white bag with food items in it, unlabeled. Lastly, a bottle of Bio salad dressing, expiration date 5/25. The freezer had a Styrofoam cup with frozen red substance, unlabeled. One cold compress, unlabeled. During observation on 7/27/25 at 2:02 p.m., the refrigerator for residents on the 2nd floor contained a TPN (Total Parenteral Nutrition) container unlabeled with an expiration date of 11/24. During observation on 7/28/25 at 8:35 a.m., the refrigerator on the 4th floor still had red, dried liquid substance on bottom of it, all remaining items are labeled and dated, no expired items, additionally, the plaid thermos was on top of refrigerator. During observation on 7/29/25 at 8:25 a.m., the refrigerator on the 4th floor still had red, dried liquid substance on the bottom of it, additionally, the plaid thermos remained on top of refrigerator. During observation on 7/30/25 at 10:28 a.m., fridge was cleaned, and plaid thermos was removed from top of 4th floor refrigerator. During interview on 7/27/25 at 1:11 p.m., certified nursing assistant (CNA)-B stated the housekeeping department was responsible for cleaning and the disposal of unlabeled and expired items. CNA-B verified items unlabeled and expired in the 4th floor refrigerator. During interview on 7/27/25 at 1:17 p.m., CNA-D stated the kitchen staff was responsible for cleaning and the disposal of unlabeled and expired items. CNA-D verified items unlabeled and expired. They removed items from the refrigerator and put into trash, however, did remove an unlabeled plaid thermos and placed it on top of refrigerator on the 4th floor. During interview on 7/27/25 at 1:53 p.m., CNA-C verified unlabeled and expired items in 3rd floor refrigerator. During interview on 7/27/25 at 2:11 p.m., registered nurse (RN)-A stated they were unsure of which department was responsible for cleaning and disposal of unlabeled or expired items. They verified the unlabeled and expired items in the 2nd floor refrigerator. They stated ice compresses were to be stored in the medication fridge, not in resident's refrigerator. During interview on 7/29/25 at 7:22 a.m., dietitian-A stated there is a policy for residents receiving food from outside of facility. During interview on 7/29/25 at 7:25 a.m., culinary director (CD)-A stated nurses and CNA's check dates on items and disposes of any unlabeled or expired items, the dietary staff check and document temperatures, and housekeeping is responsible for cleaning the inside and outside of resident refrigerators on each floor. During interview on 7/29/25 at 8:47 a.m., housekeeping-A stated refrigerators were cleaned every Wednesday on all floors, items not labeled, check with nurse manager before disposing of items. If a container is open for more than two days, it is to be disposed of. Also, no items are to be on top of refrigerators. During interview on 7/29/25 at 9:17 a.m., CNA-A stated kitchen staff or aides clean fridges on the floors. Items should have dates and name of resident. During interview on 7/29/25 at 9:25a.m., licensed practical nurse (LPN)-B stated mostly nurses and managers clean the fridges on the floors. Items need to be labeled with name and date. if an item is expired, inform resident that the item was disposed of. A facility policy titled Food Receiving and Storage implemented on 7/29/25, indicated the refrigerator and freezer cleanliness will be maintained by housekeeping services. The labeling, monitoring and assisting residents/family of incoming product labeling will be maintained by nursing staff. The maintaining of daily temp logs, monitoring dates of products stored will be maintained by dietary staff. The facilities policy titled, Food Brought into a Monarch Healthcare Management Facility policy revised 9/12 indicated the food must be in a closed, leak-resistant container, it must be labeled with: Resident name and date item was received. Food must be disposed of properly after 3 days.

Based on interview and record review the facility failed to ensure target behaviors were monitored for 1 of 5 residents (R3) who received psychotropic medications (medications that affect mood, thoughts, or behaviors). Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and had diagnoses of acute respiratory failure, Amyotrophic Lateral Sclerosis (disease that affects the spinal cord causing loss of muscle use), and major depressive disorder. R3 was ventilator dependent and was taking psychotropic medications.A review of R3's current provider orders indicated R3 required:-as of 4/3/2025, Clonazepam (psychotropic medication) 0.5 milligrams (mg) via gastrostomy tube (G-tube) at noon for anxiety.-as of 4/2/25, clonazepam .025 mg twice daily for anxiety related to major depressive disorder. R3's orders lacked monitoring for target behaviors for anxiety. R3's care plan revised 11/11/2024, indicated R3 had potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medications. Interventions included to administer medications as ordered, monitor for adverse reactions, and pharmacy to review medications. However, R3's care plan lacked identification or monitoring of target behaviors. When interviewed on 7/28/25 at 10:20 a.m., registered nurse (RN)-D stated R3 took medications for anxiety and has for a while. RN-D stated staff look for restlessness. R3 had been very anxious at times, especially when needing suctioning. R3 had recently been declining and at one point was going to go onto hospice, however decided not to. RN-D verified there was no documentation of target behaviors related to R3's anxiety or psychotropic medications and stated there was no longer daily documentation of any specific anxiety behaviors or anything to that extent. Currently, nurses only document if R3 had a change in condition. When interviewed on 7/29/25 at 2:25 p.m., RN-C stated R3 had recently deteriorated and almost signed on to hospice a few months ago. R3 used to be able to mouth his words, and now he can only blink to communicate. R3 used to be very anxious with repositioning and used to over breathe the vent. Currently, R3 had good days and bad days with the anxiety, breathing and repositioning. RN-C verified R3 had orders to monitor for side effects of the psychotropic medications, however there was no monitoring of target behaviors related to R3's anxiety and need for the medications. When interviewed on 7/30/25 at 10:19 a.m., the Director of Nursing (DON) expected residents who were taking psychotropic medications to have monitoring for target behaviors related to those medications. DON further stated it was important to understand if the medications were effective and if they were supporting a positive outcome for the resident. A facility policy titled Psychotropic Medication Use Policy revised 5/2025, directed staff to identify and monitor target behaviors when a resident was prescribed psychotropic medications.

Based on observation, interview and record review the facility failed to ensure call light was accessable for 1 of 1 residents (R61) reviewed for call lights. Findings include: R61's quarterly Minimum Data Set )MDS) dated [DATE], indicated R61 was cognitively intact and had diagnoses of respiratory failure and quadriplegia (unable to move arms or legs). Furthermore, R4 was dependent on staff for all cares.R61's care plan revised 6/5/25, indicated R61 was a risk of falls and staff were to ensure R61's call light was within reach.An observation on 7/27/25 at 12:39 p.m., R61 was laying in bed. R61's head was on a pillow and on the right side of the pillow was a tent call light. R61 was unable to move his head to hit the call light if staff assist was needed. When interviewed on 7/27/25 at 12:42 p.m., R61 was able to answer yes and no questions and mouthed words. R61 indicated it was sometimes hard to breath and they waited on staff for help. R61 shook their head no when asked if able to turn on the call light from where it was located. An observation on 7/28/25 at 1:54 p.m., R61 was laying in his bed watching their tablet. To the right of R61's pillow was a tent call light. R61 indicated no when asked if he could turn it on if assistance was needed. When interviewed on 7/28/25 at 2:05 p.m., registered nurse (RN)-B stated R61 was able to use the call light to alert staff for assistance. R61 was able to nudge it with his head. RN-B verified R61 was not able to reach their call light. RN-B placed the tent call light on R61's pillow close to their head and asked R61 to put it on to ensure it was in reach. When interviewed on 7/28/25 at 2:23 p.m., RN-C stated call lights should be placed where residents could use them. RN-C further stated that is an important part of how residents let staff know they need help. When interviewed on 7/30/25 at 10:59 p.m., the Director of Nursing (DON) expected staff to ensure call lights were in reach for all residents. DON further stated this was needed to ensure residents can get assistance when needed. A facility policy titled Call Light Policy revised 5/16/23, directed staff to ensure call lights, cords or other communication devices must be placed where they are within reach of each resident.

Based on document review and interview, the facility failed to identify triggers to avoid potential re-traumatization and failed to develop the care plan to include individualized trauma-informed approaches for 1 of 1 resident (R6) who had a history of trauma. Findings include:R6's Comprehensive Minimum Data Set assessment (MDS) dated [DATE], indicated cognitively intact with depression. R6 had a diagnosis of major depressive disorder and PTSD (post-traumatic stress disorder) on admit on 4/22/25. R6 had a diagnosis of quadriplegia required full cares with bed mobility and transfers, unable to walk, and required total assistance with dressing and hygiene.R6's admission Psychosocial assessment dated [DATE] was not triggered for a care area assessment, therefore, not placed on care plan.R6's admission Trauma Informed Care history dated 4/23/25, identified the resident had a diagnosis of PTSD and R6 declined to talk about it. Further, R6 responded yes to having been through anything life threatening or traumatic but did not give any further details on traumatic event. However, assessment lacked further details regarding triggers to prevent re-traumatization.R6's physician visit note dated 4/25/25, identified R6 had major depressive disorder with anxiety, aggressor identification syndrome and PTSD.R6's physician orders on 4/28/25 and 6/3/25, identified orders for ACP Psychiatry consult to evaluate and treat. R6's vulnerability care plan dated 7/24/25, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization.During an interview on 7/27/25 at 6:09 p.m., R6 stated someone, thinks it was social work employee, came in and talked, but I didn't want to talk at that time, I should see someone, I have been in a panic mode, they stated just trying to get everything all together.During an interview on 7/28/25 at 2:13 p.m., R6 was speaking rapidly, changing subjects quickly, I'm a little depressed, and concerned about keeping things in order, phone in mothers name right now. I wanted own line. Social worker was here about 1.5 weeks ago,to see a therapist, social services was going to do it but hasn't happened yet. I am in kind of panic mode. R6 rambled about Lake City, Milwaukee, packing up stuff and wanting to leave. They mentioned Bayview, it closed. There is nothing to do around here, no shopping, no restaurants, nothing to do outside. They talked about being in restraints in an ambulance and hospital. They were unaware of why they were taken to the hospital nor any outbursts or behaviors that would have caused that to happen to them. They claimed they called KTTCP and had an administrator fired for embezzling money. They stated they raged on Facebook against family, for not helping them. R6 stated they are in constant pain, Oxy doesn't touch the pain, worried about getting hooked on drugs. R6 also mentioned had a hard time sleeping, severe insomnia. They stated they were an advocate and did community service in Lake City and Red Wing.During an interview on 7/29/25 at 8:48 a.m., certified nursing assistant (CNA)-A met R6 needs by doing everything R6 asked, cleaned them up, had items next to them. The behavioral health training provided is on Med Trainer, a computer program, no hands-on or teach back methods utilized. CNA-A was unable to give a specific time frame for education, they replied the education happened, pretty often. They stated R6 mood was fairly stable, if there were any behaviors they would mark yes in the electronic medical record (EMR). That was the only place and information documented, no interventions or what type of behaviors were displayed.During an interview on 7/29/25 at 9:00 a.m., licensed practical nurse (LPN)-A stated a resident received mental and psychological counseling by calling provider, obtain an order, inform the nurse manager and the family of appointment. If a resident was a trauma survivor, it would be written in a report and communicated in shift report. The approach to a resident with PTSD would be different, if the environment is too loud, too bright, if the resident is stressed. The behavioral health training provided was on Med Trainer, a computer program, no additional education provided.During an interview on 7/29/25 at 11:14 a.m., LPN-A manager stated the processes in place to provide individualized care for a resident was in the care plan. The types of communication were used to keep floor staff aware of cares, changes in condition, behavioral issues were in the nurse-to-nurse report, 24-hour book, and in EHR. The process for a resident received mental and psychological counseling was to have the social worker put them on a list and notify ACP of whom they should see every morning. It is the expectation that doctors' orders are to be followed. It is the expectation that a resident would be seen if two orders are placed. The interdisciplinary team (IDT) meets every morning with nurses, director of nurses, administrator, social worker, physical therapy, occupational therapy and speech, they address behaviors, discuss upcoming meetings, update treatment administration record (TAR) and put in progress notes.During an interview on 7/30/25 at 8:47 a.m., social service director (SSD)-A stated to obtain mental and psychological counseling services, they reviewed hospital charts, there is a 48 admit process, notify provider, obtain orders, get consent from resident, send referrals to ACP Psychiatry. The plan was to discuss with the resident, provide effective listening, have the resident feel safe and to get to the underlying issues. The doctor's orders absolutely should be followed, the expectation for two orders for a resident to be seen by ACP, should be completed. However, the resident needs to sign a consent for treatment. R6 stated they requested therapy, however R6 declined signing consent when SSD-A approached them. The care plans are important to know the total picture of the resident; mobility, diet, psychosocial, nursing, medication, therapies, every staff member needs to review and look under every section of care plans to provide individualized care for each resident. The underlying causes of the resident's behavioral expressions or indications of distress, specifically included in the care plan were individual needs of each resident, such as, grief, a loner, anything effects them, psychosocial issues, past trauma, mood and behavior, financial issues, health reasons, triggers, history of substance or alcohol abuse, homelessness, can influence their cares and their discharge planning, The behavioral health training is on the computer, Med Trainer. There was not role playing, teach back, hands on, classes outside of facility utilized. If resident was a trauma survivor, the process for providing care, you don't need to know what the trauma was but be aware of the triggers. Understand that it affects behavior, be aware of their individualized needs. If resident a appears hopeless, loss of control, staff need to be present, be respectful and understanding of everyone, be extremely mindful of retraumatizing the resident. The IDT meet every morning, all the disciplines administrator, nurses, business office, culinary, activities, MDS coordinator, infection control, health unit coordinators. They discuss discharges, changes of condition, falls, grievances, hospitalization, care conferences, MDS, any meetings, new admissions and behaviors. R6 behaviors/ trauma informed care was not discussed due to it not being triggered on care area assessment or care plan. The policy titled Trauma Informed Care, dated 2/24/23, identified the purpose is to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. As part of the comprehensive assessment, staff will identity history of trauma when possible. Residents that have a history of trauma will have goals and interventions added to their care plan to address potential triggers and approaches to minimize or eliminate the effect of the trigger on the resident.

Based on document review and interview, the facility failed to identify triggers to avoid potential re-traumatization and failed to develop the care plan to include individualized trauma-informed approaches for 1 of 1 resident (R6) who had a history of trauma. Findings include:R6's Comprehensive Minimum Data Set assessment (MDS) dated [DATE], indicated cognitively intact, had a diagnosis of major depressive disorder with anxiety and PTSD (post traumatic stress disorder) on admit on 4/22/25. R6 had a diagnosis of quadriplegia required full cares with bed mobility and transfers, unable to walk, and required total assistance with dressing and hygiene.R6's admission Psychosocial assessment dated [DATE] was not triggered for a care area assessment, therefore, not placed on care plan.R6's admission Trauma Questionnaire dated 4/23/25, identified the resident had a diagnosis of PTSD and R6 declined to talk about it.R6's physician visit note dated 4/25/25, identified R6 had major depressive disorder with anxiety, aggressor identification syndrome and PTSD.R6's physician orders on 4/28/25 and 6/3/25, identified orders for ACP Psychiatry consult to evaluate and treat. R6's vulnerability care plan dated 7/24/25, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization.During an interview on 7/27/25 at 6:09 p.m., R6 stated someone, thinks it was social work employee, came in and talked, but I didn't want to talk at that time, I should see someone, I have been in a panic mode, they stated just trying to get everything all together.During an interview on 7/28/25 at 2:13 p.m., R6 spoke rapidly, changing subjects quickly I'm a little depressed, and concerned about keeping things in order, phone in mothers name right now, I wanted own line. Social worker was here about 1.5 weeks ago, I need to see a therapist, social services was going to do it but hasn't happened yet. I am in kind of panic mode. R6 rambled about Lake City, Milwaukee, packing up stuff and wanting to leave. They mentioned Bayview, it closed. There is nothing to do around here, no shopping, no restaurants, nothing to do outside. They talked about being in restraints in an ambulance and hospital. They were unaware of why they were taken to the hospital nor any outbursts or behaviors that would have caused that to happen to them. They claimed they called KTTCP and had an administrator fired for embezzling money. They stated they raged on Facebook against family, for not helping them. R6 stated they are in constant pain, Oxy doesn't touch the pain, worried about getting hooked on drugs. R6 also mentioned had a hard time sleeping, severe insomnia. They stated they were an advocate and did community service in Lake City and Red Wing.During an interview on 7/29/25 at 8:48 a.m., certified nursing assistant (CNA)-A met R6 needs by doing everything they ask, clean them up, had items next to them. The behavioral health training provided by the facility is on Med Trainer, a computer program, no hands-on or teach back methods utilized. CNA-A was unable to give a specific time frame for education, they replied the education happened, pretty often. They stated R6 mood was fairly stable, if there were any behaviors they would mark yes in the electronic medical record (EMR). That was the only place and information documented, no interventions or what type of behaviors displayed.During an interview on 7/29/25 at 9:00 a.m., licensed practical nurse (LPN)-A stated a resident received mental and psychological counseling by calling provider, obtain an order, inform the nurse manager and the family of appointment. If a resident was a trauma survivor, it would be written in a report and communicated in shift report. The approach to a resident with PTSD would be different, if the environment is too loud, too bright, if the resident is stressed. The behavioral health training provided was on Med Trainer, a computer program.During an interview on 7/29/25 at 11:14 a.m., LPN-A manager stated the processes in place to provide individualized care for a resident was in the care plan. The types of communication were used to keep floor staff aware of cares, changes in condition, behavioral issues were in the nurse-to-nurse report, 24-hour book, and in EHR. The process for a resident to receive mental and psychological counseling was to have social worker put them on a list and will notify who they should see every morning. It is the expectation that doctors' orders are to be followed. It is the expectation that a resident would be seen if two orders are placed. The interdisciplinary team (IDT) meets every morning with nurses, director of nurses, administrator, social worker, physical therapy, occupational therapy and speech, address behaviors, discuss upcoming meetings, update treatment administration record (TAR) and put in progress notes.During an interview on 7/30/25 at 8:47 a.m., social service director (SSD)-A stated to obtain mental and psychological counseling services, review hospital charts, there is a 48 admit process, notify provider, obtain orders, get consent from resident, referrals to ACP Psychiatry. Discuss with the resident provide effective listening, have the resident feel safe and to get to the underlying issues. The doctor's orders absolutely should be followed, the expectation for two orders for a resident to be seen by ACP, should be completed. However, the resident needed to sign a consent for treatment. R6 stated they requested therapy, however declined signing consent when SSD-A approached them, it was not documented. The IDT meet every morning, all the disciplines administrator, nurses, business office, culinary, activities, MDS coordinator, infection control, health unit coordinators. They discuss discharges, changes of condition, falls, grievances, hospitalization, care conferences, MDS, any meetings, new admissions and behaviors. R6 behaviors/ trauma informed care was not discussed due to it not being triggered on care area assessment or care plan. The care plans are important to know the total picture of the resident; mobility, diet, psychosocial, nursing, medication, therapies, every staff member needs to review and look under every section on care plans to provide individualized care for each resident. The underlying causes of the resident's behavioral expressions or indications of distress, specifically included in the care plan were individual needs of each resident, such as, grief, a loner, anything effects them, psychosocial issues, past trauma, mood and behavior, financial issues, health reasons, triggers, history of substance or alcohol abuse, homelessness, can influence their cares and their dc planning, The behavioral health training is on the computer, Med Trainer. There was not role playing, teach back, hands on, classes outside of facility utilized. If resident was a trauma survivor, the process for providing care, you don't need to know what the trauma was but be aware of the triggers. Understand that PTSD affects behavior, be aware of their individualized needs. If resident a appears hopeless, loss of control, staff needed be present, be respectful and understanding of everyone, be extremely mindful of retraumatizing the resident.The policy titled Trauma Informed Care, dated 2/24/23, identified the purpose is to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. As part of the comprehensive assessment, staff will identity history of trauma when possible. Residents that have a history of trauma will have goals and interventions added to their care plan to address potential triggers and approaches to minimize or eliminate the effect of the trigger on the resident.

Based on observation, interview and record review the facility failed to ensure staff followed transmission-based precautions (TBP) for 1 of 2 residents (R7) reviewed for TBP. Furthermore, the facility failed to ensure hand hygiene was completed during medication administration for 3 of 11 residents (R15, R21, R78) observed for medication administration. Findings include:R7's Minimum Data Set (MDS) dated [DATE], indicated R7 had severely impaired cognition and diagnoses included chronic respiratory failure, quadriplegia (inability to move arms and legs) Furthermore, R7 had a tracheostomy (a surgical incision into the windpipe to assist with breathing) and hepatitis B (liver disease that was spread through infected blood and bodily fluids) and Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, a multidrug resistant infection that is transmitted via contact). R7's provider orders dated 10/8/24, indicated R7 required enhanced barrier precautions (EBP) for colonized multidrug resistant organism (MRDO) while providing high contact cares every shift for CRPA. R7's electronic medical record banner special instructions no date, directed staff to follow EBP for CRPA and history of hepatitis B. R7's care plan revised 8/12/24, indicated R7 required EBP related to tracheostomy, history of hepatitis B, and wound care to left toe. Interventions included use of appropriate communication to follow RBP, explain reason for EBP use, and for staff to don/doff personal protective equipment when providing high contact care. An observation on 7/27/25 at 6:08 p.m., R7's door was open. On the door was an orange sign that read Contact Isolation. The sign directed all staff who enter the room to perform hand hygiene and don a gown and gloves. An observation on 7/28/25 at 1:19 p.m., R7 was laying in their bed with the door open. On the door was an orange sign that read Contact Isolation and directed all staff who enter to perform hand hygiene and don gown and gloves. Central supply staff- A performed hand hygiene and donned gloves and entered R7's room without donning a gown. Central supply staff-A brought a box of supplies into the room and exited with an empty box. With gloves in place, the empty box was broken down and placed on a cart. Central supply staff-A then removed gloves and performed hand hygiene before entering the next room. When interviewed on 7/28/25 at 1:23 p.m., Central supply staff-A stated gloves were worn when delivering supplies to resident rooms in case something was needing to be moved. Central supply staff-A stated a gown was needed if supplies were stored close to the resident or the resident belongings. Since R7's box was not near him or his personal items, a gown was not needed. Central supply staff-A verified R7's sign that read Contact Isolation and further stated she was told if going in and out and not touching resident or resident items, only gloves were needed. When interviewed on 7/29/25 at 2:04 p.m., nursing assistant (NA)-B verified the sign on R7's door and stated R7 was on contact isolation for an infection or bug they had and that was to protect staff from his infection. Furthermore, R7 required staff to don a gown and gloves when providing personal or hands on cares with the resident. NA-B stated it was fine to enter the room without a gown or gloves to turn off the light or open the blinds, but if the bed was going to be touched, then a gown and gloves must be worn. When interviewed on 7/29/25 at 2:15 p.m., registered nurse (RN)-C stated when residents were on EBP, staff can perform hand hygiene and enter the room. If staff were to provide any hands on cares, gloves and a gown was required. Contact isolation required gown and gloves each time staff entered the room. RN-C verified the discrepancy between R7's contact isolation sign on the door and the orders in R7's medical record indicating R7 was on EBP and stated staff should follow the contact isolation sign. RN-C believed the contact isolation was in place when R7 had been actively infected with something but had to clarify if R7 still required contact isolation. Follow up information was received and RN-C verified R7 required EBP for hepatitis C and CRPA. Medication administration:R15's significant change MDS dated [DATE], indicated was cognitively intact and diagnoses of chronic respiratory failure with tracheostomy, had trouble swallowing, and had a gastrostomy tube (G-tube, a tube placed in the stomach to help with nutrition/tube feeding). R15's providers orders lacked indication R15 required EBP. R15's electronic medical record banner special instructions no date, directed staff to follow standard precautions. R21's quarterly MDS dated [DATE], indicated R21 was cognitively intact and had diagnoses ofR78's significant change MDS dated [DATE], indicated R had mild cognitive impairment and diagnoses of A medication observation on 7/30/25 at 12:05 p.m., RN-E was preparing R15's medication before going to R15's room. R15 was lying in bed with the door open. A sign on the door read Enhanced Barrier Precautions and directed staff to don gown and gloves when providing contact cares such as transferring, ADLs and repositioning. RN-E performed hand hygiene, donned gloves and without donning a gown, entered R15's room. RN-E flushed R15's g-tube, administered the medication via the G-tube and flushed the tube again. RN-E then cleared out the supplies, removed gloves and without hand hygiene exited R15's room. RN-E returned to the medication cart and without hand hygiene, prepared medications for R21. R21's medication was placed into a medication cup and RN-E went into the dining area where R21 was sitting finishing up lunch. RN-E administered the medication, took the empty medication cup and returned to the medication cart. The empty cup was thrown away and without hand hygiene, RN-E reviewed and prepared medications for R78. Without hand hygiene, RN-E donned gloves and brought R78's medications to the dining area where R78 was finishing up lunch. RN-E gave the oral medications and asked if the ointment could be placed on R78's knee. R78's left pant leg was raised and ointment applied. RN-E lowered the pant leg and let R78 know the other ointment will wait until they were done with lunch. RN-E then removed the gloves and threw them away and performed hand hygiene. When interviewed on 7/30/25 at 1:03 p.m., RN-E verified R15's door had a sign that stated Enhanced Barrier Precautions and said a gown and gloves were normally worn, however since there was not a long time spent in the room and the only interaction was with the G-tube, it was ok to be without a gown. RN-E further verified hand hygiene was not completed in between residents when administrating medications and should have been completed. When interviewed on 07/30/25 at 9:45 a.m., the infection preventionist (IP) expected staff to follow TBP signs on the door. If there was a discrepancy between the banner and the sign on the door, the expectation was for the staff to follow the sign on the door and reach out to the nurse manager for clarification. If there was not a nurse manager in the building, then staff should reach out to the provider.When interviewed on 7/30/25 at 10:59 a.m., the Director of Nursing (DON) expected staff to perform hand hygiene before entering and exiting a room. If the resident had TBP/EBP signs in place, staff were expected to follow the sign on the door or seek clarification if there was conflicting information between what was on the door and in the medical record. This was important to minimize risk of spreading infection. A facility policy titled Transmission Based Precautions revised 7/31/23, directed staff to ensure resident who require TBP will have pertinent signage that alerts staff, visitors and vendors of personal protection equipment needed. Proper hand hygiene remains a key preventative measure regardless of what TBP were in place.

Based on observation, interview and document review, the facility failed to ensure a hand splint/brace was used consistently for 1 of 1 resident (R37) reviewed for range of motion (ROM).Findings include:R37's annual Minimum Data Set (MDS) dated [DATE], indicated R37 has minimal cognitive deficit, had limited ROM with impairment of upper extremities on one side, dependent with upper body dressing, and received zero minutes of ROM or splint/brace assistance in the 7 day lookback period. R37's diagnoses included hemiplegia and/or hemiparesis (weakness/paralysis affecting one side of the body) following a stroke affecting left non-dominant side.R37's care plan dated 4/14/25, indicated R37 severe contractures (condition where muscles or tendons become permanently shortened, causing loss of movement) of extremity. R37's care plan indicated hand splint to left arm, on in a.m. up to six hours and off at 2:00 p.m. and to wash both hands every shift before applying left hand splint/hand protector.R71's provider order dated 7/10/25, indicated apply hand splint to left arm, on with a.m. cares.R71's provider order dated 7/10/25, indicated remove left arm splint at the end of day shift at 1400 [sic].After the electronic medical record reviewed on 7/29/25, no evidence in R37's progress notes of physician notification of potential pain during usage of the left hand splint. Further, no evidence of any therapy orders during the year of 2025. During observation on 7/27/25 at 1:00 p.m., R37 in bed with no splint noted to left hand/arm.During observation on 7/28/25 at 8:04 a.m., R37 was up in wheelchair (w/c) in room with no splint noted to left hand/arm.During observation on 7/28/25 at 11:49 a.m., R37 up in w/c in room with no splint noted to left hand/arm.During observation on 7/28/25 at 1:47 p.m., R37 in bed with no splint noted to left hand/arm.During observation on 7/29/25 at 7:14 a.m., R37 in bed with no splint noted to left hand/arm.During observation on 7/29/25 at 8:01 a.m., R37 in bed with no splint noted to left hand/arm.During an interview on 7/29/25 at 8:43 a.m., nursing assistant (NA)-F stated not being aware of R37 requiring a splint to either hand and further stated R37 only requires the blue boots to the legs/feet only. NA-F verified R37 did not have a splint on the left hand/arm.During an interview on 7/29/25 at 8:46 a.m., trained medication aide (TMA)-A stated being aware of the blue boots for R37's legs/feet however, was not aware R37 required anything for the hands/arms. TMA-A pulled up the point of care documentation and noted there was no area to document a splint for R37's left arm. TMA-A pulled up the kardex for R37 on the laptop and noted there was documentation which indicated R37 required a splint to left arm to be applied in the a.m. and to be removed at 2 p.m. on day shift. TMA-A verified R37 did not have a splint on the left hand/arm. During an interview on 7/29/25 at 8:50 a.m., registered nurse (RN)-F stated R37 used to wear a splint to the left arm however, the staff are unable to find the splint for months. RN-F stated therapy was informed the splint was missing months ago however, denied following up on the missing splint status. During an interview on 7/29/25 at 8:54 a.m., RN nurse manager (RN)-G stated R37 refuses to wear the left arm splint due to pain however, further stated Health Partners was called and an order for therapy was received and therapy has been working with R37 regarding the splint. Further, RN-G stated R37 hadn't wore the splint to the left arm in months. During an interview on 7/29/25 at 9:02 a.m., certified occupational therapy assistant (COTA)-A stated R37 hadn't been on case load for therapy since 2024 and at the time it was an evaluation only due to a return from a hospital stay. Further COTA-A stated the last time R37 had been on therapy case load for the splint to the left arm was during 2021. COTA-A verified R37 needed the splint for pain management and to maintain what movement R37 has in the left arm.During an interview on 7/29/25 at 9:08 a.m. director of nursing (DON) stated if a splint was missing or causing pain the provider should be notified and therapy orders obtained as well as a new splint should be reordered and fitted. DON verified it was important for R37 to utilize the splint to maintain as much range of motion to the area as possible.Splint usage policy requested on 7/29/25 however, was not provided.

Based on observation, interview, and document review the facility failed to provide nail care for 1 of 1 (R79) resident reviewed for activities of daily living (ADL).Findings include:R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side and vascular dementia. It further indicated R79 had an impairment on one side of his upper extremities and required staff assistance with most ADL's and mobility.R79's care plan dated 6/18/25, indicated current functional performance was assist of 1 with ADLs. R79's skin assessments for the month of July 2025 (7/6/25, 7/13/25, 7/20/25, 7/27/25) indicated trimming fingernails was not necessary. During observation and interview on 7/27/25 at 3:01 p.m., R79's fingernails (on both hands) were approximately an inch long and he stated he wanted them cut. During observation on 7/28/25 at 8:08 a.m., R79 was sitting in his wheelchair, waiting in line to go outside to smoke. His fingernails were observed to be approximately one inch long. During observation and interview on 7/28/25 at 10:00 a.m., nursing assistant (NA)-E stated the nurses were responsible for cutting the residents nails, especially when they were diabetic and it should be done at least once a week on bath day. If the resident refused, it should be documented. NA-E also verified R79's nails were long, and they appeared to have not been trimmed in a few weeks. R79 repeatedly asked NA-E to cut his nails during this time. During interview on 7/28/25 at 10:46 a.m., licensed practical nurse (LPN)-B stated NA's and nurses were responsible for cutting the resident's fingernails unless they were diabetic. If the resident was diabetic, then the nurses were responsible for cutting them. This should be done weekly on bath day and refusals should be documented.During interview on 7/28/25 at 3:04 p.m., LPN-A stated the NA's or activities staff were responsible for cutting the resident's nails (unless they were diabetic). If they were diabetic, then the nurses were responsible for cutting them. The residents' nails should be cut once a week on bath day and refusals should be documented. During interview on 7/30/25 at 12:42 p.m., the director of nursing (DON) stated the nurses or podiatry were responsible for cutting residents nails if they were diabetic. If the resident was not diabetic, then the NAs were responsible for doing it. The DON further stated the resident's nails should be cut at least once a week on bath day, along with the skin assessment. The nurses were responsible for documenting it was completed, and refusals should be documented. The facility's policy regarding ADL's dated 3/31/23, indicated a resident who is unable to carry out activities of daily living will receive the necessaryservices to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review the facility failed to ensure a Provider Order for Life Sustaining Treatment (POLST) was updated to reflect the current wishes for 1 of 1 residents (R7) reviewed for advanced directives.Findings include:R7's Minimum Data Set (MDS) dated [DATE], indicated R7 had severely impaired cognition and never made decisions. R7's diagnoses included chronic respiratory failure, quadriplegia (inability to move arms and legs) and locked in state (lacked motor responses used to measure responsiveness). Furthermore, R7 had a tracheostomy (a surgical incision into the windpipe to assist with breathing) and required mechanical ventilation. R7's provider order dated 8/9/24, indicated R7 did not want resuscitation and was Do Not Resuscitate (DNR). R7's POLST dated 9/4/24, indicated R7 was DNR with selective treatment. Selective treatment included no intubation, advanced airway and no mechanical ventilation. Along side of the selective treatment section read per brother DNR/Do not Intubate (no advanced airway).R7's provider order dated 8/9/24, indicated R7 did not want resuscitation and was Do Not Resuscitate (DNR). R7's hospital Discharge summary dated [DATE], indicated R7 was hospitalized with acute on chronic hypoxic respiratory failure (an exacerbation of respiratory failure that led to low oxygen saturations). The summary further indicated R7 had been dependent on a tracheostomy prior to hospitalization and had not required oxygen supplementation or mechanical ventilation. R7 now needed mechanical ventilation as needed during the day and be placed on mechanical ventilation at night upon discharged .R7's care conference form dated 3/21/25, indicated R7's POLST was reviewed with resident/representative. When interviewed on 7/28/25 at 1:47 p.m., licensed practical nurse (LPN)-C stated the nurse manager reviewed the POLST with the resident or family when admitted . LPN-C wasn't sure how often a POLST was reviewed after that. When interviewed on 7/28/25 at 2:24 p.m., registered nurse (RN)-C stated a POLST was reviewed with the resident or family upon admission and then should be reviewed with any changes, at care conferences and hospitalizations. Full recusation and DNR was explained to the resident/family to help them decide what was wanted. They sign and then the nurse practitioner signed. RN-C verified R7's current POLST indicated R7 wanted to be DNR/DNI, however R7 had a tracheostomy and used a mechanical ventilator. RN-C further stated this did not make sense and R7 had a change after a hospitalization and had been using the ventilator for a while. RN-C stated R7's brother who was the medical decision maker, would need to be notified so R7's POLST could be clarified as R7's brother was involved and knew the status of the ventilator use. RN-C further stated during care conferences, while the POLST was discussed, the actual form was not reviewed for accuracy. When interviewed on 7/30/25 at 10:59 a.m., the Director of Nursing (DON) expected the resident's wishes and POLST to be verified and completed during admission and reviewed as needed, which included when residents returned from the hospital. Furthermore, the DON stated this was important to ensure the residents received the care they wanted. A facility policy titled POLST Documentation Procedure revised 4/2025, directed staff to complete a routine audit of POLST documentation to ensure consistent and accurate documentation of the POLST form, provider orders and care plan entry.

