Every finding on record at The Estates at Chateau LLC

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded when 1 of 1 residents (R59) reviewed who had a had a submitted entry tracking record but had left the same day of admission prior to admission assessments or paperwork completion.Findings include: R59's entry tracking record dated 4/7/26, indicated R59 had been admitted to the facility on [DATE] from a hospital. R59's progress note dated 4/7/26, indicated R59 had arrived at the facility and immediately asked for a wheelchair to go smoke prior to signing any paperwork or an assessment was completed. The note indicated R59 did not come back to the floor, and a staff member had observed the resident being picked up by someone. R59's medical record was reviewed and did not indicate that R59 returned to the facility after this initial arrival. During an interview on 9/2/26 at 11:54 a.m., the director of reimbursement (DOR, a registered nurse), stated that given that R59 left the facility within a few hours of arrival, an entry record should not have been completed. The DOR stated she would inactive the entry record. A policy regarding MDS completion was requested, and during an interview on 9/3/26 at 10:24 a.m., the administrator stated that they did not have a policy and would instead reference the RAI manual.

Based on interview and document review, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) was completed after a change of hospice providers for 1 of 1 resident (R4) reviewed for hospice care. Findings include: The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, included a section labeled Significant Change in Status Assessment (SCSA). The section outlined that a SCSA was required to be performed when a resident changed hospice providers and remained a resident at the nursing home. The manual indicated that the assessment reference date (ARD) must be within 14 days from the effective date of the hospice election. R4's quarterly MDS dated [DATE], indicated R4 was receiving hospice care. R4's provider note dated 7/29/26, indicated R4 was admitted to the facility on hospice, but was now switching from hospice company (HC)-A to HC-B. R4's hospice comprehensive assessment and plan of care report dated 8/19/26, indicated R4's start of care date with HC-B was 7/31/26. R4's MDS listing dated 8/31/26, did not include a SCSA. During an interview on 9/2/26 at 9:25 a.m., the director of reimbursement (DOR, a registered nurse) confirmed that a SCSA was not completed for R4 and stated that she would have expected one to be completed within 14 days of the hospice start of care. A policy regarding MDS completion was requested, and during an interview on 9/3/26 at 10:24 a.m., the administrator stated that they did not have a policy and would instead reference the RAI manual.

Based on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASSAR) was completed to screen for mental health needs for 1 of 1 resident (R3) reviewed for PASSAR. Findings include: R3's quarterly Minimum Data Set (MDS) dates 8/23/26, indicated R3 was admitted to the facility on [DATE] and had moderated cognitive impairment. R3's Clinical Medical Diagnosis report dated 9/2/26 indicated diagnoses of cerebral infarction (stroke), hemiplegia affecting left non-dominant side, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, alcohol dependence, cocaine abuse, suicidal ideations, anxiety disorder, border personality disorder, schizoaffective disorder, and bipolar disorder. R3's PAS notice dated 2/5/26 indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing home. R3's medical record was reviewed and lacked evidence that a final determination had been received. During interview on 9/2/26 at 8:56 a.m., social service director (SSD) verified R3 did not have a final letter on her record and said she will need to call the county to follow up and obtain the necessary documentation. During an interview with the director of nursing (DON) and regional nurse consultant (RNC), they stated it was important to complete step I and step II to determine if R3 could have more psych services to improve her quality of life. During interview with the director of admissions (DOA) on 8/14/25 at 11:54 a.m., DOA stated she was responsible to make sure new residents had pre-screening done before they were admitted to the facility. DOA stated the social worker was responsible for following up to obtain the final determination. During an interview on 8/14/25 at 12:04 p.m., the social worker director (SWD) verified R9's medical record did not have the final determination documentation. The SWD stated the admission team followed up to obtain the final determination. Facility's policy titled Pre-admission Screening (PASSR) dated 11/25, indicated the initial screening must be completed prior to admission to a nursing home. This policy also include directions how to request redeterminations but does not include directions about requesting final letters.

Based on observation, interview, and document review, the facility failed to ensure personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R3) reviewed for activities of daily living (ADLs) and who was dependent on staff for her care.Findings include: R3's quarterly Minimum Data Set (MDS) dates 8/23/26, indicated R3 had moderated cognitive impairment, needed set up/clean-up assistance with eating, moderate assistance with personal hygiene, maximal assistance with dressing, total dependency with toileting hygiene and oral hygiene. R3's clinical medical diagnosis report dated 9/2/26 indicated diagnoses of cerebral infarction (stroke), hemiplegia affecting left non-dominant side, diabetes Type I, major depressive disorder, and bipolar disorder. R3's ADL's care plan dated 9/2/26 indicated self-care deficit related to cerebral infarction and hemiplegia affecting the left non-dominant side. The care plan directed staff to assist R3 with personal hygiene. During observation on 8/31/26 at 11:59 a.m., R3 was in bed wearing a night gown covered with a sheet and a light comforter, she was awake and answered simple questions. Her right hand was on top of the bed linen and her fingernails were long and partially covered with light violet nail polish. During interview on 8/31/26 at 3:30 a.m., family member (FAM) stated R3's fingernails were always overgrown and when she visited, she needed to soak them in warm water and Vaseline before she could cut them and apply nail polish. FAM stated the facility needed to provide better nail care for her family member. During observation and interview on 9/1/26 at 1:04 p.m., R3 was in her room eating finger foods with her right hand. R3's right hand's fingernails were about 1.8 cm long and had black matter underneath. C3's left hand was closed on a fist and only her left index and middle fingernails were visible, they were about 1.2 to 1.5 cm long with yellowish matter underneath. During observation and interview on 9/2/26 at 12:05 p.m., nursing assistant (NA)-B verified R3's nails were long and had black matter underneath. NA-B stated, we cut their nails [residents] if they want us to cut them. NA-B said R3's nails needed to be cleaned, and she would do it later, and added R3's left hand fingernails were not as dirty as the ones on her right hand. During interview on 9/2/26 at 12:14 p.m., registered nurse (RN)-A asked R3 Do you want your nails trimmed? R3 said, yes. RN-A verified R3's nails were almost 2 cm long and had black matter underneath her right fingernails, and yellowish matter underneath her left fingernails. LPN-B said her nails needed to be cleaned because she ate some foods with her hands like chicken fingers and bread. During interview on 9/3/26 at 10:34 a.m., director of nursing (DON) stated she expected the nurses to do a head-to-toe skin check on shower days, cut their fingernails, and toenails. Assessments need to be documented and as well as refusal of cares. The concern regarding long dirty fingernails is bacteria growth, especially if a resident uses her hands to eat. Facility's policy titled Activities of Daily Living (ADLs) indicated It is the policy of the facility to specify the responsibility to specify to create and sustain an environment that humanizes and individualizes each resident's quality by ensuring all staff, across all shifts and departments, understands the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.

Based on observation, interview, and document review, the facility failed to routinely, comprehensively monitor and assess for edema (swelling caused by fluid retention) so intervention effectiveness could be determined, and new interventions could be developed if needed. In addition, the facility failed to ensure recommended edema management interventions were followed as appropriate for 1 of 1 residents (R62) reviewed for edema management.Findings include: R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 had intact cognition with no rejection of care behaviors exhibited during the look-back period. R62's Medical Diagnosis List dated 4/24/26, indicated R62 was diagnosed with prostate cancer that had spread to bone, liver disease, and kidney disease. R62's order summary dated 7/22/26, included an order for compression stockings that were to be applied to R62's bilateral lower extremities every morning and removed at night for edema. The summary included an order for 20 milligrams (mg) of furosemide (a diuretic, used to treat fluid retention) daily for hypertension and edema. The order summary did not include orders for monitoring R62's edema. R62's treatment administration record (TAR) dated 8/1/26 through 8/31/26 at 1:59 p.m., included an order for compression stockings that were to be applied to R62's bilateral lower extremities every morning and removed at night for edema. The TAR indicated the stockings had been applied daily (except for two occurrences in the morning and one in the evening (for removal) where 3, absent from home, was recorded) and did not indicate R62 had refused stocking application. The TAR did not include edema monitoring. R62's progress notes dated 8/1/26 to 9/1/26 were reviewed and included a progress note dated:-8/12/26 at 6:07 p.m., indicated R62 had bilateral lower extremity edema without note of severity.-8/14/26 at 11:51 a.m., the provider indicated R62 had lower extremity edema, so furosemide was increased from 20 mg to 40 mg for five days and then R62 would resume his previous dose.-8/30/26 at 9:52 a.m., indicated R62 had pitting edema to his left foot with the note including ++ signage. The note indicated facility staff would encourage R62 to elevate the foot and endorse nursing to follow up with his provider in the morning.-8/31/26 at 11:52 a.m., the provider indicated that R62 had bilateral ACE wraps for lymphedema, as the resident had significant edema to bilateral lower extremities with a note, 3+?. R62's care plan dated 8/31/26, indicated R62 had a risk and benefits form in place for refusing a shower and finger and toenail clipping. The care plan indicated that staff would reapproach R62 when he refused care. The care plan did not include edema, needed assessments, or what interventions were in place related to edema. R62's medical record was reviewed, and scheduled edema monitoring was not found. During an observation and interview on 8/31/26 at 11:54 a.m., R62 was observed sitting in his wheelchair in his room; significant (unable to see ankle bone, skin appeared tight, leg/ankle appeared as if it was swollen) edema was noted in his left lower extremity. R62 stated he was supposed to wear compression stockings on his legs, but he was unable to put them on by himself, and staff did not offer to help him apply them. During an observation and interview on 9/1/26 at 1:46 p.m., R62 was observed sitting in his wheelchair in his room, significant (unable to see ankle bone, skin appeared tight, leg/ankle appeared as if it was swollen) edema noted in his left lower extremity. R62 was asked if staff had offered to assist in applying his compression stockings today, and R62 stated, staff don't help me do [expletive] and denied that staff had offered to help. During an interview and observation on 9/1/26 at 1:53 p.m., trained medication assistant (TMA)-A stated she was the aide/TMA working with R62 today and yesterday. TMA-A stated that if someone needed compression stockings, she would be the one to help them put them on. When asked if R62 wore compression stockings, TMA-A stated she didn't believe so. TMA-A was then observed to check the TAR and stated she had missed the order to apply them and had not done so yesterday or today. TMA-A stated that R62 would not be able to apply these himself. During an interview on 9/1/26 at 2:02 p.m., registered nurse (RN)-B stated she was the nurse in charge of R62's care for the day shift. RN-B stated R62 had a history of significant edema, but she was unaware of documentation where they track R62's edema status. RN-B stated that R62's compression stockings were supposed to be applied in the morning. RN-B stated that she was also in charge of the nursing care for another floor, so she had not had time to check and ensure the TMA had applied these stockings and apply them herself, if necessary, until a few minutes ago. During an interview on 9/2/26 at 11:21 a.m., nurse practitioner (NP)-A stated that R62 had a history of lower leg edema, so she had ordered bilateral ace wraps for this. NP-A stated that compression devices should be applied before the resident's feet hit the floor in the morning but at least applied during the morning hours. NP-A stated she would expect nursing staff to assess the resident for edema every day so worsening or resolving edema could be tracked. During an interview on 9/2/26 at 11:27 a.m., the director of nursing (DON) stated that she expected the nurse to round on R62's floor in the morning and ensure that morning treatments had been completed. The DON stated the facility did not have a system in place for tracking changes in a resident's edema. A policy regarding edema management was requested and not received.

Based on observation, interview and record review, the facility failed to implement a brace to prevent worsening of range of motion (ROM) and hand contracture for 1 of 1 resident (R3) reviewed for limited range of motion (ROM).Findings included: R3's quarterly Minimum Data Set (MDS) dates 8/23/26, indicated R3 had moderated cognitive impairment, needed set up/clean-up assistance with eating, moderate assistance with personal hygiene, maximal assistance with dressing, total dependency with toileting hygiene and oral hygiene. MDS identified R3 had upper and lower extremity impaired ROM but did not indicate a ROM program or the use of a brace/orthotic device. R3's Clinical Medical Diagnosis report dated 9/2/26, indicated diagnoses of cerebral infarction, hemiplegia affecting left non-dominant side, major depressive disorder, schizoaffective disorder, and bipolar disorder. R3's Clinical Orders included an order dated 2/5/26 for occupational therapy to evaluate and treat as indicated. R3's had a Therapy Communication Form under the therapy section of miscellaneous records dated 4/1/26. The order read Left hand splint. Help her put it on in the morning and help her take it off at night. If soiled remove padding and hand wash with soap. The order was signed by an occupational therapist. R3's care plan dated 9/2/26, Alteration in Mobility related to cerebral infarction, hemiplegia affecting left non-dominant side and type I diabetes. The care plan's goal was for R3 to move safely within the environment. The care plan directed staff to follow physical therapy instructions, indicated R3 was dependent on locomotion, movement in bed, and transfers. The care plan was last revised on 6/9/26. There was no mention about the left-hand brace. During observation and interview on 8/31/26 at 11:59 a.m., R3 was in bed covered with bed linen and only her right hand was visible. There were 2 letter-sized papers with pictures showing a brace, and directions on how to put it on and another sign on how to remove it. The signs included when to put it on and when to put it off. The signs were posted on the wall by the foot of the bed. During observation on 8/31/26 at 3:14 p.m., R3 was observed sitting on the front patio and she was not wearing a brace on her left arm. During observation on 9/1/26 at 12:09 p.m., R3 was sitting on the outside patio, conversing with a peer, and she was not wearing a brace. During interview on 9/1/26 at 2:36 p.m., nursing assistant (NA)-A stated he helped R3 to get up in the morning. NA-A said R3 did not have a brace and was not aware of the signs posted in her room. Upon returning to her room, he looked in R3's bed, nightstands, drawers and closet but couldn't find the brace. During observation and interview on 9/1/26 at 2:37 p.m., nurse manager/licensed practical nurse (LPN)-B stated the brace should be in her room. LPN-B found the brace on the floor next to a box. LPN-B verified the order for the brace was not on medical orders or the NA assignments to be completed as recommended/ordered by the occupational therapist. LPN-B stated she needed to review R3's medical record, review her orders, and update her records. During interview on 9/2/26 at 12:05 p.m., RN-A stated according to the medication administration (MAR) or the treatment administration record (TAR), R3 did not have a brace. During an interview on 9/3/26 at 10:42 a.m., director of nursing (DON) stated sometimes the therapy department gave them a communication form in which they provided recommendations for ROM programs, braces, slings, transfers techniques, mobility devices, and eating utensils among others. DOM stated her expectation was for the nurse manager to make sure the orders were scanned, implemented and placed in the group sheets. If the orders were not implemented as ordered, it could cause a decrease in mobility and increased contractions. Facility's policy titled Activities of Daily Living (ADLs)/Maintain Abilities Policy indicated It is the policy of the facility to specify the responsibility to specify to create and sustain an environment that humanizes and individualizes each resident's quality by ensuring all staff, across all shifts and departments, understands the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. Based on the comprehensive assessment a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.