Based on interview and document review the facility failed to ensure that 1 of 3 residents (R1) reviewed for pressure ulcers received care and services to prevent occurrence of newly developed pressure ulcers. The facility's failure resulted in actual harm to R1 when R1's skin was not comprehensively assessed and failed to develop a care plan for pressure ulcer prevention that resulted in six (6) pressure ulcers including Stage 4 pressure ulcer to R1's nose and deep tissue injuries to R1's ear. Findings include Findings include:According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 08-08-2024, included the following definitions:-Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.- Stage 4 pressure ulcer refers to full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. Slough and /or eschar may be visible on some parts of the wound bed.- Eschar refers to dead or revitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab like, Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides and edges of the wound.- Unstageable pressure ulcer refers to a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. - Deep tissue pressure injury (DTPI) refers to intact skin with localized area of non-blanchable deep red, maroon or dark purple discoloration due tot eh damage of underlying soft tissue.- Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.R1's Braden Scale for Predicting Pressure Sore Risk dated 6/11/25, identified a score of 13 indicating R1 was at moderate risk due to the following factors: 1. Sensory perception-very limited, responds to only painful stimuli.2. Moisture-occasionally moist requiring an extra linen change once a day, 3. Activity-chairfast ability to walk severely limited or non-existent, cannot bear own weight and must be assisted into a chair or wheelchair. 4. Mobility-very limited makes occasional slight changed in body or extremity position but unable to make frequent or significant changes daily. 5. Nutrition was adequate.6. Friction and Sheer-a problem required moderate to maximum assistance in moving. Complete lifting without sliding against sheets was impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had highly impaired hearing that required a hearing device and had impaired vision with corrective lenses. R1 had severe cognitive impairment, no speech and was completely dependent on staff for all activities of daily living (ADL's). R1's diagnoses included acute and chronic respiratory failure (when the lungs can't adequately provide oxygen to the blood or remove carbon dioxide from it) with hypoxia (when the body doesn't receive enough oxygen), encounter for tracheostomy (a surgical procedure creating an opening in the trachea (windpipe) to facilitate breathing) and anxiety disorder. R1 was at risk for pressure ulcers and had no identified skin concerns.R1's MDS triggered Care Area Assessments (CAA) for pressure ulcers, vision, and communication. R1's Pressure ulcer CAA dated 6/17/25 identified R1 at risk for skin breakdown related to decreased mobility, incontinence. R1 requires assistance from staff with mobility, transfers, and toileting needs R/T physical limitations but R1 can make some position changes on her own however, staff assist with repositioning and offloading as needed. Staff will monitor skin and report changes for evaluation/intervention/treatment as appropriate. R1's vision CAA identified R1 had impaired vision related to multiple comorbidities and used glasses on a daily basis. R1's Communication CAA identified R1's ability to hear was highly impaired related to multiple comorbidities. R1 did not use hearing aide/device. Will proceed to care plan. According to R1's care plan audit report (printed on 7/14/25) did not specifically include a pressure ulcer focus nor identify R1 was at risk for pressure ulcers. However, the care plan did include a Skin care plan focus that was created and initiated on 4/9/25, which identified R1 was at risk for impaired skin integrity and advised R1 had a fluid filled blister on her arm with no other skin issues identified. The intervention also dated 4/9/25 directed staff to monitor skin integrity daily during cares and weekly skin inspection by nurse. R1's communication focus created on 4/9/25 included the intervention Staff to apply hearing box on resident when communicating with her which also had a created date of 4/9/25.In review of CAA's and R1's care plan dated 6/11/25 through 7/4/25, there was no indication R1's external devices (glasses and hearing box) used over bony prominences (nose and ears) were comprehensively assessed nor identified as risk for factors for pressure ulcer development. Additionally, or alternatively, there was no indication individualized pressure relieving/reducing interventions associated with devices were developed and implemented except for turn and reposition every 2 to 3 hours dated 4/9/25.R1's order summary dated 6/11/25, identified to perform weekly skin inspection by licensed nurse. Complete weekly skin Inspection in Point Click Care (PCC-an electronic health record) every Wednesday and Sunday evening shift.Review of R1's record between 6/11/25 through 7/4/25 identified Weekly Skin Inspections assessments were completed on 6/11/25, 6/15/25, and 6/25/25. These assessments identified R1 did not have any skin issues. R1's Treatment Administration Record (TAR), dated July 2025, identified weekly skin inspection by licensed nurse. Complete weekly skin inspection in PCC every Wednesday and Sunday evening shift. The box on 7/2/25, identified a nurse had put their initials in box indicating the skin assessment was completed. However, in review of R1's record no comprehensive weekly skin inspection assessment completed for R1 on 7/2/25. R1's progress note dated 7/4/25 at 10:21 a.m., identified R1 was transferred to the hospital related to a large amount of blood in R1's colostomy bag.R1's Emergency Department (ED) to hospital admission record dated 7/4/25, identified R1 was admitted to ED at 10:33 a.m. for gastrointestinal (GI) bleed. Conditions present on admission identified R1 had severe skin breakdown on nasal bridge, visible bone (photo in chart) with significant concerns for elder abuse/neglect. This was escalated to charge nursing.R1's glasses were removed, and bilateral wounds present on bridge of nose where glasses rest. Headphones (for pocket talker) were removed, and wounds noted to left ear. Upon speaking with R1's family member (FM)-A. FM-A stated she had asked facility staff about routinely removing R1's eyeglasses and headphones at night and was told by staff that they are not allowed to remove these items if R1 refused. R1 had significant skin breakdown on nasal bridge in shape of R1's glasses nose pads. Bone was visible beneath. R1 was noted to have a suspected pressure ulcer to the left side of her nose, suspected pressure ulcer to the right side of the nose and wounds to R1's left ear.Picture description of left nasal bridge: one rectangular shaped ulcer located to her left lateral side of her nasal bridge with clear slough over exposed bone, scabs surrounding the open area. (consistent with stage 4 pressure ulcer).Picture description of right nasal bridge: one rectangular shaped ulcer noted to right lateral side of nasal bridge with exposed bone, surrounded by bloody drainage. (consistent with stage 4 pressure ulcer).Picture description of left ear: one wound on the end of the tragus (small, cartilaginous flap of tissue located on the outer ear, situated in front of and partially covering the opening of the ear canal) with eschar formation, one wound on the edge of the antitragus (It's situated above the earlobe and points anteriorly, meaning towards the front of the head) with eschar formation. R1's [NAME] (The visible, fleshy part of the ear on the side of the head. It is made up of cartilage covered in skin) of the ear was pulled forward to identify two darkened areas of skin on the mastoid process (area just below and behind your ear) where the stems of the glasses would lie. (coincides with medical device related pressure injury). Tragus and antitragus wound coincide with an unstageable pressure ulcer. According to R1's care plan audit report (printed on 7/14/25) there were no identification of pressure ulcer risk associated with external devices (glasses and pocket talker) and no corresponding interventions were developed to reduce pressure and/or mitigate the risk for pressure ulcers associated with devices until after R1 was hospitalized . R1's vision focus identified R1 had alteration in vision as evidenced by: Resident wearing glasses and Resident has history of refusing glasses and will often sleep with them on; this focus was created on 7/5/25 (after R1 was transferred to the hospital) but had an initiated date of 6/19/25 (prior to R1's hospitalization). A corresponding intervention that directed staff to Encourage resident to remove glasses while resting and at HS [at night] was created on 7/7/25 (three days after R1's transfer to the hospital) but had an initiated date of 7/3/25 (one day prior to R1's hospitalization). R1's communication focus was revised 7/5/25 to include Resident often refuses to remove pocket talker. An additional intervention was created on 7/7/25 that directed staff to Encourage resident to remove pocket talker while resting and at HS, however identified 7/3/25 as the date the intervention was initiated. During a phone interview on 7/9/25 at 9:31 a.m., hospital social worker (HSW)-A stated R1 was hospitalized on [DATE] and when R1 first admitted the nurse had to peel the glasses off R1's face. and it was like R1 never had her glasses removed off her face while she resided at the facility. HSW-A explained there were good pictures of her wounds in her hospital record; HSW-A remarked R1's wounds to her nose were definitely from pressure from her glasses and could have been prevented.During an interview on 7/10/25 at 11:54 a.m., hospital RN (HRN)-A stated she was working on 7/4/25, the day R1 was admitted around 5:00 p.m., she did a full body skin assessment on R1 and noticed redness around her glasses. HRN-A used R1's pocket talker to explain what she was going to do and removed R1's glasses without refusal. HRN-A stated she had trouble removing R1's eyeglasses because like they were stuck to her face HRN-A noted R1 to have full thickness pressure ulcers that were rectangular shaped on either side of R1's nose directly from the rectangular nose pieces of her glasses. HRN-A had never seen anything like it before and she believed R1 to have pain because during the removal of the glasses, R1 had facial wincing and grimacing. HRN-A stated when she removed R1's headphones she noted two unstageable pressure ulcers to the tragus and antitragus portion of the left ear with eschar formation and two deep tissue pressure injuries behind the left ear from the stems of the glasses where they wrapped around the ear. R1's pressure ulcers were from pressure from her eyeglasses and headphones and were completely preventable. HRN-A indicated it looked like they had never been removed from the facility she resided at.During an interview on 7/10/25 at 10:33 a.m., family member (FM)-A stated she visited R1 at the facility twice a day. FM-A would see the aides come in to do skin assessments, but they would just usually look at her bottom. FM-A never witnessed the staff ever remove R1's glasses or headphones from her ears. FM-A stated when she came to visit in the morning R1's headphones and glasses were always on even though she was sleeping and indicated she would come back at night and stay until R1 fell asleep. FM-A reiterated that no staff ever came in to remove R1's glasses or headphones. FM-A was at the hospital on 7/4/25, when the nurse at the hospital took R1's glasses off and stated, she had deep wounds on either side of her nose that were rectangular shaped from her nose piece of her glasses. FM-A described the wounds as, bloody gashes in the sides of R1's nose. FM-A stated she had wounds in and behind her left ear where her headphone being on her ears at all times and her glasses digging in.During an interview on 7/10/25 at 11:40 a.m., nursing assistant (NA)-A indicated she was familiar with R1's morning cares. NA-A stated R1 would never allow me to remove her headphones, R1 would push her hands out at me, so I would just move them a little bit forward to clean her face and had never noticed any sores on R1's ears. NA-A stated R1 never allowed anyone to remove her eyeglasses, she would kick and flail when staff tried. NA-A did notice R1 had red marks on her face from the eyeglasses but didn't think they were open sores and thought the nurses were aware.During an interview on 7/10/25 at 12:22 p.m., NA-B stated R1 always wore her glasses and headphones for her pocket talker. NA-B never noticed any redness under R1's glasses and never noticed skin concerns under her headphones but admitted she never removed R1's headphones or eyeglasses due to refusals.During an interview on 7/10/25 at 11:21 a.m., licensed practical nurse (LPN)-A indicated he worked with R1 on the day shift of 7/2/25 and had noticed R1 had redness on the bridge of her nose under her eyeglasses when they were repositioning her and stated he put a cream on it but was not sure what cream he put on it. LPN-A reported this skin concern to registered nurse (RN)-B who was the nurse manager. LPN-A never took R1's glasses off to fully assess R1's skin and stated he did not document the redness he had seen. LPN-A further stated R1 always kept her glasses and her headphones on her ears 24 hours a day. R1 would refuse to take her glasses or her headphones off. When R1 would refuse to take them off, LPN-A never explained to R1 the risks of pressure ulcer development from not removing the devices. During an interview on 7/10/25 at 12:28 p.m., RN-B stated he was the nurse manager for R1 and indicated R1 kept her eyeglasses and headphones for her pocket talker on 24 hours a day seven days a week. R1 refused to have her glasses, or her headphones removed. RN-B indicated that the care plan did not identify this and there were no prevention interventions implemented to prevent pressure ulcers to her nose or her ears and there should have been. R1's last comprehensive skin assessment was completed on 6/25/25, and it was missed on 7/2/25. RN-B explained LPN-A had notified him on 7/2/25 that R1 had redness under her eyeglasses, but admitted ly he did not complete a comprehensive skin assessment. R1 was sent to the hospital on 7/4/25, and the hospital had reached out to the facility stating R1 admitted with pressure ulcers to R1's nose and left ear that he had not been aware of. During an interview on 7/10/25 at 11:08 a.m., registered nurse (RN)-A stated she was a regular floor nurse that worked on R1's unit. RN-A never saw R1 with her glasses and her headphones from her pocket talker off of her ears. R1 had never refused cares for her, as long as you used R1's pocket talker to explain what you were doing [R1] did not refuse cares. RN-A explained the risk of never taking R1's eyeglasses and headphones off her ears would be a high risk for pressure ulcer development. During an interview on 7/10/25 at 2:17 p.m., the director of nursing (DON) stated staff shared with him that R1 was resistive to having her glasses and headphones removed after hearing from the hospital about R1's pressure ulcers. DON indicated R1 was a mechanical ventilator resident who was fully dependent with adl's putting her at high risk for pressure ulcer development. R1's care plan should have identified she would be at risk for pressure ulcer development if R1's glasses and headphones were not removed, and prevention interventions should have been developed to prevent pressure ulcers to these areas. DON indicated R1's 7/2/25, skin assessment was missed and the staff at the hospital did notify the facility that R1 admitted to the hospital with pressure ulcers to her nose and left ear. DON stated comprehensive skin assessments must be performed weekly. DON indicated R1's pressure ulcers were preventable.A facility policy, Skin Assessment and Wound Management, revised 2/2025 indicated Provide guidelines for assessing and managing wounds were: A pressure ulcer risk assessment (Braden Scale) will be completed per Monarch's Assessment Schedule/Grid. Implement appropriate preventative skin measures. Examples include, but are not limited to-nutritional interventions, mobility and repositioning plan, pressure redistribution plan. Skin Evaluation and Skin Risk Factors Form is completed before initial MDS, annually, and upon significant change. Staff will perform routine skin inspections (with daily care). Nurses are to be notified if skin changes are identified. Licensed staff will complete a weekly skin inspection.

Based on interview and document review the facility failed to ensure a comprehensive care plan was developed for 1 of 1 resident (R1) reviewed for pressure ulcersFindings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had highly impaired hearing that required a hearing device. R1 had severe cognitive impairment, no speech, and was completely dependent on staff for all activities of daily living (ADL's). R1's diagnoses included acute and chronic respiratory failure (when the lungs can't adequately provide oxygen to the blood or remove carbon dioxide from it) with hypoxia (when the body doesn't receive enough oxygen), encounter for tracheostomy (a surgical procedure creating an opening in the trachea (windpipe) to facilitate breathing) and anxiety disorder. Further identified R1 was at risk for pressure ulcers. R1's care area assessment (CAA) dated 6/17/25, identified Section 3; Visual function: identifying triggers indicated an ability to see in adequate light (with glasses or other visual appliances) was impaired. Analysis of findings identified R1 had impaired vision related to multiple comorbidities, used glasses on a daily basis. Overall objective for care planning was to minimize risks. Section 4 Communication triggering conditions identified R1's ability to hear was highly impaired. Analysis of findings identified R1 was at risk for communication difficulty related to multiple comorbidities. R1 had no speech, sometimes understands and sometimes make self-understood. R1 had impaired vision, impaired hearing, does not use hearing aide/device. Will proceed to care plan. Staff will repeat messages as necessary to assure communication has been successful.R1's Nurse Practitioner (NP) visit dated 6/27/25, identified R1 was severely hard of hearing with hearing device responds appropriately. R1's Care Plan Audit Report for R1 Printed: 7/14/25 Revision Date: 7/5/25Focus: Communication R1 experienced altered communication due to a tracheostomy (chronic respiratory failure), hearing impairment, and lack of speech. R1 often refuses to remove her pocket talker device (an amplified hearing tool).Interventions: 4/9/25: Staff to apply hearing box when communicating with R1; speak clearly, face R1, use writing tools; minimize background noise (e.g., TV, suctioning machine). 7/7/25: Ensure R1 wears headphones when communicating or watching TV, per her preference. 7/9/25: Ensure R1 has box talker device at all times and within reach.Focus: Vision R1 has altered vision and wears glasses consistently, often refusing to remove them even during sleep with a revision date of 7/5/25.Interventions: 7/5/25: Assist with daily wear of glasses; monitor/document vision changes or eye pain; ensure call light is accessible; monitor for eye infection; staff responsible for care and maintenance of glasses; schedule ophthalmology appointments as needed/requested. 7/7/25: Encourage R1 to remove glasses while resting and at HS. Care plan was reviewed and did not identify interventions for skin breakdown for eyeglasses or headphones for pocket talker even though according to the care plan R1 had a history of refusing to remove and R1 was at risk for pressure ulcers according to the assessment dated [DATE]. During an interview on 7/10/25 at 12:28 p.m., registered nurse (RN)-B stated he was the nurse manager for R1and indicated R1 kept her eyeglasses and headphones for her pocket talker on 24 hours a day seven days a week. RN-B reviewed R1's care plan, then stated the care plan did not identify this and there were no prevention interventions implemented to prevent pressure ulcers to her nose or her ears and there should have been.During an interview on 7/10/25 at 2:17 p.m., the director of nursing (DON) stated staff shared with him that R1 was resistive to having her glasses and headphones removed. R1 was a mechanical ventilator resident who was fully dependent with ADL's putting her at high risk for pressure ulcer development. DON further stated R1's care plan should have identified R1 was at risk for pressure ulcer development if R1's glasses and headphones were not removed, and prevention interventions should have been developed to prevent pressure ulcers to these areas. Facility Care Planning policy revised 11/2024, identified.comprehensive care plan: the interdisciplinary team (IDT), in conjunction with the resident and the resident representative, will develop and implement a comprehensive individualized care plan no later than the 21st day of admission of the resident. The care plan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will be consistent with the resident's rights to identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on interview and record review the facility failed to ensure medical records were accurate and readily accessible for 1 of 1 resident (R1) reviewed for pressure ulcers. Findings include:On 7/14/25 the facility had provided electronic health record (EHR) access to review resident records. The viewable access to R1's record included care plan history dates, however, when printed the dates were inconsistent with what was displayed that was readily accessible. The facility provided R1's care plan on 7/14/25 at 7:51 a.m. This care plan included a communication focus that identified an initiated date of 4/9/25, Resident has Alteration in communication R/T [related to] Placement of Tracheostomy D/T [do to] chronic respiratory failure, HOH [hard of hearing], No speech. and Resident often refuses to remove pocket talker device. The corresponding goals were initiated on 4/9/25 with revision dates of 7/9/25 (did not identify what the revisions were); the goals included resident will have adequate communication as evidenced by: ability to communicate basic needs and Residents needs will be anticipated and met by staff. There were no other dates that were included in the focus area column and the interventions did not include any dates including when they were initiated.R1's care plan that was provided on 7/14/25 at 7:51 a.m. also included a focus area for vision that was initiated on 6/19/25; Resident has Alteration in vision AEB (as evidenced by): related to: Resident wearing glasses. Resident has history of refusing to remove glasses and will often sleep with them on. The corresponding goals had an initiated date of 7/5/25 with a revision date of 7/9/25 which was not consistent with when the vision care plan focus was initiated. The interventions did not include any dates of initiation or revision. The facility then provided another copy of R1's care plan on 7/14/25 at 8:46 a.m. via email from the administrator in which the administrator wrote, See attached. I had to have Corporate change the configuration for CP [care plan] The attachment was labeled cp with revisions. This care plan included the focus area of communication with the initiated date of 4/9/25, the goals remained the same and included dates the interventions were initiated. The interventions were all initiated on 4/9/25, with the exception of staff to ensure resident has her headphone one [sic] when communicating . which was 6/19/25, and Staff to ensure resident has his [sic] box talker . which was dated 7/5/25. This version of the care plan included an intervention that was not reflected on the first version provided at 7:51 a.m. which was Encourage resident to remove pocket talker while resident and at HS [at night] with initiated date of 7/3/25. -In the same copy of the care plan provided at 8:46 a.m. was the vision focus that was initiated on 6/19/25. The goals were unchanged between this copy and the previous copy that was provided at 7:51 a.m. The interventions that were listed all identified they were initiated on 7/5/25 with the exception of Encourage resident to remove glasses while resident and at HS which identified an initiated of 7/3/2025. There was no revision dates identified for any interventions listed. The facility then provided Care Plan Audit [resident initials] via email on 7/14/25 at 10:50 a.m. The audit report identified the focus of communication was created and initiated on 4/9/25 and had a revision date of 7/5/25. The corresponding goals identified they were created and initiated on 4/9/25 and had a revision date of 7/9/25. The audit report identified most of the interventions had been created on and initiated on 4/9/25, except for one intervention that was created by the administrator and one intervention was created by registered nurse (RN)-B in which those interventions had a created-on date after the initiation date. The intervention Encourage resident to remove pocket talker while resting and at HS Date was created on 7/7/25 by the administrator, however the initiated date of the intervention was 07/03/2025. The intervention Staff to ensure resident has her headphone one [sic] when communicating and watching TV per her choice was created on 7/9/2025 by registered nurse (RN)-B however the initiated date of the intervention was 6/19/25. -In the same copy of the Care plan Audit report that was provided at 10:50 a.m. included the vision focus which identified RN-B created the focus on 7/5/25 and the administrator revised the focus on 7/5/25, but the initiated date was 6/19/25. The corresponding goals were created on 7/5/2025 and revised on 7/9/25 by RN-B. The intervention Encourage resident to remove glasses while resting and at HS was created on 7/7/25 by the administrator however the care plan identified the initiated date was 7/3/25. All of the interventions were created and initiated on 7/5/25 by RN-B. The care plan did not identify any revision dates. During an interview on 7/14/25 at 10:17 a.m., administrator stated she was unsure why the care plans when printed showed the wrong dates. Administrator stated she initiated the focus of R1's refusal of removing pocket talker on 7/5/25 after her hospitalization on 7/4/25. Administrator further stated R1 focus of vision with history of refusing to remove her glasses was not implemented until 7/5/25. Administrator was unsure why the care plan was printing out with inaccurate dates. During an interview on 7/14/25 at 10:33 a.m. regional nurse consultant (RNC)-A stated R1's care planned dates for the focus of vision and communication were not accurate or readily accessible and should be. RNC-A stated R1's care plan audit report would be most accurate and was not sure why the dates on R1's care plan revision was inaccurate. During an interview on 7/14/25 at 11:12 a.m., registered nurse (RN)-B stated he was the nurse manager for R1's unit and indicated the dates were not accurate when printed for the focus of vision and communication. R1's refusals were not initiated until after her hospitalization on 7/4/25. RN-B stated the care plan should be printing out accurate dates.Policy regarding resident medical record was requested and was not received.

Based on observation, interview, and document review, the facility failed to provide adequate supervision and identify a foreseeable hazard for 1 of 3 residents (R1) reviewed who required supervision. R1's was found unsupervised on two occasions; On 6/7/27 while outside in the staff smoking area and on 6/13/25 as a result of nonfunctional wanderguard and the facility not performing physician ordered 15-minute checks was found at a busy intersection. This resulted in an immediate jeopardy for R1 health and safety.The Immediate Jeopardy (IJ) began on 6/7/25, was corrected on 6/14/25 when the facility implemented interventions to prevent reocurrance. The Administrator, Director of Nursing (DON), Regional Director of Operations, and Regional Nurse Consultant were notified of the IJ on 6/24/25 at 5:50 p.m. The facility implemented immediate corrective action on 6/14/25 to prevent recurrence, so the IJ was issued at past none compliance.Findings include:R1's St. Louis University Mental Status Exam dated 7/19/24 (SLUMS- is a screening tool used to detect mild cognitive impairment and dementia in older adults) identified R1's score was indicative of dementia. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no behaviors, used a walker and wheelchair, was independent with walking and wheeling, had no upper or lower extremity impairments, and used a wander/elopement alarm daily. The MDS also identified R1 required care and monitoring for diagnoses of diabetes, dementia, malnutrition, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). R1's Care Plan Report focus initiated 7/23/24, identified R1 was at risk for elopement related to diagnoses of bipolar affective disorder (disorder with episodes of mood swings), alcohol abuse, dementia with behavioral disturbances, and history of elopement attempt. R1 had a history of cutting off the Wanderguard device (off his person). The goals identified R1 would not leave the building alone and would follow the facility leave of absence (LOA) policy. The interventions initiated on 7/23/24, directed staff to invite R1 to all activities of choice; answer door alarms promptly; monitor Wanderguard per manufacturer's guidelines; new wander guards were kept at the receptionist desk or/and the director of nursing (DON) office; and Wanderguard was to be monitored for proper functioning, placement, and expiration date per orders. R1's most recent elopement assessment on 11/13/24, identified R1 had a habit/history of wandering or attempts to leave the unit/building and was able to ambulate or able to self-propel his wheelchair. The assessment resulted in a score of three which did not meet the facility's guideline of four or greater to indicate at risk for elopement. Despite the score of three, an elopement risk care plan was indicated with the goals and interventions listed in R1's care plan. R1's medical record did not include quarterly elopement assessments for February 2025, May 2025.R1's nurse progress note dated 6/7/25 at 9:34 a.m., written by registered nurse (RN)-A, identified R1 was found seated at the back of the building near the kitchen door. Reception staff reported R1 left the building around 5:30 a.m. and had his Wanderguard in his pocket. R1 returned at 7:20 a.m. and appeared to be fine. R1 did not recall how he exited the building. The Wanderguard had been secured on his ankle. Would do 15-minute safety checks every shift. Director of Nursing (DON) and nurse manager were notified. R1's Medication Administration Record (MAR) dated June 2025, identified an order entered on 6/7/25 directed staff to do hourly safety checks due to increased risk for elopement. Document any exit seeking behaviors or comments in the progress notes and update provider, as needed. Another order entered on 6/7/25 directed staff to do 15-minute checks every shift for confusion and were signed by staff as completed. R1's administrator progress notes on 6/7/25 at 9:34 a.m., R1 stated he was trying to go outside to smoke and mistakenly went to employee smoking area instead of resident smoking area. R1 stated he was not trying to leave the facility. Staff confirmed R1 was smoking and returned inside afterward. R1 was reoriented to resident smoking area. During an interview on 6/24/25 at 8:00 a.m., the administrator identified the video footage of R1's 6/7/25 incident was not reviewed and was no longer available to be viewedR1's smoking assessment dated [DATE], indicated R1 had cognitive loss, smoked two to five cigarettes a day, smoked morning, afternoon, evenings, and nights, was found to be able to smoke safely and independently. However, the smoking assessment did not define the location where R1 was deemed safe to smoke and there was no indication the facility had thoroughly investigated the incident on how/why R1 was found in the employee smoking area. Further, despite R1 going to the wrong smoking area on 6/7/25, R1's record did not include a follow-up assessment that identified if R1 continued to be safe to leave the building to smoke independently after 6/725. Additionally even though 15-minute checks were implemented it was not evident R1's care plan was updated with safety interventions to prevent R1 from going to the wrong smoking area. During an observation on 6/24/25 at approximately 1:00 p.m. the facility's secured resident smoking area noted an area of grass and concrete with locked gates surrounding the area. The back of the facility where R1 was found unsupervised in the staff smoking area was facing the alley where there was also delivery area and had ungated concrete steps to the lower level of the facility, dumpster's. There was a locked and coded door to re-enter the facility. There was no resident access areas accept from the front side of the building which would entail crossing a parking lot, public sidewalk, and public alley. During an interview on 6/25/25 at 2:13 p.m., receptionist (RCP)-C indicated she worked the night shift of 6/6/25 at 11:00 p.m. to 7:00 a.m. on 6/7/25. RCP-C was aware R1 went outside early that morning because she had to shut the door alarm off. RCP-C identified she thought it was about 6:50 a.m. or 6:55 a.m. RCP-C had historically been directed by someone (could not recall who) that if a resident were to go outside she was not supposed to chase after the resident but instead report it to the nurse. When RCP-C called the charge nurse (not sure which nurse she talked to) she was told, this is just what he [R1] does with no further direction given. RCP-C further identified no one was ever available to relieve her when she took her breaks, so would leave the floor unsupervised during those times, During an interview on 6/25/25 at 2:03 p.m., RCP-B indicated when she arrived for her shift on 6/7/25 at 7:00 a.m., the night receptionist was not at the front desk, she was not aware of where she was, and the alarm was not sounding. The overnight nurse left but did not report R1 was outside. A resident told RCP-B (but could not recall which resident) that R1 had left the building and was sitting outside in the back of the facility by the alley. RCP-B stated she told R1 that he was not supposed to be out there, it was not safe, and tried to get R1 to come in but he refused to come in. She reported it to the charge nurse. The charge nurse and a nursing assistant (NA) came down and got him back in the building. RCP-B indicated the only way R1 could have gotten out was the front entrance door, down the sidewalk, over a curb, and around to the back-alley way. RCP-B further stated she found an unsigned note on the receptionist desk that said R1 had left the building about 5:00 a.m. but was not sure who wrote the note and threw the note away. During an interview on 6/24/25 at 11:18 a.m., registered nurse (RN)-A identified the receptionist on first floor was responsible for monitoring the Wanderguard system and the doors 24/7. The Wanderguard alarms did not alert to the 2nd, 3rd, or 4th floors so staff would not be aware if a resident tried to get out of the facility through the main entrance on the first floor. RN-A indicated she was working day shift on 6/7/25. At approximately 7:10 a.m. a resident (she could not recall which resident) had informed her that since 5:30 a.m., R1 was sitting outside the back of the building by the kitchen door and employees smoking area. R1 was not in a resident area or a safe area and should not have been there. R1 had his Wanderguard in his pocket and it alarmed when he entered back into the building. R1 did not know how he had gotten out of the building or how he had gotten to the back of the building. RN-A indicated there was not a receptionist at the desk when she arrived for work at approximately 6:50 a.m. and the only way R1 could have gotten out was the front door was someone had to silence the Wanderguard alarm but was not sure who would have done that. RN-A indicated 15-minute checks were implemented and R1's Wanderguard was reapplied. R1's Late Entry behavior progress note for 6/12/25, recorded on 6/14/25 at 7:08 p.m., identified nurse manager was notified that R1 had removed/cut off Wanderguard to right ankle and Wanderguard was reapplied to right ankle. On 6/13/25, at 4:00 p.m., the nurse manager noted R1's Wanderguard was on his bed and R1 was not in his room. R1 was located and the attempt to re-apply the Wanderguard was unsuccessful due to R1 using threats and throwing punches at the nurse manager. R1 was not redirectable and left the room to go smoke. Nurse manager updated evening staff to reinforce application of Wanderguard. R1's nurse progress note on 6/13/25 at 10:05 p.m., identified the nurse attempted to place the Wanderguard on R1 but he refused. The nurse tried again after a short while but R1 refused again. R1's record did not identify immediate interventions were implemented as a result of R1 refusing to wear Wanderguard. Observation of facility's video footage of R1's elopement on 6/13/25, identified the following timeline: 8:00 p.m. R4 and visitor leave the facility through the main entrance; 50 seconds later R1 exits through the main entrance and wheels to the right out of sight; at 8:52 p.m. R4 enters the facility through the main entrance; 9:07 p.m. a staff person enters through the main entrance; 9:08 p.m., 1 hour and 16 minute later R1 enters through the main entrance and appears to be talking to someone at the front desk. R1's progress notes did not address R1 exiting the facility on 6/13/25 but identified a note on 6/14/25.R1's behavior progress noted on 6/14/25 at 1:13 p.m., indicated social service designee (SSD) was informed by another resident (later identified as R4) that R1 had eloped from the facility the evening prior (6/13/25). R4 found R1 on the corner of (intersection of two streets) between 6:30 p.m. - 7:00 p.m. R1 was noted to be in his wheelchair and R4 guided R1 back to the facility. R4 reported there was not a receptionist at the desk when they returned. The SSD instructed nurse to apply a Wanderguard on R1 but R1 became combative so the Wanderguard was applied to the wheelchair. A follow up note at 1:29 p.m., identified staff applied a Wanderguard on R1's wheelchair and on R1's left ankle and directed staff to continue the 15-minute checks. A behavior note on 6/14/25 at 3:54 p.m., identified nursing staff informed that R1 was to have 1:1 staff supervision. R1's SLUMS examination completed by a psychology provider on 6/16/25, identified R1 had dementia. During an interview on 6/24/25 at 2:37 p.m., the social service director (SSD) indicated she was informed of R1's 6/7/25 incident of the leaving the building on 6/9/25 during an interdisciplinary team (IDT) meeting. R1 could only have exited through the front door as the back two doors have codes to exit and R1 would not have known the codes. The SSD indicated R1 would have had to go over a curb with his wheelchair and around to the back alley to get to that location. SSD reported R1 being outside in that area was not a safe area as there have been drug addicts in that area digging through the trash, R1 could have fallen and hit his head, and it was fortunate he ended up where he did instead of wandering further off the campus. SSD stated, if we would have taken the necessary steps on the seventh [6/7/25], he would not have gotten out the second time [6/13/25]. SSD further described the area R1 was found on 6/13/24 as a very busy intersection with a college close by. On 6/14/25, the SSD was the manager on duty and was at the facility when R4 informed her that he had to bring R1 back to the facility the evening before (6/13/25). SSD immediately notified the charge nurse, administrator, DON, and the State Agency. SSD noted R1 was not wearing a Wanderguard. SSD and charge nurse applied a Wanderguard to R1's wheelchair until he would cooperate to place a Wanderguard on his ankle.The facility's internal investigation dated 6/14/25, identified potential contributing factors leading to R1's elopement included: receptionist was on break; no one monitoring the front entrance; alarm not sounding and door not locking due to R1 removing his Wanderguard; staff not following the order for 15-minute safety checks on R1; nurse failed to follow direction from manager and place Wanderguard on resident. During observation and interview on 6/23/25 12:40 p.m., R1 was noted to be lying in his bed, unshaven, with a pack of cigarettes and lighter lying next to him. R1 yelled and used foul language when discussing the facility and the care he received but refused interview. R1 was noted to have a nursing assistant (NA) outside his door. During follow up interview attempt on 6/24/25 at 9:28 a.m., R1 was lying in bed and noted to be wearing a Wanderguard on his right ankle and had a second Wanderguard on the back of his wheelchair. NA outside of his door. R1 indicated he was angry and not in the mood to visit. During an interview on 6/23/25 at 12:55 p.m., R4 who had no cognitive impairment according to BIMS (Brief Interview for Mental Status) dated 5/19/25 stated R1 had eloped from the facility the week prior and found him near the corner of an intersection about a block away from the facility. R4 further indicated on 6/13/25 at approximately 7:00 p.m. to 8:00 p.m., he and a friend (not a fellow resident) left the facility by electric wheelchair to go out for supper at a restaurant about a mile away and R1 must have followed them out the door. R4 indicated there was usually a receptionist at the front desk that the residents check in and out with when they leave but the desk was unoccupied when he left. When they were returning from the restaurant, they saw R1 in his wheelchair wheeling toward the intersection and was approximately ten feet away from the corner. R4 further indicated, when R4 approached R1, R1 asked what intersection he was at and told him he was on a weeklong leave of absence from the facility and was not going back. R4 knew R1 was confused and usually wore a Wanderguard. R4 stated he was able to convince R1 to return to the facility and escorted him back. R4 indicated R1 had difficulty maneuvering the wheelchair over the uneven sidewalk but returned to the facility without incident. Once back at the facility, R1 wanted to stay out in front of the building to smoke so R4 entered the building and told the receptionist at the desk that R1 had eloped and was out front smoking. R4 stated the next day, he reported R1's elopement to social services. During an interview on 6/23/25 at 4:38 p.m., RCP-A acknowledged working the evening of 6/13/25. RCP-A indicated she did not see R1 leave because she was on break and he did not have a Wanderguard on so the Wanderguard system did not alarm when he left the building. No one had told her R1 left and stated R4 did not tell her R1 had left the facility until the next day which contradicts R4's interview statement. RCP-A indicated she took her break between 8:00 p.m. and 8:30 p.m., and when she returned, she noted R1 coming in the front door, but the door did not alarm. RCP-A was just glad to see him coming in. RCP-A denied checking R1 to see if he was wearing a Wanderguard but stated she just assumed since he did not alarm, the nursing staff had removed his Wanderguard and he could go outside without supervision. RCP-A denied checking with the nursing staff about R1's Wanderguard status or reporting R1 had been outside the facility unsupervised the evening of 6/13/25. RCP-A stated she was not aware of R1 leaving the facility unsupervised on 6/7/25.During an interview on 6/24/25 at 7:03 p.m., RN-B indicated she was working on 6/13/25 and had attempted to re-apply R1's Wanderguard but he had refused and was aggressive. RN-B had RN-A try to reapply it but R1 refused again. RN-B indicated she checked on R1 to the best of my ability, it was busy but thought she had checked on him about every 30 to 60 minutes. RN-B stated she was informed on 6/14/25, that R1 had eloped from the facility and was informed at that time that R1 was supposed to be on 15-minute safety checks.During an interview on 6/24/25 at 9:51 a.m., nurse manager (NM)-A, indicated R1 had attempted to elope before so required a Wanderguard but also had a history of removing it or cutting it off. NM-A indicated the Wanderguard system only alarms on the first floor and there was always a receptionist at the front desk and was responsible to monitor the doors and respond to the alarms. The elevators were not locked or alarmed except the doors that open to the kitchen and back of the building which required a code. R1 spent most of his time on first floor because he went out to smoke. NM-A indicated knowledge R1's 6/7/25 incident and had initiated 15-minute checks. NM-A stated, there was a systems breakdown when R1 eloped on 6/13/25, further identifying the 15-minute checks were not being completed, the receptionist was not monitoring the front desk, and his elopement was not reported to nursing until the next day. During an interview on 6/24/25 at 3:58 p.m., the DON summarized R1's elopement events as the facility's multiple layers of security to prevent elopement failed and their systems broke down. The DON further clarified the system of staff supervision broke down by not completing the ordered 15 minute checks; the nurses did not follow through when R1 refused to allow them to apply the wander guard; nurses did not report the refusal to their manager; the staff assumed R1 was in the facility if they did not hear an alarm, staff did not monitor R1 yet signed that they were monitoring R1; R1 was able to cut his Wanderguard off; the receptionist assumed staff removed R1's alarm; the receptionist did not look at the binder to confirm, and the receptionist did not report R1 leaving the facility unsupervised to anyone. The DON was aware of R1's 6/7/25 incident but did not think he was aware of the details. The DON understood R1 left the facility out the front door early morning to smoke and staff found him and brought him back in. The DON indicated if a resident was found outside of where they should not be and had breached the facility security, he considered it an elopement. The DON further identified R1 was not safe to be outside unsupervised due to R1's fluctuating cognitive status and R1's elopements are a serious concern. During an interview on 6/24/25 at 3:24 p.m., the administrator indicated SSD notified her of R1's 6/13/25 elopement on 6/14/25 early afternoon and began 1:1 staffing with R1, immediate education with all staff, The administrator stated, he [R1] knew where he was going and he got back after running into [R4] and following him back [to the facility]. The administrator indicated that although R1 safely navigated to the intersection, he required supervision when out of the facility. Further noted about a week prior (6/7/25), R1 attempted to go out and smoke and was redirected back in but was not aware he was outside for approximately two hours and did not feel the area was unsafe as it was on campus. The administrator verified the area that R1 was found in was in the back of the facility with concrete stairs close, a delivery area, next to an alley, and near the employee smoking area. The administrator verified the facility failed to provide supervision and the ordered 15-minute checks leading to the elopement on 6/13/25. The facility policy titled Elopement Policy last reviewed 6/2023, included the facility is committed to provide a safe environment for all residents and will assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. All residents will be reassess quarterly, annually, and as needed due to significant changes. The facility will identify such environmental hazards such as entrances, stairwells, or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The facility will implement interventions to minimize these risks and hazards as appropriate. Documentation should include: admission assessment, which may indicate potential to wander or exit facility; care plan that address potential to wander or exit facility and the measures taken to prevent wandering/elopement; all attempts to elope, efforts to locate, notification and results of efforts; full observation visualization after an elopement for any injuries or new symptoms or conditions which may have developed; entries that are time specific to reflect the responsiveness and timeliness of actions taken to locate and asses the resident; bracelet alarm/device is in place and functioning (per TAR or other form of documentation), if applicable. Post elopement assessment: after the resident is located and returned to the unity, assess for changes identifying the following items: observed behaviors or resident statements; objective data, underlying illnesses, or diagnoses; physical assessment; general appearance. Document findings in an interdisciplinary team progress note (IPN) The administrator, or designee, shall notify State Agency, as necessary by state requirement, family/family representative, and physician. The immediate jeopardy that began on 6/7/25, was removed on 6/14/25, prior to the survey when the facility implemented 1:1 supervision for R1, reviewed and updated R1's care plan; comprehensively reassessed all residents for risk of elopement and implemented interventions to protect all residents at risk for elopement; all residents checked for Wanderguard placement and functioning; reviewed elopement policy and procedures; reception desk supervised 24 hours a day, 7 days a week with required coverage for breaks; re-education on Wanderguard checks at all mag-locked exits; re-education on elopement, 15-minute safety checks, abuse policy, reception area coverage, and elopement binder; and conducted elopement drills.

Based on observation, interview and document review, the facility failed to establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. This resulted in an immediate jeopardy (IJ) when R1 did not receive the necessary care and services for the treatment of pressure ulcers and pain management. R1's pressure ulcer went untreated for approximately six weeks and R1's pain was not controlled, limiting staff's ability to perform activities of daily living for R1. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met. The immediate jeopardy began on 3/19/25, when R1 was signed on to hospice services, was noted to have pressure ulcers and uncontrollable pain with no process in place to determine who was responsible to ensure R1's need were met. The Administration, director of nursing, and regional nurse manager were notified of the immediate jeopardy at 5:10 p.m. on 5/1/25. The immediate jeopardy was removed on 5/2/25, but noncompliance remained at the lower scope and severity level 2 D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set, dated [DATE], indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 14, indicting R1 was cognitively intact. R1's facility care plan dated 9/6/24, added a focus on 4/17/25 - one month after R1's admission to hospice - for hospice cares related to end stage disease process. The goal was for resident and family to receive comfort cares as desired. Interventions included communication with hospice on R1's condition, changes, medications, involve in care conferences, follow directions from hospice, and follow hospice standing orders. There was no hospice focus care planned intervention included in the facility care plan at admission of hospice 3/19/25. R1's hospital Discharge summary dated [DATE], received by the facility 3/19/25 indicated R1 was discharged with hospice services. R1 was discharged with comfort medications hydromorphone (narcotic pain medication) and Lorazepam (anti-anxiety medication). R1 had the following wounds per the hospital summary: -Wound first assessed on 3/17/25 on his coccyx (tailbone) the wound was identified as moist and blanchable (skin discoloration that disappears when pressed upon and returns when pressure is released indicating the blood vessels in the areas are occluded therefore blood flow is obstructed), the peri wound (area surrounding the wound) was excoriated, red and moist. Mepilex dressing was used to cover the wound following cleansing. -Suspected pressure ulcer to R1's left heel first assessed 3/17/25 the wound was purple, red, and fragile, the peri wound area was intact and red. The wound was cleansed and a Mepilex dressing applied. -Suspected pressure ulcer to R1's right heel first assessed 3/17/25 the wound was red and intact, cleansed and covered with a Mepilex dressing. -Suspected pressure ulcer to the left anterior foot first assessed 3/17/25 the wound was fragile, red, and intact, cleansed and covered with a Mepilex dressing. -Wound to the right lateral foot first assessed 3/18/25 the wound was fragile, red, pink with black eschar (scabbing) painful, cleansed and covered with Mepilex. -Wound to the right anterior knee first assessed 3/17/25 the wound was fragile and tan, cleansed and covered with a dressing. R1's hospice plan of care dated 3/19/25, indicated R1's terminal diagnosis was acute hypoxic respiratory failure. Wound care order: Sacral wound and bilateral lower extremity wounds: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound skin. Cover with a foam bandage three times a week and as needed. Wound care was to be performed by the facility staff. R1's pain was to be managed and reported. If not controlled at 0-3 of 10 pain scale. R1's facility nursing readmit data collection dated 3/19/25, indicated under additional evaluation no pain was identified for R1. R1's skin condition indicated the coccyx, in the description, wound to right buttock cover with foam dressing. R1's significant change MDS dated [DATE] did not indicate a BIMs score. R1 was dependent on staff assistance with toileting, showering, dressing, personal hygiene, rolling in bed, bed to chair transferring. R1 was always incontinent of bowel and bladder. R1's pertinent diagnoses were chronic congestive heart failure, opioid dependent, pain and chronic obstructive pulmonary disease. R1 had occasional pain with an intensity of an 8 (rated the worse pain over the last five days of the assessment on a zero to ten scale with zero being no pain and ten being the most pain imaginable. No further pain assessment was conducted per the MDS. R1 was identified on the MDS as being at risk of pressure ulcers, but had no pressure ulcers, nor was the MDS coded as having any other ulcers, wounds, or skin problems. Upon observation and interview on 4/28/25 at 3:39 p.m., R1 was lying on his back in a hospital bed wearing a hospital gown telling a friend about his back pain. R1 had dried blood on all five toes of his right foot. The second toe of his right foot had a dirty bandage on it. R1 agreed to a skin inspection, but stated he was in so much pain and it caused severe pain to move him. He requested the assistance of three staff members and requested they move him slowly. R1's sheet was pulled back and pressure ulcers were observed on both heels, and a pressure ulcer on his right lateral foot. Staff attempted to roll R1 onto his left side. R1 screamed in pain and gripped the side rail. He was screaming for staff to stop. He was laid back on this back. R1's coccyx area appeared red, it was difficult to visualize and make an assessment as R1's pain level was so great the staff had to reposition him back on his back within seconds. At 3:58 LPN-B gave R1 a pain medication. At 5:00 p.m. R1 continued to state his pain was a 10/10 and staff was still unable to move him. R1 was not offered any addition management for his pain. The director of nursing (DON) was notified, and the staff began to assess R1's skin. Upon interview on 4/28/25 at 4:12 p.m. licensed practical nurse, LPN-B stated she was unable to complete R1's readmission skin assessment because she was unable to reposition him to view, his back. Since his readmission on 3/19, LPN-B stated staff had difficulty completing cares on R1 because touching him made him scream in pain. She stated she did not reach out to hospice as they were completing their own visits with him, and her job was to follow their orders which included giving as needed pain medications. She stated she had placed a foam dressing over R1's coccyx from time to time, however did not chart placing the dressing because there were no orders for a dressing change and the wound was small. She did not recall the last time she placed a dressing on his coccyx. LPN-B believed the wound care team or hospice was tending to R1's skin. Upon interview on 4/29/25 at 8:55 a.m. nursing assistant (NA)-A stated she completed incontinence cares on R1. He only allowed her to reposition him when he had a bowel movement requiring assistance with cleaning, because the repositioning was so painful for him. NA-A had seen an open wound on R1's coccyx and had seen a dressing covering the area at times. She stated at times the dressing would be dirty and she would mention it to the nursing staff (unidentified staff and dates) and would be told the facility is not responsible for R1's skin. Upon interview on 4/29/25 at 10:04 a.m., hospice registered nurse, RN-B stated state she was aware that R1 had a coccyx wound and was not certain whether the facility had orders to tend to the wound or not. She was not aware of any heel or foot wounds. She stated she was completing the unscheduled visit on 4/29/25, because the family had reached out to hospice regarding R1's pain on 4/25/25. Hospice RN-B made changes to R1's pain regimen. Upon interview on 4/29/25 at 11:14 a.m. family member (FM)-A stated she received a call from the facility on 4/28/25 that R1 had some sores and hospice should have been taking care of them and the facility found out hospice was not. FM-A was not told the location or severity of the wounds. She stated she wondered if that was why R1 had so much pain. R1 had been calling her almost daily crying and when FM-A mentioned his pain to the facility, she was told they were giving him everything they could. She stated on 4/25/25 he called her sobbing on the phone wanting to go to the hospital due to his pain. FM-A notified Hospice. In addition, FM-A stated she had not seen staff reposition R1. R1 was laying in the same position on his back every time she visited him, and he had only attempted to get out of bed once since his hospital discharge of 3/19/25. Upon interview on 4/29/25 at 11:57 a.m., licensed practical nurse, LPN-A, nurse manager, stated she was not aware until the survey observation findings that R1 had any pressure ulcers. She stated she reviewed the hospice notes and stated hospice was responsible for R1's ADL's (activities of daily living) so if there were any wound care treatments they would be performing them. She denied communicating with the hospice nurses regarding R1's pressure ulcers. In addition, LPN-A stated, staff should have reported uncontrolled pain to hospice and to her. She stated staff are to follow-up if pain had not resolved after they administered a pain medication. She was not certain if R1's pain regimen was effective. She stated hospice was responsible for his pain control. LPN-A denied reaching out to hospice regarding R1's pain. Upon interview on 4/29/25 at 4:37 p.m., hospice registered nurse, RN-B stated hospice does not complete wound care. He stated the orders were clear in R1's admission plan of care. He denied communication with the facility about R1's skin as he assumed since the facility did not reach out to him there were no concerns. He denied the facility reached out to him with regarding R1's pain control. Upon interview on 4/30/25 at 11:30 a.m. the facility's Medical Director stated he had not had any conversations with the hospice agency the facility uses since there had not been any concerns brought to his attention. Upon interview on 4/30/25 at 2:14 p.m. the assistant director of nursing ADON stated he is the certified wound specialist for the facility. R1's skin condition was brought to his attention on 4/29/25 at around 5:00 p.m. He stated he was able to assess R1's lower extremity wounds, but the facility could not manage R1's pain to assess his coccyx wound until the morning of 4/30/25. He ordered treatments for the wound and reported the wounds to hospice. The ADON told hospice he wanted an as needed order so the facility could also change the dressing if they needed to, as he believed hospice was treating the wounds. The ADON stated LPN-A told him as he was assessing R1's wounds and that hospice was handling R1's wound treatments because they were doing his activities of daily living (ADL's). (see tag F686 for wound assessments). Upon interview and record review on 5/1/25 at 9:46 a.m., the DON stated the nurse who completed R1's assessment did miss the wounds, however the wounds were the responsibility of hospice, so the facility would not necessarily have documented the wounds. The DON reviewed R1's hospice care plan indicating the facility was to be completing wound care. His response was he had never seen the care plan from hospice before and would need to investigate it. Regarding R1's pain, the DON stated hospice oversaw him since his re-admission on [DATE]. The DON stated there was a fine line for what pain medications would be covered by insurance, so the facility had to use what was provided for R1. R1 was a former opioid addict, therefore no matter how much medication the facility gave him he would ask for more. Upon interview and record review on 5/1/25 at 11:30 a.m. the Administrator stated the facility, and hospice should communicate to discuss the hospice resident, and the facility should document the communication. She would expect the facility to note and assess all wounds on their residents no matter who was completing the wound care. If during a facility assessment, a wound was covered, she would expect the staff to remove the dressing if it were removable and assess the wound. If a resident were in so much pain that cares could not be performed, she would expect staff to reach out to the provider, hospice, or the regular provider if hospice were not involved. She reviewed the hospice care plan that indicated the facility should be providing wound care and stated she would look into the concerns. Upon interview on 5/1/25 at 10:30 a.m. hospice supervisor, RN-F stated since R1 resided in a skilled facility hospice and the facility work concurrently, meaning the standard is they work together. Hospice took the lead on providing treatment recommendations and orders. The facility was responsible for the day-to-day care for the residents since hospice only had one skilled nursing visit per week. She stated during R1's hospice period the facility called hospice on 4/3/25 with a question about R1's hospital bed. Per hospice charting on 4/8/25 hospice RN-B documented R1 had multiple pressure ulcers, and the facility was completing dressing changes. On 4/15/25 during a hospice visit hospice nurse RN-B asked facility nurse RN-C about R1's pain and RN-C told him R1 asked for pain medications frequently. On 4/25/25 R1's daughter called hospice and complained of R1 calling her crying in pain. On 4/28/25 hospice RN-E visited R1 and increased his pain medications. The immediate jeopardy was removed on 5/2/25, when it was verified, the facility implemented the following action: On 5/2/25 The facility designated a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff to do the following: They appointed the Director of Social Services and educated her on the new responsibilities. On 5/2/25 the facility coordinated hospice care planning process for 6 residents receiving hospice services. The facility obtained the following information from the hospice: -The most recent hospice plan of care specific to each patient. -Names and contact information for hospice personnel involved in hospice care of each patient. On 5/25/25 the facility provided education on how to and when to access the hospice's 24-hour on-call system through the hospice residents banner on their face sheets and in their hospice hard copy chart. On 5/2/25 the facility identified hospice medication information specific to each patient including ineffective medication regimen, i.e., uncontrolled pain. each hospice resident was reviewed, and staff educated on monitoring effectiveness of pain medication and to reach out to the provider when the pain levels were uncontrollable. On 5/2/25 the facility providing hospice care under a written agreement ensured: Each resident's written plan of care included both the most recent hospice plan of care, and a description of the services furnished by the LTC facility. Care plans were updated implementing the hospice care plans into the facility's care plans. The Nursing Facility Service Agreement dated 3/8/2018 indicated a facility policy titled Hospice dated 11/2023 indicated contracted hospice providers must have a written agreement with the facility outline (in detail) the responsibilities or the facility and the hospice agency. Are held responsible for meeting the same professional standards and timeliness of service as any contract individual or agency associated with the facility. It is the responsibility of the facility staff to notify the hospice provider and primary care provider about a significant change in the resident's condition or situations requiring a revision of the plan of care. The hospice agency will provide the facility staff with a copy of the hospice plan and a schedule of visits. Hospice staff will communicate and coordinate care with the interdisciplinary team (IDT). Facility Services. At the request of an authorized hospice staff member, facility shall admit Hospice Patients to Facility, subject to Facility's admission policies and procedures and the availability of beds. Facility shall immediately notify Hospice if Facility is unable to admit a Hospice Patient. Facility shall comply with Hospice Patient's Plan of Care and shall ensure Hospice Patients are kept comfortable, clean, well-groomed, and protected from negligent and intentional harm including. but not limited to, accident, injury, and infection. Facility's primary responsibility is to provide Facility Services. It is Facility's responsibility to provide Facility Services that meet the personal care and nursing needs that would have been provided by a Hospice Patient's primary caregiver at home, and Facility shall perform Facility Services at the same level of care provided to each Hospice Patient before hospice care was elected. While Facility's nursing personnel may, as specified by Facility, assist in administering prescribed therapies to Hospice Patients under the Plan of Care, such assistance may only be provided to the extent the activity is permitted by law and only to the extent that Hospice would routinely utilize the services of a Hospice Patient's family in implementing the Plan of Care. Availably- Facility shall be available to provide Facility Services 24 hours per day, 7 days per week and shall maintain sufficient personnel who have the requisite training, skills, and experience to meet this obligation. Notification of Services - Facility shall fully inform Hospice Patients of Facility Services, Other Facility Services and Uncovered Items and Services to be provided by Facility. [NOTE: It is important for the hospice to ensure that the patient is fully aware of who is responsible for services and who will pay for services that are not related to the patient's terminal illness.] Coordination of Care. a. General - Facility shall participate in any meetings, when requested, for the coordination. supervision and evaluation by Hospice of the provision of Facility Services. Hospice and Facility shall communicate with one another regularly and as needed for each Hospice. Patient Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. b. Resident of Plan of Care. In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient. Hospice retains primary responsibility for development of the Plan of Care. c. Modifications to Plan of Care. Facility will assist with periodic review and modification of the Plan of Care. Facility will! not make any modifications to the Plan of Care without first consulting with Hospice. Hospice retains the sole authority for determining the appropriate level of hospice care provided to each Hospice Patient d. Notification of change in condition - Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient This includes, without limitation, a significant change in a Hospice Patient's physical, mental, social or emotional status, clinical complications that suggest a need to alter the Plan of Care, a need to transfer the Hospice Patient to another facility, or the death of a Hospice Patient Facility\ Representative: Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice to coordinate care provided by Facility staff and Hospice staff to any Hospice Patient under Hospice's care. Such interdisciplinary team member shall be responsible for the following: (i) collaborating with Hospice and coordinating Facility staff participating in the hospice care planning process for those Hospice Patients who are under Hospice's care; (ii) communicating with Hospice end other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the Hospice Patient and family; {iii) ensuring that Facility communicates with the Hospice medical director, the Hospice Patient's attending physician, and other practitioners participating in the provision of care to the Hospice Patient as needed to coordinate the hospice care with the medical care provided by other physicians; (iv) obtaining the following information from Hospice: (A) The most recent Hospice Plan of Care specific to each Hospice Patient; (B) Hospice election form; (C) Physician certification and recertification of the terminal illness specific to each Hospice Patient; (D) Names and contact information for Hospice personnel involved in hospice care of each Hospice Patient; (E) Instructions on how to access the Hospice's 24-hour on-call system; (F) Hospice medication information specific to each Hospice Patient; (0) Hospice physician end attending physician (if any) orders specific to each Hospice Patient; (v) ensuring that the Facility provides to Hospice an orientation with respect to the policies and procedures of the facility, including Hospice Patient rights. appropriate forms, and record keeping requirements. Facility shall notify Hospice promptly of any change in the designated interdisciplinary team member.The Facility care must ensure that each Hospice Patient's written plan of care includes both the most recent hospice plan of care if applicable, and a description of the services furnished by. Facility to attain or maintain the Hospice Patient's highest practicable physical, mental, and psychosocial well-being as required. Facility shall monitor the delivery of Facility Services to the Hospice Patients to assure the services provided meet the assessed needs of each Hospice Patient.

Based on observation, interview, and record review the facility did not ensure a residents pain was managed in accordance with professional standards of practice and hospice plan care, for 1 of 3 residents (R1) reviewed for pain. R1's medication regimen was ineffective; he would scream and moan in pain contacting EMS and his daughter for help. This resulted in immediate jeopardy (IJ) when the facility did not have a system in place to manage R1's pain causing R1 unnecessary physical and psychological harm. The immediate jeopardy began on 4/1/25 when R1's pain medication became ineffective and subsequently lacked follow-up of effectiveness, the patient called emergency services for pain medication, and called his daughter crying in pain, and was identified on 4/28/25. The Administration, director of nursing, and regional nurse manager were notified of the immediate jeopardy at 5:10 p.m. on 5/1/25. The immediate jeopardy was removed on 5/2/25, but noncompliance remained at the lower scope of and severity level 2, D - isolated, which indicated no actual harm with potential for more than minimum harm that is not immediate jeopardy. Findings include: R1's facility care plan dated 9/6/24 - 4/28/25 did not have any pain focus, goals, or interventions. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 14 indicting R1 was cognitively intact. R1's providers orders dated 2/24/25 indicated staff was to monitor R1 for pain daily on every shift. Staff was to provide non-pharmacological pain interventions. 1. Ice 2. Heated blankets 3. Massage 4. Repositioning 5. Music 6. Essential oils 7. Food and drink 8. Relaxation and breathing. R1's nursing progress notes dated 3/17/25 - 4/28/25 did not indicate any documentation that the facility communicated R1's pain levels with the hospice agency. R1's hospital Discharge summary dated [DATE], received by the facility 3/19/25 indicated R1 was discharged with hospice services. He was discharged with the comfort medications hydromorphone 2 mg 1 tablet as needed every three hours for pain (narcotic pain medication) this was changed by hospice on 3/22/25. R1's hospice plan of care dated 3/19/25 indicated R1 was admitted to hospice with a terminal diagnosis of acute hypoxic respiratory failure. R1's medications orders were hydromorphone 2 mg every hour as needed (PRN) for pain. Gabapentin 300 (2 tablets) scheduled for three times a day for pain and Acetaminophen 500 mg 2 tablets scheduled for three times a day for pain. R1's hospice goals were to monitor pain and use/effectiveness of prn hydromorphone and patient/caregiver will report pain and or below patient's desired level of (0-3/10) using the standardized scale of (0-10 where 0 in no pain and 10 is the greatest pain ever felt.) If patient's pain exceeded the level of his goal, appropriate interventions would be initialed by an encounter to return to patient's desired level of pain. R1's facility readmission Data Collection assessment dated [DATE] had a blank entry under the title additional evaluation for pain and description. No other pain assessments were documented. R1's hospice providers orders dated 3/20/25 indicated R1 was to take scheduled Buprenorphine HCl-Naloxone HCl Sublingual 4 mg / 1 mg film (a narcotic pain medication often used for patients with opioid addiction) give 1 mg scheduled three times a day for pain. R1's eMAR dated 3/20/25 indicated R1's pain levels administration of Hydromorphone was a 6 at 9:06 a.m. and was documented as effective, at 4:49 p.m. his pain was an 8 and documented as effective. The eMAR did not indicate how many tablets of Hydromorphone R1 had taken. Under R1's Buprenorphine HCl-Naloxone scheduled three times a day for 8:00 a.m. 2:00 p.m. and 8:00 p.m. R1's pain was at 8:00 am was a 6 at 2:00 p.m. his pain was a 4 and at 8:00 p.m. his pain was a 0. R1's eMAR dated 3/21/25 at 2:35 p.m. indicated R1 was given a prn Hydromorphone 2 mg for a pain level of 8 documented as effective. The eMAR did not indicate how many tablets were administered. Under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 4 at 8:00 a.m., a pain of 8 at 2:00 p.m. and a pain of 8 at 8:00 p.m. R1 was not given any as needed (prn) medication for his pain levels ranging from 4-8. R1's eMAR dated 3/22/25 at 10:09 a.m. indicated R1's was given a prn Hydromorphone 2 mg for a pain level of an 8 and documented as effective, at 1:09 p.m. his pain level was a 9 and was not effective. He given another prn dose of Hydromorphone at 1:09 p.m. The eMAR did not indicate how many tablets R1 was given. Under R1's Buprenorphine HCl-Naloxone documentation R1's pain was an 8 at 8:00 a.m., a pain of 8 at 2:00 p.m. and a pain of 8 at 8:00 p.m. R1's eMAR dated 3/23/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone documentation R1's pain was a 9, at 2:00 p.m. his pain was 8 and at 8:00 p.m. his pain was a 3. There was no documentation of effectiveness when medication given. R1 was not given a prn pain medication Hydromorphone for his pain levels of an 8 and 9. R1's eMAR dated 3/24/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 6, at 12:00 p.m. a pain of 0, and at 8:00 p.m. a pain of 0. There was no documentation of effectiveness when medication given. R1 was not given a prn narcotic when his pain level was a 6. R1's eMAR dated 3/25/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 0, at 12:00 p.m. his pain was a 7, at 8:00 p.m. his pain was a 2. There was no documentation of effectiveness when medication given. R1's eMAR dated 3/26/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was 0 at 8:00 a.m., at 12:00 p.m. his pain was a 4, at 8:00 p.m. his pain was a 2. There was no documentation of effectiveness when medication given. R1's significant change MDS dated [DATE], identified frequent pain rated at an 8 out of 10 which occasionally interfered with day-to-day activities. However, this was not added to the care plan. R1's eMAR dated 3/27/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was an 8, his pain was a 0 at 4:00 p.m., and his pain was a 3 at 8:00 p.m. There was no documentation of effectiveness when medication given. No prn medication was given when his pain level was an 8. R1's eMAR dated 3/28/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration. R1's pain was documented as an x at indicating to read progress note, at 4:00 p.m. documentation was also an x indicating to read progress note. At 8:00 p.m. his pain level was a 3. There was no documentation of effectiveness when medication given. R1's eMAR dated 3/29/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 0, at 4:00 p.m. his pain was a 4, at 8:00 p.m. his pain was a 7. There was no documentation of effectiveness when medication given. A prn pain medication was not given when his pain level was a 7. R1's eMAR dated 3/30/25 under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 0 at 8:00 a.m., 4 p.m., and 8:00 p.m. R1's eMAR dated 3/31/25 at 8:00 a.m. under R1's Buprenorphine HCl-Naloxone administration R1's pain was a 9, at 4:00 p.m. his pain was a 4 and at 8:00 p.m. his pain was an 8. There was no documentation of effectiveness when medication given. No prn pain medication was given when his pain levels were an 8 and a 9. R1's electronic medication record (eMAR) dated 4/1/25 at 8:00 a.m. indicated R1's pain level was 0. At 8:43 a.m. R1's pain level was a 4 and was given a prn dose of Hydromorphone 2 mg. R1's follow-up indicated the medication was ineffective. At 2:47 p.m. R1's pain was an 8 and he was given Hydromorphone 2 mg, and the follow-up indicated the medication was effective. At 4:35 p.m. R1's pain was an 8 and he was given prn dose of Hydromorphone 2 mg and his pain follow-up indicated effective. At 7:00 p.m. R1's pain level was an 8 and was given a prn dose of Hydromorphone 2 mg and the pain follow-up was documented as effective. R1's providers orders dated 4/2/25 indicated R1 used a Lidocaine patch non-narcotic pain patch) 4% lidocaine 1 patch on his hip and one patch on his knee daily. R1's eMAR dated 4/2/25 at 7:25 a.m. indicated R1's pain level was an 8 and was given a prn dose of Hydrocodone 2 mg the follow-up indicated the medication was effective. At 10:28 a.m. his pain level was a 7 and was given a prn dose of Hydrocodone 2 mg and the medication was effective. At 3:42 p.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/3/25 at 5:25 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 10:23 p.m. R1's pain level was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/4/25 at 6:23 a.m. indicated R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given R1's follow-up relief was documented as unknown. At 12:22 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 1:24 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 3:23 p.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 7:48 p.m. R1's pain was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/5/25 at 11:36 a.m. indicated R1's pain was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 1:11 p.m. R1's pain was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 3:47 p.m. R1's pain was a 4 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 9:12 p.m. R1's pain was a 4 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/6/25 at 7:51 a.m. indicated R1's pain was 9 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 1:50 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 6:25 p.m. R1's pain level was a 0 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 7:12 p.m. R1's pain level was a 4 and a prn dose of Hydromorphone 2 mg was given, and the results were documented as unknown. R1's nursing progress note dated 4/6/25 at 6:36 indicated R1 had called the Administrator asking for help instead of using his call light or asking for help from the nursing assistant or nursing staff. R1 denied pain, his vitals were normal, and he was offered an ice pack, and his prn hydromorphone was administered. R1's eMAR dated 4/7/25 at 4:38 a.m. indicated R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and the resulted were documented as unknown. At 8:25 a.m. R1's pain level was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 10:25 a.m. R1's pain level was a 7 and a prn dose of Hydromorphone 2 mg was given and documented at ineffective. At 11:35 a.m. R1's pain was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 1:50 p.m. R1's pain was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 5:31 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 7:00 p.m. R1's pain level was 5 and a prn dose of Hydromorphone 2 mg was given, and his pain was documented as effective. R1's eMAR on 4/8/25 at 9:51 a.m. R1's pain was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 2:15 p.m. R1's pain level was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 9:07 p.m. R1's pain was a 5 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/9/25 at 8:08 a.m. indicated R1's pain was a 0 and a prn dose of Hydromorphone 2 mg was given. At 2:55 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 7:07 R1's pain was a 5 and a prn dose of Hydromorphone 2 mg was given and documents as effective. R1's eMAR dated 4/10/25 at 4:49 p.m. R1's pain was a 4 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/11/25 at 5:33 a.m. indicated R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documents as effective. At 8:18 a.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 3:20 p.m. R1's pain was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/12/25 at 4:49 p.m. indicated R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and was documented as effective. At 11:16 a.m. R1's pain was a 5 and documented as ineffective. At 6:02 p.m. R1's pain was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's eMAR dated 4/13/25 at 6:12 a.m. R1's pain was a 9 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 7:30 a.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 9:29 a.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 11:03 a.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 1:05 p.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's nursing progress note dated 4/13/25 at 6:15 a.m. indicated at approximately 6:05 a.m. emergency medical transport (EMT) showed up for R1's room and stated a resident called and gave them a room number. Staff checked on R1 and asked if he called (EMT) R1 was watching pictures on his phone and stated he had called EMT so he could get his pain medications as soon as he woke-up. EMT spoke with R1, he did not want to go the hospital, he just wanted his pain medications. R1 did not use his call light to call the staff. R1 rated his pain a 9/10 and was given his Hydromorphone 2 mg. R1's eMAR dated 4/14/25 at 6:12 a.m. R1's pain was a 5 and a prn dose of Hydromorphone 2 mg was given and was documented as effective. At 1:31 p.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and was documented as effective. At 5:22 p.m. R1's pain was a 6 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's nursing progress note dated 4/14/25 at 11:46 by Social Services indicated Social Services was called by staff who were providing care to observe and support as needed. It was observed that R1 was expressing pain even before staff initiated any physical contact, indicating a high level of sensitivity. Staff were observed to be careful and communicated with R1 throughout each step of the care process. They demonstrated patience and empathy, ensuring that the resident felt as comfortable as possible despite his ongoing pain. At the conclusion of care, R1 appeared more settled and was made comfortable by the staffs attentive approach. The note did not identify whether Social Services communicated with nursing management or hospice. R1's eMAR dated 4/15/25 at 9:00 a.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 10:12 a.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as effective. At 11:49 a.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 3:10 p.m. R1's pain was an 8 and a prn dose of Hydromorphone 2 mg was given and documented as ineffective. At 8:30 p.m. R1's pain was a 7 and a prn dose of Hydromorphone 2 mg was given and documented as effective. R1's providers orders dated 4/16/25 indicated R1 was to take Hydromorphone HCI (a narcotic pain medication) 2 mg 1.5 tablets. This was increased from 1 tablet every hour as needed to 1.5 tablets (3 mg) as needed for pain. R1's eMAR indicated on 4/16/25 R1 was to have Hydromorphone HCl 2 mg scheduled every 4 hours for pain. 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. R1 was given his pain medication at 12:00 a.m. with a pain level of 0 and 04:00 a.m. with a pain level of 0, at 8:00 a.m. with a pain level of 5, at 12:00 p.m. with a pain level of 8, 4:00 p.m. at 8, 8 p.m. at 4. R1's eMAR indicated on 4/17/25 R1 was to take Hydromorphone HCl 2 mg 1.5 tablets every hour by mouth as needed for pain. If medication was not helping enough after 3 doses in a row to call hospice. R1's was given medication at 12:00 a.m. and his pain level was 5, at 4:00 a.m. his pain was a 5, at 8:00 a.m. his pain was a 5, at 12:00 p.m. his pain was a 5, at 2:28 p.m. R1's pain level was a 5 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as ineffective, at 4:00 p.m. his pain was a 6 at 8:00 p.m. his pain was a 0. R1 was not administered any prn Hydromorphone until 2:28 p.m. even though his pain levels were a 5 prior to that dose. R1's eMAR dated 4/18/25 at 12:00 a.m. R1's pain level was a 2, at 4:00 a.m. his pain was a 3, at 8:00 a.m. his pain was a 5, at 12:00 p.m. his pain was a 3 and at 4:00 p.m. his pain was a 6, at 6:15 p.m. R1's pain level was a 6 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as ineffective. At 8:00 p.m. R1's pain remained at a 6 without any additional prn medication administered. R1's eMAR dated 4/19/25 indicated at his levels with his schedules hydromorphone at 12:00 a.m. R1's pain was a 3, at 4:00 a.m. his pain was a 3, at 8:00 a.m. his pain was 3, at 12:00 p.m. his pain was a 5, at 4:00 p.m. his pain was a 6, at 8 p.m. his pain level was a 6. No prn Hydromorphone was administered even though R1's pain ranged between a 3 and an 8. R1's eMAR dated 4/20/25 indicated R1's pain levels with his scheduled medications were at 12:00 a.m. the pain was a 0, at 4 a.m. the pain was a 0, at 8 a.m. the pain was a 0, at 12:00 p.m. the pain was a 0, at 1:43 p.m. R1's pain was a 10 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as effective. At 2:00 p.m. his pain was a 6, at 8:00 p.m. his pain was a 6. No further prn doses were administered even though R1's pain continued to be a 6. R1's eMAR dated 4/22/25 indicated R1's pain level with his scheduled doses of Hydromorphone indicated at 12:00 a.m. pain was a 0, at 4:00 a.m. pain was 0, at 8:00 a.m. pain was a 0 at 12:00 p.m. Hydromorphone was held, pain level was not indicated, at 4:00 p.m. pain level was a 6, at 8:00 p.m. pain level was a 6. No prn doses of hydromorphone were administered even though R1 had pain levels of 6. R1's eMAR dated 4/23/25 indicated R1's pain levels with scheduled doses of hydromorphone at 12:00 a.m. pain was 0 at 4:00 a.m. pain was a 0 at 8 a.m. pain was held at 12:00 p.m. pain level was a 5, at 4:00 p.m. pain level was a 5 at 5:00 p.m. indicated R1's pain level was a 10 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as effective. At 8:00 p.m. R1's pain level was a 6. At 8:43 p.m. R1's pain level was a 5 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and indicated as effective. R1's eMAR dated 4/24/25 indicated R1's pain levels with scheduled doses of Hydromorphone at 12:00 a.m. pain was a 0, at 4:00 a.m. pain was a 0, at 8:00 a.m. pain was a 3, at 12:00 pain was a 4, at 4:00 p.m. pain was a 5, at 8:00 p.m. pain was a 0. No prn Hydromorphone was administered even though pain levels reached a 5. R1's eMAR dated 4/25/25 indicated R1's pain levels with scheduled doses of Hydromorphone at 12:00 a.m. pain was 0, at 4 a.m. pain was 0, at 8:00 a.m. pain was a 4, at 12:00 p.m. pain was a 5, at 4:00 p.m. pain was a 4, at 8:00 p.m. pain was not identified, and medication was refused. R1's eMAR dated 4/26/25 indicated R1's pain levels with scheduled doses of Hydromorphone indicate at 12:00 a.m. pain was a 5, at 4:00 a.m. pain was a 0 at 8:00 a.m. pain was a 0 at 12:00 p.m. pain was pain was a 4, at 2:59 p.m. indicated R1's pain was a 9 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as effective. At 1:00 p.m. pain was a 9, at 8:00 p.m. pain was a 5. R1 was not administered additional prn Hydromorphone when his pain level continued to be a 9 and then a 5. R1's eMAR dated 4/27/25 indicated R1's pain levels with schedules doses of Hydromorphone at 12:00 a.m. pain was a 0, at 4:00 a.m. pain was a 0, at 8:00 a.m. pain was a 0 and 12:00 p.m. pain was an 8, at 4:00 p.m. pain was 0, at 8 p.m. pain was a 0. R1 was not administered a prn Hydromorphone when his pain level was an 8. R1's eMAR dated 4/28/25 indicated R1's pain levels with scheduled doses of Hydromorphone at 12:00 a.m. pain was a 0, at 4:00 a.m. pain was a 0. At 8:00 a.m. pain was a 0, at 12:00 p.m. pain was a 5 at 4:00 p.m. pain was a 5, at 6:22 p.m. indicated R1's pain was an 8 and a prn dose of Hydromorphone 2 mg (1.5 tablets) for a total of 3 mg was given and documented as effective. At 8:00 p.m. R1's pain was an 8. R1's pain continued at an 8 and no prn Hydromorphone was administered. Upon observation and interview on 4/28/25 at 3:39 p.m. R1 was on his back in a hospital bed wearing a hospital gown telling a friend about his back pain. R1 agreed to a skin inspection, but stated he was in so much pain it caused severe pain to move him. He requested the assistance of three staff members and requested they move him slowly. R1 had dried blood on all five toes of his right foot. The second toe of his right foot had a dirty bandage on it. R1's sheet was pulled back and pressure ulcers were observed on both heels, and a pressure ulcer on his right lateral foot. Staff attempted to roll R1 onto his left side. R1 screamed in pain and gripped the side rail. He was screaming for staff to stop. He was laid back on this back. R1's coccyx area appeared red, it was difficult to visualize and make an assessment as R1's pain level was so great the staff had to reposition him back on his back within seconds. At 3:58 LPN-B gave R1 a pain medication. At 5:00 p.m. R1 continued to state his pain was a 10/10 and staff was still unable to move him. R1 was not offered any addition management for his pain. The director of nursing (DON) was notified, and the staff began to assess R1's skin and pain. R1 did not have a lidocaine pain patch on his right up or knee. Upon interview on 4/28/25 at 4:12 p.m. licensed practical nurse, LPN-B stated since his readmission on [DATE], staff had difficulty completing cares on R1 because touching him made him scream in pain. She stated she did not reach out to hospice as they were completing their own visits with him, and her job was to follow their orders which included giving as needed pain medications. R1's facility care plan dated 4/29/25 (during the survey process) indicated R1 had an alteration in comfort related to a history of pain and closed fracture of the right acetabulum and wound to coccyx. R1's goals were to have adequate relief from pain as evidenced by verbalization, and freedom from signs/symptoms of nonverbal indicators of pain. Upon interview on 4/29/25 at 8:55 a.m. nursing assistant (NA)-A stated she completed incontinence cares on R1; however, he would only let her reposition him when he required cleaning following a bowel movement because moving him was too painful. She reported his pain to nursing staff (unidentified staff and unidentified dates), she was told that R1 was on hospice, and they handle his pain. Upon interview on 4/29/25 at 10:04 a.m. hospice registered nurse, RN-B stated she was at the facility completing an unscheduled visit because R1's family had reached out to hospice regarding R1's pain. RN-B made changes to R1's pain regimen. She was going to include ketamine injections to assist in controlling R1's pain if approved by her superiors at hospice. Upon interview on 4/29/25 at 11:57 a.m. licensed practical nurse, LPN-A nurse manager stated staff should be reporting uncontrolled pain to hospice and to her. She stated staff were to following-up and indicate if pain had resolved after they administer a pain medication. She was not certain if R1's pain regimen was effective. She stated Hospice was responsible for his pain control. LPN-A denied reaching out to Hospice regarding R1's pain and was not aware R1's family had spoken with staff regarding R1's pain control. Upon interview and record review on 5/1/25 at 9:46 a.m. the DON stated hospice oversaw R1 since his re-admission on [DATE]. He stated there was a fine line for what pain medications would be covered so the facility had to use what hospice provided for R1. R1 was a former opioid addict; therefore, no matter how much medication the facility gave him he would ask for more. Upon interview and record review on 5/1/25 at 11:30 a.m. the administrator stated If a resident were in so much pain that cares could not be performed, she would expect staff to reach out to the provider, hospice or the regular provider if hospice were not involved and the nursing management would be aware and try to implement other measures to control the pain. Upon interview on 5/1/25 at 10:30 a.m. hospice supervisor, RN-F stated on 4/25/25 R1's daughter called hospice complaining of R1 calling her constantly and crying in pain and being told by the facility they were giving R1 everything they could for his pain. On 4/28/25 hospice RN-E visited R1 and increased his pain medications. A nursing progress note dated 5/25/25 indicated R1 had passed away. An undated note in R1's handwriting found in his notebook after his passing indicated, took last pain pill at 8:00 a.m. why can they send a man to the moon, yet still not stop a man from acute pain physical and mental. An undated note in R1's handwriting found in his notebook after his passing indicated, Minnesota adult reporting center [PHONE NUMBER]. An undated note in R1's handwriting found in his notebook after his passing indicated, further duration or stronger frequency, NO MORE PAIN. An undated note in R1's handwriting found in his notebook after his passing indicated, Others do not want to get involved with me because I need to get some help from others and management will not participating in facilitating that. A facility policy regarding pain was requested however none provided. The immediate jeopardy was removed on 5/2/25, the facility took immediate action to identify other residents at risk for uncontrolled pain, to reviewed policy and procedures, and educated staff on the following on 5/2/25 Manage or prevents pain: -Consistent with the comprehensive assessment and plan of care. -Current professional standards of practice. -Along with the resident's goals and preferences. -Monitored appropriately for effectiveness. -Defined how and when to monitor the resident's symptoms and degrees. but noncompliance remained at the lower scope and severity level 2 with a scope of D which indicated no actual harm with potential for no more than minimal harm that is not immediate jeopardy.