Based on observation, interview and document review, the facility failed to ensure a catheter drainage bag (CDB) remained below the level of the bladder and that catheter tubing was free of dependent loops (instances of catheter tubing dipping below the level of the CDB) for 1 of 2 residents (R11) reviewed for catheter care.Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses of chronic kidney disease and urethral stricture with obstructive uropathy (blockage of the urinary tract which impedes normal urine flow). R11 had an indwelling urinary catheter and was frequently incontinent of bowel.R11's care plan dated 8/25/26, indicated he was independent with most cares, but required assistance with toileting hygiene after bowel movements. R11 was dependent on a wheelchair for mobility and required total assistance with transfers. The care plan also identified he had a chronic indwelling catheter for urinary obstruction. Interventions to prevent urinary tract infection (UTI) dated 4/7/25, directed staff to provide catheter care per facility policy.R11's progress notes included:A provider note dated 5/29/26, indicated R11 was discharged from the hospital with a diagnosis of UTI and was prescribed Cefadroxil (an antibiotic). A provider note dated 8/21/26, indicated R11 had a UTI and was prescribed Macrobid (an antibiotic).A nursing progress note dated 9/1/26 at 11:12 p.m., indicated the resident had returned from the hospital after undergoing a urinary stent placement for complicated UTI and was prescribed Levofloxacin (an antibiotic). During observation on 8/31/26 at 10:57 a.m., R11 was reclined in his wheelchair with his feet elevated. R11's CDB was hooked on the right wheelchair armrest with the CDB above the level of the bladder. The catheter tubing was coiled with two loops hanging below the level of the CDB and contained urine that had not drained into the CDB.During interview on 8/31/26 at 12:08 p.m., R11 stated he had a history of UTIs, the most recent of which was in July 2026.During observation on 8/31/26 at 5:45 p.m., R11's CDB was hooked on the right wheelchair armrest with the CDB above the level of the bladder. The catheter tubing was coiled and contained urine which had not drained into the CDB.During interview on 9/1/26 at 12:27 p.m., the Assistant Administrator (AA) stated the resident had gone to the hospital that morning for replacement of a urinary stent (a tube to ensure urine flows from the kidney to the bladder) related to a complicated UTI.During observation on 9/1/26 at 2:01 p.m., R11 was in his room and reclined in his wheelchair. He stated he had just returned from the hospital. R11's CDB bag was hung over the right armrest above the level of his bladder with urine noted in the catheter tubing. Resident stated he knew the bag was supposed to be below the level of his bladder. During observation and interview on 9/2/26 at 10:18 a.m., R11's catheter tubing was clipped to the front of his shorts. Two loops in the catheter tubing were present between his legs with one section of tubing resting below the level of the CDB. Urine was present in the tubing. R11's CDB was hung on the right arm of his wheelchair above the level of the bladder.During interview in R11's room on 9/2/26 at 10:32 a.m., nursing assistant (NA)-A stated the CDB was in the wrong place. He confirmed the CDB was hung above the level of R11's bladder, the tubing was looped so urine had to flow in an upward rather than downward direction, and there was urine in the tubing. NA-A stated while this was not the best way to hang the bag, R11 preferred it that way and R11 usually controls his own bag. NA-A stated the CDB should ideally be hung on the left side below R11's bladder, but since there was nowhere to hang it on the left side, staff hung it on the right side. He stated R11 had returned from the hospital with the CDB hooked on the lower part of the right side of the wheelchair below his bladder, but R11 must have moved it back onto his armrest. R11 stated he did not really care whether the CDB was hung lower, as long as it would not drag on the floor.During interview on 9/2/26 at 10:53 a.m., registered nurse (RN)-A stated the CDB should be hung below the level of the resident's bladder, but R11 will just keep the bag the way he wants it. She said staff have tried to educate him, but he will just shut you off and move the bag over to his right arm rest. She stated she was not aware of any UTIs prior to R11's urinary stent placement on 9/1/26.During interview on 9/3/26 at 9:45 a.m., the Director of Nursing (DON) stated staff were expected to keep CDBs below the level of a resident's bladder, with no kinks or dependent loops in the tubing.A review of progress notes dated 5/1/26 to 9/1/26 lacked evidence of any attempts by staff to educate R11 on correct positioning of the CDB and catheter tubing to help prevent UTIs.A policy regarding urinary catheter care was requested, but the facility indicated they did not have one.

Based on observation, interview, and document review, the facility failed to ensure a medication administration error rate of less than five percent (%). Two medication administration errors occurred out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 3 residents (R5) observed during medication pass.Finding include:Administration per Manufacturer's InstructionsR5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses of asthma, chronic obstructive pulmonary disease (COPD, incurable lung disease causing breathlessness, frequent coughing, and chest tightness), schizoaffective disorder, depression, central cord syndrome (spinal cord injury), chronic pain, prediabetes, and hypertension (high blood pressure).R5's Order Summary Report dated 9/2/26 indicated one milligram (mg)/two milliliter (mL) Pulmicort (an inhaled steroid to prevent airway inflammation) inhalation suspension was to be administered two times daily via nebulizer (a medical machine used to turn liquid medication into a breathable mist).Per the manufacturer's instructions, Pulmicort should be administered via nebulizer, and staff are directed to advise patients to rinse the mouth immediately following inhalation, as this will lessen the chance of getting a fungal infection (thrush) in the mouth.During a medication pass on 9/1/26, the following observations were completed:At 11:10 a.m., licensed practical nurse (LPN)-A removed a vial of Pulmicort from a multidose box in the medication storage cart. The outside of the box was labeled with a blue sticker that said, Rinse mouth after use.At 11:34 a.m., LPN-A emptied the contents of the Pulmicort into the nebulizer cup, turned on the compressor, and R5 began inhaling the medication.At 11:43 a.m., the mist from the nebulizer treatment stopped indicating the treatment was finished. R5 placed the mouthpiece next to him on the bed. R5 was not observed to rinse his mouth after nebulizer use and LPN-A was not observed to remind the resident to do so.During interview on 9/1/26 at 11:58 a.m., when LPN-A was asked about the protocol to be followed after a steroidal nebulizer treatment was given, LPN-A stated he was supposed to rinse the mouthpiece and medicine cup and allow them to air dry. When asked if there was anything he was expected to assist the resident to do, he said he was supposed to help R5 rinse his mouth with water. When asked when this should have occurred, LPN-A stated as soon as possible after treatment. LPN-A then filled a cup with water from the nursing station and returned to the resident's room. The resident asked, What's that water for?. LPN-A explained R5 needed to rinse his mouth to keep it from becoming dry due to the medication. LPN-A exited the room to get a second cup for the resident to spit in. R5 stated the facility's nursing staff had never asked him to rinse his mouth after a nebulizer treatment. LPN-A returned with the second cup and the resident rinsed his mouth and spat the contents into the second cup.During interview on 9/2/2026 at 10:53 a.m., registered nurse (RN)-A stated residents should rinse their mouths as soon as possible after an inhaled steroid nebulizer treatment.During interview on 9/3/26 at 9:45 a.m., the Director of Nursing (DON) stated she expected staff to assist residents with rinsing their mouths immediately after administration of an inhaled steroid nebulizer treatment.Late AdministrationR5's Order Summary Report dated 9/2/26 indicated one drop of carboxymethylcellulose sodium PF ophthalmic solution 0.5% (a lubricating eye drop) was to be instilled in each eye every six hours. This was scheduled in the facility's electronic medical system (EMS) for 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.During observation on 9/1/26 at 11:03 a.m., LPN-A pulled R5's scheduled morning oral and inhaled medications from the storage cart. He did not pull or administer R5's carboxymethylcellulose eye drops.During observation of R5's medication administration record (MAR) on 9/1/26 at 2:04 p.m., it was documented R5 received his last dose of carboxymethylcellulose eye drops on 9/1/26 at 6:01 a.m. The 12:00 p.m. dose was not documented as administered.During interview on 9/1/26 at 3:10 p.m., LPN-A stated he had not administered any eye drops to R5 that day. He confirmed overnight nursing staff administered the last dose of carboxymethylcellulose eye drops at 6:01 a.m. He said the eye drops were scheduled to be given every six hours. LPN-A stated he should have administered the eye drops no later than 1:00 p.m., and the medication was now overdue. LPN-A stated he did not administer the eye drops because he was not sure where to find them. Upon further inspection of the medication storage cart, LPN-A located R5's eye drops. He stated he would check with the nurse manager regarding whether to administer the medication, given the next dose was scheduled for 6:00 p.m.During interview on 9/2/26 at 8:55 a.m., RN-B stated she thought nursing staff had an hour on either side of a scheduled time to administer a medication.During interview on 9/3/2026 at 9:45 a.m., the DON stated nursing staff typically had one hour on either side of a scheduled medication administration time to give a medication. She said she thought a medication scheduled for 12:00 p.m. would be administered no later than 1:00 p.m. The DON stated if a medication was past due, the facility's electronic medical record should flag the medication with a red box so nursing staff were alerted.The facility's Medication Administration-Documentation policy dated 11/2019, did not reference either best practice related to inhaled medications or timing of medication administration relative to provider orders.

Based on observation, interview, and document review, the facility failed to post a notice indicating that the last three years of survey results would be made available upon request. In addition, the facility failed to include the plan of correction when posting the results of the most recent survey. This had the potential to affect all 60 residents residing in the facility. Findings include: During observation and record review on 9/2/26 at 9:00 a.m., the annual survey results binder was observed in the main hallway on the first floor of the building. The annual survey binder was reviewed, and although survey results were observed, no plan of correction was included. No signage or indication that survey results from the last three years could be made available on request was found. During an interview on 9/2/26 at 9:02 a.m., the administrator stated she was in charge of posting survey results. The administrator stated that the previous three years of survey results were available on request but acknowledged that they did not have a sign or a way for residents/visitors to know these results were available. The administrator stated she was unaware that the plan of correction was to be included with the posted survey results, so they had not been included in the binder. A policy regarding posting survey results was requested and not received.

Based on interview and document review the facility failed to ensure contracted hospice agency staff reported allegations of sexual abuse immediately to the administrator for 1 of 1 residents (R1) reviewed for allegations of abuse. Findings include:R1's face sheet dated 5/14/26, identified diagnoses of anxiety disorder, and schizoaffective disorder (schizophrenia and mood disorders).R1's care plan dated 2/12/26, identified R1 was a vulnerable adult and was at risk for decreased cognitive and physical abilities. Interventions included monitor for signs of emotional distress or mood and behavior changes, staff will follow the facility vulnerable adult and abuse reporting policy, local Ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.R1's care plan dated 5/9/26, identified R1 had hospice care related to end stage disease process. Interventions included maintain communication with hospice and keep them informed of R1's condition as needed, keep hospice informed of any changes in R1's condition, offer medication as needed, utilize hospice standing orders per policy, follow direction from hospice as needed, involve hospice care workers in care conference, hospice care workers as setup by hospice staff, increase 1:1 visits as needed, monitor for signs of increased depression or comments of suicidal ideation, see hospice plan of care and visit schedule, refer to psych services and/or clergy as needed.R1's physician visit progress note dated 5/12/26, identified R1 had recently readmitted to facility after a hospitalization with diagnoses of acute encephalopathy (brain dysfunction) and readmitted to facility with hospice order.During an interview with hospice nurse (date and time omitted intentionally) stated she was R1's hospice nurse, was not full time, and R1 did not have the ability to communicate. Nurse indicated on 5/12/26, the hospice aide found sex grease premium personal lubricant in R1's room and sent her a picture. After the report from the aide hospice nurse had not made a visit to do a sexual assault exam nor had she notified any facility staff or the administrator of the concern relating to the presence of personal lubricant in R1's room.During an interview on 5/14/26 at 10:34 a.m., nursing assistant (NA)-A stated he worked on 5/12/26, hospice staff were at facility and did not say anything about concerns of sexual abuse to him.During a phone interview on 5/14/26 at 12:32 p.m., registered nurse (RN)-B stated on 5/12/26, a hospice aide was at the facility performing cares for R1. Hospice aide did not report any concerns of sexual abuse she had when they talked.During an interview on 5/14/26 at 12:18 a.m., social worker (SW)-A stated she was the hospice liaison. The nurses and aides will communicate with the floor staff. SW-A typically had communication with hospice SW. SW-A expected someone from hospice would have communicated the concern of suspected abuse to her.During an interview on 5/14/26 at 12:12 p.m., director of nursing (DON) and regional nurse consultant (RNC)-A stated the hospice company trains their own staff as part of the contract they have with them. SW-A is the facility contact with hospice. DON stated the concern for sexual abuse should have been reported to her immediately by hospice staff so they could begin an investigation.During a phone interview on 5/14/26 at 11:23 a.m., hospice supervisor (HS)-A and B stated if their staff thought a resident was being sexually abused they should report immediately to the facility and then to them. The hospice protocol would be to get in touch with the facility, be aware, collaborate, and investigate. Hospice will triage with facility floor staff before and after providing cares to residents on hospice. HS-A and B stated they were unaware of any situation involving sexual abuse at the facility and their staff did not report the situation to them.During an interview on 5/14/26 at 12:22 p.m., Administrator stated hospice staff are mandated reporters and hospice had the responsibility to report to the administrator and/or facility staff immediately for any concerns of abuse or neglect. The facility expectation was that the hospice agency trains their staff to competently care for the facility residents. Hospice staff are expected to check in and out with the floor nurse and discuss any changes so continuum of care is followed.The facility Inpatient Hospice Services Agreement dated 10/27/17, identified facility shall ensure all Inpatient Services are provided competently and efficiently. Inpatient Services shall meet or exceed the standards of care for providers of such services and shall be in compliance with all applicable laws, rules, regulations, professional standards and licensure requirements. Hospice and facility shall communicate with one another regularly and as needed for each particular hospice patient. Upon execution of this agreement facility shall provide hospice with facility's established policies and protocols and shall promptly provide hospice with any amendments or modifications thereto. Facility shall fully cooperate with hospice in its effort to respond to and resolve any inquiry, audit, investigation, review or request. Either party shall immediately notify the other party of any of the following alleged incidents involving a hospice patient: mistreatment or neglect, verbal, mental, sexual, or physical abuse.The facility Sexual Abuse Allegations Procedure dated 6/2019, identified: 1. The Charge Nurse of the unit where the alleged victim resides will verify that anallegation of criminal sexual conduct has been made. The Charge Nurse will thenconduct an assessment of the alleged victim, initiate an Incident Report andimmediately call the Administrator and/or Director of Nursing to determine if 911should be called. The Charge Nurse will ensure that no potential evidence (bedlinens, resident undergarments) is touched, so as to protect against itscontamination.2. The Charge Nurse will take immediate steps appropriate to the situation to ensure theprotection and safety of the resident. If the alleged perpetrator is a staff member,the staff member will be immediately suspended, pending further investigation, andanother staff member will be assigned to complete care of the resident until aninvestigation is complete.3. The Charge Nurse will immediately notify the facility Administrator. In case ofabsence of the Administrator, follow the chain of command for notification. TheDirector of Nursing, Nurse Manager, Social Worker, and other department directorsshould be notified as needed. If the alleged perpetrator is one's supervisor ordepartment head, notify their supervisor.4. The Administrator, Director of Nursing, or Social Worker will notify MinnesotaDepartment of Health immediately. This notification MUST be made as soon aspossible after learning of the allegation.5. The Nurse or Nurse Manager will notify the physician and family regarding the facts ofthe situation. Inform them that an investigation is in progress.6. The Charge Nurse/Nurse Manager or the Social Worker will arrange for a physician toexamine the alleged victim as soon as possible, but no longer than 24 hours from thetime of initial knowledge the incident occurred has been received.7. The facility will fully cooperate with the investigation of external entities (local Police,Office of Health Facility Complaints, Survey and Certification Agency, etc.)NOTE: If abuse/neglect is substantiated following investigation by designated StateAgency, the facility is responsible for reporting the results to the licensing board orappropriate State Nursing Assistant Registry.The facility Abuse Prohibition/Vulnerable Adult Policy dated 11/2025, identified a supervisor would be notified immediately of suspected abuse and neglect and an internal investigation started. Suspected abuse shall be reported to the State Agency not later than 2 hours after forming the suspicion of abuse.