Based on observation, interview, and document review, the facility failed to complete a comprehensive skin assessment identifying pressure ulcers, treatments, and monitoring, resulting in serious harm, for 1 of 3 residents (R1) reviewed for pressure ulcers. R1 returned from a hospital admission and the hospital discharge summary indicated upon admission to the hospital, R1 had pressure ulcers to his coccyx, left heel, right heel, lateral right foot. The treatment for all the wounds was to cleanse and change the dressing. This resulted in an Immediate Jeopardy for R1 when the facility failed to provide the necessary treatment to R1 upon his return from the hospital for approximately six weeks. The immediate jeopardy began on 3/19/25, when R1 returned from a hospital admission with pressure ulcers. These pressure ulcers were not treated for approximately six weeks. The administrator, director of nursing, and regional nurse manager were notified of the immediate jeopardy at 5:10 p.m. on 5/1/25. The immediate jeopardy was removed on 5/2/25, but noncompliance remained at the lower scope and severity level 2 D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Upon observation and interview on 4/28/25 at 3:39 p.m. R1 was on his back in a hospital bed wearing a hospital gown telling a friend about his back pain. R1 agreed to a skin inspection, but stated he was in so much pain it caused severe pain to move him. He requested the assistance of three staff members and requested they move him slowly. R1 had dried blood on all five toes of his right foot. The second toe of his right foot had a dirty bandage on it. R1's sheet was pulled back and pressure ulcers were observed on both heels, and a pressure ulcer on his right lateral foot. Staff attempted to roll R1 onto his left side. R1 screamed in pain and gripped the side rail. He was screaming for staff to stop. He was laid back on this back. R1's coccyx area appeared red, it was difficult to visualize and make an assessment as R1's pain level was so great the staff had to reposition him back on his back within seconds. At 3:58 LPN-B gave R1 a pain medication. At 5:00 p.m. R1 continued to state his pain was a 10/10 and staff was still unable to move him. R1 was not offered any addition management for his pain. The director of nursing (DON) was notified, and the staff began to assess R1's skin. According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 08-08-2024, indicated: -Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. - Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. -Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). -Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). R1's physician orders dated 2/24/25 - 4/27/25 indicated on 2/25/25 R1 was to have the skin around his nose and behind his ears checked due to any skin concerns due to his oxygen tubing. On 3/4/25 R1 was to have weekly skin inspections by nursing staff. On 4/8/25 R1 had wound care to cleanse wound to right ankle with wound cleanser, pat dry and apply foam gauze dressing daily and as needed. No other wound orders were documented. R1's nursing progress note dated 3/4/25 indicated the wound practitioner saw R1 on wound rounds for an abscess on buttocks. The abscess was improving. The abscess was located on the right gluteal fold (area where the leg meets the buttocks). R1's nursing progress note dated 3/7/25 the interdisciplinary team (IDT) team met and reviewed the weekly wound rounds. R1's orders were up to date for the abscess to his right gluteus. R1's nursing progress note dated 3/14/25 a chest x-ray was ordered. R1 was alert and oriented. Vital signs within normal limits. Administered all medications to and wound care completed to coccyx/buttocks, no signs of infection. There were no measurements, assessment, or what type of treatment were completed to coccyx. The note failed to identify if this was a new area and/or if physician had been notified. R1's nursing progress notes dated 3/15/25 identified R1 was transferred to the hospital due to acute confusion, jitteriness, and a blood pressure of 70/40 (normal 120/80). R1 had ongoing wounds on his buttocks. The note failed to identify what types of wounds, any measurement or description. R1's hospital Discharge summary dated [DATE] received by the facility on 3/19/25 indicated: -Wound first assessed on 3/17/25 on his coccyx (tailbone) the wound was identified as moist blanchable (skin discoloration that disappears pressed upon and return when pressure is released indicating the blood vessels in the areas are occluded therefore blood flow is obstructed), the peri wound (area surrounding the wound) was excoriated, red and moist. Mepilex dressing was used to cover the wound following cleansing. -Suspected pressure ulcer to R1's left heel first assessed 3/17/25 the wound was purple, red, and fragile, the peri wound area was intact and red. The wound was cleansed and a Mepilex dressing applied. -Suspected pressure ulcer to R1's right heel first assessed 3/17/25 the wound was red and intact, cleansed and covered with a Mepilex dressing. -Suspected pressure ulcer to the left anterior foot first assessed 3/17/25 the wound was fragile, red, and intact, cleansed and covered with a Mepilex dressing. -Wound to the right lateral foot first assessed 3/18/25 the wound was fragile, red, pink with black eschar (scabbing) painful, cleansed and covered with Mepilex. -Wound to the right anterior knee first assessed 3/17/25 the wound was fragile and tan, cleansed and covered with a dressing. R1's hospital Discharge summary dated [DATE], received by the facility 3/19/25 indicated R1 was discharged with hospice services. There was no documentation of skin integrity. R1's nursing progress note dated 3/19/25, indicated R1 returned from the hospital. R1 signed onto hospice. R1's hospice plan of care dated 3/19/25, indicated R1's terminal diagnosis was acute hypoxic respiratory failure. Wound care order: Sacral wound and bilateral lower extremity wounds: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound skin. Cover with a foam bandage three times a week and as needed. Wound care was to be performed by the facility staff. R1's facility nursing readmit data collection dated 3/19/25, indicated under additional evaluation no pain was identified for R1. R1's skin condition indicated an area on the coccyx. In the summary notes included, wound to right buttock cover with foam dressing. Will continue to follow wound nurse. No monitoring, assessing, or any type of treatment was added to the care plan or the Treatment Administration Record (TAR) for this area on the coccyx. R1's nursing progress note dated 3/20/25, indicated the IDT met to review the weekly wounds to the abscess of his right gluteus. Wound improving. The note did not identify any new wounds as identified in the hospital record. The progress note did not address the pressure ulcers on his coccyx, left heel, right heel, or lateral right foot. R1's nursing progress note dated 3/21/25, indicated R1 refused his weekly skin assessment. R1's significant change Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score, R1 was dependent on staff assistance with toileting, showering, dressing, personal hygiene, rolling in bed, bed to chair transferring. R1 was always incontinent of bowel and bladder. R1's pertinent diagnoses were chronic congestive heart failure, opioid dependent, pain and chronic obstructive pulmonary disease. The MDS included there were no pressure ulcers or any other skin conditions or wounds to the feet. There was no mention of pressure ulcers on his coccyx, left heel, right heel, or lateral right foot as identified by the hospital on 3/17/25. R1's nursing progress note dated 3/27/25, indicated IDT weekly wound review indicated R1's abscess of the right gluteus had been resolved. There was no assessment of pressure ulcers on his coccyx, left heel, right heel, or lateral right foot. R1's electronic treatment administration records (eTAR) dated 4/1/25 - 4/27/25, indicated R1 was to have a weekly skin inspection. Wound cares to cleanse wound to right ankle with wound cleanser pat dry and apply foam gauze daily and as needed. Nurse to monitor and chart on resident picking at skin, scabs, wounds, if noted bleeding. If noted clean area and cover with bandage every day and evening shift. All treatments were marked as complete. The ulcer to his coccyx was not identified on the TAR. The pressure ulcers on R1's heels were not identified on the TAR either. No assessment of these areas was documented. R1's weekly skin inspection dated 4/4/25, indicated R1 had the same old wounds, no new skin issues noted. No actual assessment of any area of his skin was documented. R1's nursing progress note dated 4/7/25, indicated the facility nurse spoke with RN-B from hospice and asked if he would be writing orders for R1's wounds to his right foot/ankle and he stated he would. Writer asked for a treatment order and wanted R1 to be added to the facility wound rounds. Hospice RN-B stated he would be coming the following day or the next and would assess the leg and write treatment orders. The provider was updated, and nurse will clean and dress wounds daily. R1's facility care plan dated 4/9/24 - 4/28/25, did not indicate any skin integrity concerns for R1. R1's nursing progress note dated 4/11/25, indicated wound treatment to right foot was completed with assistance from a fellow nurse. There was no mention of pressure ulcers on his coccyx, left heel, right heel, or lateral right foot or any assessment of the right foot. R1's nursing progress note dated 4/17/25, indicated for nurses to please monitor and chart on R1 for picking at skin, scab's wounds. If noted bleeding if noted clean area and cover with bandage. There was no mention of pressure ulcers on his coccyx, left heel, right heel, or lateral right foot. R1's weekly skin inspection dated 4/18/25, indicated R1 had no new skin issues. Ongoing wound care to his right foot. There was no assessment of any skin ulcers or skin conditions documented. R1's nursing progress note dated 4/23/25, indicated for nurses to please monitor and chart on R1 for picking at skin, scab's wounds. If noted to be bleeding, clean area and cover with bandage. The following skin and wound evaluations and orders were completed during the survey process: -R1's skin and wound evaluation on 4/28/25 at 4:51 p.m., indicated R1 had a pressure ulcer (deep tissue injury) on his right medial malleolus (inside of the ankle) in-house acquired with an area 1.5 centimeters squared (cm), length 1.9 cm, width 1.1 cm. There was no documentation of the wound bed. -R1's Skin and wound evaluation on 4/28/25 at 4:56 p.m., indicated R1 had an unstageable (obscured full-skin and thickness skin and tissue loss) pressure ulcer on his right lateral (outside) foot in-house acquired. The wound area measured 4.3 cm, length 3.1 cm, width 1.8 cm, 0 depth, 60 % granulated (healing tissue in a wound bed), 40% slough (dead tissue and debris in a wound bed), light exudate (fluid in the wound, part of the healing process). -R1's skin and wound evaluation on 4/29/25 at 7:24 a.m., indicated R1 had unstageable pressure ulcer on his sacrum in-house acquired with an area of 32.9 cm, length 5.4 cm and with 7.8 cm, 0 depth. The wound was 50% granulated and 20% slough and 30% eschar (scab, dead cells). The wound had moderate serosanguineous exudate (mixture a watery bodily fluid and blood). -R1's weekly skin inspection summary dated 4/29/25 at 7:57 a.m., indicated R1 had a pressure ulcer on his sacrum, left and right buttocks. Pressure wound on his right lateral malleolus. Pressure wound on his right lateral foot. Pressure wound on his right medial malleolus. Abrasion of his left dorsum (top) 5th toe. Abrasion of his right dorsum 2nd toe. Abrasion of his right dorsum 1st toe. The wounds were assessed by the in-house wound nurse and treatment completed. Hospice and medical provider updated, and treatment orders obtained. -R1's clinical physician orders dated 4/29/25, indicated R1 was to have wound care to his sacrum (left and right buttock) cleanse wound with wound cleanser pat dry, apply skin prep to peri-skin. Apply calcium alginate to wound bed and cover with foam. -R1's clinical physician orders dated 4/30/25, indicated R1 was to have wound care to his right later malleolus and right lateral foot. Cleanse wound with wound cleanser, pat dry, apply skin prep to peri-skin. Apply Calcium Alginate to wound bed and cover with foam dressing. -R1's clinical physician orders dated 4/30/25, indicated R1 was to have wound care to his right medical malleolus. Apply skin prep to discolored area. -R1's clinical physician orders dated 4/30/25, indicated wound care to left 5th toe, right 2nd toe and right 1st toe. Apply skin prep to scabbed areas and cover with bandage. Upon interview on 4/28/25 at 4:12 p.m., licensed practical nurse, LPN-B stated she was unable to complete R1's readmission skin assessment because she was unable to reposition him to view his back. Since his readmission on [DATE] staff had difficulty completing cares on R1 because touching him made him scream in pain. She did not reach out to hospice as they were completing their own visits with him. She had placed a foam dressing over R1's coccyx at some point. She did not chart placing the dressing because there were no orders for a dressing change and the wound was small. She did not recall the last time she placed a dressing on his coccyx. LPN-B believed the wound care team or hospice was treating R1's skin. Upon interview on 4/29/25 at 8:55 a.m., nursing assistant (NA)-A stated she completed incontinence cares on R1, R1 would only let her reposition him when he needed cleaning following a bowel movement due to his pain. NA-A saw an open wound on R1's coccyx and at times the area had a dressing covering the area. She stated the dressing would be dirty and she would tell the nursing staff (unidentified staff and dates) and would be told the facility is not responsible for R1's skin. Upon interview on 4/29/25 at 10:04 a.m. hospice registered nurse, RN-B stated she was aware that R1 had a coccyx wound. She was not certain whether the facility had orders to tend to the wound or not. She was not aware of any heel or foot wounds. Upon interview on 4/29/25 at 11:14 a.m., family member (FM)-A stated she received a call from the facility on 4/28/25 that R1 had some sores and hospice should have been taking care of them, but the facility found out they were not. FM-A was not told the location or severity of the wounds. She stated she wondered if that was why R1 had so much pain. R1 had been calling her almost daily crying in pain. FM-A mentioned his pain to the facility, she was told they were giving him everything they could. She stated on 4/25/25, R1 called her sobbing on the phone wanting to go to the hospital due to his pain. FM-A notified Hospice. FM-A stated she had not seen staff reposition R1. Every time she visited him, he had was laying in the same position, on his back, and he had only attempted to get out of bed once since his hospital discharge of 3/19/25. Upon interview on 4/29/25 at 11:49 a.m. RN-A stated during her weekly skin assessment she did not notice any pressure ulcers on R1, however repositioning him due to his pain made it difficult to visualize his skin. She stated she would not be measuring his wounds during an assessment as the facility has a wound team that takes care of all the measurements. She was unable to perform a full body assessment at any point due to pain. She did not notify hospice or the provider about this. Upon interview on 4/29/25 at 11:57 a.m. licensed practical nurse, (LPN)-A nurse manager stated she was not aware until the survey observation findings that R1 had any pressure ulcers. She stated she reviewed the hospice notes and stated hospice was responsible for R1's ADL's (activities of daily living) so if there were any wound care treatments they would be performing it. She did not communicate with the hospice nurses regarding R1's pressure ulcers. LPN-A did not know hospice was only providing care once a week and did not see the orders that R1 had pressure ulcers. Upon interview on 4/29/25 at 4:37 p.m., hospice registered nurse, RN-A stated hospice does not complete wound care. He stated the orders were clear in R1's admission plan of care. That the facility was to complete the wound treatment. RN-A did not communicate with the facility about R1's skin because the hospice plan of care indicated the facility was completing R1's wound treatments. He assumed since the facility did not reach out to him there were no concerns with R1's skin. Upon interview on 4/30/25 at 11:30 a.m., the facilities Medical Director stated the facility is the main provider of care to the residents and must know who is providing any treatments. Upon interview on 4/30/25 at 2:14 p.m. the assistant director of nursing ADON stated he was the certified wound specialist for the facility. R1's skin condition was brought to his attention on 4/29/25 at around 4:45 p.m. He was able to assess R1's lower extremity wounds, but the facility could not manage R1's pain enough to assess his coccyx wound until the morning of 4/30/25. He ordered treatments for the wounds and reported the wounds to hospice. He stated he ordered daily dressing changes and hospice changed the orders to three times a week, Monday, Wednesday, and Friday. The ADON told hospice he wanted as needed order so the facility could also change the dressing, believing hospice was completing R1's treatments. He stated LPN-A told him upon his wound assessment that hospice was handling R1's wounds because they were doing his activities of daily living (ADL's). R1's progress note dated 5/1/25 at 7:02 a.m. indicated R1 had passed away. An undated note found in R1's handwriting in his notebook found after his passing undated indicated Thursday morning 7 a.m. convinced nurse to take bandage off lower back burning pain in lower back, bandage not looked at or attended for over 1 month. Upon interview and record review on 5/1/25 at 9:46 a.m. the director of nursing (DON) stated the nurse who completed R1's assessment did miss the wounds, however the wounds were the responsibility of hospice, so the facility would not necessarily have documented the wounds. The DON reviewed R1's hospice care plan indicating the facility was to be completing wound care and stated he never saw the hospice plan of care before and would need to investigate it. Upon interview and record review on 5/1/25 at 11:30 a.m., the Administrator stated the facility, and hospice provider should communicate to discuss the hospice resident, and the facility should document the communication. She would expect the facility to note and assess all wounds on their residents no matter who was completing the wound care. If during a facility assessment a wound was covered, she would expect the staff to remove the dressing if it were removable and assess the wound. The Administrator was not certain who was providing wound care for R1. The immediate jeopardy was removed on 5/2/25, when it was verified, the facility completed the following actions, on 5/2/25 The facility identified other residents at risk for pressure ulcers, reviewed policy, and procedures, and educated staff on the following: -Completion of comprehensive skin assessments according to professional standards. -Developed care planned treatments and monitoring to accurately reflect resident needs. A facility policy titled Skin Assessment and Wound Management with a revised 2/2025 indicated Provide guidelines for assessing and managing wounds were: A pressure ulcer risk assessment (Braden Scale) will be completed per Monarch's Assessment Schedule/Grid. Implement appropriate preventative skin measures. Examples include, but are not limited to-nutritional interventions, mobility and repositioning plan, pressure redistribution plan. Skin Evaluation and Skin Risk Factors Form is completed before initial MDS, annually, and upon significant change. Staff will perform routine skin inspections (with daily care). Nurses are to be notified if skin changes are identified. Licensed staff will complete a weekly skin inspection. When a significant alteration in skin integrity is noted; (i.e., large, or multiple bruising, large skin tear, or other non-pressure related wounds such as diabetic, venous, or arterial ulcers), the following actions will be taken: Notify Provider/Treatment Ordered. Notify resident representative. Complete education with resident/resident representative including risks & benefits. Initiate Skin and Wound Evaluation. Notify Nurse Manager/Wound Nurse. Referral to dietary, if appropriate. Referral to therapies, if appropriate. Review and update care plan including interventions. Update resident care lists. Update Care Plan to identify risks for skin breakdown. When a pressure ulcer is identified, the following actions will be taken: Notify Provider/Treatment Ordered. Notify resident representative. Complete education with resident/resident representative including risks & benefits. Initiate Skin and Wound Evaluation. Notify Nurse Manager/Wound Nurse. Referral to dietary, if appropriate. Referral to therapies, appropriate. Review and update care plan including interventions. Update resident care lists. Update Care Plan to identify risks for skin breakdown. Follow ongoing treatments per provider order. Update provider and resident/representative as needed. Update care plan as needed.

Based on observation, interview and document review, the facility failed to assess, monitor for side effects and drug interactions, implement interventions and follow facility policy to ensure the safety of 2 of 3 residents (R1, R6) who were reported to use crack cocaine all weekend on the facility smoking patio. This resulted in an immediate jeopardy (IJ) for R1 and R6 and had the potential to affect 20 other residents who were identified at risk for illicit drug use. The IJ began on 7/6/24 when R1 and R6 were seen smoking crack cocaine on the facility patio and were not assessed or monitored for potential life-threatening side effects and drug interactions. The director of nursing and administrator were notified of the IJ on 7/25/24 at 5:10 p.m. The IJ was removed 7/26/24, but noncompliance remained at the lower scope and severity level of an D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment. R1 was her own decision-maker. R1's Face Sheet printed 7/12/24, lacked family or friends listed in her contact information to help make decisions and listed R1 as the responsible party for her own care and admitted to the facility 12/3/23 with intraabdominal and pelvic mass. R1's Smoking Evaluation dated 6/12/24 indicated R1 was a safe smoker and could keep her smoking materials stored in her personal belongings. The evaluation indicated R1 had cognitive loss, used oxygen, and was educated to remove and store oxygen prior to smoking. R1's care plan dated 3/4/24, lacked indication R1 had a history of smoking marijuana or other illicit substances. R1's Provider Orders printed 7/9/24 lacked directions about monitoring or use of illegal substances. R1 provider orders included paroxetine (Paxil, an antidepressant) dated 2/23/24, Dilaudid (a narcotic pain medication) dated 4/3/24, and gabapentin (an anticonvulsant used to treat seizures and nerve pain) dated 2/22/24. On 3/28/24 a progress note indicated R1 was educated about the facility substance use policy regarding the use of marijuana. On 4/16/24 a progress note indicated R1 was seen smoking marijuana on the smoking patio and refused to give the marijuana or smoking materials to the social worker (SW). R1 was updated on the facility substance use policy. The facility Substance Use Policy dated 6/23, specified illegal or illicit non-prescribed substances or paraphernalia were not allowed on the facility premises and staff would confiscate any illegal or illicit substance or paraphernalia. On 5/30/24 a progress note indicated social services met with R1 after R1 was seen exchanging money and a bag with another resident, R2. R1 denied the behavior but admitted use of marijuana. On 7/5/24 a progress note indicated R1 was seen smoking crack out of a small pipe, and R1 stated she would do whatever she wanted. The progress notes further indicated social service staff re-educated R1 about the substance use policy, offered substance use support, and informed R1 she was banned from smoking on the smoking patio with other residents. R1 continued to smoke on the patio regardless of social services staff asking her not to. On 7/8/24 a progress note indicated R1 and another resident (R6) were smoking crack all weekend on the smoking patio (7/6/24 and 7/7/24) and were seen purchasing drugs across the street from the facility. The progress note indicated R1 confirmed smoking crack with the other resident, and [R6] sold it to her. R1's room was searched, and nine broken glass crack pipes were taken from her room because drug paraphernalia was not allowed on campus per the Substance Use Policy. R6's admission MDS dated [DATE] did not include a cognitive assessment as R6 refused to participate, but indicated R6 was an independent decision-maker. R6's Face Sheet printed 7/12/24, indicated R6 admitted to the facility with diagnoses of osteomyelitis (inflammation of the bone), and a history of frost bite. R6's care plan dated 6/19/24 indicated R6 smoked in the facility and was noted to smoke marijuana in the facility. The care plan further indicated R6 had a history and diagnosis of substance use. R6's Provider Orders printed 7/9/24, lacked directions about monitoring or use of illegal substances. R6's provider orders included Oxycodone (a narcotic pain medication) dated 6/11/24, lisinopril (a medication used to treat high blood pressure and heart failure) dated 7/9/24, and gabapentin dated 6/11/24. On 7/5/24 a progress note indicated R6 was seen smoking a white substance out of a small pipe, and R1 admitted to using drugs. On 7/9/24 a progress note indicated R6 and another resident (R1) were seen smoking crack all weekend on the smoking patio and were seen purchasing drugs across the street from the facility. R6 denied smoking crack and denied selling it to the other resident. Staff searched R6's room and found a marijuana pipe and a pocketknife. On 7/9/24 at 2:27 p.m., during an interview anonymous reporter (AR)-B stated R1 used marijuana, and used both marijuana and crack on the smoking patio. You can smell the marijuana. AR-B stated R1 smoked crack cocaine on the patio or by the facility front door. AR-B stated, It's just known she uses and she does it on the patio. On 7/9/24 at 2:55 p.m., during an interview nursing assistant (NA)-A stated R1, Puts something in a little glass pipe and smokes it outside, with other residents, and had seen it. NA-A denied reporting it to administration. On 7/25/24 at 11:58 a.m., in a subsequent interview NA-A stated she did not report drug use because she didn't know she needed to because, Everyone knew already. On 7/9/24 at 4:17 p.m., during an interview NA-F stated a lot of the residents smoked marijuana, and residents from the apartment building across the street sat in front of the facility with facility residents. She has seen, Stuff is exchanged from one hand to another, and you know it is something illegal by the way they act. On 7/25/24 at 11:37 a.m., in a subsequent interview NA-F stated she didn't report drug use to administration because, They [administration] knew people were smoking marijuana. Nobody said what we were supposed to do. On 7/9/24 at 4:49 p.m., during an interview the administrator stated during her investigation several residents reported seeing R6 buy drugs across the street from the facility in the previous two days on 7/6/24 and 7/7/24. Further, the administrator stated R1 admitted to using crack cocaine and R6 sold it to her. All we can do is ask if we can search, remove it if we find it, and re-educate the resident. If I actually saw them using [drugs] I would call the police. The administrator stated she suggested R1 relocate to a different facility as R1 was known to use illicit drugs. The administrator stated residents told a social services staff they saw drug deals and crack smoked on the patio, R1 has always purchased marijuana and, Wouldn't put it past her to share. The Substance Use policy dated 6/2023, indicated staff should confiscate illegal or illicit substances or paraphernalia, and if any amount of illicit substance was found, staff would contact police for instructions on how to handle it. On 7/10/24 at 9:20 a.m., during an interview social services designee (SS)-A stated R1 reported to her she bought drugs from R6 and could do what she wanted. SS-A stated R1 had a friend across the street who staff suspected was selling drugs to R1, and had come to facility twice in the prior two days. SS-A stated the administrator banned this friend from the facility. SS-A stated she offered R1 drug treatment, but R1 declined. Further, SS-stated if staff saw drug deals, it had not been reported to her. SS-A stated she asked administrative staff for supervised smoking for R1 and R6 and was told there was no staff available for that intervention, or for supervised leaves of absence for either resident. SS-A acknowledged knowing R1 and R6 smoked crack on the patio no longer qualified them as safe smokers. SS-A further acknowledged another resident, R6, was the resident who smoked crack cocaine with R1, but R1 did not acknowledge buying drugs from R6. SS-A stated R1 had less money than she used to, and wasn't buying anything other than drugs. On 7/25/24 at 9:58 a.m., during a subsequent interview SS-A stated when drug use was suspected facility interventions included room searches, staff removed drug paraphernalia, and resident re-education. SS-A stated the facility asked residents to smoke marijuana on the public sidewalk instead of on the facility grounds but resident met people from across the street and bought drugs from them. SS-A stated the facility staff told residents they were not allowed to smoke cannabis on the patio, but the facility policy did not indicate that. SS-A stated she did not report drug use to administration right away, but puts a note in the medical records, re-educates the residents and then updates the nurse manager and the administrator. On 7/10/24 at 10:44 a.m., during an interview pharmacist (PH)-A stated he was not aware of illicit drug use by either R1 or R6. PH-A stated if either R1 or R6 were using crack cocaine or marijuana, the pharmacist should have been notified as there could be contraindications or side effects with other medications. The pharmacist should have been notified due to potential drug interactions, including death, and amphetamines could worsen resident health conditions. R6 could have negative interactions between crack cocaine and Oxycodone which could make R6 more high, or have addiction results, and the reaction between crack cocaine and gabapentin could be increased sedation. Those two would be a big concern. R6 used lisinopril for elevated blood pressure, but if R6 was not taking his medications as he often refused, his blood pressure could elevate and he could have heart problems, drug interactions, and death. R1 could have similar sedating effects from using crack cocaine and gabapentin together, and if R1 used paroxetine with crack cocaine she could have increased anxiety, depression, and suicidal thoughts. On 7/10/24 at 12:13 p.m., during an interview R6 stated, Don't be asking me no questions about drugs. On 7/10/24 at 1:33 p.m., during an interview nurse practitioner (NP)-B stated she was not informed R6 was using illicit drugs. Staff should have informed her of suspected drug use so she would know what was safe to prescribe and, If they knew on Friday, they should have called on Friday. On 7/10/24 at 2:05 p.m., during an interview the director of nursing (DON) stated when staff knew residents were using drugs, staff should report it to their supervisors, try to remove the drugs safely, and report it to the provider and family members. He was unsure if the pharmacist was notified about R1's and R6's drug use. On 7/5/24 staff was educated about checking on R1 every hour to monitor for adverse effects of drug use, intoxication, and to notify the provider right away if drug use was suspected. He did not have a copy of the education provided, nor a list of which staff was educated on 7/5/24, and acknowledged the orders for hourly checks started on 7/10/24. He expected staff to pass the information to other staff during report, but acknowledged he did not add the information to the report sheet. He acknowledged police were not notified of crack cocaine use on the property. Nursing staff was likely not wanting to get involved in the drug issue. If the pharmacist was not informed about illicit drug use, there could be reactions to some medications. He denied knowledge of any other residents other than R1 and R6 using marijuana or crack cocaine. On 7/25/24 at 2:11 p.m., during a subsequent interview the DON stated he was not told about the drug use until 7/8/24, and did not know why staff did not report it to him over the weekend. The DON stated there was no indication staff assessed R1 and R6 after the reported drug use, the provider was notified, or medications were held. On 7/10/24 at 2:11 p.m., during an interview NP-A stated she was notified of R1's crack cocaine use on 7/5/24, and acknowledged R1 used crack cocaine previously. On 7/10/24 at 3:20 p.m., during an interview the administrator stated the police were now notified about R1's and R6's crack cocaine use in the facility. She would have expected to see a care plan for both residents about it, providers updated, the pharmacists, and responsible parties updated. The administrator stated the policy indicated the provider would be notified and the police were notified if drugs other than cannabis was found. Additionally, the administrator acknowledged the policy lacked instruction to notify the pharmacist. On 7/10/24 at 12:48 p.m., during an interview AR-A stated he saw R1 and R6 smoke marijuana in their rooms and on the smoking patio, and on 7/4/24 he saw them smoke crack cocaine on the smoking patio. AR-A further stated he witnessed R6 wheel his wheelchair up to a car in the street to buy drugs. [R6] goes every day between two and three p.m., to buy drugs. Everyone knows. On 7/10/24 at 1:58 p.m., during an interview R1 stated she did use crack cocaine, didn't care if it interacted with her other medications, and would do it if she wanted. She admitted to smoking crack cocaine on the smoking patio. On 7/10/24 at 4:49 p.m., during an interview AR-C stated R6 was on the patio smoking crack and was known to go to a nearby hospital, Hustling people for money. AR-C stated she requested supervised outings for R6 but was told there was no staff or family to take R6 out. AR-C stated R6 was deemed a safe cigarette smoker, but was not assessed for smoking illicit drugs on the patio, It is not safe for other residents on the patio. AR-B stated other residents were trying to stay drug-free and using drugs, marijuana, or crack on the patio near them could trigger relapse to using again. Additionally, AR-C stated administrative staff was aware of many marijuana users in the facility. AR-C stated R6 got drugs from the shelter where he used to live and wanted to go back to R6 for that reason. AR-C further stated other residents were trying to maintain sobriety, and could be triggered to use drugs again if others were using drugs around them. On 7/25/24 at 9:25 a.m., during a subsequent interview AR-C stated the facility had no interventions in place to prevent drug use and further stated all she was allowed to do was re-educate the residents about it. The administration identified on 7/25/24, at 12:05 p.m. identified they had approximately 20 current residents who had a history of drug abuse and were potentially at risk for relapse for drug abuse. Although the facility was aware R1 and R6, were smoking and using illicit drugs in which broken crack pipes were found in R1's room and staff were aware this was occurring. The facility had not assessed or monitored these resident for potential life-threatening side effects and drug interactions when using these drugs. In addition the facility had not implemented interventions to mitigate the risk of residents purchasing and bringing these drugs back to the facility even though the facility identified approximately 20 residents in their facility had a history of drug abuse and were potentially at risk for a relapse. The facility's Substance Use Policy dated 6/23 directed due to negative health side effects from mixing some prescribed medications with alcohol and/or illegal substances, a resident who the facility has a reasonable suspicion or believe has been using alcohol or illegal substances will be subject to the policy. The policy directed illegal or illicit non-prescribed substances or paraphernalia were not allowed on the facility premises. The policy directed care plans should include risks of leaving the facility without notification, signs and symptoms of use, and risk of overdose. The policy further directed staff to review medication administration records and orders for medications that are contraindicated with substance use, call physician or NP, and document notification. The policy directed social services staff would revise the resident plan of care focus for Substance Use and Disorders. The policy lacked direction to notify the pharmacist of suspected or known drug use. 46885 The immediate jeopardy that began on 7/6/24, was removed on 7/26/24 at 5:00 p.m., when the facility updated R1's orders and the care plan was updated to include monitoring and reflect history and use of smoking marijuana and substances. R1 was educated on the risks and benefits of substance use and re-educated on the substance use policy. Additionally R1's physician and pharmacy consultant were notified of R1's substance use and like residents were reviewed to ensure orders were in place, care plans updated, providers and pharmacist were notified and the risk versus benefits completed. Additionally, staff education was completed on signs of intoxication and how to respond along with notification to the hospice provider. This was verified through observation, interview and document review.

Based on interview and document review, the facility failed to evaluate a resident's discharge needs to ensure self or appropriate discharge location could accommodate his medical needs including blood sugar checks, insulin administration, and wound care, for 1 of 1 resident (R6) who was discharged to a homeless shelter that was unable to meet R6's complex medical needs. This resulted in the potential for serious harm, injury, impairment, or death to R6. The immediate jeopardy began on 7/23/24, when R6 was discharged from the facility when facility transportation dropped R6 off at Union Gospel Mission, a homeless shelter that was not equipted to meet R6's medical needs. The administrator, director of operations, and the director of nursing were notified of the immediate jeopardy at 5:22 p.m. on 7/26/24. The immediate jeopardy was removed on 7/27/24, but noncompliance remained at the lower scope and severity level D scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 admitted to the facility on [DATE], from the hospital, did not have a change in mental status, had verbal behavioral symptoms directed toward others 1 to 3 days that significantly interfered with R6's care, participation in activities, or social interactions, used a wheelchair, was independent with most activities of daily living (ADLs) and required supervision or touching assistance with transfers. Additionally, ambulation and picking objects up was not attempted due to medical condition or safety concerns and was admitted due to amputation, multidrug resistant organism (MDRO) infection, diabetes mellitus, acute osteomyelitis (bone infection) of the left and right ankle and foot, frostbite with tissue necrosis (death of body tissue) of right and left toes. The MDS further indicated R6 used tobacco, had recent major surgery, was at risk of developing pressure ulcers, had an infection of the foot, surgical wounds, had pressure reducing devices for the chair and bed and had surgical wound care. The MDS indicated R6 had insulin injections 7 of 7 days. R6's care area assessment (CAA) dated 6/18/24, was not triggered for a referral to return to the community. R6's 48-hour care plan form dated 6/12/24, indicated a self-care deficit related to amputation to bilateral feet and had an alteration in mobility due to a non-weight bearing status on the left foot and needed assist with transfers and bathing. Additionally, R6 had pain issues due to amputations to bilateral feet, had an alteration in skin integrity and had sutures via surgery to bilateral feet. R6 had an alteration in mood and behavior with a history of substance abuse, and was on enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.) R6 was at risk for falling due to non-weight bearing on the left foot R6's history and physical dated 6/2/24, indicated R6 was admitted to the hospital on 6/2/24, for evaluation of a foot infection. Additionally, R6 had prediabetes and a history of type 2 diabetes mellitus but was not on any chronic medications and appeared to be diet controlled. Additionally, the notes indicated R6 started insulin glargine (a long-acting insulin) 100 units/milliliter (ml) 10 units at bedtime on 6/6/24, along with insulin lispro (a fast-acting insulin) 2 to 10 units three times a day with meals. R6's hospital discharge summary dated 6/11/24, indicated R6 was at a homeless shelter and discharge diagnoses included the following: diabetic foot infection, cellulitis and abscess of foot, osteomyelitis of toe, maggot infestation, open wounds of the right and left foot, acute osteomyelitis of the left foot, methicillin resistant staphylococcus aureus (MRSA) (an infection resistant to certain antibiotics), and a left retinal detachment. R6 arrived at the hospital on 6/2/24, for evaluation of bilateral foot infections. R6 had bilateral frostbite in April 2024, R6 was unable to maintain follow up and both feet became significantly infected. The left foot had multiple digits that were infected with maggots and a maggot born bacteria, ignatzschineria, as well as MRSA that was identified on blood cultures. R6 was taken to the operating room on 6/2/24, and had a left foot TMA (transmetatarsal amputation, a surgery to remove part of the foot) and right foot partial amputation and recommendations indicated R6 should continue non-weightbearing to the right lower extremity. The discharge summary included a medication list that indicated R6 needed to start taking insulin glargine-yfgn 100 units per milliliter (ml), inject 10 units subcutaneously daily at bedtime for type two diabetes, insulin lispro 100 units/ml inject 1-5 units subcutaneously three times a day with meals as needed for diabetes: 1 unit for a blood glucose of 150 to 200, 2 units for a blood glucose of 201 to 250, 3 units for a blood glucose of 251 to 300, 4 units for a blood glucose of 301 to 350, 5 units for a blood glucose of 351 to 400, and call the provider if blood glucose is greater than 401. Further, the summary included instructions to change how R6 took the following medications: Tylenol, and oxycodone and provided instructions to continue taking a list of medications that included gabapentin, multivitamin, and rosuvastatin. Additionally, documentation indicated a referral was sent to a long- term care facility in anticipation R6 would no longer need a transitional care unit (TCU) once medically ready. R6's admission assessment dated [DATE], indicated R6 had an amputation to both feet, and had an IV. R6's Resident Discharge Plan form dated 6/12/24, indicated R6 was homeless and would need a place to stay and was awaiting a medical grant to be approved for R6 to get his own place, and would need a wheelchair upon discharge. Under the heading, What is the capacity of the resident and or caregivers to meet the needs of resident upon discharge/transfer indicated R6 was homeless and was unable to adequately care for himself and a discharge or transfer was feasible. The form identified other sections, How was the resident involved in discharge plan development Is the resident interested in receiving information regarding return to the community If so, was referral made to the local contact agency Date evaluation results were discussed with the resident/resident's representative. These areas were left blank. R6's Orders form in the electronic medical record (EMR) indicated the following orders: 6/13/24, staff to follow contact precautions for MRSA in wounds every shift. 6/21/24, wound care to surgical site TMA left #2 surgical site first MTP joint right instruction: cleanse with Vashe or sterile normal saline. Apply Betadine and allow to dry completely before covering wound with sterile 4 by 4 dressing, then wrap with Kerlix and ACE wrap. Change daily every shift for surgical wound. 7/10/24, Tobramycin ophthalmic solution 0.3% instill 1 drop in left eye four times a day for chronic total retinal detachment (a condition that affects vision and can lead to blindness if not treated). 7/10/24, Atropine Sulfate ophthalmic solution 1% instill 1 drop in the left eye two times a day for chronic total retinal detachment. 7/10/24, prednisolone acetate ophthalmic suspension 1% instill 1 drop in the left eye four times a day for chronic total retinal detachment. 7/19/24, R6 can get bilateral extremities wet in shower but should not submerge the feet. Elevate and ice as needed. 7/19/24, therapy to order orthotic and shoes from Tillges due to diabetes and history of amputation bilaterally. 7/22/24, Ok to discharge to Union Gospel Mission (homeless shelter) on 7/23/24, with remaining medication. 7/22/24, Lantus SoloStar 100 u/ml (units per milliliter) inject 15 units subcutaneously at bedtime. 7/22/24, mechanical wheelchair for impaired mobility. 7/22/24, glucometer with testing supplies to check blood sugars twice daily. 7/22/24, appointment for foot and ankle follow up on 8/19/24 at 1:00 p.m. R6's medication administration record (MAR) and treatment administration record (TAR) for July 2024, indicated the following: a check box was marked indicating wound care (surgical site TMA Left and first MTP joint right, cleanse with Vashe or Sterile NS. Apply Betadine and allow to dry completely before covering wound with sterile 4 by 4 then wrap with Kerlix and ACE wrap) was administered on the following dates: 7/6/24, 7/10/24, 7/11/24, and 7/21/24. Wound care was completed 4 times out of 23 opportunities. a check box was marked indicating Tobramycin ophthalmic drops were administered 41 times from 7/10/24, to 7/22/24. Tobramycin was administered 41 time out of 54 opportunites. a check box was marked indicating Atropine Sulfate ophthalmic drops were administered 21 times out of 27 opportunities from 7/10/24, to 7/22/24. a check box was marked indicating prednisolone acetate ophthalmic suspension 1% drops were administered 41 times out of 54 opportunities from 7/10/24, to 7/22/24. a check box was marked indicating R6 received 12 units of Lantus SoloStar insulin at bedtime 11 times out of 21 opportunities from 7/1/24, to 7/21/24, and did not receive 15 units on 7/22/24. R6's blood sugar was checked 26 times out of 68 opportunities from 7/1/24, to 7/22/24, and ranged from 113 to 341. R6's Resident Family Education form dated 6/17/24 at 1:39 p.m., indicated R6, and family/caregiver were present when refusal of cares, medications, and verbal vulgarity were discussed. R6 was educated on the importance of communicating needs to staff and respecting other residents and staff. R6's discharge potential was expected in the next 90 days and R6 understood basic information. R6 continued to be agitated. R6's nurse practitioner (NP) note dated 7/8/24, indicated R6 was refusing cares consistently and was verbally abusive to staff, threatening physical abuse and staff had concerns for crack cocaine use that R6 denied and did not allow the foot dressing to be changed. Additionally, R6 had also refused some doses of his antibiotics and the NP was concerned about the wound status and infection given R6's refusal to adhere to antibiotics, dressing changes. R6's nursing progress notes dated 7/8/24 at 11:58 a.m., indicated a late entry was entered from administration that it had been reported R6 was smoking crack (an illegal substance) all weekend on the smoking patio and was seen purchasing drugs across the street from the facility. R6 agreed to a room search and denied smoking crack and selling crack to another resident. A marijuana pipe with a cleaner, pill bottle with multivitamins, and a pocketknife was found. R6's Risk vs Benefits form dated 7/11/24, in progress and saved on 7/26/24 at 10:30 a.m., indicated R6 refused to go to his follow up eye surgery appointment and staff explained it was important to follow up to promote healing. R6's progress notes dated 7/11/24 at 11:59 a.m., indicated a referral was sent to River Oaks residential treatment facility for review, R6 had a history of aggressive behaviors due to MH (mental health) and substance use that was exhibited regularly at the facility. R6's relocation worker was notified who was looking into whether R6 could enter the residential facility found for R6 by 7/12/24, but if not, would like to know the outcome of the River Oaks referral. R6's progress note dated 7/11/24 at 12:26 p.m., indicated R6's relocation coordinator was not able to get R6 into the residential facility anytime soon and was ok with R6 going to River Oaks if accepted and were awaiting an update from River Oaks residential facility. R6's progress note dated 7/11/24 at 4:10 p.m., indicated a referral was sent to Victory Health and Rehab, a nursing facility. R6's facility referral form to River Oaks of Minnesota dated 7/11/24, from the director of social services indicated R6's case manager had his MH diagnoses and further indicated the facility had issues with R6 having substance issues causing safety concerns. The record did not identify if admission was accepted or denied. R6's nurse practitioner (NP) note dated 7/12/24, indicated R6 was aggressive and abusive and declined all cares and assessments of wounds. R6's progress note dated 7/12/24 at 11:57 a.m., indicated R6's family member contacted the facility and was belligerent and the call was ended, and the director of nursing was informed of the conversation. R6's skin and wound evaluation note dated 7/15/24, indicated R6 had 13 sutures to the right dorsum 1st digit amputation site that measured 0.6 centimeters (CM) long by 4.5 cm deep with no drainage and was healable, the dressing was dry, and the progress was stable. R6's skin and wound evaluation note dated 7/15/24, indicated R6 had 35 sutures to the left transmetatarsal amputation site that measured 0.9 cm long by 7.6 cm wide with no drainage, the wound was healable, and the dressing was dry, and the area was stable. R6's Integrated Wound Care progress note dated 7/15/24, indicated wounds were healing well to the left TMA with 35 sutures in place, and to the first MTP (metatarsophalangeal) joint (the joints between the metatarsal bones of the foot and the proximal bones of the toes) on the right with 13 sutures in place. The treatment recommendation for both sites included cleansing with Vashe or sterile normal saline, application of Betadine and allow to dry completely before covering wound with sterile 4 by 4 dressing then wrap with Kerlix and ACE wrap and change daily. Additionally, the note indicated the following factors that affected wound healing: diabetes, neuropathy, obesity, non-compliance, age, pain, limited weight bearing status, general weakness, reduced mobility, and tobacco. Additionally, miscellaneous orders included partial weight bearing status, optimize nutrition, and diabetes control. R6's progress notes dated 7/17/24 at 10:55 a.m., indicated R6 had an appointment at the HealthPartners infection clinic and wound treatment was completed and the PICC (peripherally inserted central catheter) was removed and discontinued. R6's doctor of podiatric medicine (DPM) note dated 7/19/24, indicated R6's sutures were removed and R6 could get bilateral extremities wet in the shower but should not submerge the feet and elevate and apply ice as needed and a prescription for orthotics/shoes from Tillges due to diabetes and history of amputations bilaterally. R6's signed physician discharge summary dated 7/22/24, indicated R6's follow up podiatry appointment was on 7/19/24, in which sutures were removed and surgical sites were healed and R6 was being fitted for orthotic shoes and did not need any routine follow up with podiatry. R6 refused to remove socks on physical exam so the surgical sites could be evaluated. R6 was weight bearing as tolerated using a wheelchair for longer distances. The note also indicated R6 would benefit from a manual wheelchair because R6 had difficulty walking due to bilateral partial foot amputations which impaired the ability to accomplish mobility related ADLs safely and was unable to bear weight for normal mobility. Under the heading, Changes in Chronic Problems/Medications, indicated R6 had diabetes mellitus and started on daily Lantus insulin and was receiving a sliding scale insulin that was stopped before discharge. Additionally, discharge medications included: atropine 1% eye drop solution 1 drop into the left eye twice daily. prednisolone acetate 1% eye drop 1 drop into left eye 4 times a day. Tobramycin 0.3% eye drop solution place 1 drop into the left eye 4 times a day. insulin glargine (Lantus SoloStar) 100 unit/ml pen inject 15 units subcutaneously daily at bedtime. An email from the facility administrator dated 7/22/24 at 2:23 p.m., to Growth Services (a support organization to help reduce barriers for people with disabilities or disabling conditions to find and keep housing), indicated they felt it was in the best interest of the facility to expedite R6's discharge due to his illicit drug use and complaints made to the Minnesota Department of Health, as R6 posed a safety risk to other residents. The administrator requested a response to the email or a returned voicemail as soon as possible to get a plan in place. An email from the facility administrator dated 7/22/24 at 2:53 p.m., to Growth Services indicated the administrator spoke with Union Gospel Mission (UGM) intake who stated they could take R6 in their transitional care while waiting for his group home to open and the administrator communicated this to R6 who verbalized understanding he would discharge 7/23/24. The administrator's progress note dated 7/22/24 at 2:48 p.m., indicated the administrator called and spoke with Union Gospel Mission (homeless shelter) intake who stated they could take R6 in their transitional care while awaiting his group home to open and would need a valid photo ID, cannot be a level three sex offender and the information was communicated to R6 who verbalized understanding he would discharge 7/23/24, a ride was set up for 1:00 p.m., and a call and email was sent to R6's relocation coordinator. An email from Growth Services to the facility administrator dated 7/22/24 at 4:06 p.m., indicated Growth Services was still waiting to hear back from the group home who assessed R6 the previous week and was waiting to hear back from the CADI (community access for disability inclusion, a program that provides home and community based services to children and adults with disabilities who require the level of care provided in a nursing facility) case manager to help process paperwork for R6 to move in and there was nothing Growth Services could do on their end until those things happened. The director of social service's progress note dated 7/22/24 at 4:46 p.m., indicated R6 will be discharged from the facility and going to Union Gospel Mission (UGM) and R6 verbally agreed to the plan and an order for a wheelchair would be sent to Reliable to be delivered to Union Gospel Mission and R6 would take the wheelchair he had from the facility until he received the new one. Additionally, a referral for orthotics would go with R6 at the time of discharge and R6's family member and relocation coordinator were notified. R6's hand written physician orders dated 7/22/24, indicted the following orders: discontinue scheduled tylenol Tylenol 560 milligrams (MG) by mouth three times a day as needed for pain. Discontinue insulin sliding scale increase lantus to 15 units subcutaneously every day for diabetes. glucometer with testing supplies to check blood sugars twice daily mechanical wheelchair for impaired mobility ok to discharge to Union Gospel Mission with remaining medications. The hand written physician orders lacked information regarding whether wound care orders should be changed or discontinued. The order for wound care (surgical site TMA Left and first MTP joint right, cleanse with Vashe or Sterile NS. Apply Betadine and allow to dry completely before covering wound with sterile 4 by 4 then wrap with Kerlix and ACE wrap) was not discontinued in R6's electronic medical record. R6's Discharge Instructions and Summary form dated 7/22/24, indicated R6 was discharging to Union Gospel Mission (Homeless shelter). Under the heading, Reason for Discharge, the reason for discharge was blank. Under the heading, Reason for Discharge/Transfer indicated R6 completed IV antibiotics and sutures to bilateral feet were removed and goals were met. Additionally, R6 is homeless and not able to care for his feet and developed a severe infection. R6 refused to work with therapy, swore, was non-compliant with cares, and had retinal reattachment surgery to the left eye and continued eye drops and was discharged to Union Gospel Mission (UGM) with remaining medications. R6 had an order for a new wheelchair that will be sent to Reliable Medical and delivered to R6 at UGM and a referral R6 will take in hand for orthotics. Under the heading, Ability to See in Adequate Light with Glasses or Other Visual Appliances indicated R6 was impaired. Under the heading, Medications, indicated R6 had Lantus Solostar 100 units/ml inject 12 units subcutaneously at bedtime for diabetes, along with Humalog KwikPen 100 units/ml with instructions to administer according to a sliding scale and was last administered on 7/21/24. Under the heading, Treatments, Specific Skin Treatment Instructions indicated amputation to bilateral feet with no additional treatment instructions documented. Under the heading, Activity, indicated non weight bearing. There were no orders for a home health nursing referral, and under the heading, Mood/Behavior/Psychosocial Wellbeing: the resident has a history of verbal aggression, substance use and non-compliant with cares while at the facility. Under the heading, Follow Up Appointments, UGM will access (sic) for needs. Under the heading, Information to be Communicated to Receiving Health Care Institution or Provider, no physician name or phone number was identified. Under the heading, Items Provided, gave options for check boxes for advance directives, copy of most recent labs, most recent MD consultation, most recent MDS, comprehensive care plan including goals, most recent H&P. All items were left blank and under the heading, List of Any Other Documents Attached to Ensure a Safe and Effective Transition of Care indicated a referral for orthotics. In bold type indicated this form including reconciled medication list was sent with resident, family and or caregiver, subsequent provider and home health care if indicated by paper. Under the heading, Other Special Instructions/Isolation Precautions, indicated R6's relocation worker's name and phone number. Additionally, R6 signed the form below a heading, Client/Patient/Resident verbalized understanding of instructions, explanations regarding medications and other instructions on 7/23/24. The form lacked information R6 was sent with a prescription for a blood glucose monitor, or that one was provided, that an assessment for self-administration of insulin, eye drops, and other medications was completed, and that an assessment indicating R6 was able to check his own blood glucose was completed. The above referenced instructions included medication and dose amount, but lacked instruction for how to administer insulin, eye drops, and how to check a blood glucose level. R6's medical record was reviewed and lacked information R6 was provided instruction or education on how to self-administer eye drops, insulin, or check his own blood glucose, or that a medication self-administration assessment was completed. R6's discharge Minimum Data Set (MDS) in progress, dated 7/23/24, indicated R6 had a planned discharge with a return not anticipated on 7/23/24. R6's discharge status location for section A2105 was not completed. Additionally, on section A2121, 'did the facility provide the resident's current reconciled medication list' was not documented if it was provided to the subsequent provider, along with A2122 'the route of the current reconciled medication list transmission to the subsequent provider' was also not documented. R6 was cognitively intact, had verbal behavioral symptoms 4 to 6 days, rejected care daily, was on a scheduled pain regimen, and a referral to a local contact agency was not made because the discharge date was three or fewer months away. R6's care plan printed 7/25/24 at 9:49 a.m., indicated R6 would have an appropriate discharge plan with a goal R6 and family would make safe and appropriate decisions regarding discharge and staff would make necessary referrals as needed to carry out R6's discharge goals. The administrator's progress note dated 7/23/24 at 11:50 a.m., indicated the administrator contacted UGM to confirm R6 was able to admit, and the administrator gave a short handoff that R6 was independent with cares and activities of daily living (ADLs), IV antibiotic was discontinued, and surgical sutures were removed on 7/19/24, and the primary care physician felt R6 was stable for discharge to UGM. R6's nursing progress note from licensed practical nurse (LPN)-A dated 7/23/24 at 1:27 p.m., indicated R6 discharged to UGM and was discharged with belongings, all medications, one insulin pen and R6 would follow up with primary physician. The progress note lacked information how R6 would receive medication refills or that R6 was able to demonstrate self-administration of medications and understanding of how to use medications and glucometer. The administrator's progress note dated 7/23/24 at 3:45 p.m., indicated R6's sister called to inform her that UGM declined to allow R6 in the building and R6 was sitting on the sidewalk. The administrator contacted a staff person from UGM who told the administrator R6 looked like he required more care and the administrator called and spoke with the director at UGM who stated they could not accept R6, and the administrator asked what their plan was since R6 was discharged from the facility. The director of UGM indicated they planned to send R6 to the hospital. The administrator's progress note dated 7/23/24 at 4:10 p.m., indicated R6's family member contacted the facility and stated she intended to sue the facility due to discharging R6. The administrator explained to R6's family member that the primary care physician felt R6 was stable to discharge to UGM due to no longer requiring IV antibiotic and having surgical sutures removed and R6's family member hung up the phone. The administrator's progress note dated 7/23/24 at 4:16 p.m., indicated she received a call from a staff person at UGM who informed her R6's family member (FM)-A took R6 home before they could contact the hospital. R6's progress note dated 7/23/24 at 5:40 p.m., indicated R6's RSC was notified of the situation via email. An email from the facility administrator to Growth Services dated 7/23/24 at 5:44 p.m., indicated R6 discharged at 1:00 p.m. to Union Gospel Mission and upon arrival, could not provide appropriate care for R6 and allowed R6 to sit on the patio until they could figure out where to send R6 since he was discharged from the nursing facility. R6's family member took R6 home before UGM could send R6 to the hospital. An email dated 7/26/24 at 12:52 p.m., from the director of emergency services (DOES)-C at Union Gospel Mission indicated standard questions asked about potential guests included: are you [AGE] years old or older, do you have a government issued ID, are you a level three sex offender. Additionally, if there were concerns of someone's condition, they asked whether they are independent and ambulatory. DOES-C indicated the facility informed DOES-C that R6 was fully independent and required no additional care. Additionally, DOES-C indicated UGM did not provide a higher level of care. A text from family member (FM)-A sent on 7/25/24, at approximately 4:30 p.m., included images FM-A stated was R6's foot, and socks with a reddish-brown discolored area located on the socks. The image of R6's left foot showed an incision site and all R6's toes were absent. A dark line was present along the incision line and the foot appeared to have dry flaky skin to the surrounding incision. During interview on 7/25/24 at 10:44 a.m., family member (FM)-A stated the facility was going to discharge R6 two weeks ago, they were going to throw him on the street and told the relocation coordinator. FM-A further stated the facility told her UGM could accommodate R6. FM-A stated UGM did not have rooms and could not take people in wheelchairs and added that R6 was dropped off on the sidewalk with 7 bags and the wheelchair and R6 did not know what to do and contacted FM-A. FM-A further stated she wished she would have stayed with R6 when she went to help R6 pack adding R6 was traumatized. FM-A stated RC-A had three emails the facility planned to discharge R6. FM-A stated she had pictures of R6's foot and added R6 could only walk a few steps on flat surfaces and stated he was with FM-A in her apartment and stated she did not know what to do with R6's foot because she has never done wound care and added one foot had one toe amputated which she felt looked good, but added the left foot had 5 toes amputated and was concerned about the appearance. FM-A further stated she did not receive any instructions for R6's eye and stated R6 could not retain any of that information. FM-A stated R6 did not want to leave the facility, the facility told him they were discharging him and ensured R6 he was discharging to a care place and added it seemed like R6 was discharged like trash. FM-A stated she was notified R6 was discharging on 7/22/24. Further FM-A stated R6 had no glucose monitor and wondered how they were supposed to give insulin if they did not know the level and stated if someone measured insulin, he could give himself insulin. FM-A stated R6 had drainage his socks and stated her wound nurse friend suggested R6 go to the hospital because she did not think R6's foot looked ok. She did not think the facility had R6 demonstrate how to self-administer insulin and stated she did not know how to give eye drops. FM-A stated she spoke with staff at UGM who informed her no one had contacted them about R6's care and stated they did not have a room for R6. During interview on 7/25/24 at 11:03 a.m., R6 stated he was notified of discharge the day prior on 7/22/24, when the facility told him he would be discharging to UGM. R6 stated the driver pushed him to the door and R6 went inside and gave paperwork over. R6 was then told UGM could not help him and could not accommodate people in a wheelchair so R6 picked up his bag and went outside and contacted FM-A and stated he was still in pain and his feet were still healing. R6 further stated he did not receive instruction on how to administer insulin and stated he had never taken insulin before hospitalization . R6 stated he had no way to check his blood sugars, the facility did not go over discharge instructions, and stated the first night he was discharged , R6 slept in FM-A's vehicle because he was unable to ascend the stairs to FM-A's apartment. The following day R6 received help from some people to navigate the stairs to FM-A's apartment. R6 further stated, They dropped me like a lost dog. During interview on 7/25/24 at 12:13 p.m., UGM administration staff (A)-B stated UGM does not provide any personal care, nor do they administer medications or complete wound care. During interview on 7/25/24 at 12:31 p.m., R6's relocation coordinator (RC)-A from Growth Services stated he worked with homeless clients to find housing. RC-A stated he met R6 on the street and R6 had frostbite. RC-A worked to get R6 certified disabled to receive a waiver for services and was involved in finding placement during R6's hospitalization . R6's goal was to end up somewhere like an assisted living facility that could provide the care R6 needed. When R6 discharged from the hospital he went to the facility and was supposed to be there for 6 to 9 weeks and worked with Minnesota Choices Underground who handled the waiver. RC-A stated he met with the facility and looked at a few assisted living facilities and the facility was on board with the plan and somewhere along the line, whether due to behaviors, they wanted to discharge R6 and received emails R6 had to leave and could no longer stay at the facility. RC-A told the facility you can't just put him back on the street and added the facility was not happy with him. RC-A stated it was about two and a half weeks ago they were told R6 could not be there any longer and stated the next couple of weeks things slowed down because they knew they could not kick him out. RC-A stated they sent a referral to Oaks but did not hear back. Then, this past Monday, RC-A stated he received [TRUNCATED]

Based on interview and document review the facility failed to timely respond to ventilator alarms for 1 of 3 residents (R1) reviewed for response to ventilator alarms. This resulted in an immediate jeopardy (IJ) for R1 when R1's ventilator alarmed intermittently on [DATE] from 3:19 a.m. to 5:47 a.m., 237 times, for an alarm that indicated high pressure in the ventilator or an obstruction in the ventilation system. The IJ began on [DATE] at 3:19 a.m., when R1's ventilator alarmed intermittently on [DATE], 237 times between 3:19 a.m., and 5:47 a.m., without staff response. The director of nursing (DON), facility owner, and senior nurse consultant were notified of the IJ on [DATE] at 1:31 p.m. The IJ was removed [DATE] at 2:28 p.m., but noncompliance remained at the lower scope and severity level of a D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's face sheet, undated indicated R1 admitted to the facility with diagnosis of chronic respiratory failure and dependence upon a ventilator when she is sleeping. R1's quarterly Minimum Data Set, dated dated dated [DATE], indicated R1 was moderately cognitively impaired. R1's care plan dated [DATE] indicated R1 had chronic respiratory failure with ventilator dependence. The interventions included monitor for cyanosis, shortness of breath, increased respirations, and difficulty coughing up sputum. The care plan indicated R1 was ventilator-dependent related to chronic respiratory failure, but lacked mention R1 was ventilator-dependent only when asleep. R1's Physician's Orders dated [DATE], indicated R1 used a ventilator with oxygen to keep oxygen saturations greater than 90%. R1's ventilator report for [DATE] from 3:19 a.m. to 5:47 a.m., indicated R1's ventilator alarmed for high inspiratory pressure. The ventilator alarm self-corrected for most of the alarms without measuring the number of seconds the ventilator alarmed. The ventilator report indicated alarm times were lengthier than a few seconds and identified the following: At 4:07 a.m., the ventilator alarmed for 114 seconds. At 4:10 a.m., the ventilator alarmed for 115 seconds. At 4:13 a.m., the ventilator alarmed for 81 seconds. At 4:16 a.m., the ventilator alarmed for 141 seconds. At 4:20 a.m., the ventilator alarmed for 785 seconds (13 minutes). At 4:38 a.m., the ventilator alarmed for 695 seconds (11 minutes). At 4:57 a.m., the ventilator alarmed for 1288 seconds (21 minutes). At 5:19 a.m., the ventilator alarmed for 92 seconds. At 5:33 a.m., the ventilator alarmed for 82 seconds. At 5:40 a.m., the ventilator alarmed for 339 seconds (5 minutes). At 5:47 a.m., the ventilator alarmed for 566 seconds (9 minutes). At 5:59 a.m., the ventilator was disconnected as R1 was up for the day. On [DATE] at 12:05 p.m., R1's family member (FM)-A stated a video indicated R1's ventilator alarmed on [DATE] from approximately 3:00 a.m., to about 6:00 a.m. without staff attention. On [DATE] at 4:47 p.m., respiratory therapist (RT)-A stated R1 required a ventilator at night because of her weight and her chronic respiratory failure. If a ventilator alarmed for high ventilator pressure, staff should check on the resident as it could mean the ventilator was obstructed with a mucus plug, the resident was not able to breathe, or was in respiratory distress. Every alarm should be treated as an emergency. The facility was not doing audits on ventilator alarms nor on how long staff took to respond to each of the alarms. She was not aware R1's alarms were not answered. The RT department checked the ventilator settings every working shift and reviewed the alarm settings. On [DATE] at 10:13 a.m., licensed practical nurse (LPN)-A stated she worked on [DATE], night shift and was assigned to R1. If a typical ventilator patient's alarm went off it was an emergency, but not R1, as she was more stable than the rest of the ventilator residents. If R1's was going off for 10 minutes, it was not an emergency, but staff should still check on her. At 12:48 p.m., LPN-A stated there were times she could not hear alarms if she was working on other hallways. LPN-A acknowledged she didn't check R1's alarms on [DATE] and had worked other times with only two nurses but was unable to identify dates. During a subsequent interview on [DATE] at 11:12 a.m., LPN-A stated on [DATE], during the night there was a new admission, and all four working staff were in that resident's room together. She was sure she heard alarms that night when she was walking down the hall, but there were other alarms going off too, and there were only two nurses working that night. No one told her R1's alarm was going off. I don't know what happened that night. Maybe other residents were more critical. On [DATE] at 10:33 a.m., the director of nursing (DON) stated a ventilator should not alarm for greater than 10 minutes without staff looking at it, as the resident could die. Other staff didn't hear the alarm going off for so long. On [DATE] at 11:28 a.m., registered nurse (RN)-B stated if a ventilator alarmed more than 5 minutes the resident would be in respiratory distress, and more than 10 minutes, the resident could be deceased . If a ventilator alarmed, it should be assessed. He did not respond to R1's alarms on [DATE], as R1 was assigned to LPN-A. On [DATE] at 11:55 a.m., nurse practitioner (NP)-A stated R1 required nocturnal ventilation related to obesity hypoventilation syndrome (a condition in which severely overweight people fail to breathe rapidly or deeply enough resulting in low oxygen levels and high carbon dioxide levels) and it was not feasible nursing staff didn't hear the alarms for hours. On ,d+[DATE] 24 at 1:57 p.m., R1 stated she did not know how long the ventilator alarms went off on [DATE], as she was asleep at the time. On [DATE] at 2:21 p.m., RN-A stated he worked night shift on [DATE]. He did not respond to R1's alarms as he was working with other residents, and R1 was assigned to LPN-A. At approximately 3:00 a.m. to 3:30 a.m., all four staff working that night were in one room with one resident who was in respiratory crisis. If R1 was sleeping when the ventilator alarmed, R1 might not know she was in respiratory trouble. There was a night, [DATE], he worked with 17 ventilated residents as was the only nurse on the floor for approximately four hours. On [DATE] at 11:28 a.m., during a subsequent interview the DON stated the facility had 15 ventilator-dependent residents on [DATE], who required two nurses and two nursing assistants for care, but would staff three nurses for 16 ventilator-dependent residents. The DON stated with fewer than 16 ventilator-dependent residents two nurses was enough and safe. The facility had not reviewed ventilator alarm response times prior to this incident, there was no policy for answering ventilator alarms, and he did not know the ventilator-dependent residents were not mentioned in the acuity section of the facility assessment. On [DATE] at 11:51 a.m., RT-B stated if a ventilator alarm persisted to go off, staff should investigate. If a ventilator alarmed for 11 minutes, R1 was not getting the required air volume, and R1 would not be getting enough air to the lungs. A single high-pressure alarm could indicate a cough, but, No one coughs for two and half hours. There was an alarm for 1288 seconds, or 21 minutes, and staff should have checked to see what was going on. There were codes on R1's ventilator report which indicated the alarm escalated to three higher levels, indicating more emergent need because the alarms were not answered timely. He spoke to the DON on [DATE] about R1's alarms, and the DON told him staff might have been in another room. On [DATE] at 12:39 p.m., RT-B stated he did not think the machine malfunctioned on [DATE], The alarms are there for a reason. The Facility assessment dated [DATE], indicated the acuity of the residents was based upon the activities of daily living (ADLs) of each resident, and whether the resident was independent, required the assistance of ,d+[DATE] staff for assistance, or was fully dependent upon staff for ADL assistance. Additionally, the FA identified resident mobility as a measure of acuity based upon whether the resident was independent, required an assistive device, or was, In a chair most of the time. The FA lacked ventilator-dependent resident consideration to determine resident acuity. The Respiratory Therapy Policy dated [DATE], directed respiratory therapy services were for the assessment, treatment and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services included coughing, deep breathing, nebulizer treatments, assessing breath sounds, and mechanical ventilation which must be provided by a respiratory therapist or trained respiratory nurse. The policy stated a respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws. The policy stated nurses who performed respiratory therapy services would complete competencies for pre-assessment/evaluation of respirations and lung sounds, set up, administration and clean-up of nebulizer and post-assessment/ evaluation of respirations and lung sounds. The policy did not address how staff should manage ventilator alarms. A ventilator policy was requested, but not provided. The immediate jeopardy that began on [DATE], was removed on [DATE], after it was verified nursing staff and respiratory therapists were educated about the policies and procedures for ventilator care and response to ventilator alarms, with the expectation staff would answer ventilator alarms within two minutes. R1's care plan was reviewed and updated to ensure her ventilator needs were identified. The facility ordered walkie talkies to ensure timely access to assistance from other units' staff as needed. Facility staff was educated to ensure one staff was always available to monitor ventilator alarms. A third nurse was added to third shift to ensure adequate nurse to resident care ratios. Audits for response to ventilator alarms were implemented. The noncompliance remained at the lower scope and severity level of a D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm, that is not immediate jeopardy.

Based on interview and document review, the facility failed to ensure the safety interventions for elopement were implemented for 1 of 3 residents (R1) reviewed for elopement. This failure resulted in an immediate jeopardy (IJ) when R1 eloped from a basement door that was not alarmed with a wander guard (WG) alarm. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. The IJ began on 6/3/21, when R1 eloped from the facility and was missing for 1.5 hours and was found walking on the side of Interstate 35 East by police. The facility administrator and director of nursing (DON) were notified of the IJ at 4:25 p.m. on 6/8/21. The facility implemented immediate corrective action on 6/4/21, prior to the start of the survey and was issued as past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired with a Brief Mental Status (BIMS) score of 8. He had a medical diagnosis of unspecified sequelae of cerebral infarction (stroke). R1 required an assist of 1 with activities of daily living (ADLs). He ambulated independently with the use of a cane. R1 was a standby assist of 1 for transfers. The MDS indicated R1 did not have any behavior where he wandered. R1's admission elopement risk assessment dated [DATE], identified R1 had a score of 5 (0-14 was no risk and over 15 indicated a risk for elopement). R1's care plan with revision date of 3/16/21, did not address wandering as an identified concern. Nursing progress notes dated 4/16/21, at 1:14 p.m. identified R1 attempted to elope from the facility. R1 was on the elevator and attempted to exit through the back part of the elevator and follow staff into the kitchen. R1 was easily redirected back to the nursing floor. R1 was immediately put on 15 minute checks for seven days, his care plan was reviewed and updated, a WG (device worn on the ankle or wrist that would sound when a resident went through a door that had a WG alarm system) was placed on R1's ankle, and an elopement evaluation was re assessed and the assessment identified him as high risk for elopement. Nursing progress notes dated 5/22/21, 9:49 p.m. identified R1 attempted to elope from the facility. R1 eloped outside of the building through the back door on the first floor. The wander-guard sounded, the receptionist followed R1 out the door. Staff approached R1 who refused to reenter the building at that time. 911 was then called and police officers were able to convince R1 to return inside the facility. R1 was immediately put on 15-minute checks, his care plan was reviewed and updated, and an elopement assessment was completed with a score of 13 which indicated low risk, however additional assessment notes in the elopement assessment identified him as a high risk due to elopement events. R1 was placed on 15-minute checks for seven days and after seven days the 15 minute checks were removed without further attempts from R1 to elope. The WG remained on his ankle. Nursing progress notes dated 6/3/21, 7:17 p.m. identified a call was received from Regions Hospital at approximately 4:30 p.m. The progress note indicated R1, was found wondering by the state patrol. Location unclear. The note indicated the emergency room social worker noted R1 was not harmed and did not seem distressed. R1 reportedly told police that he was walking home. R1 was appropriately dressed for the weather and wore a light sweater and sweat pants. Nursing home facility staff were unaware R1 was gone from the building. The facility investigative report dated 6/3/21, identified the administrator saw R1 at 2:07 p.m. in the facility lobby on her way to a meeting. R1 was last seen on the facility lobby security camera at 3:09 p.m. Regions Hospital called the facility at 4:30 p.m. to inform them that R1 was found walking on Interstate 35 E by police. R1 was taken to the emergency room for evaluation. The facility was unaware R1 had eloped. The outdoor temperature on 6/3/21, was 90 degrees Fahrenheit. The facility investigative report was not able to conclude how R1 left the building. During an interview on 6/8/21, at 1:31 p.m. the social services manager (SS) reported that R1 had been in a wheel chair since his admission in December. R1 was reassessed for elopement risk after the elopement events on 4/16/21 and 5/22/21. SS reported if a resident eloped or made an attempt to elope, a resident would go on 15-minute check for seven days and then the check would be discontinued if a resident did not make any further attempts to elope. R1 progressed with his therapy and became ambulatory with the use of a cane and liked to get on the elevators. It was not unusual for R1 to be off of the nursing unit. SS indicted R1 was allowed to be in the lobby, on other floors of the facility, and in the fenced in outdoor courtyard because he had a WG on and exit doors would alarm if R1 attempted to leave. When asked how R1 left the building the SS said the management team speculated that R1 left the building through the basement door. The SS said the basement had an exit door with a WG alarm that was not functional and would not alarm in response if a WG bracelet passed through it. The elevator required an access code be entered in order for the elevator to go down into the basement, however if someone pushed the elevator button while in the basement the elevator it will override the need for a code. The SS stated it is unlikely that R1 knew the elevator code. During an interview on 6/8/21, at 1:37 p.m. the maintenance director said the WG was a good system that didn't require maintenance but needed to be checked to make sure the system worked with routine tests. The maintenance director checked the WG system one time per week. The receptionist also checked it two times per week. The maintenance director believed the basement door was the only way that R1 could have gotten out of the building without detection. He identified the basement door that leads to the alleyway had a WG system but that it had not been plugged in and had not likely been armed for at least a year. He knew R1 and indicated, he was able to move around the facility freely. The maintenance director did not feel like R1 tried to exit the building. During an interview on 6/8/21, at 1:44 p.m. the DON indicated that R1 was most commonly found in the lobby but was able to go outside too into the courtyard. The DON identified the facility had a receptionist in the lobby 24 hours a day and kept an eye on R1 when he was in the lobby. She stated that R1 like to wander but she was unsure if he tried to get out of the building or just wandered out. The DON stated R1 rode the elevator frequently and on 6/3/21, R1's WG had been checked per his care plan and functioned appropriately. On 6/3/21, at approximately 4:30 p.m. the facility received a call from Regions Hospital that R1 was found walking about 1.5 miles away on Interstate 35 E and was brought to the hospital by police for an assessment. R1 was evaluated and sent back to the facility. The DON believed he must have gotten out of the building through the basement door. She identified it was discovered there is an alarm on the basement exit door that was not activated at the time of R1's elopement. During an interview on 6/8/21, at 2:30 p.m. the administrator stated the facility received a call on 6/3/21, from the ER at Regions Hospital. No time given by the administrator. R1 was found by the state patrol and brought into Regions Hospital for evaluation. The administrator started the last time she saw R1 was on 6/3/21, at 2:07 p.m. on her way to a meeting. An elopement assessment of R 1 was done upon his return on 6/3/21, and was put on a 1:1 supervision where a staff member was with him at all times until his discharge. Education began with staff on 6/3/21. The WG system was also checked to ensure it functioned. Signs were placed at the elevator to instruct staff to wait for the elevator if they have pressed to button. Through the investigation it was found the basement door did not have an active wander guard alarm on the door. The facility thought a code was needed to access the basement however if someone from the basement called the elevator to the basement and someone was on the elevator at the time of the call, the elevator would go straight to the basement. The facility was not certain but felt this may have been how R1 eloped from the basement. The facility elopement guideline and policy last revised in November of 2017. defined elopement as, that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety, needs and therefore at risk of injury outside the confines of the facility, had left the facility without knowledge of staff. All residents are evaluated at admission to establish elopement risk. All residents at risk for elopement are assessed quarterly and as needed. Only the administrator (or designee) may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm. The past noncompliance immediate jeopardy began on 6/3/21. The immediate jeopardy was removed and the deficient practice corrected by 6/4/21, after the facility implemented a systemic plan that included the following actions: When R1 returned to the facility he was placed on 1 to 1 supervision, R1 was transferred to a sister facility with a secured locked unit on 6/4/21. The Quality Assurance Performance and Improvement (QAPI) notes dated 6/4/21, identified the facility management team met and the following were completed; all other residents with wander-guards were evaluated to ensure their wander-guards were working and care plans were updated. The facility reviewed policy on elopement and no changes were needed. The alarm on basement door was activated. Signs were placed by elevators to indicate if the elevator is called to stay and wait for the elevator. Stop signs were placed on the doors to remind staff not to have residents follow staff out the door. All staff were educated on the elopement guidelines (policy), everyone's responsibility to respond to a door alarm, not to clear the door alarm until it was confirmed no residents were missing, nursing staff to check wander guard placement, if alarm did not work to contact the administrator. Education was done by 6/4/21, with all staff. Staff that were not present on 6/4/21, were educated prior to the start of their next shift or via phone. Staff interviews were conducted on 6/8/21, from approximately 2:00 p.m. to 4:00 p.m. with staff that included; RN's LPN's NA's, social services staff, front desk staff and physical therapy staff. Staff identified education was provided to them about the elopement policy, staff's responsibility when the WG alarms sound and what to do if a resident cannot be found. Review of the facility education entitled Elopements dated 6/3/21 and 6/4/21, confirmed the facility implemented corrective action and therefore this will be cited at past noncompliance. Observation of sign on 6/8/21, between 2:00 p.m. and 4:00 p.m. were verified on 6/8/21.

Based on observation, interview and document review, the facility failed to fully assess for chemical dependency safety; implement interventions to prevent residents from obtaining non prescribed medications; and prevent overdoses from reoccurring for 1 of 3 residents (R1) reviewed for behavioral health services. This resulted in an IJ for R1 when she returned from the hospital after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility immediately implemented interventions and corrected the deficient practice on [DATE]. This is issued as past noncompliance at Immediate Jeopardy (IJ). The immediate jeopardy (IJ) that began on [DATE], at 1:34 a.m. was corrected on [DATE], when the facility implemented interventions to prevent reoccurrence. The director of nursing (DON) was notified of the IJ on [DATE], at 3:50 p.m. as past noncompliance, as a result of the immediate corrective action taken by the facility, prior to the start of the survey. Findings include: R1's face sheet dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, with a brief inventory of mental status (BIMS) score of 14. The MDS also indicated R1 was totally dependent on staff for mobility, transfers, toileting, and dressing and R1 needed assistance of one staff to be mobile on or off the unit, using a wheelchair for mobility. R1's care plan dated [DATE], indicated R1 had a substance use history (cocaine and [MEDICATION(S)]) and R1 was on [MEDICATION(S)] (opioid); interventions included offering community resources and staff monitoring and assessment if R1 was suspected of being under the influence of a substance. R1 provider orders dated [DATE], indicated R1 was prescribed [MEDICATION(S)] (opioid) 300 micrograms (mcg) every twelve hours for chronic pain and [MEDICATION(S)] (opioid reversal medication) one spray in nostril for suspected OD and call 911; [MEDICATION(S)] could be repeated in three minutes if no response. R1's Progress Note (PN) dated [DATE], indicated mental health and substance use resources were offered to R1 and she declined. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's nurse practitioner (NP) note dated [DATE], indicated R1 was evaluated on [DATE], and referrals were made to psychiatry and addiction services. R1's PN dated [DATE], indicated R1 was found groggy during medication administration time and when approached a few minutes later was not responding to stimuli and her blood pressure was ,d+[DATE] millimeters of mercury (mmHg). The PN indicated R1 was sent to the emergency department at 4:35 p.m. where she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's PN dated [DATE], indicated R1 arrived back to the facility from the hospital at 1:34 a.m. R1's hospital record dated [DATE], indicated R1 admitted to taking [MEDICATION(S)] and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's PN dated [DATE], at 5:50 a.m. indicated R1 was found in her bed with signs of irreversible death: cyanosis (blue skin), cold, and with rigor mortis (stiffening of the joints and muscles of a body a few hours after death). The PN also indicated two oxycodone (narcotic) were found in R1's cigarette box. During an interview on [DATE], at 3:20 p.m. licensed practical nurse (LPN)-A stated LPN-C sought her assistance when he found R1 non-responsive on [DATE]. During an interview on [DATE], at 3:30 p.m. LPN-C stated on [DATE], when he found R1 not responding, with dilated pupils, and low blood pressure he contacted the supervisor. LPN-C stated R1 was sent to the hospital. LPN-C stated he spoke to R1 when she returned to the facility on [DATE], at 1:34 a.m. but did not talk about narcotics, had no idea how she got the narcotics, and did not do a room search. LPN-C stated, in this job, you do not look into it. LPN-C stated he did not give R1 [MEDICATION(S)]. LPN-C stated on [DATE], he found R1 dead. LPN-C stated he checked on R1 and found her: * at 2:00 a.m. in bed awake with the television (TV) on * at 3:40 a.m. in bed asleep with the TV on * at 5:50 a.m. in bed dead with rigor mortis present During an interview on [DATE], at 3:45 p.m. registered nurse (RN)-A stated on [DATE], at approximately 3:00 p.m., R1 was found groggy. When rechecked a few minutes later R1 was non-responsive and had a low blood pressure; RN-A notified the provider who instructed staff to send R 1 to the emergency department (ED) for evaluation and treatment. RN-A stated the ED staff called and reported R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated she did not search the room for opioids, alter R1's care plan, or intervene in any other way. During an interview on [DATE], at 8:35 a.m. RN-B stated R1's room was not searched on [DATE], because he did not suspect an OD and he didn't really know her history. During an interview on [DATE], at 9:14 a.m., LPN-A stated she suspected R1 had substance abuse issues before this happened, but she didni't tell anyone. LPN-A stated she suspected R1 kept narcotics in her cigarette box because R1 didn't want anyone touching it. LPN-A stated when she heard what happened, she suspected R1 overdosed because she had overdosed earlier, on a day when she wasn't working. A telephone call was placed to local police on [DATE]; recevied a return call was received on [DATE].During a telephone interview at [DATE], at 12:57 p.m., law enforcement officer (LEO)-A stated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 12:23 p.m. the DON stated the facility was aware R1 had a substance abuse history on admission. The DON verified she was notified of R1's loss of consciousness on [DATE], but stated she was unaware R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified after R1 overdosed and returned to the facility on [DATE], no room search was conducted, the care plan was not changed, and no resident or staff education was conducted. After the DON was notified of R1's death on [DATE], the DON stated the facility conducted a root cause analysis (RCA) and implemented several actions: social services assessed all residents with a history of substance abuse and reviewed the substance abuse policy with them; SW created a daily audit tool to track all incidents of suspected substance abuse to assure follow-up per facility's policies; and all staff were educated on the substance abuse policy, room search policy, and signs/symptoms of opioid OD. The facility assessment dated [DATE], indicated the facility provided care for residents with psychiatric symptoms and identified and implemented interventions to support individuals with issues such as anxiety, depression, and other psychiatric diagnoses. The facility's Substance Use policy dated [DATE], indicated the facility did not allow illegal or illicit non-prescribed substances on the facility premises. The policy further indicated residents suspected of using these substances would be subject to a room search. The facility's Room Searches for Safety Concerns/Violations policy dated ,d+[DATE], indicated residents' rooms would be subject to search when a safety violation was discovered. The policy indicated the DON, administrator, or director of social services would be notified of the safety concern who would then facilitate the search. The IJ was removed on [DATE], at 11:45 p.m. after it was verified the facility took action to address the deficiency. -- On [DATE], the social workers conducted substance abuse risk using the CAGE assessment tool on all residents (20) with a substance abuse history. They also reviewed the substance abuse policy with these residents. The residents signed a document indicating their understanding of the policy. -- On [DATE], staff education was initiated and covered a review of the substance abuse policy, signs of drug use, signs of overdose, notification of potential OD to the DON and administrator, and how to identify substance use risk and intervene in a timely manner. Education began with staff working on [DATE], and subsequent education was conducted for staff arriving to work and was completed before the staff provided any resident care. --During an interview on [DATE], a 12:58 p.m. SW-B verified all residents with history of substance abuse were assessed using the CAGE tool and the substance abuse policy was reviewed with them, noting one resident refused to be assessed. SW-B stated a SW was added to the off-hours call group so they would receive notifications of any suspected OD and could intervene immediately. SW-B stated they had begun audits of suspected OD and reviewed the audit sheet with the surveyor. --During an interview on [DATE], 3:20 p.m. LPN- C stated he had received education on opioids, room searches, and frequency of monitoring residents; he was able to verbalize what he was taught. --During an interview on [DATE], 3:30 p.m. LPN- C stated he had received education on opioids, room searches, and frequency of monitoring residents; he was able to verbalize what he was taught. --During an interview on [DATE], 3:45 p.m. RN- A stated she had received education on opioids, room searches, and frequency of monitoring residents; she was able to verbalize what she was taught. --During an interview on [DATE], at 9:14 a.m. LPN-D stated he had not received education but he had not worked since the night R1 died .