Based on observation, interview, and document review the facility failed to prevent an unintentional fire related to 1 of 1 resident (R1) who set fire to oxygen when she was smoking in her room. R1 remained in possession of a lighter and cigarettes after the fire, placing all 63 residents at likelihood of serious harm or death. The Immediate Jeopardy began on 1/29/26 when the facility failed to ensure R1's smoking materials were secured per the care plan, resulting in R1 lighting a cigarette in her room, with oxygen in use, and igniting an unintended fire. The facility did not implement appropriate supervision, monitoring, and interventions to prevent recurrence, and R1 continued to possess a lighter and cigarettes without staff knowledge resulting in the likelihood of serious harm or death for R1 and other residents at the facility. The administrator and director of nursing (DON) were notified of the IJ on 2/2/26 at 3:12 p.m. The IJ was removed on 2/2/26 when the facility implemented immediate corrective action to prevent reoccurrence, but noncompliance remained at a lower scope and severity of D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include R1's face sheet dated 1/30/26 indicated she had diagnoses of type II diabetes, pulmonary fibrosis (thickening of lung tissue), chronic obstructive pulmonary disease (damage to the lungs), depression, nicotine dependence and dementia. R1's Medicare 5-day Minimum Data Set (MDS) dated [DATE] indicated R1 was moderately cognitively impaired and independent in activities of daily living. During the assessment period R1 had no behaviors and no rejection/refusals were noted. R1 required continuous oxygen and had no limitations in her range of motion. R1's Smoking Evaluation form dated 12/19/25 indicated R1 was safe to smoke independently. R1 had no cognitive loss even though R1 had a diagnosis of dementia and the MDS identified R1 had moderate cognitive impairment. R1 had no visual deficits or dexterity problems. R1 smoked 2-5 times per day. R1 could light her own cigarette and had been deemed safe to store/handle her own cigarette and lighter. The assessment did not address if R1 demonstrated understanding of safety measures that addressed the removal of oxygen and/or placement of oxygen equipment prior to smoking. R1's smoking care plan initiated 12/23/25, identified a goal of resident will smoke safely and independently. Interventions as follows. -12/23/25 educated on potential dangers of oxygen and cigarette smoking. -12/23/25 independent with smoking per evaluation -12/23/25 smoking evaluation per facility policy and as needed. Although the care plan identified R1 was provided with education on the potential dangers of oxygen, there was no interventions that guided/directed placement of oxygen equipment prior and/or during smoking. R1's incident analysis form dated 12/24/25 identified R1 was found smoking in her room. The contributing factors identified were R1 being a new admission to the facility and she was independent with smoking according to her admission smoking form. R1 was re-educated and the care plan was updated to remove smoking materials and keep them at the nursing station. R1's smoking evaluation dated 12/24/25 indicated R1 did not have cognitive loss even though the MDS identified moderate cognitive impairment and R1 had a diagnosis of dementia, no visual deficits or dexterity problems. R1 smoked 5-10 times per day, could light her own cigarette and could not store her own smoking materials. R1's smoking materials were to be kept at the nursing station. R1 had been found smoking in her room. The smoking policy was reviewed with R1. R1's care plan was not revised until 12/29/25 (six days after R1 was found smoking in her room.) The care plan was updated with the intervention to store smoking materials at the nurse station. R1's Risk vs Benefits form dated 12/30/25 indicated the area of concern was R1 smoking in the room while on oxygen. The form did not identify the date or dates of when R1 was smoking in her room. The risks related to non-compliance was documented as smoking in a room while using oxygen is extremely dangerous because oxygen itself is not flammable but greatly accelerates combustion, causing fires to ignite faster, burn hotter, and spread explosively. Even a small spark from a cigarette, lighter or match can trigger a flash fire when oxygen has saturated clothing, bedding, hair or furniture. These fires can cause severe burns, permanent lung damage, and death within seconds, not only to the person on oxygen but also to others in the home. In addition, oxygen related fires are difficult to extinguish and can rapidly lead to structural damage. For these reasons, smoking should never occur in the same room when oxygen is in use. The form did not include any benefits associated with the risks that were identified. Furthermore, the form was not signed by R1, her guardian or any family members. In review of R1's record there was no indication of monitoring and evaluation of effectiveness of R1's care plan intervention that directed to store smoking materials at the nurse's station. R1's progress notes dated 1/29/26 at 8:39 a.m. indicated R1 was smoking in her room and caused a fire (indicating the 12/29/25 intervention was not followed that directed to keep smoking materials at the nurse's station). R1 denied smoking in her room and refused a respiratory assessment and skin check. R1 was removed from the room and responsible parties were notified. R1's Smoking Evaluation dated 1/29/26 indicated R1 did not have cognitive loss even though the MDS identified moderate cognitive impairment and R1 had a diagnosis of dementia. R1 had no visual deficits or dexterity problems. R1 smoked 5-10 times per day, could light her own cigarette and could not store her own smoking materials. The following summary was included, Per observation resident is independent lighting, smoking and extinguishing cigarettes, resident has been deemed unsafe to store smoking cigarettes independently, smoking materials are supposed to be kept at the nurse's station, daily checks to be done on room. Resident use oxygen Resident has been educated to remove and store oxygen prior to smoking. Resident has wanderguard on portable oxygen tank. Resident verbalized understanding R1's incident analysis form dated 1/29/26 identified R1's oxygen tank was on fire in her room. Staff heard R1's roommate yelling help and responded. Staff found a fire in R1's room on the oxygen tank. R1 was smoking but denied smoking. The fire was put out. R1 and the roommate were assessed; no injuries were found. R1 was moved to a different room and the roommate proceeded with a previously planned discharge. A search was completed; a pack of cigarettes was found and placed at the nurse's station. In the contributing factors section, the 12/23/25 (date conflicts with date of incident) smoking infraction was identified and R1 was re-educated at that time to the smoking policy, with the plan to start keeping smoking materials at the nurse's station. Interviews with two staff showed they had no concern with R1 after the first smoking incident. The night of 1/29/26, R1 was agitated because she thought she had an appointment in the morning. R1 may have been confused after hearing about her roommate's discharge and thought she needed to do something. Ongoing interventions included, -R1 was re-educated regarding risks of smoking with oxygen. -Nursing order to do daily room checks for smoking materials -Guardian and family contacted to give smoking materials to the nursing station during visits -ACP (Associated clinics of psychology) notified -Spanish and English sign placed in room to remind resident to not smoke -15-minute checks implemented. R1's smoking care plan identified on 1/29/26 the following interventions were added: -1/29/26 daily - request permission from resident to complete room search. If allows then please search and remove and smoking materials found. -1/29/26 safety checks -1/29/26 signs posted in room in Spanish to remind about no smoking and that oxygen is flammable -1/29/26 visualize room every shift. Remove any smoking materials that are easily observed and bring to nursing station for safety -1/29/26 wanderguard to portable oxygen tank - check placement every shift and function daily In review of R1's record between 1/29/26 through 2/2/26 the record did not include a comprehensive assessment or analysis on how 15-minute checks were appropriate or sufficient for R1 to prevent R1 from smoking in the facility. Additionally, the care plan did not address and/or give instructions to staff when if R1 was non-compliant with keeping smoking material in her room and/or refuse to give smoking materials to staff in accordance with the care plan. In review of R1's clinical record, although cognitive screening was completed as part of the MDS (Brief Interview of Mental Status) that identified moderate cognitive impairment and R1's diagnosis of Dementia, there was no documented assessment evaluating R1's task-specific decisional capacity to safely engage in smoking while using oxygen. The record did not include an evaluation of R1's ability to understand, retain, and consistently apply smoking safety requirements, including judgment and executive functioning related to compliance with the facility's smoking policy even though R1 demonstrated non-compliance on 12/24/25 and 1/29/26 when R1's care plan for storage of smoking materials was not followed, did not follow the smoking risks document dated 12/29/25, and the facility analysis that indicated R1 may have been confused. During an observation and interview on 2/2/26 at 9:13 a.m., R1 was in her room and stated she did not trust staff with her smoking materials. R1 stated she refused to give staff her smoking materials when they asked her for them. R1 reached into her coat pocket and pulled out a box of cigarettes with a lighter. She had her nasal cannula on and connected to her oxygen tank running at 2 LPM (liters per minute). R1 denied causing a fire in her room on 1/29/26. During an interview on 2/2/26 at 9:31 a.m., nursing assistant (NA)-A indicated R1 would refuse to give her smoking materials to staff when staff requested her items after she returned from smoking outside. Staff had not had time yet to check today (2/2/26) if R1 had smoking materials in her possession, but she likely did. NA-A stated staff don't always have time to check residents when they come back to the floor after smoking to make sure they have given the smoking materials to the nursing station. NA-A had warned R1 a few times because he smelled it in her room and R1 would deny it (unable to give exact dates). NA-A would report smoking concerns to the nurse or nurse manager. NA-A was not sure what new interventions were in place after the fire besides the 15-minute checks. R1 would be able to smoke a cigarette in between the 15-minute checks. R1's record reviewed between 12/24/25 through 2/2/26 did not include accounts of R1 smoking in her room except on 12/24/25 and 1/29/25. During an interview on 2/2/26 at 10:30 a.m., licensed practical nurse (LPN)-A stated she was not aware of R1 smoking in her room and was unaware she had a lighter in her possession currently. R1 had been non-complaint with her smoking care plan and had a risk versus benefits form in place. LPN-A would notify nursing management if R1 refused to give up her smoking materials. LPN-A showed the drawer at the nursing station where smoking materials would be kept. The drawer did not contain any smoking materials; it was full of miscellaneous office supplies. LPN-A verified there was no log to keep track of smoking supplies, but the facility could put a log into place. Facility records/protocols did not identify a system to track resident smoking materials when stored at the nursing station. During an interview on 2/2/26 at 3:57 p.m., registered nurse (RN)-A stated R1 was non-compliant with smoking and had a mind of her own. RN-A had educated her about not smoking in her room prior to the fire. RN-A did not clarify if R1 was understanding of the education. Staff were not sure where or how R1 was obtaining smoking supplies but sometimes residents shared with each other. Placing 15-minute checks on R1 was decided by management and facility policies and not based on a comprehensive assessment. R1 would be able to smoke in her room or go outside in between the 15-minute checks but R1 had her own will and freedom. RN-A had not received reports of R1 smoking in her room from nursing assistants. R1 knew she was supposed to keep her smoking materials at the nursing desk so she would hide her materials. RN-A did not clarify what should be done when R1 refused to give up her smoking materials. RN-A responded to the fire during the night shift on 1/29/26 when she heard someone screaming for help and shouting fire. R1 had turned her oxygen off. R1 was right next to her oxygen tank. A nursing assistant helped remove R1 and the roommate. RN-A alerted the emergency system by pulling the fire alarm, calling 911 and paging code red. No residents or staff were injured. R1's record reviewed between 12/24/25 through 2/2/26 did not include accounts of R1 hiding smoking materials and refusals to give up her smoking materials. During an interview on 2/2/26 at 10:00 a.m., NA-B stated R1 often refused to give her lighter up to nursing staff. It was a shared responsibility between nursing assistants and nurses to obtain her smoking materials. NA-B would report it to the nurse manager when R1 refused to give up her smoking materials. NA-B could not specify what would happen once management was aware of R1 not giving up her smoking materials. NA-B had not been told much about what new interventions were in place following the fire. During an interview on 2/2/26 at 12:20 p.m., the director of nursing (DON) stated it was hard to take things from R1, family would bring her smoking materials without bringing it to the nursing station first. It was noticed that R1 had a lighter on her this morning (2/2/26), she refused to give it up and she was placed on one-to-one observation. R1 had only been on 15-minute checks previously because it was determined to be the least restrictive option. Although interviews with NA-A, RN-A, NA-B, and DON's interview identified awareness of R1's refusals to keep smoking materials at the nurse's station, non-compliance with smoking care plan, and family members bringing in smoking materials without bringing to the nurses station there was no documentation of occurrences nor documented interventions for those instances in R1's record between 12/23/25 and 2/2/26. During an interview on 2/2/26 at 12:39 p.m., the administrator stated staff were not sure where R1 obtained her smoking supplies. Since it was identified the morning of 2/2/26 by the surveyor that R1 still had a lighter and cigarettes, a nursing assistant stationed by the smoking patio would be documenting smoking supplies, lighting cigarettes for residents and storing all smoking supplies at a desk. R1 was placed on one-to-one observation with staff on 2/2/26. During an interview on 2/3/26 at 10:03 a.m., the medical director (MD)-A stated he was notified of the fire in the facility. R1 was making decisions that were difficult to help maintain safety despite the precautions that were in place. R1 was choosing to hold onto her lighter. MD-A didn't think there were any system gaps since the facility implemented a new system (yesterday) to have a staff member at the front door by the smoking patio who would keep smoking materials locked. The facility was working on designing a new smoking patio that would be away from the street. The facility policy Resident Smoking Policy last revised 11/2025, directs storage of smoking supplies is determined by the facility to individualize based on the resident's smoking assessment. Any residents who do not comply with this policy may lose smoking privileges. The resident may be subjected to discharge if unsafe practices are observed which may endanger themselves or others. The IJ was removed on 2/2/26 when it was verified the facility implemented the following corrective actions: *The facility reviewed their smoking policies with the medical director and ombudsman input. *The facility developed and implemented a comprehensive system that prevented accidents, hazards and fires related to smoking inside the facility. This included a plan for residents who fail to comply with safe smoking practices. *Reassessed R1's capacity to make safe decisions regarding smoking. R1's care plan was revised with appropriate individualized interventions. *Identified like residents and their level of complying with facility policy for smoking. Individualized interventions to prevent smoking were put in place for the like residents. Residents were given safe smoking quizzes after re-education on safe smoking policies. *Educated all staff on smoking policies with a knowledge check quiz to demonstrate understanding.

Based on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators was completed to reduce the risk of foodborne illness. In addition, the facility failed to ensure the refrigerator and cooler temperatures were properly monitored and maintained to reduce the risk of foodborne illness. This had the potential to affect all 64 residents who consumed meals from the main kitchen.Findings include:UNLABLED FOODDuring the initial kitchen observation with the dietary aid (DA)-A on 9/15/25 at 11:41 a.m., the following foods were found in a double-door refrigerator in the first-floor kitchen.-One gallon of skim milk, half full, manufacture expired date 9/10/25.-Unlabeled open plastic bag of pre-made salad consisted of brown lettuce, orange carrots, purple cabbage, brown juice on the bottom of the bag.-A plastic container of opened sour cream, manufacture expired date 8/27/25, labeled 9/14/25.-A plastic container of opened deli salad, manufacture expire date 9/8/25, labeled 8/5/25. A second unlabeled opened container was marked with a manufacture expire date of 9/24/25.-Unlabeled box with approximately 10 fresh green peppers.-Unlabeled thawed, uncooked chicken covered in a plastic container. Labeled placed 9/15/25 during walk through.-One opened serving bowl of fruit cocktail, labeled 9/11/25.-One opened bag of ham slices, labeled 9/8/25.-One tall white cylinder container with thawed uncooked chicken, labeled 9/12/25.-One plate of thawed, uncooked chicken thighs labeled 9/7/25, placed on the same baking sheet as a container of chicken soup unlabeled, a bowl of beef broth labeled 9/13/25, and an uncovered bowl of hard boil eggs, labeled 9/14/25.-One sliver container, uncovered with chunks of cooked ham and pineapple, labeled 9/8/25.-Unlabeled plates (3) with lettuce and tomatoes.-Unlabeled, opened bag of uncooked hotdogs.-Unlabeled, plate of two sandwiches.-Unlabeled, five pitchers of pre-made juice.-Unlabeled personal items, one can of Pepsi, one pre-packaged caramel apple, one bottle of vanilla creamer.-An open plastic bag of uncooked bacon, labeled 9/11/25.-Unlabeled, large bowl of pasta salad with vegetables.The following food was observed on the prep table in the first- floor kitchen.-Unlabeled, opened plastic container of butter with a knife inside the container.During an observation and interview on 9/15/25 at 11:43 a.m., DA-A opened all the coolers and freezers during the initial tour. DA-A verified the dates for the skim milk, deli salads and fruit cocktail and discarded the items, the pre-made bagged salad had no date and was removed. DA-A stated many of the items were prepared for today's meal or would be used by today and couldn't explain the process for labeling or storing food. A can of Pepsi, bottle of vanilla creamer and a prepackaged caramel apple were in the miscellaneous cooler and DA-A stated they put their personal things in the miscellaneous cooler and the items were not removed during the initial walk through. During an observation on 9/15/25 at 11:45 a.m., DA-B was observed removing the unlabeled items identified for the dinner meal (three plates of salad, uncooked chicken, pasta salad, sandwiches, prepared juice), labeling them with the date of 9/15/25, and placing them back in the refrigerator. The expired sour cream remained in the refrigerator. The dietary aids could not identify if expired foods were used to prepare meals for residents.During an interview on 9/15/25 at 12:30 p.m., culinary director (CD) stated all items in the refrigerator should have a label and date when the item was received, opened, or prepared. The CD was not able to explain the process for labeling or storing food but added that prepared items were good for 48 hours and other items were good for 57 hours and indicated all prepared food should be thrown away within seven days. During a follow up interview on 9/17/25 at 8:57 a.m., the CD stated thawed, uncooked chicken could be refrigerated for three days. CD stated sour cream and all dairy products should be thrown away by the expired date but could not explain why the expired sour cream had not been thrown away. CD stated premade bagged salads should be used or discarded on the date which they were opened and unopened prepared bagged salad could be kept for two days in the refrigerator. Uncooked bacon could be kept for seven days. The CD acknowledged temperature logs were not properly completed, and temperatures were not checked daily and the facility lacked any type of monitoring system that would confirm the temperatures did not rise above 41 degrees.REFRIGERATOR TEMPERATURESThe following labeled refrigerators and freezers lacked temperature monitoring. -vegetable freezer-log present missing month/location information/temperatures-bread and dessert freezer-no temperature log-milk and dairy cooler-no temperature log-fresh fruit and vegetable cooler-log present missing month/location information/temperatures.-miscellaneous cooler-log present missing month/location information/temperatures.-meat freezer-no temperature logDuring an observation and interview on 9/15/25 at 12:15 p.m., DA-A confirmed the facility lacked temperature logs for refrigerators and freezers. Three temperature logs were removed from a clear document protector attached to the front of the double door units that had a sign which identified the units as fresh fruit and vegetable cooler, miscellaneous cooler and vegetable freezer. On the header of the page a title read Refrigerator in bold and beneath those letters were Temperature Log. An area titled, Month followed by a line was blank and Unit/Location followed by a line were located on the top was also blank. A table followed and listed Date 1-30 on the left -hand column and in the next column was AM Temp must be less than 41 degrees and next PM Temp must be less than 41 degrees. The last column was titled corrective action of temperature greater than 41 degrees. On the bottom of the page an italicized statement read if units are outside the needed temps contact your culinary manager as soon as possible. Temperatures were recorded for all three pieces of papers on the 6th, 7th, 8th, and 11th with the initials E.O. DA-A was unable to identify which month the temperature logs were completed on those dates. The temperature was checked for the dairy cooler and read 38 degrees.During an interview 9/15/25 at 11:54 a.m., DA-B stated everyone was responsible for checking the cooler and freezer temperatures. During an interview on 9/18/25 at 10:59 a.m. the director of nursing (DON) stated the expectation was for food to be labeled with a date, discarded when it expired, and to complete temperature logs on the coolers and freezers daily. The DON stated this was important to ensure the food was being stored at proper temperatures and to reduce the risk of foodborne illness to the residents. A policy for food storage was requested and not received.

Based on interview and document review, the facility failed to ensure an adequate discharge planning process was maintained to ensure resident preference for discharge was met for 1 of 2 residents (R46) reviewed for discharge planning.Findings include:R46's quarterly Minimum Data Set (MDS) assessment, dated 7/2/25, identified R46 had intact cognition with no behaviors or hallucinations or delusions. Section Q indicated there was no active discharge planning occurring for resident to return to the community. During an interview on 9/15/25 at 12:27 p.m., R46 stated she wants to move closer to family. R46 stated her family lived in a neighboring state and believed the facility was trying to find a place but hadn't heard any updates recently. R46's care plan, printed 9/18/25, indicated R46's current discharge plan is to move closer with family and family was looking for a SNF (skilled nursing facility) in the area of interest with an initiation date of 4/3/25. The focus/goal included the following interventions with initiation dates: - Mnchoice referral was completed for community-based services. 4/24/25- Referrals are being sent to SNF in [NAME] WI for facility transfers 7/10/25- Resident and family will be invited to care conferences quarterly or as needed, andd/c planning options will be discussed as needed. 4/4/25- Staff will make necessary referrals as needed in order to carry out resident's d/cgoals. 4/3/25The care plan lacked any information on where the referrals were sent, updates on referrals sent or outcome from referral made from MNchoice assessment. R46's progress notes, dated 4/2/25 to 9/16/25, were reviewed and included the following: -4/22/25: care conference note indicated a MNchoice assessment will be made.-4/21/25: referral sent to a facility-4/24/25: referral for MNchoice assessment was completed for community- based services for resident to discharge.-6/26/25: a referral was sent to facility per request of family and resident-6/30/25: referral to facility on 6/26/25 was denied and recommended two facilities-7/2/25: a referral was sent to facility (one of which was recommended) near R46's familyThe progress notes lacked information on response from referral sent 7/2/25 or 4/21/25, follow up from referral sent for assessment on 4/24/25, any additional referrals to nursing facilities for R46 to discharge since 7/2/25, and communication with R46's family regarding updates on discharge. R46's care conference, dated 7/2/25, identified R46, family, social services, nurse manager and physical therapy were present for the care conference. The document identified resident wants to transfer to another facility closer to family, multiple referrals have been sent to surrounding area, resident wants to be in independent housing and will need services set up. During an interview on 9/16/25 at 12:42 p.m., nursing assistant (NA)-A stated R46 talks about how she wants to go out in the community more. NA-A was unaware if R46 was planning on moving to another facility or if this was a goal of R46.During an interview on 9/17/25 at 1:15 p.m., social services director (SSD)-A reviewed R46's electronic medical record (EMR). SSD-A stated the EMR lacked evidence of any follow up on discharge plans, referrals, etc since R46's care conference's 7/2/25. SSD-A stated there should have been follow up since the care conference over 2 months ago as it was known resident wants to discharge. During an interview on 9/18/25 at 10:06 a.m., director of nursing (DON) stated when a resident expressed a desire to discharge from the facility the expectation would be to get social services involved, resources set up for a safe discharge in a reasonable amount of time and stated this was an ongoing process until the discharge happens. A facility policy titled Discharge Planning Policy, dated 1/2025, indicated the purpose of the policy was to identify each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge.

Based on interview and document review, the facility failed to provide a written bed hold notice for 2 of 2 residents (R3, R70) reviewed for hospitalization. Findings Include: R3 R3's significant change Minimum Data Set (MDS) assessment, dated 9/8/25, indicated R3 had intact cognition with no hallucinations or delusions and no behaviors. On 9/15/25 at 5:18 p.m., R3 was observed sitting outside. R3 declined to talk with surveyor.R3's admission record, dated 9/18/25, did not identify R3 as having a health care power of attorney (POA). R3's census log, printed 9/18/25, indicated R3 was on hospital leave the following dates:-7/5/25 with return on 7/8/25-7/22/25 with return on 8/1/25-8/8/25 with return on 8/15/25-8/19/25 with return on 8/26/25 R3's progress notes, dated 7/4/25 to 8/27/25 were reviewed and indicated the following: -7/5/25 at 5:51 p.m.: resident sent to the hospital due to confusion and found on the floor.-7/8/25 at 6:52 p.m.: resident returned to the facility-7/22/25 at 9:42 p.m.: resident was sent to the emergency room for evaluation.-8/1/25 at 11:30 p.m.: resident returned from the hospital.-8/8/25 at 4:40 p.m.: hospital transfer note indicated resident was transferred to the hospital for left groin surgical dehiscence.-8/15/25 at 10:59 p.m.: a default progress note was entered for wound vac for resident.-8/19/25 at 10:48 p.m.: resident did not come back from the appointment this evening. There is a possibility she might be going through another surgery. -8/26/25 at 12:43 a.m.: note indicated an as needed Tylenol (pain reliever) medication was administered pain.The progress notes between 7/5/25 through 7/8/25, 7/22/25 through 8/1/25, 8/8/25 through 8/15/25, 8/9/25 through 8/26/25 lacked evidence that a bed hold was completed prior to being sent to the hospital or a bed hold was sent to the hospital after resident was transferred.R3's Hospital Transfer Form, dated 7/22/25, identified R3 was transferred to the hospital on 7/22/25 for left leg swelling with beige color discharge. Section 1a contains radio buttons to indicate what forms were sent with resident with one of the options was bed hold form which was not marked. The form lacked evidence that a bed hold was sent with or discussed with resident prior to transfer to the hospital. R3's Hospital Transfer Form, dated 8/8/25, identified R3 was transferred to the hospital on 8/8/25 for left groin surgical dehiscence. Section 1a contains radio buttons to indicate what forms were sent with resident with one of the options was bed hold form which was not marked. The form lacked evidence that a bed hold was sent with or discussed with resident prior to transfer to the hospital. The electronic medical record (EMR) lacked evidence that Hospital Transfer Forms were completed for 7/5/25 or 8/19/25. During a review of R3's EMR, the EMR lacked documentation a written bed hold was sent to any of the R3's following hospital stays 7/5/25, 7/22/25, 8/8/25, and 8/19/25. R70R70's quarterly MDS assessment, dated 8/26/25, indicated R70 had intact cognition with no hallucinations or delusions and no behaviors.R70's admission record, dated 9/18/25, did not identify R70 as having a health care power of attorney (POA).R70's census log, printed 9/18/25, indicated R70 was currently on a hospital leave as of 9/11/25. R70's progress notes, dated 9/11/25 to 9/18/25 were reviewed and indicated the following:-9/11/25 at 10:25 a.m.: R3's family member was notified of R3's current condition and transferred to the hospital.-9/11/25 at 10:03 a.m.: hospital transfer note indicated resident was transferred to the hospital for severe tremors and complaints of dizzinessThe progress notes lacked evidence that a bed hold was completed prior to being sent to the hospital or a bed hold was sent to the hospital after resident was transferred.R70's Hospital Transfer Form, dated 9/11/25, identified R70 was transferred to the hospital on 9/11/25 for severe tremors and complaints of dizziness with history of cardiac complications. Section 1a contains radio buttons to indicate what forms were sent with resident with one of the options was bed hold form which was not marked. The form lacked evidence that a bed hold was sent with or discussed with resident prior to transfer to the hospital. On 9/16/25 at 1:34 p.m., surveyor called R70's family member (FM)-A but unable to connect.R70's EMR lacked evidence a bed hold was completed for hospital leave on 9/11/25.During an interview on 9/16/25 at 11:30 a.m., registered nurse (RN)-C stated when a resident transfers to the hospital, the nurse completes the Hospital Transfer Form, along with the bed hold form. RN-C stated a copy of the bed hold form is sent with the hospital and was unsure if facility keeps a copy but thinks so. RN-C stated if a copy was kept it would be uploaded into the EMR. Furthermore, RN-C stated if a bed hold was completed, the Hospital Transfer Form would indicate this as there was a box that to check that it was completed. During an interview on 9/17/25 at 1:41 p.m. licensed practical nurse manager (LPN)-A stated the expectation was nurses would obtain the bed hold when transferring a resident to the hospital. LPN-A stated a copy of the bed hold was sent to the hospital for coordination of care and a copy was scanned into the EMR. LPN-A stated if verbal consent for a bed hold was obtained, this would be written on the form, but the process was the same. During a follow up interview on 9/18/25 at 8:40 a.m., (LPN)-A reviewed R3 and R70 medical records. LPN-A verified there was no documentation of a completed bed hold for R70 current hospitalization. LPN-A verified there was no documentation of R3's hospitalizations for 7/5/25, 7/22/25, 8/8/25, and 8/19/25. LPN-A stated the expectation was that they are completed when a resident was transferred to the hospital and the bed holds should have been completed. A facility policy titled Bed-Holds and Returns, dated 5/2023, included the following information: Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds;b. The reserve bed payment policy as indicated by the state plan (Medicaid residents);c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); andd. The details of the transfer (per the Notice of Transfer).