Based on interview and document review, the facility failed to use a mechanical lift and appropriate sized sling according to manufacturer instructions for 1 of 3 residents (R82) reviewed for accidents. This failure resulted in actual harm for R82 on 10/18/19, when staff locked the wheels on the lift, and did not open the lift legs into the widest position, and the lift tipped over, causing a fall with fracture needing surgical repair. The facility developed and implemented immediate corrective actions of educating staff on the correct use of a mechanical lift, completed competency demonstration and provided oversight of staff using correct sling and monitoring to ensure staff were following manufacturer instructions while using a lift. These corrective actions were implemented and completed on 10/19/19, therefore the deficient practice is being issued at past non-compliance. Findings include: R82 quarterly Minimum Data Set assessment ((MDS) dated [DATE], included R82 was cognitively intact with a [DIAGNOSES REDACTED]. R82's falls care plan initiated 7/4/19, indicated R82 was at risk for falls related to impaired mobility, having MS, and using a full body mechanical lift. The care plan indicated on 10/18/19, R82 fell from a full body mechanical lift while staff was trying to transfer R82 into a shower chair. R82 was hospitalized with a mildly displaced right femur fracture and pubis ramus fracture 10/18/19 through 10/24/19, and had surgery to right femur on 10/20/19. On 10/18/19 after the fall, the care plan was updated to require three staff assist whenever transferring R82. R82's Resident Care Sheet indicated requiring a full body mechanical lift for transfers, with assistance of three staff, using a blue (size XL) sling. When interviewed on 10/28/19, at 6:36 p.m. R82 laid in bed, and explained that he had been in the hospital for a while because he broke his leg in a fall from a lift. R82's progress note dated 10/18/19, at 10:37 a.m. included, at 9:40 a.m. two nursing assistants (NA) were transferring R82 for a shower via the full body mechanical lift and the lift tilted. R82 fell out and landed on his right side. R82 initially complained of right leg pain rated 10/10. Staff put ice on the leg, and called 911 for a transfer to the hospital. A progress note later that day at 4:00 p.m. noted R82 was admitted for a right femur fracture. A progress note dated 10/24/19, noted R82 returned to the facility from the hospital. R82's Incident Review and Analysis form dated 10/18/19, described two NAs had been transferring R82 from bed to a shower chair via a full body mechanical lift when the lift tilted sideways and R82 fell on the floor onto his right side. R82 complained of severe hip pain with movement. After being sent to the emergency room , R82 was diagnosed with [REDACTED]. Contributing factors included: the lift legs were not in the widest position, and the lift wheels were locked. Before the fall, R82 was assessed to need two staff assist and a full body lift for transfer. After the fall, R82 was changed to three person assist for transfer. R82's investigative report dated 10/18/19, indicated the involved staff NA-H and NA-I did not open the lift's legs into the widest position, had locked the wheels on the lift, and also used a sling that was one size too small for R82. The report noted that both staff had received recent lift re-education and competencies prior to this incident, with training received on 9/23/19 and 9/27/19. After the accident, both staff were immediately re-educated, and suspended pending investigation. The lift was inspected and found to be in working order. Other immediate interventions put in place for safety included nurses being in the room to observe all lift transfers, lifts being labeled with operation instructions and warnings to keep legs open, wheels unlocked, and ensure appropriate sling size use. All nursing staff were to be re-educated on proper lift use as well as correct sling use per the NA guide sheets. All staff were to complete return demonstrations for competency assessment. All staff were to be quizzed after re-education, and if incorrect, would be immediately educated. Additionally, all residents who used lifts were to be audited to ensure correct sling size. A staff list for all nurses and NAs was reviewed and included dates that education occurred, as well as the return demonstration/competency, and quiz. During observation on 10/29/19, at 2:05 p.m. staff were observed in R82's room preparing to transfer R82 from the bed to the wheelchair via an EZ Way full body mechanical lift. Social services staff (SS)-A entered the room to comfort R82 who was nervous about transferring using the lift. Be gentle you guys! R82 repeatedly called out to staff while laying in bed. At 2:07 p.m. registered nurse (RN)-F entered the room and washed hands to assist. NA-E and NA-F stood on the window side of the bed, while licensed practical nurse (LPN)-C and NA-G stood on the door side of the bed, and all staff placed a blue XL sling, with blue border, with R82's name on it underneath R82. R82 reached out to SS-A, wanting to hold her hand. SS-A squeezed R82's hand, then had to move out of the way before the transfer. After hooking the sling up to the lift bar, NA-G operated the lift controls while four other staff stood next to R82 to assist with the transfer. R82 appeared fearful, with eyes wide, repeatedly asked the staff not to drop him. R82 was smoothly lifted into the air, positioned over the wheelchair with the lift's legs in a wide open position, with lift wheels unlocked, and smoothly lowered straight down into the wheelchair seat. R82 stated he hoped this was the last time he would have to transfer using the lift. At 2:20 p.m. SS-A explained she was not always present for transfers, but this was R82's first transfer since coming back from the hospital after surgery, so she wanted to offer support to R82 since he was nervous. On 10/29/19, at 2:35 p.m. a mechanical lift was observed in the hallway. The lift had a guide attached to it for proper use and sling sizing guide. During interview on 10/29/19, At 2:50 p.m. NA-G mentioned he did not usually work on R82's unit, but explained that he knew how to safely transfer residents by using the Resident Care Sheets. NA-G pulled paper from his pocket, and unfolded it to show what R82 required for care and transfers. The paper noted R82 required assist of three staff for transfers, and in bold text that R82 used an XL size sling, that had a blue border. NA-G said if he was ever in doubt, he would ask someone else on the unit for assistance. 10/30/19, at 1:58 p.m. the director of nursing (DON) explained the facility used lifts made by two different manufacturers, and described working with a lift manufacturer on safe patient handling. When asked how the facility determined which slings were appropriate for use, the DON referred to using the Sling and Lift Hanger Bar Compatibility guide put out by the American Association for Safe Patient Handling & Movement, for determining which lifts and slings were compatible and appropriate for all facility residents. When interviewed on 10/31/19, at 8:20 a.m. the DON provided training that had been completed with staff since the incident on 10/18/19, and confirmed all staff who were currently working had been re-educated and assessed for competency. DON assured any staff that had not received re-education yet had not worked since the accident, and would be re-trained and assessed before returning to work. DON stated NA-H and NA-I were terminated, as they had just completed training on proper lift use prior to the 10/18/19 accident, on 9/23/19 and 9/27/19, respectively. DON explained that although NA-H and NA-I had received recent training at the end of September, they did not follow manufacturer's instructions on 10/18/19, when they used the incorrect sized sling, failed to open the legs of the Invacare Reliant lift into the widest position, and when they failed to keep the lift wheels unlocked during operation. The Invacare Reliant User Manual included a warning on page 20, that the legs of the lift must be in the maximum open position .for optimum stability and safety. Additionally, another warning on page 24 warned against locking of the rear lift wheels while using an electric lift. Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object. The deficient practice was corrected on 10/19/19, after the facility developed and implemented corrective action which included mechanical lift education for all nurses and nursing assistants (NA) in the building across all shifts on 10/18/19. This included return demonstrations, education about proper transfer positioning, lift function, sling sizing, sling positioning, lift leg positioning, how to safely move a resident from one surface to another, and when to keep the lift brakes unlocked. After education, all nurses and NA staff completed a quiz and a return demonstration assessment for competency. Additionally, all lifts were immediately labeled with cue cards indicating proper use of the machine, as well as step by step instructions on how to use the lifts. Any nurses or NAs who were not in the building 10/18/19, received the training and quiz before working their next shift. A staff list was reviewed to ensure all staff received the education, quiz, and competency assessment. The facility began random audits of safe mechanical lift operation three times per week, and at the time of survey audits were completed on 10/21/19, 10/22/19, 10/24/19, 10/29/19, and 10/30/19.

Based on interview, observation, and document review, the facility failed to ensure adequate measures and monitoring were implemented to ensure residents whom utilized oxygen did not smoke while using their portable oxygen for 2 of 3 residents (R1 and R2) reviewed whom smoked and used oxygen. The deficiency was identified as past non-compliance and issued at Immediate Jeopardy (IJ) level. The IJ began on 6/12/19, when R1 was in the smoking area outside the building and used a butane lighter to light a cigarette while using his portable O2 (oxygen) at 3 liters per nasal cannula. This resulted [MEDICAL CONDITION] his nares and face requiring hospitalization . However, the facility implemented a corrective action to prevent recurrence by 6/14/19. The facility had immediately reviewed each resident's chart to verify smokers who used oxygen and placed alarms on the portable oxygen tank with a wanderguard alarm system so the door alarmed when resident entered the smoking area with a tank. Monitoring of each tank for alarms was implemented every shift. In addition, facility policies had been reviewed for adequacy and updated with an addendum. Staff education had also been implemented to ensure each shift of staff understood the facility policies and implemented testing skills to verify staff could follow through with implementation of smokers with portable oxygen tanks. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], included R1 was cognitively intact, was independent to supervision needed for activities of daily living (ADL's), used a wheel chair, and was on oxygen therapy. The MDS had not been marked if R1 was a current tobacco user or not. R1's Admission Record face sheet identified [DIAGNOSES REDACTED]. R1's care plan dated 1/8/19, included resident was independent in most activities of daily living. R1's behavior care plan dated 3/14/19, included, Resident was found smoking a cigarette in his room by his oxygen tank. Resident was talked to about not smoking a cigarette in his room and the dangers of smoking a cigarette by oxygen tanks. Resident signed the the smoking policy and understands the policy. The goal for R1 was dated 4/26/19, and listed as, Resident will continue to smoke in designated smoking area for safety and remove his oxygen tank before going outside to smoke a cigarette. R1's physician orders [REDACTED]. Staff were to ensure the tank was filled every day when in use. R1's Smoking Evaluation assessment dated [DATE], at 8:56 p.m. included, resident was capable of lighting (R1) own cigarette, did not have cognitive loss, did not have visual deficit and the summary read, Resident was seen smoking a cigarette in (R1) room. Resident completed the Smoking Policy. Resident agreed to not smoke cigarettes in (R1) room. The facility was not aware that R1 had started smoking since the admission in (MONTH) (YEAR). R1 informed SS-A that (R1) started smoking cigarettes again after 10 days of being in the facility and stated, I was upset and depressed. The assessment failed to address R1's use of oxygen and being a smoker. R1's progress notes (PN) dated 3/13/19, at 11:30 a.m. read, Resident's room smelled like cigarette smoke in AM, writer asked resident if (R1) was smoking, (R1) answered yes, but only 2 puffs. resident educated on safety hazard to self and others smoking inside building, while O2 is present in room. Resident stated (R1) understood but stated it wasn't that bad because (R1) only took 2 puffs and turned O2 off. Writer reminded resident that it is always unsafe. Updated Social worker, will continue to monitor. The progress note did not identify what type of monitoring would be continued. R1's Facility Report to the State Agency dated, 6/12/19, at 6:39 p.m. included, At 4:45 pm LNHA (licensed nursing home administrator) and Nurse Managers were working in the conference room and notified by reception that this residents O2 tank was on fire. All members ran outside to the smoking patio and there was no evidence of an active fire but there was a smell of smoke and residents hair on the side of the face was singed and black and resident was holding the nasal prongs of nasal cannula in (R1) nose. Nurse Managers immediately assessed resident for major injury and respiratory distress, resident was alert and oriented. Resident was worked up stating 'Just let me breathe' staff let resident rest for a minute with O2 on and resident respiratory status improved. Then Nurse Manager (registered nurse (RN)-B) took resident upstairs to the unit for evaluation. R1 progress notes dated 6/12/19, (no time specified) included, While upstairs in (R1) room placed on large O2 tank, nebulizer administered and vitals obtained. T 97.6, P 97, R12, O2 95% at 6 [MI] (R1) beard was trimmed to assess for [MEDICAL CONDITION] major injuries. Upon assessment, (R1) was noted to have facial burn of (R1) beard and black nasal passages. It was also observed (R1) had burn and redness on right side of zygomatic (cheek) region and around (R1) upper lip. Medical Director call (sic) and order received to sent (sic) resident to hospital for evaluation. R1 progress notes dated 6/12/19, at 10:26 p.m. included, Resident was admitted to Regions Hospital Burn Unit. The nurse at Regions Hospital Burn Unit stated that resident has [MEDICAL CONDITION] treating it with [MEDICATION NAME]. (Nurse) added that resident is stable and they're keeping the resident overnight to monitor (R1). R1's investigation document review written by the DON, dated 6/14/19, at 4:30 p.m. read, Resident stated (R1) asked the nurse at the nursing station to fill (R1) O2 tank. (R1) stated the nurse told (R1) to bring (R1) O2 tank downstairs and someone will fill it for (R1). Resident stated (R1) brought (R1) tank downstairs and left it on the table by the smoking patio door. (R1) put a note on it for 3rd floor aide to fill. (R1) went back upstairs. Later (R1) grabbed one of (R1) other portable tanks to use to go downstairs and smoke. (R1) forgot to take (R1) tank off before going out to smoke because (R1) was distracted while (R1) was chatting with someone else while (R1) was wheeling (R1) out. Resident stated (R1) is not going to smoke anymore and will continue to wear the patch. Resident stated was given an extra tank a long time ago by staff when (R1) was going to an appointment so (R1) wouldn't run out. R1 returned to the facility from the hospital on [DATE], at 3:30 p.m. and was transported via paramedics on 9 liters of oxygen. When interviewed in the outside smoking area on 6/17/19, at 8:10 a.m. R3 stated, (R1) comes out with the O2 tank on and covers it with (R1) [NAME]et. That day the flames were shooting out the top of the tank. That black spot is still there on the cement where (R9) got up out of (R9's) chair and broke the tubing by stomping on it, and so no more O2 could start on fire. (R1) jumped out of (R1's) wheel chair and ran behind the chairs to get away from the fire. I ran inside and told the desk we had a fire in the smoking area and they acted real fast to get out there. Furthermore, R3 stated, I told (R1) (R1) should not be out here and (R1) said, 'I have it covered with my [NAME]et,' (R1) knew it was a danger, we are all lucky that tank did not explode. During this interview R8 was present and verified R3's statement and R8 further stated, Pure stupidity to smoke with oxygen. R3 and R8 verified they had not been interviewed specifically by the facility but validated lots of facility people were there once (R1) started the fire. R1 was observed on 6/17/19, at 10:00 a.m. partially sitting/lying in bed with head against the wall to the left side propped by pillows, R1 expressed being in pain and waiting for the nurse to bring in pain medication. R1 expressed great discomfort in both nostrils, and the area around the mouth and cheekbone area from the, burn incident last week. Both nares appeared black and crusty. R1 verified not smoking since the incident 6/12/19, and expressed no desire to smoke at this time. There was no portable oxygen tank in the room. R1 was receiving oxygen from the large liquid cylinder in the bedroom. R2's annual MDS dated [DATE], included she was cognitively intact, had no behavior issues, required extensive assistance with most activities of daily living, but ambulated independently. The MDS indicated R2 was a current tobacco user. R2's progress notes dated 4/23/19, at 5:15 p.m. written by social service (SS)-A read, This writer met with resident after it being reported that resident was smoking a cigarette with (R2) O2 tank on. This writer and resident talked about the dangers with that. This writer asked resident if (R2) would be willing to store (R2) cigarettes up at the front desk and drop off (R2) O2 tank so there are no situations. Resident agreed. This writer and resident reviewed the smoking policy and resident signed. This writer and resident got (R2) box up at the front desk to store (R2) cigarettes. This writer uploaded the smoking policy in resident chart. R2's care plan initiated 4/24/19 and revised on 6/21/19, included, R2 had been found smoking with oxygen on in the smoking area and had entered into a contract with the facility to leave oxygen tank at front desk before smoking and a wanderguard (a tracking device that will set off an alarm to alert staff the tank is being brought outside the door going to the smoking area). R2 was required to leave her tank at the front desk in exchange for her smoking materials. R2's physician order [REDACTED]. R2 treatment sheet indicated on 6/14/19, night shift staff at 10:30 p.m. initiated the signing out to ensure the wanderguard on portable O2 every shift to ensure placement and ensure the resident have on portable tank at all times. A new entry on the Tx started 6/14/19, at 10:30 p.m. read, Portable O2 tank to be kept at NS (nursing station) when not in use. Remind (R2) to not smoke with oxygen when giving (R2) the tank every shift. Furthermore, the treatment record started 6/14/19, 7-3 shift to complete searches daily with 2 staff on day shift for smoking materials. If found, remove and give to receptionist for usage. Document in the PN (progress notes) if materials found. When interviewed on 6/17/19, at 11:22 p.m. with the administrator and director of nursing (DON) it was revealed that the facility had concerns with R2 who was observed 4/23/19, smoking outside while being on the portable O2 tank. The administrator verified that on 4/23/19, the facility started the process to assess the use of a wanderguard system on the portable O2 tanks so that the door would alarm if a resident went outside with the portable O2 tank to the smoking area. However, this process could not start until the wanderguard system was placed on the door to the smoking area on 6/6/19. This was over a month after R2 was found smoking with oxygen on while in the smoking area. They were unable to determine when R1 had been given an extra portable oxygen tank without the wanderguard system attached. The resident (R1) stated it had been, a long time ago. This allowed R1 to go to the smoking area with a portable oxygen tank running and would not alert staff. After the incident on 6/12/19, all residents who smoke and are on oxygen were assessed and educated on oxygen use and smoking. Orange tape was added to each portable oxygen tank for staff to easily identify a portable tank belonging to a resident who smokes. A system for checking wanderguard's on portable oxygen tanks every shift was initiated. In addition, facility smoking policies had been reviewed for adequacy and updated with an addendum. Staff education had also been implemented to ensure each shift of staff, prior to working, understood the facility's policies and implemented testing skills on employees for each shift to verify staff could follow through with implementation of smokers with portable oxygen tanks, so that tanks would not be taken to the smoking area. Training material and sign in sheets were reviewed. Staff were being trained prior to starting their shift on each of the following areas: Smoking policy, smoking policy addendum, incident with R1, and a list of residents who smoke and are on oxygen. Sign in sheets had started in the evening of 6/12/19. Monitoring was added to resident treatment records to ensure wanderguard's were on smokers portable oxygen tanks on 6/14/19. When interviewed on 6/18/19, at 9:20 a.m. RN-H stated she as trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 9:24 a.m. NA-B stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 9:25 a.m. RN-B stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 9:30 a.m. R6 stated she had been educated on not using oxygen while smoking, she does not have a portable oxygen tank, she just goes out twice a day to smoke without bringing any oxygen with her. When interviewed on 6/18/19, at 9:35 a.m. NA-A sated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 2:55 p.m. LPN-B stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 2:57 p.m. NA-I stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:00 p.m. LPN-E stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:03 p.m. RN-D stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:04 p.m. the health unit coordinator (HUC) stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:05 p.m. NA-J stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:07 p.m. RN-J stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:17 p.m. LPN-R stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. When interviewed on 6/18/19, at 3:20 p.m. HUC-A stated she had been trained on the smoking addendum and procedures for ensuring residents do not bring oxygen out to the smoking area. The past non-compliance that began on 6/12/19, was verified during the 6/19/19 onsite visit and was corrected on 6/14/19. The facility had immediately reviewed each resident's chart to verify smokers who used oxygen and then placed alarms on the portable oxygen tank with a wander guard alarm system. The door alarmed when resident entered the smoking area with a tank. Monitoring of each tank for alarms was implemented every shift. In addition, facility policies had been reviewed for adequacy and updated with an addendum. Staff education had also been implemented to ensure each shift of staff understood the facility policies which was reinforced by testing skills to verify staff could follow through with implementation of smokers with portable oxygen tanks. An undated Resident Smoking Policy, which R1 signed on 3/14/19, indicated, The approved designated smoking area in the facility is in the back yard smoking area on the first level. The Smoking Safety Assessment must be completed by the care plan team upon admission, annually thereafter, and must be reviewed at least quarterly or with a change in condition that impacts the resident's ability to safely smoke. Environmental Considerations addressed that were in support of the facility smoking policy included *A method of observation/supervision by facility associates *Maintenance of emergency equipment and supplies-i.e sprinklers, fire extinguishers, storage. assignment of safety equipment i.e. smoking aprons, or devices to assist residents in smoking * The furnishings within the smoking area that meet flame retardant requirements *The location of designated smoking area and provisions to assure residents with the need for supplemental O2 do not access the area while smoking is taking place *The storage of any hazardous materials i.e. oxygen, medical gas, combustible or flammable materials are not located near the approved smoking area *The placement of the fan above the door is to remain in compliance with the MN Clean Air Act and Life Safely Codes in order to keep smoke fumes out of the building. This fan is to be turned on at all times. An Addendum to the Resident Smoking Policy, dated 6/13/19, identified the risks to be,*Burn, *Fire, *Death, *Smoke inhalation, *Particularly, in the presence of flammable gasses or liquids such as Oxygen, *The fire and burn risk of smoking is much higher when around oxygen and includes risk of facial flash burn and respiratory distress. We advise you to keep at least a 10 foot radius around those who are using oxygen while you are smoking. If oxygen tanks explode, you and those around you are at risk for serious injury and/or death.

Based on observation, interview and document review, the facility failed to properly assess and implement interventions to prevent reoccurring elopements for 1 of 2 residents (R43) reviewed for accidents. This resulted in an immediate jeopardy, with the potential for serious harm, injury or death for R43. The IJ began on 10/28/18, when it was determined the facility failed to properly assess and implement interventions to prevent elopement opportunities for R43 who left the building unattended twice, having to be brought back to the facility by local authorities the second time after having been found a few blocks away from the facility. On 11/30/18, at 1:30 p.m. the administrator, corporate nurse consultant, and director of nursing were informed of the IJ situation. The immediate jeopardy was removed on 11/30/18, at 7:00 p.m. but noncompliance remained at the lower scope and severity of D-Isolated, which indicated no actual harm with potential for more than minimal harm that was not an immediate jeopardy. Findings include: During observation on 11/30/18 at 1:00 p.m. R43 and family member (FM)-D were observed in the resident's room; FM-D stated R43 was going home soon and they were getting ready. When asked if FM-D was aware of R43 ever leaving the building unattended, FM-D stated she was aware of R43 having left the building once, when he'd had to be brought back by the police. FM-D stated the incident had occurred in the fall, it wasn't too cold and was the only time FM-D had been informed of R43 leaving the building unattended. When asked whether R43 utilized any type of alarm bracelet on the an ankle or wrist, R43 and FM-D both stated no. FM-D stated she was unaware of R43 ever having worn an alarm bracelet however, FM-D stated R43 should have worn one after the elopement in (MONTH) (2018). During the conversation, R43 did not recall the incident and was not aware of leaving the building any other time. R43 lifted up both pant legs and sleeves and there was no evidence of an alarm bracelet (wander guard). However, R43's physician's orders [REDACTED]. R43's medical record was reviewed. Admission paperwork indicated R43 had been admitted with [MEDICAL CONDITION], major [MEDICAL CONDITION] and Wernickes [MEDICAL CONDITION] (a neurological disorder marked by mental confusion, abnormal eye movements and unsteady gait). The admission Minimum Data Set (MDS) assessment dated [DATE], indicated R43 had severe cognitive impairment, experienced delusions, was independent with ambulation on and off the unit, but further indicated R43 did not wander. A quarterly MDS dated [DATE], indicated R43 had delusions, but indicated no behaviors of wandering. The record also revealed R43 had been seen by the associated clinic of psychology on 9/17/18, for assessment and treatment of [REDACTED]. A progress note written by registered nurse (RN)-H on 10/28/18, at 3:07 p.m. revealed the following: Resident was not present in the building at 11:45 (a.m.). Searched the facility for missing resident, wasn't able to locate him and called Code line 10 for elopement. By 1230 p.m. still not able to locate resident and called St(NAME)Police department to report eloped resident. Received case Number 986 and notified the responsible party. At 1320 (1:20 p.m.) police escorted resident to the floor. It was reported that resident was found outside of the facility walking nearby streets. Resident was alert, oriented to self, situation, place. Some confusion noted, stated I didn't know I was outside. No Wanderguard device was located on his leg, Checked VS (vital signs) 114/73, RR 21, sats 96% T 98.1 Resident is currently on the floor, reports his needs are met. There were no follow up progress notes made after this entry, and no indication the physician was notified. A progress note, dated 11/10/18 at 4:59 p.m. entered by licensed practical nurse (LPN)-C indicated: Resident sneaked (sp) out of the building through the kitchen and found his way out at 4:30 p.m Writer was informed by the receptionist. On arrival the writer found the resident outside, I am looking for my car, I have to go home. I am done. I need to go home. Writer and staff managed to redirect the resident back to the building. On assessment has no any observable injuries noted. VS within his baseline, he is alert and oriented to self with confusion. Resident now watching TV (television) with the rest of the residents on fourth floor, 15 minute checks initiated. Staff will continue to monitor. No further documentation was found related to the incident in the progress notes. No documentation was noted regarding monitoring of vital signs or of 15 minute checks. There was no documentation of physician or of the family member being notified. No initial elopement assessment was found in the electronic medical record prior to, or immediately following, the elopement on 10/28/18. However, another Elopement Report was found in the record dated 11/10/18. This Elopement Report included much of the documentation as was included in the progress notes following the resident's elopement 11/10/18 when the resident left the facility without staff knowledge to try to find his car. A number of questions on the Elopement Report were left unanswered such as: Was alarm sounding? Is the resident cognitively impaired? Does the resident have poor decision making abilities? Does the resident have a legal guardian/POA? Does the resident have a history of wandering or elopement? Does the resident ambulate independently or independent with assistive device? Does the resident use a personal alarm of any kind? Upon request, the facility made available a facility form entitled Elopement #750. The form was dated 10/28/18, and described an earlier elopement. The form indicated the elopement incident had occurred and no injuries were observed, the resident remained alert and was ambulatory without assistance. The resident's family member was notified on 10/28/18 at 3:38 p.m. The documentation was consistent with RN-H's progress note. The facility did not provide any summary of root cause for R43's Elopement 10/28/18. In addition, a form documented as having been completed 11/12/18, was also consistent with the nursing progress notes and indicated R43 had gotten out the back door without staff noticing, and had been found outside looking for his car. The form indicated the nurse practitioner was notified and the resident had been temporarily placed on 15 minute checks. No injuries had been observed. The form lacked any further review or summary of a root cause analysis of the incident. A review of R43's care plan last revised 4/21/18, indicated R43 was independent with ambulation without assuasive devices, experienced some confusion, and had been found once sleeping in the wrong bed, and another time had been found in the facility's basement. The care plan indicated R43 wore a Wanderguard to keep safe, and to keep him from wandering away from the facility. Care plan interventions included: (R43) to wear a Wanderguard to keep safe during his wandering as tolerated by the resident, signs were placed on the door to direct R43 to his room, signs were placed on the bathroom door to direct R43 to the correct bathroom, staff was to redirect R43 when ambulating in hallway or wandering in other resident's rooms to a safe area as needed, staff will encourage R43 to report any changes in his ability to ambulate. The care plan did not identify the recent elopements from 10/28/18 or 11/10/18. On 11/29/18 at 10:35 a.m., licensed practical nurse (LPN)-C stated R43 did not display much in the area of behaviors during the day shift, and described R43 as quite happy. LPN-C stated staff watch him (R43), but that R43 was doing pretty good. On 11/29/18 at 2:57 p.m., registered nurse (RN)-G stated R43 was greatly improved since admission. RN-G stated she was not aware of R43 exhibiting any behaviors. On 11/30/18 at 9:42 a.m., RN-G was asked about R43's behaviors and recent elopements. RN-G stated R43 could go any where in building and sometimes preferred to eat meals downstairs. RN-G further stated R43 did have some confusion related to previous use of [MEDICAL CONDITION]. RN-G also confirmed R43 did not have a car parked at the facility. When the elopements were discussed, RN-G confirmed an initial elopement risk assessment had not been included in R43's medical record. On 11/30/18 at 1:17 p.m., the corporate nurse consultant verified neither elopement incidents for R43 had been reported as allegations of potential neglect of supervision to the State agency. The nurse consultant also verified the administrator should have been informed of the elopements at the time of occurrence, but had not been informed of the incidents until 11/30/18, stating failure to notify the administrator was a systems issue. The nurse consultant was asked for documentation regarding how nursing staff were supposed to check placement of the Wanderguard every shift, and the nurse consultant stated the facility had no documentation available. The IJ that began on 10/28/18, was removed on 11/30/18 at 7:00 p.m., when the facility had developed and implemented a removal plan including reassessment of R43's elopement risk, assessment of other residents at risk for elopement, development of a plan to monitor effectiveness of Wanderguards, updates to the facility policies, and initiation of audits. Non-compliance remained at the lower scope and severity of D, isolated with the potential for more than minimal harm that is not actual harm.

Based on observation, interview, and document review, the facility failed to comprehensively assess, reassess, and implement interventions to prevent the development of, or worsening of, pressure ulcers for 3 of 4 residents (R70, R90, R92) reviewed for pressure ulcers. This resulted in actual harm to R70 who developed multiple Stage 2 pressure ulcers and an unstageable pressure ulcer that worsened; and for R90 who developed worsening pressure ulcers. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. R70's Face Sheet printed 11/28/18, identified [DIAGNOSES REDACTED]. R70's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R70 had moderately impaired cognition, poor decision making and no behaviors. The MDS further identified R70 was totally dependent on staff for bed mobility, transfers, and toileting. The MDS also indicated R70 was frequently incontinent of bowel and bladder, and was at risk for developing pressure ulcers. The MDS indicated R70 had no unhealed pressure ulcers at the time of the assessment. The MDS also indicated the following interventions were in place: repositioning, and pressure reducing devices for the chair and bed. R70's Significant Change of Status (SCSA) Care Area Assessment (CAA) dated 7/10/18, indicated the following: -R70's Activity of Daily Living (ADL)-Functional Rehabilitation CAA indicated R70 had moderate cognitive loss, [DIAGNOSES REDACTED]. -R70's Urinary Incontinence CAA indicated R70 was frequently incontinent of bladder and bowel, and was totally dependent on facility staff for toileting needs. -R70's Pressure Ulcer/Injury CAA indicated R70 was at risk for developing pressure ulcers, and was totally dependent on facility staff for bed mobility. The CAA further identified R70 required a pressure relieving device for bed and chair. R70's care plan revised 10/1/18, indicated R70 was at risk for pressure ulcer development, had no current pressure ulcers, and was totally dependent on facility staff for all ADLs. R70's care plan identified pressure relieving interventions which included: staff to reposition R70 every 2 hours, pressure relieving cushion for wheelchair, and a pressure redistributing mattress for his bed. R70's care plan lacked indication of a pressure relieving cushion for his recliner. R70's unsigned Physician order [REDACTED]. days: Tuesdays and Saturdays. R70's Initial Weekly Wound Documentation Form dated 11/17/18, identified R70 had three areas of concern on the skin including: -R70 had a pressure area on the vertebrae which measured 1.7 centimeters (cm) in length (l) and 0.8 cm in width (w). The wound assessment lacked staging of the pressure ulcer, and lacked any depth measurements. -R70 had an other area on the sacrum which measured 2.4 cm by 1.5 cm. The wound assessment lacked what type of wound was on the sacrum, and lacked depth measurements. -R70 had an other area on the sacrum which measured 4.5 cm by 4.0 cm. R70's wound assessment lacked what type of wound was on R70's sacrum, and lacked depth measurements. The wound assessment further identified R70's pressure and other wounds had scant and moderate amount of serosanguious drainage, intact wound edges, and no odor. R70's wound assessment identified facility staff would clean the pressure and other ulcers with wound cleanser, pat dry, apply skin prep to peri wound and cover with a foam dressing daily. R70's wound assessment further identified his family and physician had been notified of his pressure ulcer and other wounds. R70's initial wound assessment lacked pressure relieving interventions. Following observation of the pressure ulcers on 1/28/18, the facility added the following: 11/28/18. Weekly Wound Documentation Form indicated pressure wound at sacrum unstageable 4.5 cm x 4 cm x 1 cm. Moderate amount of serosanguious drainage with no odor with wound edges pink and irregular. Wound declined with 100% soft eschar tissue with pain associated with wound. New treatment plan started new intervention in place to include foam cushion in recliner chair. R70 to be up for 1 hour at a time. 11/28/18. Weekly Wound Documentation indicated left buttock Stage 2 pressure ulcer described as 2.5 cm x 1 cm x 0.2 cm with scant amount of serosanguious drainage with no odor, pink wound edges, and improved progress from previous measurement. Review of R70's progress notes from 9/15/18, to 11/28/18, revealed the following: 9/15/18: R70's skin was intact without any open areas. 9/25/18: R70 had received a shower. The progress note lacked documentation of R70's skin condition. 10/2/18: R70 had refused a shower, and his skin was not checked. 10/16/18: R70 had refused a shower and had received a bed bath. The note lacked documentation of R70's skin condition. 10/20/18: R70 had refused a shower and had received a bed bath. The note lacked documentation of R70's skin condition. 10/30/18: R70 had received a shower, however the note lacked documentation of R70's skin condition. 11/1018: a hospice progress note indicated R70 had an open area around his rectum. The note revealed a paste was applied to the open area. The note lacked any description of the characteristics of the open area. 11/17/18: R70 had an open area on his coccyx. The note lacked any description of characteristics of R70's open area. 11/21/18: R70 complained of increased discomfort; repositioning and one-to-one staffing were ineffective. 11/25/18: R70 continued with hospice care with pain medication given per schedule with effectiveness. 11/27/18: R70 continued to be on hospice care. Pain medication given per schedule with effectiveness. Up in chair until 1:00 p.m. On 11/27/18, at 11:20 a.m. a typed schedule for repositioning was observed posted on R70's wall. The note directed facility staff to get R70 up in chair at 10:30 a.m. and back in bed after lunch between 1:00 and 2:00 p.m. R70 was again to be up in chair by 4:30 p.m., returning back in bed between 6:00 and 7:00 p.m. R70's recliner was observed at this time to not have a cushion. On 11/27/18, at 11:20 a.m. family member (FM)-I was interviewed. FM-I stated R70 was incontinent, and at times would go for five hours with no toileting or repositioning changes while in the recliner. FM-I stated it was worse on weekends. FM-I stated staff could be rude and rushed, even with FM-I in the room. FM-I stated concerns had been brought to the assistant director of nursing (ADON). FM-I stated no staff comes into R70's room when FM-I is in there, sometimes for hours. FM-I stated R70 had no recent hospitalization s, and had been on Hospice since last July. FM-I indicated R70 had been up since 10:00-10:30 a.m. that morning, and although staff had been in periodically, usually nobody comes to just check on R70 once he is up in the chair. FM-I stated R70 had an abrasive area on his coccyx that had developed within the last two weeks, he had more than one area, and none were open. On 11/28/18, R70 was continuously observed beginning at 7:04 a.m. The following observations were made: 7:04 a.m. R70 was lying quietly on his back with his eyes closed. The lights were off and the television was on. R70's wheelchair was observed in the hallway with a cushion on it. At 7:13 a.m. the ADON (assistant director of nursing) entered R70's room, spoke with R70, and exited the room without offering repositioning or toileting. At 7:16 a.m. two nursing assistants (NA)-J and NA-I entered the room, and R70 asked the surveyor to leave. At 7:35 a.m. the NAs came out of R70's room. R70 was up in the recliner, R70's recliner did not have a pressure relieving cushion in place. At 7:57 a.m. activity aide (A)-A went into the room, and asked R70 how he was doing. Activity aide (A)-A emptied a cup the refilled it with water, and placed the cup on R70's bed side stand, which was across the room. A-A then left the room. At 7:38 a.m. NA-J stated she routinely provided cares for R70. NA-J stated R70 was totally dependent for all ADLs, which included repositioning. NA-J stated R70 no longer used the bathroom, wore an incontinent pad, and required routine checking and changing. NA-J further stated all residents on the C wing (R70's unit) were on an every two hour repositioning plan, which included R70. However, NA-J indicated R70 preferred to stay in his recliner. At 8:03 a.m. registered nurse (RN)-C went into R70's room to administer medications. Following medication administration, RN-C left the room without offering or providing toileting or repositioning. At 8:28 a.m. NA-I went into the room and assisted R70 with breakfast. NA-I fed R70 breakfast, but did not offer or provide toileting or repositioning. At 9:11 a.m. the ADON checked in on R70, and asked if he needed anything. The ADON did not offer or provide toileting or repositioning. At 9:32 a.m. RN-C went in to R70's room and provided medications and oral suctioning. At 9:42 a.m. RN-C left R70's room without offering or providing toileting or repositioning. At 9:58 a.m. FM-I entered R70's room. At 10:08 a.m. NA-J passed by R70's room, looked in, and passed by. NA-J did not offer or provide toileting or repositioning. At 9:58 a.m. FM-I was interviewed outside of R70's room while observations continued. FM-I stated toileting and repositioning R70 was a recurring problem. FM-I stated staff that worked with R70 were getting him up once a day. FM-I stated R70 was never up as early as he was today, and voiced concerns the early rising would prolong R70's repositioning schedule. FM-I stated NA-J told her R70 had gotten up in the recliner around 9:00 a.m. FM-I then went into R70's room. At 10:20 a.m. RN-C entered R70's room and spoke to FM-I, who stated R70 needed a nebulizer treatment (breathing treatment). RN-C left the room, then returned with a nebulizer treatment. At 10:37 a.m. (3 hours and 2 minutes after R70 was last repositioned) the ADON was informed by the surveyor R70 had not been repositioned since 7:35 a.m. The ADON stated staff reported R70 had been offered and declined repositioning based on routine checks and visual checks every two hours that morning. The ADON stated he trusted his staff. At 10:42 a.m. the ADON asked R70 if he wanted to lay down, and R70 agreed. At 10:49 a.m. the ADON and RN-C assisted R70 to bed. R70's recliner was observed to have a white bath towel on the seat. The towel was saturated with urine. When in bed, R70's incontinence pad was observed to be saturated with urine. The ADON stated the incontinence pads often leaked. R70's pressure ulcers were observed with the ADON. On the left side of the vertebral column, R70 was noted to have a dressing dated 11/26/18. The ADON removed the dressing, which he stated was from a previously reported abscess. R70's pressure ulcer on the buttock/coccyx area was reported by the ADON to have 1.5 cm x 1 cm yellow slough, and was described as unstageable. The pressure ulcer on R70's buttocks measured 4.5 cm x 4 cm x 1.5 cm, and was also reported as unstageable by the ADON, who noted a necrotic area on the pressure ulcer. The pressure ulcer was noted to have a foul odor. FM-I observed the pressure ulcer and stated it had worsened since she'd seen it approximately one week ago. R70's left sacrum left pressure ulcer measured 2.5 cm x 1 cm, and was identified as a Stage 2 pressure ulcer. The ADON stated a NA had reported a change in R70's condition earlier in day, but he had not reported it yet. R70 remained on his back, waiting for the for the nurse practitioner (NP) to arrive after being paged to evaluate wound. At 11:19 a.m. NP-D arrived in R70's room. Upon visualizing R70's pressure ulcer on the buttocks, NP-D stated, Holy buckets, and continued to state the pressure ulcer on the buttocks was much deeper than she had remembered. NP-D stated she had not been notified of the change in the pressure ulcer, or of the new pressure ulcers on R70's buttock/coccyx area and left sacrum. NP-D stated she recalled R70 had a sore on his buttocks, but she remembered the area as superficial. NP-D stated the pressure ulcer on R70's buttocks was unstageable. On 11/28/18, at 11:35 a.m. the ADON was interviewed. The ADON stated this was the first time he had observed R70's pressure ulcers, but confirmed the pressure ulcer on the buttocks had worsened. The ADON confirmed no reassessment had been completed since the pressure ulcer worsened. The ADON stated the facility does not do a formal skin risk assessment, nor do they an assessment to see how long a resident can sit or lie without developing redness or tissue damage, but they do two hour repositioning on everyone. The ADON stated they can individualize the two hour repositioning to a every one hour repositioning if needed. The ADON stated R70's pressure ulcers were first observed on 11/17/18. The ADON stated pressure ulcers should be documented on weekly. The ADON confirmed R70 did not have a cushion in his recliner. On 11/28/18, 1:15 p.m. during a follow up interview, NA-J indicated she had not offered R70 assistance with repositioning or checking and changing. NA-J stated R70 had routinely refused to reposition in the past, and therefore she did not offer to reposition. NA-J stated she had reported R70's open sores (pressure ulcers) to a nurse the previous evening. On 11/28/18, at 1:53 p.m. the administrator was interviewed. The administrator stated it is not uncommon for residents to be repositioned every two hours, give or take a half an hour. The administrator stated the expectation would be to reposition residents more frequently if they had a pressure ulcer, or if their condition had declined. The administrator stated he would expect staff would document any report of a resident's decline in condition, update the care plan, and discuss with family the risk verses benefits of not repositioning timely. On 11/28/18, at 2:14 p.m. the hospice RN-I was interviewed. RN-I stated she had not seen R70's pressure ulcers. RN-I stated she was aware R70's skin had been breaking down, however she was not aware of the degree to which it was now open. RN-I stated the hospice NAs were not informed of changes in R70's pressure ulcers. On 11/29/18, at 12:28 p.m. the hospice NA (NA)-H was interviewed. NA-H stated at times R70 refused cares, and she would document his refusals. NA-H was unable to provide documentation of R70's refusals of care. The facility's 12/2017 Skin Program policy, indicated a resident who enters the facility without a pressure ulcer will not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. The policy further directed a baseline assessment of the resident's skin status will be competed within 2 hours of admission, and would include a Risk Assessment tool. The policy further directed a comprehensive wound assessment would be completed when a skin ulcer is identified, and the assessment would include site, stage, size, appearance of wound bed, undermining, depth, drainage, and status of surrounding tissue. The policy further directed use of a pressure ulcer monitoring tool to assess pressure ulcer healing, and the pressure ulcer will be reassessed at least weekly. The facility's 12/2017 Pressure Ulcer Risk Assessment policy, indicated a pressure ulcer risk assessment (Braden) would be conducted upon admission, readmission, quarterly, annually and with a change of condition or surface. Skin checks would be performed on weekly basis for presence of developing pressure ulcers. Staff would maintain a skin alert, performing routine skin inspections daily or every other day as needed with nurses to be notified to inspect the skin if skin changes identified, and nurses to conduct skin assessment at least weekly to identify changes. During observation on the morning of 11/29/18, R90 was on an pressure distribution air mattress bed and was repositioned every one and half hours. During observation of wound assessment, on 11/29/18 at 9:01 a.m., registered nurse (RN)-G wiped away the paste dressing covering the sacral and buttocks area of R90. Removal of the paste dressing revealed one, stage two pressure ulcer in the sacral area, measuring approximately 2.5 cm x 1.5 cm x 0.2 cm, and two eschar-covered wounds to the ischial tuberosities areas, one to each left and right ischial tuberosities area and each measuring approximately 0.2 cm x 0.2 cm. In conversation, RN-G referred to the wounds on the right and left ischial tuberosities areas as being located in the right and left trochanter area. RN-G and the surveyor discussed the difference in location of the ischial tuberosities and the trochanter. RN-G stated the wound to the sacral area was only excoriation and the right ischial tuberosity area wound was healed despite the presence of eschar tissue. Triad paste was reapplied to all wound areas by RN-G and RN-G stated Triad paste was an appropriate treatment for [REDACTED]. On 11/29/18 at 10:49 a.m., RN-G stated he was the nurse who did the wound assessments for the facility, and asked the surveyor if RN-G and the surveyor could look at R90's wounds again. RN-G told the surveyor he could show the surveyor that the right ischial tuberosity area wound was healed and the sacral wound was only excoriation. The wounds were observed again by RN-G and the surveyor at that time. RN-G attempted to brush the eschar off of the right ischial tuberosity wound. The eschar would not come off of the wound. RN-G then verbally verified the right ischial tuberosity wound was not yet healed. RN-G also agreed the sacral wound was a pressure ulcer. The surveyor asked RN-G how he would stage the sacral wound and he replied stage two. The most recent Braden Scale Assessment For Predicting Pressure Sore Risk form in the record, dated 8/7/18, showed R90 scored 11 which was classified a high risk for developing a pressure sore. Page five of the current care plan for R90, dated 7/16/18, read, Skin: I have these [DIAGNOSES REDACTED]. I currently have pressure ulcers on my LIT (left ischial tuberosity) and RIT (right ischial tuberosity) . I have a history of stage 4 pressure wound on my coccyx and recently healed pressure wound on my sacrum. When interviewed on 12/10/18 at 3 p.m., RN-G stated he believed the entry on the care plan was in error, needed to be updated, and the wounds on the coccyx and sacrum were actually the same wound. RN-G then provided a Weekly Wound Documentation Form showing R90 had a previous stage two pressure ulcer wound to the sacrum, measuring 0.5 cm x 0.2 cm x 0.2 cm which was documented as healed on 2/22/18. The current Order Summary Report contained a provider order, dated 8/7/18, indicating Wound care left IT: cleanse state 3 pressure wound with wound cleanser, pat dry, apply skin prep to peri skin and apply collagen to wound and cover with foam dressing daily. This order was documented as completed daily during (MONTH) (YEAR) on the Treatment Administration Record.` Record review of Weekly Wound Documentation Form entries from 1/18 to 11/22/18, revealed the left ischial tuberosity area wound, was mistakenly identified as a left trochanter wound. These forms included measurement, staging, and description of the wound. The 1/18/18 entry described the wound as 2.5 cm x 1 cm x 0.2 cm, and a stage two. The 11/22/18 entry described this wound as a 0.2 cm x 0.2 m x 0.1 cm stage three. The right ischial tuberosity area wound, mistakenly identified as a right trochanter wound on Weekly Wound Documentation Form entries, was first documented on 7/5/18, and described as 1 cm x 1.5 cm x 0.1 cm, and a stage two. No assessments of this wound have been documented in the past two months. No previous assessments of the sacral wound identified on 11/29/18 were found in the record. A Weekly Wound Documentation Form was completed for this wound on 11/29/18, describing it as a stage two pressure ulcer, measuring 2.5 cm x 1.5 cm x 0.2 cm. Page one of the facility's Pressure Ulcer Risk Assessment policy, dated (MONTH) (YEAR), read, c. Nurses will conduct skin assessments at least weekly to identify changes. 15. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers . R92's most recent minimum data set (MDS}, dated 10/20/18, revealed R92 was totally dependent on staff for transferring, bed mobility and toileting. R92 had no pressure ulcers. R92's cognitive status was not assessed. R92's [DIAGNOSES REDACTED]. R92's MDS, dated [DATE], revealed R92 had short and long term memory problems, no ability to recall and severely impaired skills for decision making. R92's pressure ulcer/injury care area assessment, dated 1/29/18, revealed, Is totally dependent on staff for all repositioning and is totally incontinent of bowel and bladder and dependent on staff to provide toileting and peri hygiene. Has Braden score of 13 (moderate risk for pressure ulcers based on a standardized pressure ulcer risk assessment tool). Is at risk for pressure injury due to being bedfast or chair bound and has air mattress on bed and pressure relieving cushion in w/c (wheelchair) and is receiving Z-guard (zinc barrier paste) on bottom with all toileting and changing. On 11/29/18 at 8:32 a.m,, two nursing assistants (NA)-B and (NA)-C transferred R92 into bed from her wheelchair using a full mechanical lift. NA-C and NA-B checked R92's incontinence brief, which was not soiled. R92 remained lying in bed facing the wall. At 11:35 a.m , NA-C and NA-D changed R92 soiled brief, provided peri-cares and transferred R92 from her bed into her wheelchair. NA-C reported R92 had not been changed or repositioned since before 9:00 a.m., when surveyor observed NA-B and NA-C transfer R92 into bed. NA-C reported R92 was supposed to be repositioned every two hours. NA-C reported she was busy with another resident and unable to assist R92 at 11:00 a.m, as she had intended. NA-C reported there was not a way to communicate she needed assistance with helping R92 while she was in the room with another resident. On 11/301/8 at 8:22 a.m., the nurse manager (RN)-B reported R92 should be repositioned every two hours. R92's urinary incontinence care area assessment, dated 0/17/18, revealed In very dependent on staff for toileting and is totally incontinent of bowel and bladder due to her dementia and inability to express needs and wants. and Is at risk for pressure injury, skin rashes and infection and loss of dignity. R92's care plan, last revised, 10/1/18, noted the focus area: Hygiene/ADLs (activities of daily living)/Skin: I was admitted with a stage 2 coccyx ulcer and pink areas on my buttocks which have healed. I also, have a history of right heel ulcer and blisters on my left arm and hand, pressure ulcer wound stage II on my left fingers (3rd,4th, 5th) possibly from friction d/t (due to) contracture. Per Braden Assessment recently completed, I am at a high risk for developing pressure ulcers d/t these risk factors; friction and shearing, contractures, decreased mobility and activity, incontinent of bowel and bladder, and dx of diabetes. Goals included: I would like to be free from skin irritations or wounds. Interventions included: Staff of 2 to turn and reposition every 2 hours in bed and offload for 60 seconds while in wheelchair. R92's resident care sheet, undated, directed staff Tissue Tolerance: A2 q2hrs (assist of two every two hours)