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., showers, hair care, shaving) were completed for 2 of 5 residents (R7, R1) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include: R7 R7's quarterly minimum data set (MDS) dated [DATE], indicated R7 was cognitively intact and had no hallucinations or delusions. R7 had impairments to both upper and lower extremities and used a wheelchair for mobility. They were frequently incontinent of bowel and bladder and was dependent on staff for all personal hygiene, to include shaving, toileting, baths, and oral hygiene. R7’s pertinent diagnosis included a central spinal cord syndrome (the spinal cord was bruised or damaged in the middle, at the level of the fourth vertebra in the neck and affects the arms more than the legs). R7’s care plan dated 5/30/22, identified a selfcare deficit related to maxillary fracture, cervical stenosis with central cord syndrome, weakness and preferred to keep fingernails long. R7 was dependent on one staff for bathing, dressing, grooming and personal hygiene. R7’s care plan lacked shaving preferences or their dependence on staff to perform such task. The third-floor nursing care sheets for group one, dated 5/15/25, identified dressing, grooming, oral hygiene, and bathing, but lacked instructions or preferences for resident’s dependent on staff for shaving. R7’s weekly skin assessment dated [DATE], 8/24/25, 8/31/25, and 9/14/25 all indicated a bed bath was given, but lacked shaving documentation. R7’s weekly skin assessment dated [DATE] indicated a shower was given but lacked shaving documentation. R7’s follow-up question report dated 8/1/25 through 9/17/25 indicated R7 was dependent on staff for shaving but lacked documentation shaving was completed. During an observation and interview on 9/15/25 at 1:23 p.m., R7 stated a shower was scheduled for Sundays, staff provided bed baths during the week, and R7 preferred to be cleaned shaven, but staff didn’t know how to do it. R7’s beard was approximately two inches long, curly, dark grey and full; covering the entire face and part of neck. During an interview on 9/16/25 at 10:52 a.m., registered nurse (RN)-B stated some residents preferred to shave themselves and those residents that needed assistance would be listed on the nursing assistance care sheets. RN-B confirmed R7 was dependent on staff for shaving. During an interview on 9/17/25 at 7:36 a.m., nursing assistant (NA)-A stated R7 had been asking staff for a few weeks to be shaved, but they were too busy, pointing to the call lights and stated it’s been like Christmas around here. NA-A stated she asked R7 if he was growing their beard for winter and that R7 told her no they had asked staff to shave it off, but that no one could get to it. NA-A stated she used a disposable razor this morning and that staff should shave R7 when he requested. During an interview on 9/17/25 at 11:43 am., the director of nursing (DON) stated the expectation was for resident to be shaved when and if they asked. Staff were here to provide cares, and it was expected staff create time to shave residents. R1 R1’s admission Minimum Data Set (MDS) assessment, dated 8/7/25, indicated R1 had intact cognition with no hallucinations, delusions or behaviors. R1 required staff set up for oral hygiene, upper body dressing, bed mobility, and personal hygiene, staff supervision for eating and required moderate staff assistance for toileting, lower body dressing and transfers. R1’s diagnosis report, printed 9/18/25, included the following diagnoses: acute respiratory failure with hypoxia (lungs can’t get enough oxygen to the body leading to low blood oxygen levels), dysphagia (difficulty swallowing), fracture of thoracic vertebra (a break in one of the bones in your spine) and adult failure to thrive (general decline in older adults). R1’s care plan, printed 9/18/25, indicated R1 had a self-care deficit related to diagnosis including but not limited to acute respiratory failure with hypoxia and facture of thoracic vertebra with a goal of “resident will be dressed, groomed and bathed per preferences,” with the following interventions: - “Assist of 1 with bathing and dressing” - “Assist of 1 with personal hygiene and oral hygiene” The care plan lacked any preferences. Furthermore, the care plan lacked evidence of refusals of accepting of assistance of staff or refusals of bathing. R1’s nursing assistant care sheet, printed 9/16/25, indicated R1 required assist of 2 staff for pivot transfers to wheelchair, and was incontinent of bowel and bladder with assist of 1 to toilet every 2-3 hours. In addition, R1 required assist of 1 staff for dressing, grooming, bathing and oral hygiene. R1’s weekly skin assessments indicated the following which were answered with radio-buttons: -8/7/25: refused bath -8/14/25: refused bath -8/21/25: refused bath -8/24/25: bed bath completed -8/28/25: refused bath -9/4/25: refused bath -9/11/25: refused bath R1’s progress notes, dated 7/28/25 to 9/16/25, were reviewed. Progress notes lacked evidence of R1 refusing showers/baths or staff assistance with ADLs. Furthermore, lacked documentation of staff offering an additional showers/bed bath/partial bath since last documented bath/shower on 8/24/25. During an observation and interview on 9/15/25 at 3:25 p.m., R1 declined to talk about showering/bathing with surveyor. R1 was observed and appeared to be frail and disheveled with a large dense, knotted clump of hair that covered approximately half to three quarters of the back of her head. On 9/16/25 at 2:02 p.m., R1 was observed outside the front of the facility. R1 continued to be appear disheveled with the front of her hair appearing shiny and the back continued to have the large dense, knotted clump of hair. During an interview on 9/16/25 at 11:42 a.m., registered nurse (RN)-A stated the nursing assistant care sheets were what the nursing assistants and the nurses used to get information about the residents. RN-A verified the nursing assistant care sheets provided to surveyor were up to date as they provided them to surveyor. During an interview on 9/16/25 at 12:47 p.m., nursing assistant (NA)-A stated when R1 first admitted to the facility, she needed assistance but had become more independent. NA-A stated R1 would refuse assistance but would ask for assistance if she needed it. NA-A if a resident refuses a shower, they let the nurse know so they could document it, but they attempted numerous times. NA-A did not answer if they had ever given R1 a shower/bath. During an interview on 9/17/25 at 8:30 a.m., NA-E stated they were familiar with R1, and stated R1 could become upset easily. NA-E would ask for assistance if she needed it. NA-E stated they had not given R1 a shower, adding it must not be scheduled on a day they work with her but would think she would need some level of assistance in the shower. NA-E stated R1's hair was “matted” in the back. During an interview on 9/18/25 at 9:38 a.m., licensed practical nurse manger (LPN)-A stated R1 refused assistance. LPN-A stated R1's hair was “matted,” and verified it did not appear as though it had been washed. LPN-A stated R1 would require staff to at least stand in the shower room for safety during a shower. LPN-A reviewed R1's electronic medical record (EMR) and verified the last documented shower/bath/bed bath was on 8/22/25, which was almost 4 weeks ago. LPN-A stated the expectation would be to provide showers at least weekly, if a resident refused then staff should keep offering. LPN-A stated staff must get creative sometimes to help residents maintain their hygiene and what works for them. LPN-A stated the expectation would be that any interventions and reapproaches be documented in the progress notes. LPN-A stated showering/hygiene is important as it helps prevent infections and help people feel better about themselves. During an interview on 9/18/25 at 10:10 a.m., director of nursing (DON) stated the expectation would be to offer a shower/bath weekly and if a resident refused it should be reattempted. DON stated staff should still attempt to groom in a way they will accept and this should be documented. A facility policy titles Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, indicated “Based on the comprehensive assessment of a resident and consistent with the resident’s needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.”

Based on observation, interview, and document review, the facility failed to comprehensively monitor and assess for edema (swelling caused by fluid retention) so intervention effectiveness could be determined, and new interventions could be developed if needed, and ensure recommended edema management interventions were followed as appropriate for 1 of 1 residents (R29) assessed for edema management. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition and was diagnosed with heart and respiratory failure.R29's care plan dated 5/28/25, indicated R29 was receiving a diuretic and had a history of edema. The care plan did not include a plan for edema monitoring. R29's order summary dated 7/3/25, included an order for thigh-high compression stockings that were to be applied to R29's bilateral lower extremities during the day and then removed at night for edema. The summary included an order for 40 milligrams (mg) of torsemide (a diuretic, used to treat fluid retention) daily for localized edema. The order summary did not include orders for monitoring the severity of R29's edema or for the use of [NAME] wraps. R29's treatment administration record (TAR) dated 9/1/25 through 9/16/25 at 1:59 p.m., indicated R29 had an order for thigh-high compression stockings that were to be applied to R29's bilateral lower extremities during the day and then removed at night for edema. The TAR indicated the stockings had been applied daily and did not indicate R29 had refused the stockings. The TAR did not include edema monitoring or a treatment record for lymphedema (swelling from an accumulation of protein-rich fluid usually drained by the body's lymphatic system) wraps. R29's occupational therapy note dated 6/15/25, indicated the occupational therapist had assessed R29 and had noted lymphedema in her bilateral toes to thighs. On 7/2/25, [NAME] wraps (an adjustable compression garment used for treating lymphedema and chronic venous disease that uses Velcro and multilayer bandaging) were used on R29's lower extremities, and a printed PDF was hung in R29's room to assist R29 and staff members with donning and doffing the wraps. On 7/19/25, the occupational therapist noted that R29 would require assistance applying the wraps and should wear them during the daytime and take them off at night. On 7/27/25, the occupational therapist noted that the directions on how to don and doff the [NAME] wraps were gone from R29's wall, but nursing staff stated they had been assisting R29 with the garment. The OT noted that R29 stated that it at times took staff a long time to apply the [NAME] wraps. R29's medical record was reviewed and did not include edema monitoring. During an interview and observation on 9/15/25 at 1:14 p.m., R29 stated that staff were supposed to apply her compression wraps, pointing at a box containing multilayered wraps with Velcro, every morning. R29 stated this rarely happened as she felt the staff were too busy and/or did not know how to apply them. R29 was observed with gripper socks on, and the skin of her lower extremities was observed with no compression wraps on. During an observation and interview on 9/16/25 at 1:21 p.m., registered nurse (RN)-C confirmed she was the nurse in charge of R29's care this shift. RN-C stated she had never applied RN-C's compression wraps as she thought this was something only therapy was supposed to do. RN-C acknowledged that directions were on the wall for application but still thought that therapy was the only person who was supposed to apply her wraps. RN-C confirmed she had also not applied the compression stockings, as she thought therapy was supposed to come every morning to apply the wraps instead. During an interview and observation on 9/17/25 at 10:48 a.m., licensed practical nurse (LPN)-B confirmed she was the nurse in charge of R29's care this shift. LPN-B stated she was unsure if staff were to assess R29 for edema. LPN-B confirmed she had reviewed R29's medical record and did not see that staff had been assessing R29's edema, and so she did not know if R29's edema had improved or declined. When asked how much edema R29 had, LPN-B was observed to look and, without touching R29, stated some.During an interview on 9/16/25 at 1:33 p.m., the director of rehabilitation, physical therapy assistant (PTA)-A stated that therapy staff would assist R29 in applying the wraps if she had therapy that day and they were not applied by the time they saw her, but she only had therapy three to five times a week. PTA-A stated this was why the occupational therapist had put instructions for application on R29's wall, to assist nursing staff. On 9/17/25 at 11:42 a.m., PTA-A confirmed she had reviewed R29's medical record, and nursing staff were supposed to be assisting R29 in applying her compression wraps at the beginning of each day and then assisting her in removing them every evening.During an interview on 9/17/25 at 2:17 p.m., the nurse manager for the floor, LPN-A, confirmed she had reviewed R29's medical record and was unable to find out if nursing staff were to be applying the compression stockings or wraps, but thought it was appropriate for each nurse to decide which of the two treatments they wanted to apply and then use that one. LPN-A stated that if R29 had refused her compression stockings, she would expect it to be documented that way in the TAR and a progress note to be added but did not see that R29 had been refusing this treatment.During an interview on 9/18/25 at 7:59 a.m., the director of nursing (DON) stated he would expect nursing staff to assess R29's edema daily and document this in her medical record. The DON stated that when the new order for compression wraps was received, it should have then been clarified with the provider which treatment should be used and the medical record updated, as it was not up to nursing to decide day to day which compression device was appropriate.A policy regarding edema management was requested and not received.

Based on observation, interview and document review, the facility failed to ensure a resident who had several documented incidents of smoking in the facility was free from potential smoking accidents for 1 of 3 residents (R4) reviewed for smoking. Findings include: R8's quarterly minimum data set (MDS), dated [DATE], indicated R8 was admitted to the care facility on 3/27/25. The MDS further indicated R8 refused to be interview for mental status but was assessed with okay long term and short-term memory and was able to recall season, location, staff names and faces and where she lived.R8's care plan, dated 7/30/25, indicated R8 was able to smoke independently, with the following interventions: Resident smoked in room, No smoking signs in place, and will not allow removal of cigarettes. R4's care conference note, dated 6/16/25, indicated R4 had been smoking in her room at times. R4's smoking assessment, dated 9/3/25, indicated the assessment was completed due to smoking violations of smoking in her room and further indicated resident smoking materials will be kept at the nursing station.During observation and interview on 9/16/25 at 11:02 a.m., a plastic cup and a container of coffee grounds were observed on the back of R4's toilet. The wall of R4's bathroom shared a wall with the oxygen tank fill room next door. The plastic cup contained a dark, opaque liquid with tar-colored streaks along the inner surface. It appeared to be approximately three-quarters full and was topped with what looked like coffee grounds, partially concealing the contents beneath. The room was permeated by a strong, persistent odor of smoke, which lingered heavily in the air. The floor in her room appeared to be covered in loose tobacco and a zip lock baggie of what R8 stated was loose tobacco was on her wheelchair seat. R4 stated she rolled her own cigarettes and kept all of her smoking materials in her room. During an interview on 9/16/25 at 11:23 a.m., trained medication aide (TMA)-G stated she had heard that R4 smoked in her bathroom. TMA-G stated R4 spent a lot of time in her bathroom and staff could smell something that smelled to them like cigarette smoke. TMA-G stated R4 would not let staff in her room without knocking and waiting for a response. During an interview on 9/18/25 at 8:15 a.m., registered nurse (RN)-D stated she had completed R4's smoking assessment and assessed R4 has not being safe with her own smoking materials due to her smoking in her room. RN-D stated she had asked R4 to sign the smoking policy and a risk versus benefit of smoking in her room but R4 had refused to have her smoking materials held at the nursing station. During an interview on 9/18/25 at 11:01 a.m., the administrator and director of nursing confirmed it was the policy of the facility to ensure residents only smoke in the designated smoking areas. A facility policy titled Resident Smoking Policy, dated 10/2024, indicted any residents who do not comply with this policy may lose smoking privileges. Privileges can be reevaluated upon resident request and the facility must document in the care plan and/or progress notes other attempted interventions to manage and accommodate smoking needs before revoking smoking privileges.

Based on observation, interview, and record review, the facility failed to ensure that one of one resident (R2), reviewed for catheter use, had documented clinical decision-making regarding the use of an indwelling urinary catheter including the reason for insertion, justification for continued use, and evidence of periodic reassessment. In addition, the facility failed to attempt and document a trial removal of the catheter, despite the resident experiencing repeated urinary tract infections associated with catheter use. Findings include: R2's annual minimum data set (MDS), dated [DATE], indicated R2 was admitted to the care facility on 11/3/23 and was cognitively intact. The MDS further indicated R2 was independent with his activities of daily living and had an indwelling catheter. R2's diagnoses list, dated 11/3/23, indicated R2 had the following medical diagnoses: urethral stricture, anterior urethral stricture (an abnormal narrowing of the first part of the male urethra caused by scar tissue, leading to symptoms like a weak urine stream, spraying urine, pain, and sometimes blood or UTIs. Treatment options often include urethral dilation, urethrotomy (endoscopic cutting), or urethroplasty (surgical reconstruction)), obstructive and reflux uropathy (describes a urinary tract condition where urine flow is both obstructed and flows backward from the bladder into the ureters. Catheters, stents, or nephrostomy tubes can provide short-term relief by allowing urine to bypass the blockage. Surgery may be needed to correct the underlying cause, such as an enlarged prostate or structural issues with the ureters.)R2's Order List contained orders, dated 8/26/25 and 8/27/25 to change R2's indwelling catheter every month and to monitor output every shift. R2's care plan, dated 11/6/23, indicated R2 had alteration in elimination related to long term foley catheter use.R2's electronic medical record (EMR) lacked any evidence the facility had attempted any trial removal of R2's catheter since admission or had seen urology to provide further details on catheter plan and management. The EMR further indicated R2 had at least two urinary tract infections in the past 9 months, one in February requiring hospitalization due to going septic from the urinary tract infection, and another in April requiring antibiotics. During an interview on 9/15/25 at 2:54 p.m., R2 stated he had a history of getting urinary tract infections and felt like he had one currently. R2 stated he had his indwelling catheter for a couple of years and the plan was to have it in place until R2's knees get better and he can stand up and care for himself. During an interview on 9/18/25 at 8:22 a.m., nurse manager and registered nurse (RN)-A confirmed the facility has not attempted a trial removal of R2's catheter as he had had it in place for a long time. RN-A stated they received a referral yesterday from his primary care provider to see urology. RN-A also stated a progress noted was put in yesterday regarding a conversation with R2 regarding his catheter. R2's progress noted, dated 9/17/25, indicated R2 liked to have his catheter in place because he could not yet stand to use the toilet, stating regardless he was told a long time ago from a doctor in Duluth that the catheter would be permanent. During an interview on 9/18/25 at 11:01 a.m., the director of nursing confirmed R2's catheter should be assessed for continued use. A policy was not received.

Based on observation, interview, and document review, the facility failed to follow developed nutritional interventions to ensure nutritional status was maintained or improved for 3 of 4 residents (R22, R60, R66) reviewed for nutrition. In addition, the facility failed to ensure an order for fluid restriction was followed for 1 of 1 resident (R8) reviewed for fluid restrictions. Findings include: R22’s comprehensive Minimum Data Set (MDS) dated [DATE], indicated R22 had intact cognition and was diagnosed with diabetes and hypertension. R22's order dated 1/16/25, indicated R22 was to receive a diet with a regular texture and included the directions for large portions. R22's care plan dated 8/20/25, indicated R22 had increased nutritional needs related to a stage three pressure ulcer in the gluteal fold. R22's progress note dated 9/9/25 at 1:02 p.m., indicated R22 had a recent significant weight gain related to increased oral intake with a history of weight loss. The note indicated R22 was to receive double portions per resident request. R60’s quarterly MDS dated [DATE], indicated R60 had intact cognition and was diagnosed with Crohn’s disease and malnutrition. R60’s order summary dated 9/16/25, indicated R60 had an order for a regular diet and did not include an order for yogurt or cottage cheese with meals. R60’s care plan dated 6/9/25, indicated R60 had a potential for an alteration in nutrition related to Crohn’s disease, malnutrition, a “malabsorptive GI [gastrointestinal] condition”, and food insecurity. The care plan indicated that yogurt and cottage cheese were added to R60’s meals as R60 had refused supplements. R60’s dietary progress note dated 9/2/25, indicated R60 requested to discontinue the “magic cup” with a plan to replace it with cottage cheese and yogurt. R66’s comprehensive MDS dated [DATE], indicated R66 had moderately impaired cognition and had a diagnosis of malnutrition. R66’s MDS indicated she was admitted to the facility on [DATE]. R66's order dated 8/15/25, indicated R66 was to receive a diet with a regular texture and included the directions for large portions. R66’s care plan dated 8/8/25, indicated R66 had a potential for an alteration in nutrition related to extreme fatigue, polysubstance use, and a gastric bypass, leading to chronic diarrhea and malabsorption. The care plan indicated R66 was to receive large portions as she was at risk for malnutrition. During an interview on 9/15/25 at 12:36 p.m., R22 stated regarding food, there isn't enough of it. R22 went on to state he was supposed to get extra food with each meal, but did not think this was happening. R22 stated that if he wanted extra food, he had to buy it out of the vending machine. During an observation on 9/15/25 at 12:50 p.m., a room tray was observed to be dropped off at R22's room. The meal slip was observed to say, double portions on two plates, but only one food plate was noted. The plate was observed with one small scoop of what appeared to be a pasta dish, one small scoop of what appeared to be a cucumber salad, and one small scoop of what appeared to be another type of pasta. R22's tray was also observed to have one brownie and two bowls of a hot liquid. During an interview and observation on 9/15/25 at 1:16 p.m., R60 stated she wanted to gain weight but felt like she was not receiving enough food. R60 stated she had met with the dietician a couple of weeks ago and was supposed to get either cottage cheese or yogurt with her meals but had never gotten them. R60 was observed with a room tray with a small scoop of a pasta dish, one small scoop of what appeared to be a cucumber salad, and one small scoop of what appeared to be another type of pasta with no yogurt or cottage cheese observed on the tray. R60’s portions appeared to be the same size as R22’s. R60 confirmed that cottage cheese or yogurt had not been received with the lunch meal. During an interview on 9/15/25 at 4:10 p.m., R66 stated the facility was supposed to give her double portions for her meals, but that never happened. During an observation and interview on 9/16/25 at 12:10 p.m., Dietary aid (DA)-B was observed in the kitchen plating the lunch meals with pasta, green beans, one bread stick, and chocolate pudding with whipped cream. All plates appeared to be prepared in the same fashion and appeared to have the same portions. The plates were set onto three-tiered carts, two by two on each of the three levels. The resident meal tickets were in a uniform stack near the serving station. DA-A took the stack of meal tickets and placed a ticket with each of the plates after the meals were plated. During an observation on 9/16/25 at 12:18 p.m., R60's meal tray was observed with a small breadstick and a small serving of green beans, pasta, and pudding. No yogurt or cottage cheese was observed on R60's tray. At 12:26 p.m., R22’s meal tray was observed with similarly sized portions of a small breadstick and a small serving of green beans, pasta, and pudding. R22’s tray had the addition of two bowls with a hot liquid. At 12:31 p.m., R66’s meal tray was observed with similarly sized portions for the small breadstick and a small serving of green beans, pasta, and pudding, as both R22 and R66. During an interview and observation on 9/17/25 at 12:51 p.m., nursing assistant (NA)-A confirmed she had observed other resident meals, and R22 had not received large portions, as it looked the same as the other residents and felt the serving size was smaller than it should be. Room trays for R22 (order for large portions), R29 (no order for large portions), R60 (no order for large portions), and R66 (order for large portions) were observed, all with similar-sized portions for the piece of whole meat, cooked carrots, and potatoes. During an interview on 9/17/25 at 12:58 p.m., the culinary director (CD) stated that culinary staff were supposed to split the portions when plated so residents could visually tell when a double or large portion was given, as they had some complaints that these larger portions were not being received. The culinary director stated that a large portion meant that a portion and a half would be given to a resident and confirmed that it would appear visually larger than a regular portion, and confirmed if it did not, a regular portion was likely received. The CD stated he became aware that R60’s yogurt/cottage cheese was being missed at mealtimes today, and it was going to be taken care of. The CD stated that the facility had been out of the yogurt that was ordered to be served for R60 during lunch time, but staff could have substituted cottage cheese for this. During an interview on 9/17/25 at 1:16 p.m., the registered dietician (RD) confirmed she had assessed R66 for malnutrition on admission and had started her on a supplement and added large portions. The RD stated she had met with R66 again since then, and R66 had voiced concern that she was not getting large portions, so she had asked the CD to follow up with her and had increased her supplement intake. The RD stated that the supplements and large portions were to assist R66 in gaining weight, and without the large portions, she would be concerned that she may not be getting enough calories to reach this goal. At 1:19 p.m., the RD stated that for R60’s malnutrition, she had started a magic cup for her, but R66 didn’t like it, so a couple of weeks ago, she had ordered it to be changed to either yogurt or cottage cheese at mealtimes. At 1:23 p.m., the RD stated R22 was on large portions due to a previous downtrend in weight and for wound healing. The RD stated R22's weight had been going up this month, so she was not concerned about R22's caloric intake but did think it was important that R22 received large portions at meals, as that was his preference. The facility's Dietary Guidelines policy dated 9/2012, indicated that food and nutritional needs of the residents would be met in accordance with the attending physician's orders. The policy indicated that therapeutic diets would be prepared and served as prescribed by the attending physician and with the supervision or consultation of the qualified dietitian. R8’s quarterly minimum data set (MDS), dated [DATE], indicated R8 was admitted to the care facility on 3/27/25. The MDS indicated R8 refused to be interview for mental status but was assessed with “okay” long term and short-term memory and was able to recall “season, location, staff names and faces and where she lived.” R8’s Order list in the electronic [NAME] record (EMR) indicated an order, dated 6/23/25 for an 1800 milliliter (mL) fluid per day related to hyponatremia (when your blood sodium (salt) level is lower than it should be). R8’s care plan, revised 9/15/25, indicated R8 was on a fluid restriction, indicating R8 could have 300 mL of fluid each meal and 900 mL of extra fluid per day. R8’s medication administration record (MAR) from September indicated R8 was “independent” with her fluid restriction. R8’s EMR lacked evidence a risk versus benefit or education was done with her on the importance of her prescribes fluid restriction. During observation on 9/15/25 at 1:51 p.m., R8 was sitting in her room, drinking from a mug approximately ¼ full of an orange-colored liquid. The mug held 500 mL of liquid. During an interview on 9/16/25 at 1:58 p.m., trained medication aide (TMA)-G stated she was aware R8 was on a fluid restriction but stated nursing staff were unable to monitor her fluid intake because she was independent with her activities of daily living and could obtain fluids on her own. Durin and observation on 9/17/25 at 10:00 a.m., R8 was again observed drinking freely out of a clear, plastic jug that held 500 mL of fluids. During an interview on 9/18/25 at 8:15 a.m., nurse manager and registered nurse (RN)-D stated it would be expected that the resident’s fluid intake was monitored and that noncompliance would be documented. RN-D stated she would look for any documentation of education or a risk versus benefit regarding R8’s fluid intake as it would be expected if R8 was documented as independent with her fluid restriction. During an interview on 9/18/25 at 8:38a.m., R8 stated she was aware she was on a fluid restriction because she was made aware from an outside provider, stating nobody at the facility has talked with her about it, educated her on how to maintain her fluid restriction, the importance of following it or the risks of not if she did not. A facility policy titled Fluid Restriction Guidelines was received but did not address fluid restrictions of 1800 mL.

Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment) for 2 of 2 resident (R5, R24) reviewed for dialysis care. Furthermore, the facility failed to provide snacks/meals as ordered for 1 of 1 resident on dialysis days.Findings include:R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had intact cognition and diagnoses including anemia, high blood pressure, visual impairment and renal insufficiency and/or renal failure. In addition, the MDS outlined R5 received dialysis care while a resident at the care center.R5's provider orders dated 4/9/25, directed staff to send a dialysis communication form with resident, review upon return two times a day every Monday, Wednesday, and Friday. R5's care plan dated 6/28/24, identified potential for complications related to dialysis and included an intervention to send communication folder to dialysis with each run. A review of R5's medical record lacked consistent communication between the facility and the dialysis center. Dialysis communication logs were scanned for the following dates: 5/2/25, 5/5/25, 5/7/25, 5/9/25, 5/12/25, 5/14/25, 5/16/25, 5/19/25, 5/21/25, 5/30/25, 6/2/25, and 6/4/25. The record lacked communication from 6/4/25 through 9/15/25.During interview on 9/16/25 at 10:33 a.m., R5 verified he was on dialysis. R5 explained he went to an offsite clinic for treatment multiple times per week and wasn't aware of a process for communication between the care center and the dialysis unit and ate lunch after he returned from dialysis.During interview on 9/16/25 at 11:59 a.m., registered nurse (RN)-B stated R5 left during the night shift (early morning) and wasn't aware of the communication process between the care center and the dialysis facility. RN-B stated at one point there was a plan in place for the dialysis center to fax treatment and communication logs at the end of each week and that all nurses were responsible to monitor the electronic fax folder and upload documents into the resident's medical record. RN-B was not able to confirm if the process was still in place or describe the current process for communication. RN-B verified she was working as the floor nurse while R5 was at dialysis on 9/15/25 and had not received any communication from the dialysis center after his return. RN-B confirmed R24 had no communication log either or a binder when she returned from dialysis 9/16/25. The dialysis residents were suppose to receive a snack and bag lunch, but this was done before she arrived on the night shift and that it was the kitchens responsibility to send up snacks and bags for dialysis residents. No snacks were available on the unit and R24 returned close to lunch time and could just go eat lunch. On 9/16/25 at 12:59 p.m., registered nurse (RN)-E confirmed she was the charge nurse at the dialysis center where R5 received dialysis cares. RN-E confirmed R5 did not bring a communication log to the dialysis facility with current vital signs or weights and that this was common practice for the facility. RN-E stated if the dialysis center had an issue with R5 they would reach out directly to the facility. On 9/17/25 at 7:31 a.m., R5's dialysis binder was on the nurse station desk and R5 was out of the facility for dialysis. On 9/17/25 at 2:24 p.m., RN-B verified R5 did not take a communication binder to dialysis or bring any communication logs back from dialysis.R24R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had intact cognition and diagnoses including anemia, diabetes, high blood pressure, heart failure and renal insufficiency and/or renal failure. In addition, the MDS outlined R24 received dialysis care while a resident at the care center.R24's provider orders dated 8/25/25, identified the shift nurse collected the dialysis binder from the resident and placed referral sheets into the medical records to be scanned, called dialysis to fax a copy of the run if resident didn't have it, and the resident had dialysis every, day shift, Tuesday Thursday and Saturday. In addition, staff were to send a snack or sack lunch with resident to dialysis, every night shift every Monday, Wednesday and Friday.R24's care plan dated 8/11/25, identified the potential for complications related to dialysis and included an intervention to send communication folder to dialysis with each run. R24's care plan lacked information to send a snack or sack lunch to dialysis.On 9/16/25 at 10:56, R24 stated dialysis was this morning, I'm starving no snack or sack lunch was provided and they have never given a snack or sack lunch. On 9/16/25 at 12:07 p.m., the nurse manager, registered nurse (RN)-A stated assessments were completed before residents left for dialysis and a communication log, kept in a binder, was sent with each dialysis resident. Upon returning from dialysis nurses checked the dialysis site, obtained vital signs, and reviewed the communication logs. RN-A stated if a resident returned without communication, the nurse could call the dialysis center or tell the nurse manager. On 9/16/25 at 12:18 p.m., the registered dietician (RD) stated the culinary director coordinated bagged breakfast/lunches for dialysis residents and if a provider ordered residents to receive a snack the nurses would be responsible to give residents a snack. On 9/17/25 at 2:29 p.m., the culinary director (CD) confirmed the evening cook prepared the sack breakfast/lunches for dialysis residents and sent the sacks to the floor the night before dialysis with the dinner meal. The CD stated the menu for the dialysis residents was new this week and was done in collaboration with the dietician The CD expressed concern that the sacks were removed during the overnight because the staff on the fourth floor called and inquired on locks for the refrigerators on the unit. It was a new process to send the bags up during the dinner meal and now the bags were sent up with the residents meal ticket attached.On 9/17/25 at 2:37 p.m., dietary aid (DA)-C stated the facility used to provide cereal to residents before dialysis and this week there was a new menu to send cereal, a package of juice, milk, peanut butter and two slices of break, and two packs of butter. DA-C confirmed sacks were sent up to the floor where the nurses placed them in the refrigerator on the unit. Two sacks were observed on the counter, stapled shut with meal tickets.On 9/18/25 at 8:40 a.m., RN-A stated last week staff brought it to her attention the binders for both dialysis residents were missing and, prior to this week no communication logs were available or scanned into the residents' medical record. RN-A confirmed there was no consistent communication between the care center and the dialysis center. The expectation would be for nurses to collect the communication logs when residents return from the dialysis center and scan them into the medical records. The risk for not completing the communication logs would be missed orders and abnormal vital signs. RN-A could not confirm R24 received snacks, or a bagged breakfast as ordered, prior to this week and that the process was the food would come from the kitchen and stored in the unit refrigerator. On 9/18/25 at 10:59 a.m., the director of nursing (DON) stated the expectation was for the nursing staff to send proper communication between the care center and the dialysis center and this was important to promote optimal care of functioning and to maintain continuity of care for the residents.A policy was requested on providing meals/snacks for residents on dialysis and was not received.