Based on observation, the facility failed to comprehensively assess a change in behavior and mood and failed to provide care to promote mental wellbeing for 1 of 1 resident (R29) reviewed for behavioral health services. The lack of comprehensive assessment and failure to identify and implement non-pharmacological interventions resulted in actual harm for R29 who experienced escalating behaviors, signs of self injurious behavior, suicidal ideation, physical aggression towards others, property destruction and loss of interest in activities previously enjoyed. Findings include: R29's admission record, printed 11/29/18, revealed [DIAGNOSES REDACTED]. R29's Medication Administration Record, [REDACTED] R29's annual Minimum Data Set (MDS), dated [DATE], revealed R29 had no physical behavioral symptoms directed towards others (e.g. hitting, pushing and grabbing) and no other behavioral symptoms not directed towards others (e.g. hitting self, rummaging and disruptive sounds). R29 displayed no signs or symptoms of depression, thoughts of self-harm or self-injurious behaviors. R29 was noted as having short term memory problems and adequate long term memory. R29 was noted as able to identify staff names and faces, location of room and that he was in a nursing home. R29's most recent quarterly MDS, dated [DATE], revealed R29 displayed behavioral symptoms directed towards others and other behavioral symptoms not directed towards others on a daily basis. R29 was not screened or assessed for potential signs of depression, suicidal ideation or self-injurious behaviors. R29's cognitive status was not assessed. On 11/26/18 at 4:17 p.m., R29's roommate, R98 reported R29 acted out in an aggressive and loud manner. R29 tore up R29's headboard, ripped up bedding and banged on the wall. R98 bed was next to the window and the window was covered by a large padded mat. During periodic observations on 11/26/18 from 3:30 p.m. to 6:26 p.m., R29 was noted to spend the majority of the shift in his room in bed, not engaged in activities. On 11/28/18 at 8:24 a.m., R29 was observed sitting in his wheelchair in the commons area. R29 was feeding himself. NA-A walked over and began spooning food into R29's mouth while standing next to R29. NA-A did not converse with R29 and looked around the room and spoke with other staff and residents as he stood next to R29 and fed him. R20 walked up and did a special hand shake with R29. R29's face had a huge smile during this interaction, which he actively participated in. NA-A finished feeding R29, handed him the cup of juice, took R29's plate and walked away without any conversation with R29. R29 varied between flat affect and frowning throughout the interaction with NA-A. On 11/28/18, during periodic observations between 8:54 a.m. and 11: 00 a.m., R29 was observed lying in bed. The television in the room was on a news channel. R29's eyes were closed for most of the observation. On 11/28/18 at 12 noon, R29 was observed in his wheelchair in the commons area, adjusting the tray table and the mirror on his tray table. At 12:02 p.m., staff delivered R29's food and R29 fed himself using silverware. R29 sat alone. At 12:38 p.m., R29 finished his meal. R29 started wheeling his wheelchair around with one arm. R29 bumped into R47, who called for help. R29 then reached out and grabbed R42 as R42 wheeled towards the elevator. NA- K attempted to take R29 back to his room, but NA-A was feeding R98. R29 then continued wheeling himself down hallway with one arm. R29 bumped into the medication cart in the hallway. R29 then backed up and bumped into it with increased force several more times. At 12:41 p.m., NA-A and NA-L took R29 to his room. R29 reached out at R98 and R98 said keep your hands to yourself. NA-A and NA-L transferred R29 from wheelchair to bed using a full mechanical lift and sling. NA-L then left with the lift and sling after removing sling from under R29. NA-A removed R29's incontinence brief, turned him to his side, wiped his bottom off and applied a clean brief. NA-A did not explain care or engage in conversation with R29. R29 slapped his thighs with force and grabbed at NA-A's hand. NA-A said it's ok. NA-A then explained he would turn R29 over. R29 grabbed NA-A's hand and NA-A removed R29's hand from his hand. R29 continued to grab NA-A's hand throughout interaction. NA-A did not initiate conversation with R29. NA-A then straightened out R29's blankets, put the bed at a low level and a mattress in front of R29's bed. R29 slapped his thigh. NA-A said all right and left. NA-A did not say goodbye to R29, check to see if R29 was ok or tell R29 when he would be back. On 11/28/18 at 1:05 p.m. NA-A explained R29 spent most of his day in his room. At times R29 would go to activities but would sometimes ram his wheelchair into things. NA-A reported R29 grabbed other staff and residents. NA-A explained R29 rummaged through R98's items but had not grabbed or hit at R98, his roommate. NA-A explained R29 used to use a communication board, but lately had started throwing it. R29 communicated by pointing. NA-A reported he was directed to take R29 to his room when he was ramming into other people or items or grabbing out at others. NA-A reported he was provided no other guidance on managing or preventing R29's behaviors. NA-A reported R29 communicated non-verbally through behaviors. On 11/28/18 at 1:14 p.m., the registered nurse manager (RN)-B reported R29 did not always demonstrate behaviors such as bumping into things and grabbing other people. They had started and increased in recent months. RN-B reported staff were addressing behavior issues by not putting R29 in the commons area until staff were ready to serve him. RN-B and surveyor observed R29's room. R29 was in bed and snapped and pointed. A large mattress was placed in front of the window between R29's bed and the wall and window. RN-B explained R29 had caused damage to the wall by ramming into it. Staff placed the mattress there to protect R29. On 11/29/18 at 8:54 a.m. R29 was noted in bed, with the television on. On 11/29/18 at 2:52 p.m., the social worker (LSW)-A reported she had not been involved with assessing or managing R29's behavioral expressions outside of arranging for a psychiatrist and a mental health therapist, who visited just a few days prior. LSW-A reported R29's behavioral expressions were discussed at morning meetings, but there were not notes in R29's medical record. LSW-A reported she attempted to do a PHQ-9 (depression screening included in the MDS) and BIMS (brief inventory of mental status included in the MDS), but was unable to do so as R29 had difficulty participating in the screenings. LSW-A reported she did not participate or complete other assessments related to R29's increase in physical behaviors directed at others and other behaviors not directed at others. There were no assessment to see what R29 might be trying to communicate through the behaviors or what might be contributing to the increase in behaviors. LSW-A reported staff were managing R29's behaviors by putting a mattress between R29 and the wall since he had caused damage by ramming into the wall. LSW-A reported R29's relationship with his roommate R98 had been impacted by his increase in disruptive behaviors. LSW-A reported R98 had previously acted as an advocate for R29, but had grown tired of R29's aggressive behaviors. LSW-A reported staff spoke with R29's family member (FM)-A at the most recent care conference. LSW-A said FM-A agreed R29's behaviors had changed and was looking for R29 to relocate to another care facility that specialized in serving individuals with [MEDICAL CONDITION]. On 11/30/18 at 8:30 a.m., RN-B reported she had identified R29 communicated he was wet from incontinence through R29's pointing or crying, and said R29 expressed pain through guarding and grimacing. RN-B also said R29 was able to nod yes and no. RN-B reported there was no further assessment of R29's increase in behaviors such as grabbing others and ramming into other people and objects with his wheelchair or what they were meant to communicate. RN-B reported staff had seen R29 make hand gestures that they believed were related to a prior group affiliation of R29. RN-B believed R29 may be attempting to get attention from others. RN-B reported R29 previously would listen to music on his portable music player and watch television but had started throwing the music player and remote. RN-B reported R29 would throw a coloring book if provided coloring supplies. RN-B reported R29 was not engaged in any peer support or mentoring programs. RN-B reported R29 was a young man and required age appropriate activities to engage in on a regular basis. RN-B reported management had come to the conclusion they were not equipped to provide care for R29 and he required more skilled management for individuals with [MEDICAL CONDITION]. On 11/29/18 at 3:43 p.m., the activity aide (AA)-A reported R29 participated in playing dice, being on the patio, staff reading to him, socials with snacks, movies and music. AA-A added typically R29 would not stay more than 10 minutes before he would start to roam around. AA-A reported the music played was not specific to R29's preferences but was played for all residents in the commons room. AA-A reported typically that was rock music. When asked what kind of music R29 liked, AA-A reported I don't know. AA-A and surveyor entered R29's room. R29 was observed lying in bed. R29 had headphones on his ears. When asked what kind of music R29 was listening to, AA-A listened to the headphones and then reported they did not work. AA-A was unable to fix the headphones. Surveyor asked if R29 liked music. R29 nodded yes. Surveyor asked if R29 liked rock music. R29 nodded no. Surveyor asked if R29 liked rap music. R29 nodded yes. AA-A reported she did not have rap music to play as other residents would not like it. AA-A reported R29's increased behaviors towards others and not towards others may be due to R29 being aimless. On 11/30/18 at 10:13 a.m., the activity director (AD) reported he did not take part in assessing R29's most recent activity preferences or interests or what might be contributing to his increase in behaviors directed towards others and not directed towards others and to R29 wheeling away when brought to activities. AD reported R29's last assessment for activities was in (YEAR). AD reported she would play a stacking game with R29 and R29 liked playing with the rings on her fingers. AD reported she tried to do an extended one on one with R29 at least once a week. AD reported R29 previously listened to music but his music player was not working lately. AD reported she expected AA-A to do 1:1 activities with R29 and trusted that she was doing so. On 11/30/18 at 11:37 a.m., during a phone call with a family member of R29's (FM)-A, FM-A reported R29 used to play chess, video games, explore the Internet, text, interact with others on social media, listen to music and was active in football and basketball. FM-A reported staff would read to him and play games, but thought with R29's young age, he may need to move to a place specializing in caring for individuals with [MEDICAL CONDITION]. FM-A reported R29 had suffered multiple traumas and losses in recent years including losing contact with his significant other and child. FM-A explained R29 initially had been told he would be moving back home with FM-A but was unable to due to costs of remodeling the home to be handicap accessible. FM-A reported R29 took this very hard and had a hard time understanding why he could not move home with FM-A. FM-A explained R29 liked music but recently R29's earphones, DVD player, headphones and earphones were broken. FM-A reported R29 needed more activity such as getting outside and going on outings. FM-A reported she would also like staff working with R29 to show more [MEDICATION NAME] towards him as some of his behaviors such as grabbing at others may be related to having a [MEDICAL CONDITION] and going through multiple traumas and losses. On 12/3/18 at 11:17 a.m., the MDS nurse (RN)-I confirmed R29 was not screened for depression on the most recent MDS assessment, dated 9/17/18. RN-I explained the social worker was responsible for completing them, but recently was getting behind since there was only one social worker for the building. RN-I reported she did not have time to complete them as she was the only registered nurse responsible for completing MDS assessments. RN-I reported there was no assessment completed related to his increase in physical behavior directed towards others and behavioral symptoms not directed towards others. There was no assessment as to what the behaviors meant or what was causing them. RN-I reported she had noted R29 had behaviors of grabbing her bottom and arm when she was helping feed him. RN-I reported staff had discussed his behavioral symptoms during morning meetings, but there was no documentation or assessment. R29's care area assessments, dated 6/7/18, did not trigger for behavioral symptoms or mood. R29's dementia and cognition care area assessment revealed (R29) is a (early 20's) male with the following contributing factors: [DIAGNOSES REDACTED]. This list is not All-Inclusive. This CAA triggered due to (R29) having both short-term and long-term memory problems. (R29) is moderately impaired when it comes to making daily decisions regarding tasks of daily life. (R29) is able to communicate needs most of the time by answering yes and no questions or pointing for what he wants. Staff also anticipate needs in which he is unable to communicate clearly about and will continue to monitor and update the care plan as necessary. R29's care conference note, dated 8/23/18, included: Res (resident) remains non-verbal, has been communicating needs lifting arm, nodding yes/no, tapping on table, making crying noises etc. and Resident continues to exhibit aggressive behavior such as grab other residents and staff and (R29) often displays attention seeking behaviors. He will pull on residents and staff member's arms, or grab/pinch them. He will participate in activities if he is brought to them. TR (therapeutic recreation) will continue to engage (R29) in a variety of leisure activities as a means to replace interfering behaviors and to enhance quality of life. Resident has behavioral concerns with grabbing onto people and not letting go. Resident had some medication changes to help impulse behaviors. Resident has been referred to relocation services. ST (Speech therapy) increase irritability and aggression, communication ability with yes or no but, not as engaged as he used to be, behaviors increased. Possible medication imbalance. Other than noting R29 had behaviors related to desiring attention, there was no further analysis of behaviors, cause, triggers, meaning or potential interventions. R29's physician and nurse practitioner notes were reviewed and revealed the following: R29's nurse practitioner note, dated 6/18/18, revealed TBI ([MEDICAL CONDITION]), with L[NAME] (loss of consciousness) > (greater than) 24 hours with return to prior conscious level, subsequent encounter 2nd gunshot wounds and He gets loud and snaps fingers when wants to lie down or wants to be changed. Sometimes he is laughing. He likes juices. [MEDICAL CONDITION] is expressive no receptive. (FM)-A would like a home eval, has been ordered, goal is to take him home if it can work out. and follows commands to squeeze hands and shakes head yes and He tracks with his eyes, [MEDICAL CONDITION] is expressive not receptive. He is smiling today. No physical behaviors directed towards other or self, property destruction, or suicidal ideation noted. R29's physician note, dated 6/20/18, revealed TBI secondary to (gunshot wound) to head (approximately 2 years ago). Much more alert and interactive. Dependent on staff for all cares but has purposeful movements and seems to answer questions by shaking his head. and extensive deficits but stable. Has improved since admission. Now alert, can communicate needs minimally, able to eat. No physical behaviors directed towards other or self, property destruction, or suicidal ideation noted. R29's nurse practitioner note, dated 7/23/18, revealed He was started on trazadone during the day tid 25 mg (milligrams) and 75 mg at HS (hour of sleep). He then became really sleepy. Trazadone is now at 25 mg bid and 75 mg at HS. This has worked better for him. But still aggressive at times, grabs at staff, gives the finger or points a gun. (FM)-A has been visiting lately and she has told him to stop. Goal is for him to move home with his family in the future. He is sleeping better. The difficulty is communication, he can't speak, can only snap fingers or hit his left leg to get his needs known. and He does get loud or snaps his fingers when his needs aren't met. Lately has been hitting his left leg to get attention as well. R29's nurse practitioner note, dated 7/30/18, revealed, He is on trazadone, not really helping. Grabbing at staff, residents. Talked to his mother, he was grabbing at her as well. Discussed bringing his [MEDICAL CONDITION] (sic) player or his phone. She says that she has given both, can't find them. Those items did help distract him for some time. His roommate is very unset, not getting any sleep. Patient hits his leg, hits wall, not sleeping at night, very aggressive when get close to him. History of making a gun/shooting with left hand as well. Mother agreed to increase trazadone to 150 mg and try [MEDICATION NAME] 50 mg For a month. R29's nurse practitioner note, dated 8/13/18, revealed TBI: secondary to (gunshot wound) to head (approximately 2 years ago). Has been having more problems recently with agitation and aggression. Grabbing on to staff and refusing to let go,has picked a hole in the wall in his room, purposely tried to run his wheelchair into other residents. Started on trazadone 6/21, [MEDICATION NAME] started on 7/30. He was sedated on the trazadone so dose was decreased but then the behaviors worsened so that was increased again. Behaviors are somewhat better but still present. R29's physician note, dated 10/17/18, revealed TBI secondary to gun shot wound. He has been having problems with agitation and aggression recently. Trying to run his wheelchair into staff, physically aggressive and trying to hit other residents and staff. Requiring multiple dose adjustments in medications for safety. [MEDICATION NAME] started 8/13, increased 8/20 and 8/27; [MEDICATION NAME] started 9/12' [MEDICATION NAME] started by psychiatry on 10/4. Staff feels behaviors are only minimally better and they are working with family on finding a TBI facility for him. Family had hoped to bring (R29) home with home care but feel this is not realistic with current behaviors. R29's psychiatrist progress notes, dated 10/4/18, revealed R29 displayed an increase in agitation such as grabbing staff hands and arms and not letting them go and boring a hole in the wall in his room. R29's [DIAGNOSES REDACTED]. R29 was noted to be in his early 20's and having impairment after a gunshot wound to the head in (YEAR). R29's psychiatrist recommended R29 continue [MEDICATION NAME] .5 mg (milligrams) twice daily, [MEDICATION NAME] 400 mg four times daily, trazadone 25 mg. three times daily and 150 mg before bed and add [MEDICATION NAME] 30 mg at night. There was no analysis as to the cause or meaning for R29's increased agitation or physical behaviors directed towards others and behaviors not directed towards others. A therapist note, dated 11/19/18, revealed Client is a (description of race and age in early 20's) who is diagnosed with [REDACTED]. He legs are paralyzed, and has minimum use of his arms. and Client was able to communicate with closed questions. His mood was anxious as evidenced by the client nodding to the question of having anxiety. and Client scored a 9 on his PHQ-9 (depression screener score indicating mild depression). Client indicated (head nodding) he has suicidal thoughts after the gunshot wound. R29's tasks section for behavior monitoring noted the following target behavior: Resident exhibiting behaviors such as; pulling on other residents or staff arms, bumping wheelchair into other residents, banging on table, hitting the wall with arm, throwing food or dishes on the floor, touch staff/residents inappropriately. R29 was noted as displaying one of those behaviors 4 times between 10/29/18 and 11/28/18. R29's care plan, last revised 10/2/18, directed staff Behavior: Physical/Impulsiveness; I am displaying signs of impulsiveness during meals banging on the table with my drinking cups, cutlery and giggling. I purposely propel my w/c and bump it into other res w/c, will finish eating and then throw dishes on the floor or left over food on the floor or in the w/c. I pull on staff hair or grab their buttock or arm tightly during cares. When staff attempts to redirect me, I laugh. I also, make the (group affiliation gestures) with my fingers and point it at staff and laugh. I bang on walls, history of ripping my air mattress. I prefer to drink juice only, I refuse to drink water or milk when offered. My behavior is being managed with non-pharm and pharmacological interventions. Goals included: I will demonstrate a decrease in impulsivity during meals making less noise with my drinking cups and I will demonstrate a decrease in impulsivity during stay as evidenced by elf-report or staff observation. Interventions included Staff to redirect behaviors and ensure (R29) is safe; staff will monitor me and ensure that I am not close enough to other residents and staff to grab hold of them; Assess for environmental antecedents and reinforcers; Monitor for poor safety decisions such as throwing cups on the floor; Assess for appropriateness of adjustments to medications or medical treatment to alleviate symptoms per physician care team; Offer juices half a cup at a time. The care plan problems, goals and interventions did not address root causes or meaning of behaviors. R29's care plan, last revised 10/2/18, directed staff Communication: I am non-verbal and have difficulty communicating my needs. I do however, understands English and able to follow some directions. I can answer yes/no questions, point to objects in communication book, make sounds to alert you of my needs. Goals included I want to be able to make my needs known interventions included I would like staff to communicate my needs with me; Please ask simple direct questions that require yes/no answers; Please allow me time to respond; Please face me when talking to me; Please anticipate my needs. R29's progress notes revealed the following behavior notes for (MONTH) (YEAR) through (MONTH) (YEAR). There was no evidence of assessment related to meaning of behaviors or resident centered interventions attempted. Primary interventions included medications, putting R29 to bed and instructing or redirecting resident not to do behavior. Notes related to redirection do not clarify method of redirection. There was no evidenced staff assessed, planned or attempted to identify effective interventions after interventions attempted repeatedly proved ineffective. 6/29/18 22:37 (10:37 p.m.) Behavior Resident continues to have increase in behaviors on this shift, he was grabbing other residents and staff arms, he was banging on, flipping tables in the common area. when staff redirect him he was just laughing at staff and going back right away to do what he was doing. 7/1/18 15:47 (3:47 p.m.) Health status Stable, resident was laid down after breakfast, and he started throwing stuff out of his dresser, writer went and talked to resident and re-directed him, resident took a nap and he got his meds at noon, he is being ok since then. upcoming updated. 7/5/18 22:33 (10:33 p.m.) Behavior Resident was agitated today. Resident was shaking his vigorously. Writer gave resident prn (as needed) trazadone for agitation. After giving medication, resident seemed to be calm and relax. Upcoming nurse notified to continue to monitor resident. 7/6/18 06:18 (6:18 a.m.) Behavior Resident did not sleep whole night. Resident has thrown everything on the floor and ripped the mattress/pillows/blankets and briefs. Grabbed staff hands forcibly and very hard to make him release. Administered PRN (as needed) trazadone, but ineffective. Will continue to monitor. 7/7/18 15:20 (3:20 p.m.) Health Status Resident is stable, resident started slapping his left thigh after lunch, talked to resident offered snacks, distracted to watch TV but unfortunately not working for he resident now, incoming nurse updated. 7/14/18 17:14 (5:14 p.m.) General Note Resident rumble his room mate belongings and took his water pitcher starting to drink out of it; CNA (nursing assistant) took water pitcher and removed him from the room. Similar behavior took place in the TV and waiting room. He took resident drink and rode into to her resident's space in the sitting area. 7/16/18 0603 (6:03 a.m.) Behavior Residents behaviors continued despite PRN (as needed) trazadone, which was ineffective. Behaviors such as ripped bed, grabbed staff hands very hard while providing cares, punched wall, and unable to redirect. 7/19/18 05:58 (5:58 a.m.) Behavior: Resident is up whole night and behaviors continued that night. His roommate complains that because of him I am waking up. Administered PRN (as needed) trazadone but ineffective. Tried to redirect him, but resident agitated and more aggressive. Will continue to monitor. 7/21/18 20:16 (8:16 p.m.) Behavior: 15:30 Res(resident) up in w/c (wheelchair) rocking besides table against his w/c for about 12 seconds then stopped. About 15 minutes later he tipped the table onto it's side to the floor and wheeled away. Went to wait at end of (wing) and began to butt his foot rest against while laying down he continues to slap his left outer thigh many times, hard enough that it is heard outside his room. 7/22/18 14:41 (2:41 p.m.) General Note: Resident is stable, resident was slapping his thigh and writer redirected resident to watch TV, and gave snacks, redirection not effective. Will continue to monitor. 7/25/18 06:01 (6:01 a.m.) Behavior: Resident behaviors continued as usually: Throwing items on floor, grabbing care giver hands forcefully and very hard release, slapping himself and the wall very loudly and staffs unable to re-direct. His roommate reported he is not getting enough because of him or waking up in the middle of the night. Writer administered trazadone but not effective. Will continue to monitor. 7/25/18 16:03 (4:03 p.m.) General Note: Resident was sitting in TV room with other residents. While he was in his wheelchair, he was pushing others with his wheelchair. He was touching staff wrongfully. Resident was redirected and asked to stop. 7/26/18 23:49 (11:49 p.m.) General Note: Resident was misbehaving this evening hitting residents with wheelchair, pulling unto staff body parts. Everything was done to make him behave; he ignored and continued on misbehaving. 7/27/18 06:32 (6:32 a.m.) Behavior: Resident was up all night and increased agitation/or aggressiveness. Touching and grabbing staff body parts inappropriately and very hard to release from resident. Slapping himself very loudly and also striking/hitting the wall so hard, it small portion was broke. Staff re-approached him to provide cares, but resident got worst. Writer administered PRN (as needed) trazadone, but it is not effective. Will continue to monitor. 7/27/18 15:03 (3:03 p.m.) Health Status: Resident is stable, resident is grabbing resident and staff body parts, education not effective at this time will continue to monitor and educate. 7/30/18 06:34 (6:34 a.m.) Behavior: Resident has had a lot of inappropriate behaviors last night: Throwing everything on floor, slapping/hitting himself and wall very loudly/hard, so it broke some portion of the wall, and touching staffs inappropriately. Resident had PRN trazadone, which was ineffective. Will continue to monitor. 8/1/18 05:58 (5:58 a.m.) Behavior: Resident was up all night. Behaviors got worse last night. PRN (as needed) trazadone administered but was not effective. (Another resident) was very upset because waking up every time resident started such behaviors. Will continue to monitor. 8/1/18 18:12 (6:12 p.m.) Behavior: In addition to driving his footrests into w/c (wheelchair) of (another resident room), resident attempted to turn over a dining room table. Was stopped before he could do it. NARs put him into bed at this writing. Message to nurse manager. 8/3/18 23:51 (11:51 a.m.) Behavior: Patient running into tables, knocking over trays, grabs at writers waist, hit writer in head with hand. Patient was redirected, scheduled trazadone given. once patient was put in bed patient was calm and fell asleep. 8/3/18 18:42 (6:42 p.m.) General Note: Resident was sitting in TV room when he was moving around with his chair, pulling and hitting others with his wheelchair. Resident was remove and asked to stop. 8/7/18 05:51 (5:51 a.m.) Behavior: Resident unwanted behaviors continued. Resident on and off last night. PRN (as needed) trazadone administered, was not effective. 8/8/18 15:28 (3:25 p.m.) Health Status: resident remains alert, was grabbing staff and everybody that comes close to him, running w/c (wheelchair) toward everybody, he was difficult to be redirected, trazadone was given as ordered., he was put in bed, looks comfortable. 8/8/18 22:21 (10:21 p.m.) Behavior: Resident used aggressive behavior while in wheelchair in (another residents room. 8/11/18 14:21 (2:21 p.m.) Health Status: Stable, resident was slapping himself, writer redirected and talked but resident didn't, scheduled trazadone administered. 8/12/18 14:53 (2:53 p.m.) Health Status: Resident stable, resident has been bunging the wall while in bed and slapping himself, tried to redirect and talk to him but it was not effective, will continue to monitor. 8/23/18 22:52 (10:52 p.m.) General Note: Resident was visited today by {FM}-A; he was returned to floor about 4:00 pm. Later he was getting into everything, furniture and residents, staff and walls. Resident was carried back to his room transferred to bed. Tonight, he was acting out going into bedside table, draw getting out everything. Draw (sic) was removed away from his bed. Resident ate 100% dinner. He is asleep. 8/26/18 12:49 (12:49 p.m.) Health Status: Resident stable, resident slapping and hitting the wall, meds administered calmed down and slept and is calm now, will continue to monitor. 8/28/18 23:32 (11:32 p.m.) General Note: Resident was in bed and awake; he broke bedside table. Resident knock portable from the bedside table. He was given his medication for bedtime. After resident received his medication, he is awake and resting. 9/1/18 13:48 (1:48 p.m.) Health Status: Stable, resident behavior of grabbing staff and residents body parts, redirection and educating not effective at this time. 9/1/18 20:08 (8:08 p.m.) General Note: Resident was touching and hitting residents and staff wrongfully. He was transferred into his bed. Resident banged and punched th(TRUNCATED)

Based on interview and document review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 7 (R1) residents reviewed when R1's ventilator alarmed, but the facility did not intervene for at least 39 minutes. R1, who was ventilator dependent, died . This resulted in an immediate jeopardy (IJ) for twenty-one ventilator dependent residents. The IJ began on (MONTH) 19, (YEAR) and was identified on (MONTH) 28, (YEAR), at 3:30 p.m. when it was determined the facility failed to ensure that each resident received adequate supervision to prevent accidents. The administrator (AD)-G and director of nursing (DON) were informed of the IJ on (MONTH) 28, (YEAR) at 3:30 p.m. The IJ was removed on (MONTH) 30, (YEAR) at 3:20 p.m. however, non-compliance remained at the lower level of scope and severity of G: isolated which indicated actual harm that is not immediate jeopardy. Findings include: R1's medical record was reviewed. R1 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. R1's care plan, dated (MONTH) 8, (YEAR), indicated R1 could communicate by shaking her head yes or no. R1 received tube feeding for nutritional support. R1 was at risk for safety due to slow and limited movements, and was ventilator dependent. R1's medical orders indicated do not resuscitate. R1 was incontinent of bowel and bladder, and dependent on staff for activities of daily living. R1's nursing notes dated (MONTH) 19, (YEAR), at 11:39 p.m. indicated registered nurse (RN)-A entered R1's room at 10:45 p.m. in response to the ventilator alarm. RN-A indicated he found R1 in bed and unresponsive with a weak pulse. RN-A found the ventilator well connected and provided suctioning to R1; however, R1 remained unresponsive. RN-A initiated the emergency response and provided respiratory support via a bag valve mask. When paramedics arrived at 11:10 p.m., R1 had died . A late entry dated (MONTH) 20, (YEAR) in R1's nursing notes dated indicated on (MONTH) 19, (YEAR), RN-A returned from another resident's room in a different hallway and responded to R1's ventilator alarm. RN-A entered the room and found R1 in bed and unresponsive. An untitled facility document dated (MONTH) 20, (YEAR), at 5:31 p.m., of R1's ventilator data indicated R1's ventilator alarm began alarming on (MONTH) 19, (YEAR), at 9:58 p.m. with the following comment: Approximately 39 minutes off the vent. The same document indicated R1's alarm silenced on (MONTH) 19, (YEAR), at 10:48 p.m. with the following comment: The first time the alrm (sic) silence was pressed which is 47 minutes after the circuit disconnect. R1's ventilator alarmed for at least 39 minutes without intervention by the facility. During an interview on (MONTH) 27, (YEAR), at 4:43 p.m., RN-A stated there are three wings on the 2nd floor ventilator unit labeled Wings A, B, and C. RN-A stated that on (MONTH) 19, (YEAR) for the evening shift RN-A was assigned to Wing C, RN-B was assigned to Wing B, and a third nurse was assigned to Wing A. RN-A stated that the facility had decreased staffing levels on the ventilator floor within the last week or so when this happened. RN-A stated for that on evening shift there were three nurses and one nursing assistant, which was less than the normal staffing. Although the nursing assistant tried to cover all three wings, there were several residents that still needed nighttime cares at 10:00 p.m. when the nursing assistant's evening shift ended. There was one night shift nursing assistant that arrived at 10:00 p.m. although there used to be two nursing assistants scheduled for night shift. That nursing assistant went to Wing A to help that nurse with resident cares. RN-A stated the nurses' night shift started at 10:30 p.m. so the night nurse shift had not yet started. RN-A stated RN-B requested assistance on Wing B at approximately 10:00 p.m. with resident cares as a resident's family member refused to leave until cares were complete. Additionally, the resident was assist of two and RN-B could not complete the cares without assistance so RN-B assisted RN-A with resident cares. RN-A helped RN-B with one other resident prior to returning to Wing B. When RN-A returned to Wing C, he heard R1's ventilator alarming and went to R1's room when he found R1 unresponsive. RN-A found the ventilator well connected and provided suctioning to R1; however, R1 remained unresponsive. RN-A initiated the emergency response and provided respiratory support using a bag valve mask. RN-A stated there was not enough staff to provide resident cares and supervision on that shift. During an interview on (MONTH) 28, (YEAR), at 2:45 p.m., nursing assistant(NA)-E stated he/she usually works on the ventilator floor. NA-E state there used to be four nursing assistants and four nurses on the ventilator floor. NA-E stated that recently there are only three nurses and one or two nursing assistants working on the ventilator floor. NA-E stated it is impossible to provide adequate resident care when the facility staffs at that level on the ventilator floor. During an interview on (MONTH) 30, (YEAR) at 11:00 a.m., RN-B stated she worked on the evening shift on (MONTH) 19, (YEAR), when there were three nurses and one aide that shift, which was less than usual. RN-B stated staffing levels on the 2nd floor ventilator unit have been decreased since some time mid-August. RN-B stated she was assigned to Wing B while RN-A was assigned to Wing C. A third nurse was assigned to Wing A. RN-B stated at approximately 10:00 p.m. a resident needed assistance to bed and the resident's son said he would not leave until the resident was changed and assisted to bed. RN-B stated she could not provide this resident's cares alone because the resident required the assistance of two staff members so RN-B asked the nurse on Wing A for help but that nurse was busy providing nighttime cares for residents on Wing A and could not come. RN-B stated the night nursing assistant was helping with residents on Wing A. RN-B then asked RN-A for assistance. RN-A helped RN-B with the resident's cares. RN-A helped RN-B with one other resident that required assistance of two staff members prior to returning to R1's hallway at approximately 10:30 p.m. RN-B stated there was a charge nurse in the building, but no person that did not have a full assignment. RN-B stated that she needed to be both the nursing assistant and nurse on Wing B and since many of the residents are assist of two the staffing level was not sufficient to provide cares and supervision. During an interview on (MONTH) 29, (YEAR), at 10:20 a.m., respiratory therapist (RT)-D stated ventilator alarms indicated the resident was not receiving adequate ventilation. RT-D reviewed R1's ventilator data after R1 was deceased and stated R1's ventilator data indicated a large leak or disconnection of the ventilator system. RT-D stated R1's ventilator alarmed for at least 39 minutes. During an interview on (MONTH) 29, (YEAR), at 11:45 a.m., AD-G stated that the facility had six new louder ventilator alarms. The facility had 21 residents currently using ventilators that required the use of ventilator alarms. The remaining necessary alarms were on back order with an unknown date for delivery. During an interview on (MONTH) 14, (YEAR), at 11:24 a.m., nurse practitioner (NP)-C stated R1 was ventilator dependent. NP-C further stated that the facility's response time of 39 minutes was too slow and probably why R1 died . The policy titled Monitoring the Ventilator Dependent Resident, dated (MONTH) (YEAR) and provided by facility staff indicated under Policy 6: Respond quickly to emergencies including, but not limited to the following: a. Acute life threatening deterioration of the resident b. Accidental Ventilator disconnection c. Oxygen disconnection d. Decannulation e. Power Failure f. Equipment failure The IJ that began on (MONTH) 19, (YEAR), was removed on (MONTH) 30, (YEAR), when it could be verified by observations, conducting interviews, and document review of the policies and procedures implemented along with education of the new systems. To address supervision of the ventilator unit the facility provided a staffing plan for the unit, an additional associate to monitor patient ventilator alarms continuously, as well as additional training for the ventilator equipment, responding to ventilator alarms, and the role/responsibility of the associate. The noncompliance remained at the lower scope and severity level of G.

Based on interview and document review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety for 2 of 7 residents reviewed, when resident #1 (R1), who was ventilator dependent, was left unattended. R1's ventilator alarmed, but no facility direct caregiver intervened for at least 39 minutes. The resident died . Resident #5 when was in his recliner without assist for 6 hours and 45 minutes. Findings include: R1's medical record was reviewed. R1 admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. R1's care plan, dated (MONTH) 8, (YEAR), indicated R1 could communicate by shaking her head yes or no. R1 received tube feeding for nutritional support. R1 was at risk for safety due to slow and limited movements, and was ventilator dependent. R1's medical orders indicated do not resuscitate. R1 was incontinent of bowel and bladder, and dependent on staff for activities of daily living. R1's nursing notes dated (MONTH) 19, (YEAR), at 11:39 p.m. indicated Registered Nurse (RN)-A entered R1's room at 10:45 p.m. in response to the ventilator alarm. RN-A indicated he found R1 in bed and unresponsive with a weak pulse. RN-A found the ventilator well connected and provided suctioning to R1; however, R1 remained unresponsive. RN-A initiated the emergency response and provided respiratory support via a bag valve mask. When paramedics arrived at 11:10 p.m., R1 had died . A late entry dated (MONTH) 20, (YEAR), in R1's nursing notes indicated on (MONTH) 19, (YEAR), RN-A returned from another resident's room in a different hallway and heard R1's ventilator alarming. RN-A entered the room and found R1 in bed and unresponsive. During an interview on (MONTH) 27, (YEAR), at 4:43 p.m., RN-A stated there are three wings on the 2nd floor ventilator unit labeled Wings A, B, and C. RN-A stated that on (MONTH) 19, (YEAR), for the evening shift RN-A was assigned to Wing C, RN-B was assigned to Wing B, and a third nurse was assigned to Wing A. RN-A stated that the facility had decreased staffing levels on the ventilator floor within the last week or so when this happened. RN-A stated for that on the evening shift there were three nurses and one nursing assistant, which was less than the normal staffing. Although the nursing assistant tried to cover all three wings, there were several residents that still needed nighttime cares at 10:00 p.m. when the nursing assistant evening shift ends. There was one night shift nursing assistant that arrived at 10:00 p.m. although there used to be two nursing assistants scheduled for night shift. That nursing assistant went to Wing A to help that nurse with resident cares. RN-A stated the nurses' night shift started at 10:30 p.m. so the night nurse shift had not yet started. RN-A stated RN-B requested assistance on Wing B at approximately 10:00 p.m. with resident cares as a resident's family member refused to leave until cares were complete. Additionally, the resident was assist of two and RN-B could not complete the cares without assistance so RN-B assisted RN-A with resident cares. RN-A helped RN-B with one other resident prior to returning to Wing B. When RN-A returned to Wing C, he heard R1's ventilator alarming and went to R1's room when he found R1 unresponsive. RN-A found the ventilator well connected and provided suctioning to R1; however, R1 remained unresponsive. RN-A initiated the emergency response and provided respiratory support using a bag valve mask. RN-A stated there was not enough staff provide resident cares and supervision on that shift. During an interview on (MONTH) 29, (YEAR), at 10:20 a.m., Respiratory Therapist (RT-C) stated ventilator alarms indicated the resident was not receiving adequate ventilation. RT-C reviewed R1's ventilator data after R1 was deceased and stated R1's ventilator data indicated a large leak or disconnection of the ventilator system. RT-C stated R1's ventilator alarmed for at least 39 minutes. During an interview on (MONTH) 30, (YEAR) at 11:00 a.m., RN-B stated she worked on the evening shift on (MONTH) 19, (YEAR), evening shift when there three nurses and one aide that shift, which was less than usual. RN-B stated staffing levels on the 2nd floor ventilator unit have been decreased since some time mid-August. RN-B stated she was assigned to Wing B while RN-A was assigned to Wing C. A third nurse was assigned to Wing A. RN-B stated at approximately 10:00 p.m. a resident needed assistance to bed and the resident's son said he would not leave until the resident was changed and assisted to bed. RN-B stated she could not provide this resident's cares alone because the resident required the assistance of two staff members so RN-B asked the nurse on Wing A for help, but that nurse was busy providing nighttime cares for residents on Wing A and could not come. RN-B stated the night nursing assistant was helping with residents on Wing A. RN-B then asked RN-A for assistance. RN-A helped RN-B with the resident's cares. RN-A helped RN-B with one other resident that required assistance of two staff members prior to returning to R1's hallway at approximately 10:30 p.m. RN-B stated there was a charge nurse in the building, but no person that did not have a full assignment. RN-B stated that she needed to be both the nursing assistant and nurse on Wing B and since many of the residents are assist of two the staffing level was not sufficient to provide cares and supervision. During an interview on (MONTH) 14, (YEAR), at 11:24 a.m., Nurse Practitioner (NP)-D stated R1 was ventilator dependent. NP-D further stated that the facility's response time of 39 minutes was too slow and probably why R1 died . NP-D stated when a ventilator alarms facility staff must be able to respond promptly as ventilators are a form of life support. NP-D stated he/she had expressed concerns to facility administration about the reduced staffing levels on the ventilator unit. NP-D stated that due to reduced staffing levels he/she had heard observed on the ventilator unit, he/she had, at times, decided to send residents to the hospital for conditions treatable in the nursing home. An untitled facility document dated (MONTH) 20, (YEAR), indicated R1's ventilator data indicated R1's ventilator began alarming on (MONTH) 19, (YEAR), at 9:58 p.m. with the following comment: Approximately 39 minutes off the vent. The same document indicated R1's alarm silenced on (MONTH) 19, (YEAR), at 10:48 p.m. with the following comment: The first time the alrm (sic) silence was pressed which is 47 minutes after the circuit disconnect (sic). R1's ventilator alarmed for 39 minutes without intervention by the facility. Medical record review indicated R5 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. R5's physician orders [REDACTED]. R5's care plan dated initiated (MONTH) 4, (YEAR), indicated R5 required the extensive assistance of one staff member for activities of daily living (ADLs) including dressing, grooming, bathing, and required that staff check and change his incontinent brief every 2 hours. R5's care plan indicated R5 required the assistance of two staff members and a Hoyer lift for transfers. During an interview on (MONTH) 28, (YEAR), at 2:45 p.m., Nursing Assistant-E (NA-E) stated he/she usually works on the ventilator floor. NA-E state there used to be four nursing assistants and four nurses on the ventilator floor. NA-E stated that recently there are only three nurses and one or two nursing assistants working on the ventilator floor. NA-E stated it is impossible to provide adequate resident care when the facility staffs at that level on the ventilator floor. NA-E stated he/she worked a shift on (MONTH) 24, (YEAR), as the only nursing assistant, and it was not possible to provide all the cares to all the residents. During an interview on (MONTH) 28, (YEAR), 3:00 p.m., R5's family member (FM)-F stated she visits often for up to about 6 hours a day. R5's family member stated the number of staff has been horrible recently. FM-F stated the facility used to staff the ventilator floor with four nurses but that has been reduced to three nurses while the nursing assistants were reduced from three or four to two nursing assistants. FM-F stated that on (MONTH) 24, (YEAR), she visited R5 and R5 remained in his recliner from 8:00 a.m. to 2:45 p.m. without any staff assistance. FM-F stated she could not find any nursing assistants on the unit around 2:30 p.m. FM-F stated the facility is not providing enough staff to meet the resident's ADL needs on the ventilator unit. FM-F stated she had tried to discuss concerns regarding staffing with the facility's administration, but the concerns had not resolved. A facility-provided document entitled We Staff to Census, dated (YEAR), was reviewed. This document indicated that on the 2nd floor (the ventilator unit) the facility staffed with three nurses and two nursing assistants on both day and evening shift for five direct care givers. This document indicated 2nd floor night staffing as three nurses and two nursing assistants for a census greater than 94 residents. This document indicated 2nd floor night staffing as three nurses and one nursing assistant for a census less than 90 residents. This document did not address floor-specific census or acuity levels. A facility-provided document of staffing levels entitled Bethel Healthcare Community (BHC) for dates (MONTH) 1, (YEAR) through (MONTH) 28, (YEAR), was reviewed. BHC dated (MONTH) 1, (YEAR), through (MONTH) 14, (YEAR), indicated the facility staffed 2nd floor days and evening shifts with six or seven direct caregivers (nurses and/or nursing assistants). BHC indicated the facility staffed 2nd floor night shift usually (12 out of 14 shifts) with three nurses and two nursing assistants (five direct caregivers). BHC indicated the facility staffed the remaining two shifts (2 out of 14 shifts) with three nurses and one nursing assistants (four direct caregivers). BHC dated (MONTH) 15, (YEAR), through (MONTH) 28, (YEAR), indicated the facility staff 2nd floor day and evening shifts with four to five direct caregivers (nurses and/or nursing assistants). BHC indicated the facility staff 2nd floor night shift usually (13 out of 14 shifts) with three nurses and one nursing assistant (four direct caregivers). BHC indicated the facility staffed the remaining one shift (1 out of 14 shifts) with four nurses and one nursing assistant (five direct caregivers). Based on a review of BHC dated (MONTH) 1, (YEAR), through (MONTH) 28, (YEAR), the facility decreased direct caregiver staffing levels on the 2nd floor ventilator unit on or about (MONTH) 15, (YEAR). The facility-provided document entitled We Staff to Census indicated three nurses and two nursing assistants on days and evenings for the 2nd floor ventilator unit. The same document indicated three nurses and two nursing assistants on night shift for the 2nd floor ventilator unit with a census greater than 94. BHC dated (MONTH) 19, (YEAR), indicated the facility staffed the 2nd floor evening shift with one nursing assistant and three nurses. A comparison with We Staff to Census indicated the facility staffed short of the staffing plan. BHC dated (MONTH) 19, (YEAR), indicated the facility staffed the 2nd floor night shift with one nursing assistant and three nurses. BHC indicated the census as 98. A comparison with We Staff to Census indicated the facility staffed short of the staffing plan. BHC dated (MONTH) 21, (YEAR), indicated the facility staffed the 2nd floor day shift with one nursing assistant and three nurses. A comparison with We Staff to Census indicated the facility staffed short of the staffing plan. BHC dated (MONTH) 24, (YEAR) indicated the facility staffed the 2nd floor day shift with one nursing assistant and three nurses. A comparison with We Staff to Census indicated the facility staffed short of the staffing plan. BHC dated (MONTH) 24, (YEAR) indicated the facility staff the 2nd floor evening shift with one nursing assistant and three nurses. A comparison with We Staff to Census indicated the facility staffed short of the staffing plan. BHC dated (MONTH) 24, (YEAR), indicated the day shift nursing assistant started at 6:00 a.m. and ended at 2:00 p.m. BHC indicated the evening shift nursing assistant started at 2:00 p.m. and ended at 10:00 p.m. BHC indicated the nursing assistant assigned to 2nd floor on (MONTH) 24, (YEAR), evening shift start time at 4:00 p.m. BHC did not indicate nursing assistant coverage on (MONTH) 24, (YEAR) 2:00 p.m. through (MONTH) 24, (YEAR), 4:00 p.m.

Based on interview and document review the facility failed to ensure a patient received proper monitoring for respiratory care for 1 of 21 residents (R1) who received ventilator support. Prior to the ordered removal time, R1 was removed from the ventilator. Twenty to thirty minutes after the ventilator was removed, R1 was found to be without respirations and a pulse, was sent to the hospital and died . The failure to monitor and the failure to follow the ordered schedule had the potential to affect all 21 ventilator dependent residents at the facility. The immediate jeopardy began on [DATE] when the facility became aware that a nurse removed a resident from the ventilator two hours early and failed to ensure the resident's respitory status did not decline after the ventilator was removed. The resident died on [DATE]. The immediate jeopardy was identified on [DATE] and the Director of Nursing (DON), Administrator, and Director of Clinical Services, were notified of the immediate jeopardy on [DATE] at 3:25 p.m. The immediate jeopardy was removed on [DATE] at 6:15 p.m., but non-compliance remained at the lower scope (isolated) and severity of a G (actual harm that is not immediate jeopardy.) Findings include: R1's medical record was reviewed and revealed that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was ventilator dependent upon admission to the facility although was in the weaning process. R1's care plan dated [DATE] identified that R1 could not move in bed independently, required the assistance of two staff members for repositioning. The care plan directed staff to observe for changes in condition or abilities, further evaluate, and report pertinent information to the Medical Doctor (MD) or Nurse Practitioner (NP) for follow up. The care plan also directed staff to apply the Passy Muir Valve (PMV) (redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication and also improves swallowing, secretion management, and oxygenation) with oxygen at 3 Liters/minute via tracheotomy dome (tracheotomy dome) with humidity per orders and staff to monitor for signs of respiratory distress and return to ventilator as needed. Staff was directed to provide 1:1 companionship when R1 was restless or when exhibiting the following behavior that could compromise R1's safety: increased anxiety, heavy use of call light and restlessness. The care plan also included that the respiratory therapist was to work with R1 to evaluate the ventilator weaning process per MD order. R1's hospital discharge summary dated [DATE] revealed that R1 had failed multiple weaning trails but had been weaning recently with pressure support. During weaning trials, R1 would develop CO2 retention with prolonged tracheotomy mask weaning. The discharge orders further directed to continue with weaning, avoid further increase in sedating medications and for R1 to rest on the ventilator at night. A NP nursing home note dated [DATE] revealed that R1 was weaning off of the ventilator and was on the ventilator from midnight until 8 a.m. and was on the ventilator ,[DATE] in the past. The note indicated that R1 had made great progress as R1 was unable to wean off of the ventilator prior to admission. Review of R1's physician's orders [REDACTED]. Review of R1's progress notes include a respiratory therapy note dated [DATE] at 1:30 p.m. that revealed that "...resident using more sedation and sleeping more. Resident placed on ventilator support for increased aeration. Will continue monitor and increase Tracheotomy Dome trials again as tolerated". There was no further documentation in R1's progress noted by the respiratory therapist (RT) or nursing staff on monitoring of ventilator support or the tracheotomy dome. A document entitled Weights and Vitals Summary for R1 was reviewed and revealed vital signs on [DATE] at 1:08 a.m. a blood pressure ,[DATE], oxygen saturation of 97 (oxygen via mask), a pulse of 72 that was regular and respirations of 14. R1's medical record revealed no additional vital sign documentation for the date of [DATE]. A progress note dated [DATE] at 6:20 a.m. entered by RN-A indicated that R1 was transferred to the tracheotomy dome per repeated requests. R1 was found unresponsive. R1's color was not within normal limits. R1 had no pulse and no respirations and was not responsive to verbal or physical stimuli. R1 was placed on the floor and two person Cardiopulmonary Resuscitation (CPR) and called 911. Emergency Medical Services (EMS) arrived and transported R1 out of the facility. Review of R1's progress notes dated from [DATE]-[DATE] were reviewed and did not identify if R1 was placed on the ventilator on [DATE] at 4:00 a.m. per physician orders. The progress notes did not identify the status of the resident's condition at the time staff placed R1 on the tracheotomy dome on [DATE]. The progress notes also did not identify the time between placement of the tracheotomy dome and the time R1 was found unresponsive on [DATE]. Review of R1's certificate of death established R1's date of death was [DATE] at 3:05 p.m. The cause of death is listed as brain anoxia. When interviewed on [DATE] at 4:50 p.m. RN-A stated that on [DATE] Respiratory Therapist (RT)-B left a note on the medication cart that directed RN-A to place R1 on the ventilator from 4:00 am - 8:00 a.m. on [DATE]. RN-A stated she followed the note because R1's ventilator orders were "not always" in the TAR. RN-A stated R1 was on the tracheotomy dome when she started her shift. RN-A placed R1 on the vent at 4:00 a.m. Over the next hour, RN-A stated that R1 was frequently on the call light. At 5:00 a.m. on [DATE] R1 indicated that he wanted to talk, RN-A informed R1 that she would be administering a nebulizer treatment to R1 and once the treatment was completed, she would deflate the cuff (which would allow for verbal communication). RN-A initiated R1's nebulizer treatment and left R1's room. After R1's nebulizer treatment was completed, RN-A returned to R1's room and deflated the cuff. RN-A stated that R1 was anxious and that R1's respiration rate had increased with respirations in the "upper 20's to low 30's". RN-A directed R1 to slow his breathing down and R1's breathing returned to a normal pattern within the next few minutes. R1 stated that the ventilator was making him work too hard and he requested to be put on the tracheotomy dome. RN-A informed R1 the purpose of the vent was to aide in breathing and R1 continued to request the tracheotomy dome. RN-A confirmed that she did not discuss the risks with R1 of removing the ventilator because R1 spent 20 hours per day off of the ventilator. RN-A stated at that time she "went ahead and honored his patient rights" and placed R1 on the tracheotomy dome. RN-A was unable to provide specific times, however stated that she thought R1 was removed from the ventilator between 5:30 a.m.- 5:40 a.m. and that R1 was placed on the tracheotomy dome with oxygen. RN-A provided conflicting details on the length of time (from a "few minutes" to 20 minutes) that she was in the room with R1 after removing R1 from the ventilator. When asked about assessing R1 prior to leaving R1's room, RN-A stated the resident was not in distress because his breathing had decreased to a normal respiration rate of ,[DATE] and that R1 said he was "ok". RN-A did not R1's check vital signs (blood pressure, pulse, and oxygen saturation) because R1 was not in distress and R1's vital signs were only scheduled one time per shift. RN-A did not call R1's physician when removing R1 from the ventilator as she was honoring R1's patient rights and that it was not unusual for R1 to be off of the ventilator. RN-A returned to R1's room between 6:15 a.m. - 6:20 a.m. and found R1 unresponsive. R1's color had changed and R1 had no pulse and no respirations. CPR was initiated and 911 was called. R1 was transferred to the hospital. An interview with a licensed practical nurse (LPN)-C on [DATE] at 12:50 p.m. revealed that she worked with R1 and that R1 was anxious on the ventilator and would want to come off of the vent because R1 wanted to talk with family (who often spent the night in R1's room). LPN-C stated that she never took R1 off of the vent but provided as needed (PRN) medications and 1:1 interaction with the resident. LPN-C stated that when R1 refused to be put on the ventilator, she would tell R1 his muscles needed to rest and he needed to sleep and R1 would comply and allow LPN-C to place R1 on the ventilator. An interview with LPN-D on [DATE] at 1:20 p.m. revealed that two weeks ago, R1 had requested LPN-D to remove him from the ventilator two hours early. LPN-D stated that she repositioned the tracheotomy and explained to R1 that he needed to stay on the ventilator for the scheduled time to keep moving forward with the weaning process. LPN-D stated that R1 complied and LPN-D removed R1 from the ventilator at the scheduled time. RT-B was interviewed on [DATE] at 10:15 a.m. and stated that a nurse needs to follow physician's orders [REDACTED]. The DON was interviewed on [DATE] at 4:10 p.m. and 5:45 p.m., the DON confirmed that R1 had physician's orders [REDACTED]. The DON also confirmed RN-A removed R1 from the ventilator at 6:00 a.m. (2 hours early). The DON stated that when a resident refuses to be placed on the ventilator he would expect staff to encourage the resident to continue with the treatment, update the physician, discuss risks and benefits and monitoring should be increased. R1's physician was interviewed on [DATE] at 12:52 p.m. and stated that she would anticipate R1 to be monitored via pulse oximetry after removal of the ventilator. The physician stated that she would have expected R1 to be monitored when staff removed R1 from the ventilator. A policy entitled Mechanical Ventilation Weaning Process dated [DATE] directed staff to continue the weaning trial per prescribed duration, monitor patient during weaning trial and document patient toleration at end of weaning trial. The policy included monitor tolerance criteria as the following: 1. RR (Respiratory Rate) < 35 bpm 2. Sp 02 > 88 % 3. No respiratory distress 4. No more than two of the following: a. HR (heart rate) changes > 20 or rhythm changes b. Diastolic BP > 100 mmHg c. Marked use of accessory muscles d. abdominal paradox e. Diaphoresis f. Marked subjective dyspnea The policy also included to document patient tolerance to weaning trial. The policy also directed that staff was to update the health care team and proceed as directed. An additional facility policy entitled "Mechanical Ventilation Management" dated ,[DATE] revealed under the "PROCEDURE-MONITORING THE VENTILATOR-DEPENDANT RESIDENT" that all care to the ventilator supported resident will be performed under the supervision of the assigned nurse who must be trained in ventilator care with demonstrated ability to complete the following: 1. Assess the resident's response to mechanical ventilation 2. Ensure proper ventilator set up and use 3. Provide basic troubleshooting 4. Summon appropriate resource when unable to determine or remedy equipment or resident problem 5. Identify resident's adverse response to mechanical ventilation 6. Respond quickly to emergencies including but not limited to the following: a. acute life threatening medical deterioration of the resident b. accidental ventilator disconnection c. oxygen disconnection d. decannulation e. power failure f. equipment failure. The policy included under "FREQUENCY OF MONITORING" that ventilator function is observed with scheduled resident monitoring every two hours as per policy or more frequently as clinical condition dictates. A thorough assessment of the resident's mechanical ventilator system is completed and documented on the ventilator worksheet every shift. Under the "SCOPE OF RESIDENT VENTILATOR CHECK AND MONITORING" the policy includes that at the beginning of each shift, the resident's assigned nurse performs and assessment of the resident and includes the following: 1. Resident's physical condition a. resident positioning b. blood pressure c. spontaneous respiratory rate d. breathing pattern e. heart rate f. color changes g. peak inspiratory pressures h. breath sounds- abnormal breath sounds i. temperature j. pulse oximetry k. tracheotomy tube position l. cuff- inflated/deflated m. suctioning needs. The IJ that began on [DATE] was removed on [DATE] at 6:15 p.m. after the facility implemented a corrective action plan which included revising the facility's policy on refusal of treatment, change of condition and clinical monitoring guidelines for acute change in condition and provided immediate education of all licensed nursing staff of the revised policies. The facility also updated ventilator flow sheets that are in every ventilator dependent resident room. The implementation of these interventions were confirmed by observations and interviews conducted with licensed nursing staff on [DATE], and review of the facility's revised policies.

Based on observation, interview, and record review the facility failed to provide services to prevent the development of pressure ulcers for 1 of 3 (R1) residents reviewed with pressure ulcers. R1 developed three avoidable pressure ulcers when there was a decline in mobility and R1 did not have preventative measures assessed and implemented. This resulted in actual harm for R1. Findings include: The medical record was reviewed and included: R1 was readmitted to the facility in December 2014 after an inpatient hospitalization ; at the time of the re-admission assessments were completed. The initial nursing evaluation dated 12/11/14 noted that R1 was continent for urine and used the bathroom; the Braden Scale (for predicting pressure ulcers) dated 12/11/14 scored 17 which is a low risk for pressure ulcers. She was noted at that time to be independent in walking with a cane, and needed help to turn in bed. The Care Area assessment note dated 12/22/14 for pressure ulcers noted that risks factors were incontinence, and limited need for assistance with bed mobility. The note included that R1 was independent with ambulation and transfers, and used a walker for ambulation. It was noted that R1's skin was intact at that time. The nurse note dated 1/20/15 noted that R1 used a wheelchair for mobility but could walk slowly independently with encouragement. On 1/22/15 and 1/23/15 the nurse note that the wheelchair was used for mobility. The Occupational Therapy (OT) note dated 1/26/15 noted that R1 needed maximum physical assist to complete basic self-care tasks, and the Physical Therapy (PT) note dated 2/2/15 noted a setback in function with transfers and ambulation and was only able to walk 2 ft. with maximum assist. The record did not contain an updated assessment of the skin risks with the noted change in R1's mobility. The nurse's note on 2/6/15 at 10:13 a.m. noted that R1 had an 'open area on the coccyx 1.5 x .25" (inches)', it was cleaned with wound cleanser and allevyn dressing applied. There was no record of the resident's skin being assessed for any breakdown elsewhere, and no skin risk assessment was completed. The nurse documented placing a call to the nurse practitioner (NP) but no return call was documented. A nurse note dated 2/8/15 at 4:48 a.m. noted that R1 was " in bed with a pillow under ankles with heels touching the bed surface, heels have discoloration and blistering bilateral on the dorsal side of the heel " . The nurse documented cleaning the feet and applying dressings, and applying heel protection boots on both feet. A 'Weekly Wound Assessment ' dated 2/9/15 and completed by the facility's wound care nurse noted that R1 had 3 pressure ulcers, the wounds were measured, the coccyx wound was 3 c.m. by 0.5 c.m. and was noted to be unstageable due to a cover of 100% yellow slough. The right heel ulcer was 1c.m. by .5 c.m., the left heel was 5 c.m. by 6 c.m., with suspected deep tissue injury. The National Pressure Ulcer Advisory Panel Guidelines dated 2007 defined an unstageable wound as "Full thickness tissue loss in which the base of the wound is covered by slough in the wound bed. Suspected Deep Tissue Injury - depth unknown- "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." physician's orders [REDACTED]. The coccyx wound treatment changed to silversorb gel and covered with foam dressing daily until healed. A tissue tolerance assessment was completed on 2/10/15 and noted R1 was to be repositioned every 2 hours in the bed by 2 staff, and offloaded every 2 hours in the wheelchair. An air mattress was noted to be added. The last available Braden scale to assess the risk of skin breakdown was completed 12/11/14 and noted R1 was low risk to develop pressure ulcers. The visit note from the nurse practitioner dated 2/19/15 noted a physical examination, but did not note the skin breakdown or an assessment of the wounds. No new [DIAGNOSES REDACTED]. an order written [REDACTED]. (patient) to have offloading bilateral splints to treat heel breakdown, physical therapy to evaluate." the order was signed off, the facility did not change the boots the resident had, or document communication with the outpatient physician. The wound nurse (RN-C) verified in an interview 2/23/15 at 1:40 p.m. that the wounds had been discussed with the nurse practitioner, but there had been no communication with the outpatient physician to coordinate care. The care plan for R1 was updated on 2/23/15 noting the skin breakdown on the coccyx and heels, interventions that were added on 2/23/15 were to reposition R1 every 2 hours in bed and every hour in the wheelchair, an air mattress was added also. The pressure relieving boots were not noted on the care plan. The care plan noted that R1 was independent with toileting, and may need assist for pericare and changing pad at times. The nurse aide care sheet for 2/23/15 did not note the pressure relieving boots and noted to reposition every 2 hours. It was noted that R1 was incontinent and needed assist of 1 person, it did not note to assist to check and change every 2 hours. R1 was observed to be in a wheelchair returning from a meal at 8:40 am on 2/23/15, R1 was assisted by 2 aides to be transferred to bed and positioned on her side. R1 had boots on both feet, and an air mattress on the bed. At 10:15 a.m. on 2/23/15, wound care was observed with RN-C, the coccyx wound was observed to have clear edges and a pink base, and the wound nurse verified that slough had come off at that time. The heels were dark purple wounds with skin intact, again verified by the wound nurse to be suspected deep tissue wounds. R1 had 'Rooke' brand boots on both feet; the manufacturer's product information for the Rooke boot dated 2015, noted that the boots provided off-loading of the heels and provided no pressure points on the heel. The licensed practical nurse (LPN-E) stated at 10:30 a.m. on 2/23/15 that R1 used to walk with a walker on her own, now doesn't walk. The nursing assistant (NA-F) verified at 10:38 on 2/23/15 that R1 was totally incontinent and was "check and change". The facility policy for 'Pressure Ulcer Risk Assessment" date February 2014 noted the need for an assessment of risk with a change of mobility, and noted that immobility and incontinence were factors which put residents at risk. The policy titled 'Pressure Ulcers/ Skin Breakdown dated February 2014 noted that the nursing staff and attending physician will assess and document significant risk factors for skin breakdown, and the physician should monitor the wounds and treatments. The policy for 'Care Planning Process' dated April 2013 noted that care plans "need to be altered as the resident's condition improves or deteriorates." The nurse manager was interviewed on 2/23/15 at 2:05 p.m. and stated that she was new to the nurse manager role in mid-January and had noted at that time that R1 had slowed down and was not as verbal. She stated she had asked therapy for a new wheelchair because R1 was not walking, and had difficulty with transfers. She noted that R1 used to have support (TED) stockings and wear her shoes, when R1 had ulcers on her heels; R1 had ACE wraps applied to her legs. She was not sure if the boots were worn at all times, such as when R1 went for outpatient treatments. On 2/26/15 at 1:08 p.m. the nurse manager was interviewed and stated that R1 had only walked 1-2 times a shift for short distance, and was in a wheelchair most of the time, but the nurse manage was not sure when that started. She stated she did not think R1 could walk with the "Rooke' boots on. She verified that the care plan had not been updated to reflect the changing needs for R1 with mobility, wounds, and incontinence. The director of nursing was interviewed on 3/16/15 at 2:20 p.m. and verified that a comprehensive assessment of the risk for skin breakdown occurred for residents on admission and with a change in condition the risk should be reassessed. He noted that R1 did not have a comprehensive skin assessment completed until after 2/23/15 because there was confusion if the changes for R1 were permanent. He also verified that the care plan should be updated regularly with changes in the care needs of the resident.

Based on observation, record review and interview, the facility did not provide the necessary care and services for 1 of 3 residents (R94) who was admitted with a pressure ulcer and developed further pressure ulcers which resulted in harm to the resident. Findings include: R94 was admitted with a pressure ulcer on the right ishcial tuberosity (IT). On 5/11/11 during wound care R94 was observed to have several black areas on the toes bilaterally and a large black area on the sole of the left foot that had not been previously identified. An assessment was lacking, related to the pressure areas on the feet, to identify and implement interventions to minimize and/or prevent the development of pressure ulcers. R94, alert and able to communicate needs, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CAA's (care area assessment) form dated 4/8/11, indicated R94 had lower extremity [MEDICAL CONDITION]. During observations on 5/11/11 at approximately 9:30 a.m., LPN-HH performed wound cares to a pressure ulcer on the right ishcial tuberosity (IT). When packing the wound, the LPN noted tunneling at approximately 11:00 o'clock position that extended up approximately 4-5 cm. The surrounding area appeared red with some excoriated areas. There was one area that was blackened approximately 2 cm around. The LPN cleansed the area and applied the wound treatment. During the wound care process, Velcro heel protectors were noted on the feet but no TED hose. The resident's left foot was observed to have dry black areas on the 2nd, 3rd and 5th toes. Under the fifth toe on the ball of the foot there was a large black area that measured approximately 6 cm by 2 cm. There also were black areas noted on the 4th and 5th toes of the right foot. LPN-HH reported she was not aware of the blackened areas. The resident was admitted with a pressure ulcer on the right ishcial tuberosity. The wound documentation form, dated 3/25/11, identified the area as 4 centimeters (cm) long by 6 cm wide with slough covering the wound making it unstageable (described as full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) in the wound bed. No other wounds were noted on the wound documentation form. A review of admission nurses notes (NN), dated 3/25/11, described a 2 cm by 1.3 cm black area on the left heel which was very soft and appeared necrotic. Wound treatment was instituted for the IT wound. There was no documentation of any treatment or monitoring for the blackened area of the left heel. A tissue tolerance assessment form (which is used to describe how long a resident can be in a position without the resident skin becoming red) was completed on 3/28/11. The resident was assessed as being able to lie and sit in the same position for 2 hours with an air mattress on the bed and a cushion when in the chair. The only area identified on the tissue tolerance form was the IT pressure ulcer. The tissue tolerance assessment lacked identification of additional risk factors for skin breakdown such as other potential pressure points on the soles of the feet. The admission MDS (minimum data set) dated 4/1/11 identified the resident as having one stage 2 pressure ulcer. A stage 2 was described on the wound care record as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough; may also present as an intact or open/ruptured blister. It was identified as having [MEDICATION NAME] tissue loss and not slough or eschar. The Braden scale (used to predict pressure ulcer risk) was completed on 4/4/11 and identified the resident as a moderate risk for the development of pressure ulcers. It indicated the resident had a ishcial tuberosity pressure ulcer. The CAA (care area assessment) form had been completed by RN-WW on 4/8/11 in conjunction with the MDS. In the section that identified pressure ulcers, RN-WW wrote, "admitted to the facility on [DATE] with a stage 2 decubitus ulcer. He has reddened areas on his buttocks. He has a right heel stable black eschar with no drainage noted. He has bilateral LE (lower extremity) [MEDICAL CONDITION] and he uses prafo boots on at all times to help relieve pressure off the heels." The care plan, last reviewed on 4/14/11, indicated the resident had a wound on the right buttocks with yellow slough and unable to stage at the time. It also noted redness on the right heel. The interventions included right buttocks wound care, air mattress, heel protectors on at all times and staff to remove each shift. Ted hose were also on in the am and removed in the p.m. Staff was to monitor the residents skin during cares and baths for signs of irritation or breakdown and report any changes. Resident bathing times were Sunday p.m. and Thursday a.m. A review of nursing notes indicated the following: A nursing note on 4/10/11 indicated the resident had reddened areas on the pedal area of the left foot closest to the 4th and 5th metatarsal and reddened area on the right heel apex 4 cm in diameter. A foot boot was applied and pillows were placed to keep heels off the bed. The note indicated staff would be updated and would continue to monitor. However, there was no further documentation in the nursing notes of such monitoring. A nursing note on 4/29/11 indicated the IT wound had a large amount of foul smelling drainage described as "slimy." The Registered Nurse Practitioner (RNP) ordered wound culture specimens sent and antibiotics were started. The facility policy and procedure for skin observation revised 4/27/09 and reviewed 8/1/10, indicated that after bathing the nurse was to do a head to toe body assessment. It further indicated that in addition to directly observing all pressure point areas, alteration in skin integrity was to be observed, documented, and reported. This assessment was requested but not provided. The weekly wound rounds were completed by the assistant director of nursing (ADON) on 5/10/11. The wound was described as 2 cm long by 3.5 cm wide by 3 cm. deep. It was identified as unstageable with 75% granulation and 25% slough. There was moderate amount of serosanguinous drainage. No tunneling or undermining was identified and the buttocks were reddened. The weekly wound rounds documentation lacked mention of any blackened areas of the resident's feet. The registered nurse practioner note dated 5/11/11 at 12:27 p.m. indicated dry blisters on the 2nd, 3rd, and 5th toes on the left and 4th and 5th toes on the right foot and indicated the sole of the left foot had eschar. The RNP further indicated the areas appeared shallow with no fluctuance, redness, bruising or slough and the areas were probably caused by the feet up against the foot board. On 5/11/11 at approximately 9:30 a.m., an interview with R94 was attempted. Although the resident was alert and oriented, R94 refused to be interviewed. On 5/11/11 at 3:00 p.m., the ADON/Nurse manager indicated he had just been informed about the toes. The ADON was not aware of the areas when he did wound rounds on 5/10/11. On 5/11/11 at 3:10 p.m., the registered nurse practioner was questioned about the blackened areas. The NP verified the blackened areas were pressure areas and may have been there for 5-6 days; that the areas were dry and intact and may have been caused by the bed foot board. On 5/12/11 at 12:55 p.m the ADON indicated he had reviewed the resident the day of admission (3/25/11) and noticed only the IT wound and not the blackened area on the left heel. The ADON indicated he was not aware the pressure ulcer was identified as a stage 2 on the MDS or about the heel eschar identified in the CAA's. The ADON indicated the staging on the admission MDS may have been inaccurate, however the nursing note identifying the blackened heel should have been followed up on. The ADON also indicated he was not aware of the IT wound tunneling when he completed the wound rounds on 5/11/11.

Based on interview, closed record review and policy review, the facility failed to provide the necessary care and services to 1 of 2 residents (R147) in the closed record sample who expired. Findings include: R147 was a "Full Code", code status, experienced respiratory distress, was not provided a nursing assessment by a registered nurse and was not provided timely interventions to minimize further respiratory decline, which resulted in actual harm. R147 was admitted into the facility on [DATE] for rehabilitation after suffering a [MEDICAL CONDITIONS]. R147's other [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated R147 had severe cognitive impairment, required extensive to total assistance with all activities of daily living (ADL's) and exhibited no mood or behavioral issues. The Bethel Care Center Healthcare Directives Summary indicated the resident wished to have a "FULL CODE" code status (In acute cardiac or respiratory arrest, cardiopulmonary resuscitation (CPR) will be initiated, and 911 called. Full emergency treatment will be provided). Record review for R147, revealed a Nurses Note dated [DATE], which indicated, "At 10:00 a.m. alerted by nursing assistant to come to residents room, noted resident in bed with copious amounts of white frothy secretions from mouth". The note identified respirations (RR) at an uneven rate ,[DATE], "cleared secretions by wiping". The note identified that vital signs were checked and the blood pressure (BP) was ,[DATE], heart rate (HR) 72, temperature 102.6, oxygen (O2) saturation 62%, and that the resident was started on oxygen nasal cannula (NC) at 4 liters/minute. "Obtained suction machine and suctioned away large amounts of oral secretions. 02 sat rebounded to 72% with NC 02 at 4L/min". The note identified that a call was placed to the on call nurse practitioner (NP-1) and a telephone order (TO) for chest x-ray STAT (immediately) was ordered. The note indicated, "Continue to monitor resident. 02 sats remained in the low to mid 70's with RR relaxed ranges from ,[DATE]. At 10:45 a.m. noted 02 sats at ,[DATE]%, call placed to NP, received order to send to ER. 911 called. Returned to residents room." The note identified that the TMA was asked to call the building charge (BC). "Noted upon return to room the resident was not breathing, confirmed by look, listen and feel. Nursing Stat called over head. Unable to obtain BP, HR not palpitable, nor could I hear HR with stethoscope. By the time 2 other nurses had shown up, informed that there is no HR, no RR and resident is full code. CPR initiated, delegated NA to call 911 to inform that resident's condition had worsened and we have started CPR. Ambulance crew arrived at 11:10 a.m. and took over for us. Report given to in charge EMT. Copies of paperwork including face sheet and advanced directives, PO provided. Resident left in the care of the EMT via gurney at 11:20 a.m." On [DATE] at 1:31 p.m., the DON was interviewed regarding the services provided to R147 on the morning of [DATE]. The DON indicated the nurse suctioned the resident and administered oxygen. "The NP was updated and aware of the situation. The nurse was following the orders." On [DATE] at 8:43 a.m. RN/AA (building charge nurse) was interviewed regarding the services provided to R147 morning of [DATE]. RN/AA stated, "The TMA came and got me, by the time I arrived the other nurses had already started CPR, the crash cart was there. The ambulance arrived soon after and the EMT shocked and intubated the resident. " On [DATE] at 4:05 p.m. the DON was interviewed regarding what type of assessment and documention would be expected for condition changes or emergency situations. The DON stated, "I would expect them to document all their findings in a note and do a thorough assessment". When asked what tools or reference guides were made available to assist staff with documenting an emergency or change in condition, the DON stated, "We don't have any type of references." On [DATE] at 4:30 p.m. the Licensed Practical Nurse (LPN) II, that provided care to R147 the morning of [DATE], was interviewed and stated, "A nursing assistant found the resident and let me know. The resident's respiratory rate was fast and his oxygen saturations were low, he had white frothy secretions coming from his mouth. I suctioned him and his breathing got better. I called the Nurse Practitioner and she ordered a chest x-ray". LPN II stated that "I was the only nurse on the floor that day. We were short staffed, I was checking on the resident in between checking on the other residents". LPN II was questioned regarding the resident's vitals and saturations and LPN II stated "I had a sheet of paper, where I was writing my time frames on. When the other nurses came down it disappeared. I did't have my exact times." When asked if it was ever considered to send the resident to the emergency room , LPN II stated "I would have liked to but, the NP ordered a chest x-ray". When asked if the NP was told the resident was a full code, LPN II stated "I don't remember if I told her or if she asked. When asked what the procedure was when finding a resident who is a full code with an oxygen saturation of 62%? LPN II stated, "To suction the resident get his saturations up. The resident started breathing and I called the NP. I was thinking he had pneumonia at the time." On [DATE] at 10:55 a.m. a voice mail message was left for the NP requesting a return phone call regarding the incident on [DATE]. The NP did not return the phone call. The Bethel Care Center Physician/Nurse Practitioner Notification policy, undated, directs staff, in the event the individual resident's condition warrants, emergency "911" transfer may be initiated, and the physician or nurse practitioner notified after emergency medical staff assume resident care.