Based on observation, interview, and record review, the facility failed to ensure resident safety by allowing former resident FR4, who had been discharged , to repeatedly gain unauthorized entry through an unsecured door without staff awareness, resulting in non-consensual contact (a kiss) involving Resident R5 and misappropriation of property from Resident R7; this systemic failure placed all 61 residents at risk and resulted in a finding of Immediate Jeopardy. In addition, the facility failed to protect two residents (R1 and R2) from abuse when R3 had a verbal and physical altercation with R1, which escalated to a physical incident with R2 later that day. The Immediate Jeopardy (IJ) began on 5/24/25 after a FR4 was issued a no tresspass order but failed to ensure entrances were secured and protect residents from allegation of abuse. This resulted in FR4 continously entering the building without staff knowledge. The Administrator, Director of Nursing (DON), regional director of operations, corporate nurse leader, and regional social services were notified of the IJ on 6/5/25 at 3:09 p.m. The IJ was removed on 6/6/25 at 1:00 p.m. but non-compliance remained at a lower scope and severirty of a level E indicating no actual harm but potential for more than minimal harm that is no immediate jeopardy. Findings include: The nursing home incident report (NHIR) dated 5/31/25, identified a man FR4 came into R5's room at 4:30 a.m., and R5 woke up to the man kissing her on the forehead. This created difficulty sleeping and mental anguish for R5. FR4's face sheet dated 6/5/25, identified FR4 had diagnoses of major depressive disorder, alcohol dependence in remission, generalized anxiety disorder, and mild cognitive impairment. FR4's comprehensive MDS dated [DATE], identified FR4 had resided at the facility for almost one year. FR4 had no cognitive impairment, no behaviors towards other residents or staff. FR4 was independent with all cares. FR4's progress notes from 5/13/25-5/21/25, identified FR4 had increased behaviors towards staff and residents, and FR4 was frequently intoxicated. FR4's progress note dated 5/22/25, identified FR4 was asked to leave another unit as he was not allowed on the unit due to behaviors towards female residents and staff. FR4 attempted to enter a female resident's room who was not in the building currently. FR4 became verbally aggressive and said he was going to have the nurses fired. FR4 continued to be verbally aggressive and abusive to staff until he went to his own unit. FR4's progress note dated 5/22/25 at 4:59 p.m., identified nurse manager, social services director (SSD), and Administrator met with FR4 and FR4's family. Discussed disobeying rules of the facility and potentially putting other residents at risk, which he had been previously educated on. The note indicated FR4 agreed to in-patient treatment, declined a bed hold, but signed a form indicating he was discharging against medical advice (AMA). FR4 was stated he was not coming back. FR4 loaded belongings into a car with his family and left facility at 5:08 p.m. During an interview on 6/4/25 at 9:44 a.m., Administrator and social services designee (SSD) stated FR4 was on the independent floor of the facility and had been working towards relocation with SSD. FR4 had spent most of his time in his room until the past 3-4 months. FR4 had a monumental shift in his behavior and personality. FR4 created friendships with residents that would give him something in return. While he was here FR4 became the alcohol runner; the liquor store is three blocks from the facility, he would hide alcohol in his backpack or dispense on the smoking patio. On 5/22/25, they had a care conference with family involved and FR4 did not want to go to inpatient treatment at the beginning of the meeting by the end of it he was excited and packed his bags. FR4 said he was not going to return to the facility after inpatient treatment and we had him sign an AMA. FR4 left in a taxi with his family. FR4 showed up to the facility the evening of 5/23/25, Administrator had a long talk with him. FR4 said he changed his mind on treatment and wanted to come back to the facility. Administrator explained this was not a good environment for FR4 and that he needed an alternative option. FR4 said he would figure it out. Since then, it has been a constant battle with FR4 sitting across the street, on the smoking patio, in front of the patio and trying to sneak in the building. FR4 brought alcohol to residents on 5/24/25, and SSD provied FR4 with a trespass order. FR4 would not sign the trespass notice and threw it away and kept walking around the building. The staff were notified of the trespass notice and knew to keep him out of the building and signs were posted for awareness. On 5/27/25, it was becoming an increasing issue and FR4 knew if he was on the sidewalk in front of the patio it was not facility property, and he would not be considered trespassing. FR4 would hang out with residents for a couple of hours and disappear and then return. On 5/27/25, the police were called because FR4 kept saying the facility was his home, refusing to leave and bringing alcohol to the residents on the patio. FR4 was given another trespass notice by the police During a phone interview on 6/4/25 at 1:25 p.m., police officer (PO)-A stated the police are only able to respond to FR4 trespassing. If the facility has physical evidence, they can arrest FR4 and charge him with a misdemeanor, and release FR4 the next day. The facility was given advice to change the door codes. The residents that smoke leave the door propped open. PO-A stated when responding to police calls at the facility, it takes a long time for the doorbell to be answered, and voiced understanding of why the residents prop the door open when smoking and would not prevent intruders from walking into the facility unseen. In review of FR4's record in conjunction with facility trespass documentation, and police call records identified FR4 was able to enter the facility multiple times without the awareness of staff and without implementation of interventions to stop FR4 from gaining access into the facility. The records identified the following: The police public record incidence for calls made from the facility regarding FR4 to the police identified reports were made on: -5/23/25 at 11:26 p.m., -5/24/25 at 6:20 a.m. and at 9:05 p.m. -5/26/25 at 11:08 a.m. and at 11:03 p.m. -5/27/25 at 6:35 a.m. and 9:04 a.m. -5/28/25 at 1:55 p.m., at 3:53 p.m., at 5:22 p.m., and at 6:21 p.m. -5/30/25 at 9:29 p.m. -5/31/25 at 10:50 a.m. -6/2/25 at 9:20 a.m., 12:02 p.m., and 4:34 p.m. -6/5/25 at 7:00 a.m., and 12:19 p.m. The facility reported timeline, undated, for trespassing incidents involving FR4 included: -5/24/25 at 11:33 a.m., SSD was at facility when FR4 attempted to enter. FR4 was informed that he was trespassed from the facility and given a copy of the notice that he threw away. FR4 left facility and staff were informed. -5/27/25 at 4:30 p.m., Administrator called 9-11 for FR4 being on the smoking patio. FR4 did not enter the building. Police arrived and FR4 was no on scene. Officers informed Administrator that unless FR4 is on scene when they get there or on the property there is nothing they can do. Officers did present FR4 with a trespass order in addition to the one the facility provided FR4 and explained the rules to him. Officer gave Administrator and email for crime preventionist to reach out regarding a Geofence trespass order. -5/28/25 at 8:51 a.m., Administrator sent email to crime preventionist. -5/28/25 at 5:20 p.m., Administrator called 9-11 due to FR4 being outside facility. At 5:36 p.m., officer arrived on scene and FR4 was sitting out front on the sidewalk. Officer talked to FR4 and staff and educated FR4 on the trespass orders. FR4 took his chair and moved across the street. At 6:50 p.m., officer arrived on scene again after another call of FR4 being in front of the facility. Officer told FR4 not to move and while in the facility, FR4 sat down on the smoking patio. Officer arrested FR4 for violating the trespass order and threatening staff. At 8:21 p.m., FR4 was booked at the county jail on trespassing charges. -5/29/25 at 4:17 p.m., FR4 was released from county jail. -5/30/25 at 9:00 a.m., FR4 was in front of the facility but not on facility property. At 3:00 p.m., Maintenance Director changed the stairwell code to first floor and residents were not given the code. -5/31/25 at 11:00 a.m., R5 reported that FR4 was in her room around 4:30 a.m., and she awoke to FR4 kissing her forehead. At 12:31 p.m., Trespass notice sign posted at all nurses stations, staff on shift were verbally educated on FR4 being trespassed. -6/2/25 at 8:00 a.m., interdisciplinary team (IDT) discussed the reported incident, risk vs benefits were done with all residents who use the patio to smoke or socially on the risks of putting stuff in the front door which prevents it from properly locking. Maintenance investigated the front door and confirmed that the door does lock from the outside and functions properly when residents use it correctly. The administrator collected staff statements and working with human resources on proper corrective action. At 9:18 a.m., FR4 attempted to enter facility via the front staircase and when unable to do that, attempted to run to the elevator. Staff in the front office intervened and escorted FR4 outside and educated on the trespass orders. 9-11 was called. At 1:00 p.m., 9-11 was called for FR4 being on front sidewalk. Officers were unable to arrest as FR4 was not on scene when they arrived. Administrator was given a new email for crime preventionist. At 4:17 p.m., 9-11 was called for FR4 being out front and previously entering facility in the morning with video proof. At 4:47 p.m., officer arrived on scene and FR4 was outside of the facility and arrested at 5:12 p.m. at 6:51 p.m., FR4 was booked at county jail. -6/3/25 at 4:30 p.m., Administrator implemented hourly checks on the front door to ensure residents were not leaving it propped open. Facility staff were educated on completing hourly checks on the door. At 5:35 p.m., FR4 was released from county jail. -6/4/25, FR4 hung around facility most of the day but did not cross the property line. At 4:25 p.m., Administrator sent a follow-up email to crime preventionist. At 5:30 p.m., front door was locked on the outside. Maintenance disabled the push bar on the front door from the inside, 1:1 was placed on the door next to the handicap button to let residents in and out. 1:1 kept log on residents that entered and exited the door, and the duration of time residents were outside on the patio smoking. At 6:00 p.m., maintenance director reached out to fire company on changing door and floor codes. At 11:00 p.m. front doorbell education was started with all staff along with additional trespass education. Administrator emailed all staff a copy of the education and continues to individually educate staff that are working. -6/5/25 at 4:30 a.m., FR4 stepped one foot on smoking patio and facility staff stood up and FR4 ran across the street. 9-11 was notified. At 8:00 a.m., FR4 was out front, 9-11 was called. At 8:30 a.m., officers arrived on scene. FR4 was at the park down the street watching. Officers were not able to pursue at the time. 9:15 a.m., officers looking for FR4. 10:00 a.m., maintenance director reset the front and back door codes. At 12:00 p.m., FR4 is outside the facility, 9-11 was called. -FR4 has not entered the facility since 6/2/25. R5's face sheet dated 6/5/25, identified diagnoses of hemiplegia and hemiparesis affecting left dominant side (paralysis on one side of the body/weakness on one side of the body), cerebral palsy (affects movement and posture caused by brain damage before birth), alcohol and nicotine dependance. R5's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognition issues. R5 required moderate assistance with transfers but was able to roll, go from a sitting to lying position and from a lying to seated position independently. R5's progress note dated 5/31/25 at 12:48 p.m., identified a skin check was completed on R5 due to an incident where another individual had kissed her on her forehead while she was in bed. R5 insisted the individual only kissed her forehead and nowhere else and that nothing else happened. Administrator, and police were notified of the incident and a report to the State Agency (SA) was completed. R5 was safe in the facility at this time. During an interview on 6/4/25 at 1:40 p.m., R5 stated on 5/26/25, around 4:30 a.m., R5 woke up to FR4 sitting in her wheelchair. R5 told FR4 to leave and he left without incident. R5 did not tell staff about this occurrence. R5 thought FR4 would also go to another floor and go into R7's room. FR4 was always asking people for things outside. R5 explained on 5/31/25, she woke up around 4:30 a.m. to FR4 kissing her on the forehead. R5 put on her call light. When the nursing assistant (NA) came into the room, FR4 had already left the room by the time the NA responded. R5 told the NA there had been an intruder in her room, (FR4), and he kissed her forehead. NA told R5 that she must have been dreaming. R5 did not feel threatened per se, but did not appreciate FR4 coming into her room uninvited and wished the facility had more security. During an interview on 6/4/25 at 3:37 p.m., NA-E indicated one night (but could not remember the date) around 3:00-4:00 a.m., FR4 went to his old room and was trying to sleep in the empty bed. FR4 threatened NA-E and registered nurse (RN)-A when they asked him to leave saying he would hit RN-A if she came close to him, he had nowhere to go, and we could not force him outside. The police were called but FR4 had already left the building when they arrived. During an interview on 6/4/25 at 4:47 p.m., NA-F stated FR4 was in the building last week and NA-F was not aware that he was not supposed to be here so did not ask FR4 to leave. During an interview on 6/4/25 at 3:43 p.m., RN-B stated it was a big problem at night with residents propping the front door open. FR4 will go up the stairwells and peak around the corners and if he does not see staff, FR4 will sneak into rooms and hide in the bathrooms. FR4 could be in the building a lot more than staff are aware. During a phone interview on 6/5/25 at 9:28 a.m., licensed practical nurse (LPN)-C stated one night towards the end of May, NA-E found FR4 in his old room, trying to go to sleep. LPN-C stated FR4 was talking violently to her and NA-E and they were worried FR4 was going to hit them. LPN-C called the police and FR4 left before the police arrived. According to the facility reported timeline on 6/2/25 at 8:00 a.m., interdisciplinary team (IDT) discussed the reported incident, risk vs benefits were done with all residents who use the patio to smoke or socially on the risks of putting stuff in the front door which prevents it from properly locking. Maintenance investigated the front door and confirmed that the door does lock from the outside and functions properly when residents use it correctly. The administrator collected staff statements and working with human resources on proper corrective action. At 9:18 a.m., FR4 attempted to enter facility via the front staircase and when unable to do that, attempted to run to the elevator. Staff in the front office intervened and escorted FR4 outside and educated on the trespass orders. 9-11 was called. At 1:00 p.m., 9-11 was called for FR4 being on front sidewalk. Officers were unable to arrest as FR4 was not on scene when they arrived. Administrator was given a new email for crime preventionist. At 4:17 p.m., 9-11 was called for FR4 being out front and previously entering facility in the morning with video proof. At 4:47 p.m., officer arrived on scene and FR4 was outside of the facility and arrested at 5:12 p.m. at 6:51 p.m., FR4 was booked at county jail. An email from the Administrator to crime preventionists dated 6/2/25, identified a subject of a Geofence. The body of the email included FR4 will not leave the premise. FR4 had been trespassed for a week and a half by the facility and was given a formal trespass by the police department. FR4 refuses to leave, camera footage shows him attempting to enter the facility multiple times, sneaking up the stairwells, taking the elevator, going into resident rooms. When the police are notified, as soon as FR4 sees or hears them, he will walk down the street. Multiple residents are scared of him. On 5/31/25, he was accused of entering a female resident's room and kissing her on the forehead and it was not consensual. He has threatened residents and staff, providing alcohol and potentially drugs, sleeping across the street in the backyard of an apartment complex. Administrator was running out of ways to protect the residents and was looking for solutions. Multiple residents want to file a restraining order against him due to his threats and inappropriate behavior. According to the facility reported timeline on 6/3/25 at 4:30 p.m., Administrator implemented hourly checks on the front door to ensure residents were not leaving it propped open. Facility staff were educated on completing hourly checks on the door. At 5:35 p.m., FR4 was released from county jail. During an interview on 6/4/25 at 1:36 p.m., R6 was in his room. R6 explained FR4 has been in the building since he was discharged . FR4 would get into the building through the front door and usually went to the fourth floor because he believed FR4 had a girlfriend on fourth floor. R6 stated FR4 was in the facility last night (6/3/25) on the second floor halls, probably around 8:00-9:00 p.m. R6 did not notify staff that he saw FR4. R6's face sheet dated 6/5/25, identified diagnoses of alcohol dependency and mild cognitive impairment. R6's Risk vs Benefits dated 6/3/25, identified area of concern was propping the front door open so it does not fully close after hours, using signs, paper, bricks, rocks etc. Risks related to the non-compliance included anyone from the community can come into the building during the evening or overnight making it less safe for residents. Staff are no [not] watching the front door 24/7 so they are not able to monitor who comes into the facility. The front door camera is on the third floor and when the residents use the button it will ring on the third floor and the staff can see who is at the door and let them in. R6's corresponding progress note identified R6 refused to sign the document. R7's face sheet dated 6/5/25, identified diagnoses of alcohol abuse and dependance. R7's record identified the same Risk vs Benefits for as R6. The form was dated 6/3/25 and was not signed by R7. During an interview on 6/4/25 at 12:48 p.m., R7 stated when he first met FR4 he was a nice guy, and it seemed he started going down a steep hill very quickly and lost his mind. FR4 would yell at people on the smoking patio. FR4 was in his room on 5/29/25 and took a can of chewing tobacco. Another time, R7 could not recall what day, but knew it was after R4 had been discharged from the facility. R7 had woken up around 2:30-3:00 a.m., and found FR4 had reorganized his desk and was cleaning his room. R7 reported this instance to the SSD. During an observation from the second-floor window on 6/4/25 at 11:01 a.m., FR4 was across the street at an apartment complex on the back patio, however then moved off the patio and started pacing around the apart complex grounds. An unidentified facility staff member was outside on the facility patio. During an observation and interview on 6/4/25 at 11:03 a.m., FR4 had walked across the street and behind the facility fence. FR4 had two clear plastic cups with a gas station logo on them. One cup was half full of clear bubbly fluid like soda and the other cup was half full of a thicker viscosity clear fluid. While there was no staff present, FR4 placed the non-bubbled clear liquid on the fence that was opposite of the smoking patio, towards the street and asked a resident in a wheelchair for a cigarette. The resident balanced the cigarette on the fence so FR4 could reach it without going onto the facility property. Another wheelchaired resident handed a thick plastic travel mug to FR4 and said, thanks for the coffee and laughed. There was a light brown liquid in the mug that was not consistent with coffee. FR4 stated he was not a resident at the facility, he had been arrested twice for trespassing. When he tried to sneak in, he was unable to get past the front door because facility scheduler (FS)-A and nursing assistant (NA)-A were always watching him from windows. It was not worth going to jail. A facility staff member came outside and went to the clear plastic cup that was sitting on the outer fence, picked it up, sniffed it, and dumped it in the grass. FR4 began to get upset but then took a drink from the travel mug. FR4 stuttered while he talked and was telling stories that ranged in subjects from the past to current. FR4 migrated back towards the facility entrance and continued to talk with the residents who were outside. FR4 got another cigarette from a resident but did not light it. FR4 denied being inside the facility except for his attempts where he was caught by FS-A. During an interview on 6/4/25 at 1:54 p.m., NA-C stated the staff keep an eye on the exit doors on each end of the units and the elevator doors for R4. NA-C could recall two times when she worked that FR4 was on her unit after he was discharged . When FR4 would be spotted in the facility, he would go to multiple floors and when approached would tell staff that he was looking for someone or wanted to do favors for someone. Staff would remind FR4 he was not allowed in the facility, and he would respond I know. FR4 would try to go in rooms and staff chased FR4 around the unit until they could get him onto the elevator. NA-C stated staff would not escort FR4 out of the building after he was on the elevator because all the nurses knew what they were supposed to do. Last week, NA-C could not recall the date, but thought it was the day FR4 received the trespass notice, she saw FR4 by the entrance while she was leaving work. This morning (6/4/25), NA-C came to work between 6:30-7:00 a.m., and the front door was propped open with a wet floor sign. An email from the Administrator to crime preventionists dated 6/4/25, identified FR4 was arrested on 6/2/25 and released on 6/3/25 and had been back at the facility at 5:00 a.m. During an interview on 6/4/25 at 9:44 a.m., Administrator and social services designee (SSD) stated the residents were very active at night, almost more during the night than during the day. The front door is locked by 5:00 p.m. every day and the residents were supposed to push the button on the door, and it would send a video feed and ring for the staff on third floor to open the door. Administrator identified that after hours the residents would put all sorts of things including a walker, brick, wet floor sign, and shirt in the door to keep it propped open. A risk vs benefits was done with all residents that go outside and education provided that the facility was unable to monitor who was coming and going in the facility if this practice is done. There was a large homeless population and people walking around this area, the residents could not be kept safe if the door continued to be propped open. The Administrator and SW believe this is how FR4 entered the building on 5/31/25. FR4 knew the facility very well and knew where to hide and sneak around. FR4 has a bond with the residents on the smoking patio, he knew R5 from when he was a resident and would give her a ride to her room. The facility began a log for one-hour checks on the door to make sure no one is propping it open on 6/3/25. During an observation on 6/4/25 at 3:18 p.m., FR4 was in front of the building, not on the property, on the sidewalk in front of the fence. FR4 had his travel mug in one hand and a package in the other, a brown paper bag is on the ground next to him. A resident on the smoking patio gave FR4 a cigarette. FS-A came outside and FR4 began walking away from the facility. During an observation and interview on 6/5/25 at 8:10 a.m., PO-B and PO-C came to the facility. PO-B stated the station had received two calls on FR4 being in the building at 3:00 a.m. During an interview on 6/5/25 at 12:25 p.m., Administrator stated that FR4 did not enter the building at 3:00 a.m. or 8:00 a.m. FR4 had stepped onto the property in the smoking area at 3:00 a.m., when the staff member providing 1:1 at the door stood up, FR4 ran away. At 8:00 a.m., FR4 put one foot over onto the property and Administrator called the police. During a phone interview on 6/5/25 at 9:21 a.m., medical director (MD)-A stated the facility has a specific population that have a comradery between each other with lifestyle choices and struggles that they face. It is harder for them to cope with new trauma or assault. MD-A stated this is a sad situation, much like children, you want to give them some freedom and not make them feel like they are locked up, they are adults and able to move freely in and out and make bad decisions. In the end, the best that can be done is try to protect them. The facility abuse prohibition policy revised 3/2024, identified the purpose was to protect residents against abuse by anyone, including, but not limited to, facility staff, and other residents. Abuse will be reported to the SA no later than two hours and immediately to supervisors The IJ began that began on 5/24/25 was removed on 6/6/25 at 1:00 p.m., when the facility implemented the following actions: -1:1 staff at the front door to ensure visitors are signing in/out and to monitor the smoking patio for unwanted visitors including FR4. -Education completed including front door monitoring expectations including the smoking patio, how to respond to unwanted visitors, abuse policy, visitation policy, filling out the 15 minute check form to verify staff are present at the front door/patio area 24 hours each day. -Trespass binder at each nurses station and the front door. Trespassed people will have the trespass notice and picture (if available) in the binder including name, description, reason for trespass. Staff will be alerted by email of any new trespassed individuals including name, description, reason for trespass, and photo if available. Resident to Resident: R1's face sheet dated 5/31/25, identified diagnoses of multiple fractures of pelvis, alcohol abuse, and open wound on left lower leg. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive issues. R1 had verbal behavior issues directed at others, was independent with all self-cares, and used a wheelchair for mobility. R1's care plan identified that she would remain free from abuse or neglect. Interventions included monitoring for signs of emotional distress or mood and behavior changes, safety monitoring will be implemented as needed to ensure residents safety, staff will continue to follow the facility vulnerable adult and abuse reporting policy. R1's progress note dated 5/26/25 at 11:37 p.m., identified at 6:00 p.m., registered nurse (RN)-D was alerted to a verbal altercation in R3's room. Upon entering, R1 and R3 were observed arguing and screaming. R1 appeared visibly upset, crying and said R3 took her phone and hit her. No visible injuries on assessment, no active bleeding or bruising at time of assessment. Residents were separated. R1's progress note dated 5/29/25, identified a Risk vs Benefits was completed with R1 regarding boundaries with other residents. R1's Risk vs Benefits dated 5/29/25, identified Respecting others personal space and boundaries. Respecting personal boundaries offers numerous benefits for individuals and relationships, including fostering trust, enhancing well-being, and reducing stress. However, it also presents potential risks, such as the possibility of misunderstandings or damaging relationships. Disrespecting boundaries can damage relationships but creating a sense of distrust and disrespect, potentially leading to conflict or avoidance. Resident is to leave other residents spaces (rooms) when asked or resident risks losing the privilege/ability to spend time on other floors/units in the facility. During an interview on 6/3/25 at 1:07 p.m., licensed practical nurse (LPN)-D stated that to her knowledge, R1 was not intoxicated on 5/26/25. R1 and R3 were dating and she spent most of her time with him and would only come to her floor for medication. During an interview on 6/3/25 at 12:23 p.m., R1 had a cell phone in her hand. R1 stated it happened so fast and she does not want anything done about it. R3 was having a bad day and he hit her and she is just over it. R3 was letting R1 use his old cell phone and he accused R1 of stealing his found and R1 found out he sold it and that was what the whole argument was about. When the staff separated R1 and R3, R1 left the room and went out to the smoking patio. The staff did not tell me not to hang out with R3. R2 and R3 also were outside and R1 thought R3 was going to hit her and R2 stepped in between them. R1 thought R3 was going to hit R2 so she wheeled away and called 9-11. R3 was physical with R2 outside and staff were present. R1 thought NA-A was outside and was not sure who the other NA would have been. R2's face sheet dated 5/30/25, identified diagnoses of major depressive disorder, altered mental status, and alcohol dependence. R2's quarterly MDS dated [DATE], identified R2 had no cognitive issues, no behaviors, and was independent with all self-cares, walked with no assistive devices. R2's care plan dated 7/22/24, identified R2 was a fall risk related to history of fractures, history of falls, alcohol dependence. R2's progress note dated 5/26/25 at 11:29 p.m., identified at approximately 7:00 p.m., RN-D was informed there was a physical altercation between residents which occurred in the elevator. On assessment no injuries were found. Neurological check was clear. R2 was clear, calm, and under no emotional distress. Residents were separated. R2's physician visit note dated 5/27/25, did not identify the physical altercation with R3 on 5/26/25. R2's progress note dated 5/29/25, identified a Risk vs Benefits was completed with R2 regarding being involved voluntarily in a resident-to-resident altercation. R2's Risk vs Benefits dated 5/29/25, identified getting involved in other residents altercations. Risks related to getting involved in other altercations could include physical and or emotional injury affecting overall wellbeing, possible arrest if law enforcement is to be involved, and even death. Furthermore, injury to your person could result in hospitalization. When another resident to resident altercation is taking place, R2 should contact and inform staff members to handle the situation. During an interview on 5/30/25 at 12:07 p.m., R2 stated he was not sure what was going on between R1 and R3 but he was trying to break it up. They were swinging at each other and yelling. The facility is usually pretty mellow and R2 had never witnessed anything like this during his stay. R2 and R3 rode the elevator together after R2 intervened between R1 and R3 outside. While in the elevator R3 became verbally aggressive towards R2 and was surprised when R3 punched him twice in the face. R2 then tipped R3 over in his wheelchair to stop the altercation. and got two surprise punches to the face before R2 tipped R3 over in his wheelchair to stop the altercation. R2 had a discolored area under his right eye and stated his right jawline hurt to the touch. R2 was unsure if the area under his right eye was from when R3 punched him. R3's face sheet dated 6/2/25, identified absence of left lower limb below knee, depression, anxiety, post traumatic stress disorder (PTSD), opioid dependence, and fall from non-moving wheelchair. R3's quarterly MDS dated [DATE], identified R3 had no cognitive deficits, no behavior issues, independent with all self-c[TRUNCATED]

Based on interview and document review, the facility failed to continue cardio-pulmonary resuscitation (CPR) after initiating CPR, in accordance with resident wishes and physician orders [REDACTED]. This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found with an absent pulse and respirations, CPR was initiated, discontinued, then initiated again due to confusion over resident code status and R1 died . The IJ began on [DATE], when R1 was found with an absent pulse and respirations, CPR was initiated and discontinued due to an outdated Do Not Resuscitate (DNR) order, when the updated POLST (Provider Orders for Life Sustaining Treatment) to resuscitate was discovered, CPR was reinitiated unsuccessfully, and R1 died . The administrator and director of nursing (DON) were made aware of the incident on [DATE], and immediately initiated corrective actions. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 11:15 a.m. The facility implemented corrective action on [DATE]. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore past noncompliance. Findings include: R1's Admission Record printed [DATE], indicated [DIAGNOSES REDACTED]. R1's physician progress notes [REDACTED]. R1's hospital discharge orders to facility dated [DATE], at 11:45 AM indicated R1's resuscitation status as do not resuscitate (DNR). R1's progress note dated [DATE], at 7:50 p.m. included, R1 was admitted to the facility. The progress note indicated R1 was cognitively intact and, able to communicate needs and concerns without any difficulty. R1's progress note from social worker (SW)-B dated [DATE], at 2:14 p.m. indicated SW-B met with R1 to complete intake paperwork and at R1's request, the meeting was discontinued with SW-B to check back with R1 to complete the intake paperwork. No further SW meetings with R1 were recorded in the progress notes. R1's Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE] directed, Attempt resuscitation/CPR. Full treatment: Use intubation, advanced airway interventions and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. treatment plan: [REDACTED]. R1's Care plan dated [DATE], included, under the heading of focus; current code (resuscitation) status: Resident and family wants a full code (resuscitation). Under the heading of goal; Directive in place and will be honored during review. Under the heading interventions/task; Staff to follow POLST guidelines. R1's progress note dated, [DATE], at 7:10 a.m. included, CNA (certified nursing assistant) was doing 0620 (6:20 a.m.) round and resident was found gasping for air with a faint pulse. Nurse initiated oxygen and called a code. Staff immediately came up and started CPR until the paramedics arrived. Staff updated the family (FM-A) at 0640 (6:40 a.m.) regarding paramedics doing CPR and informed her that staff will keep them updated. Resident expired at 0700 (7:00 a.m.) according to Paramedics. R1's facility internal investigation interview dated [DATE] included, (Licensed practical nurse (LPN)-A) was on 2nd floor when she heard code Blue called around 6:25 a.m. (registered nurse (RN)-D) and (LPN-A) immediately went to 4th floor. RN-C reported that (R1) was gasping for breath and had a faint pulse. The nursing team immediately started CPR. When we started CPR (R1) did not have a pulse for signs of life. We continued CPR for about 15 minutes. RN-C came back to the scene after checking his POLST and said he is a DNR/DNI. When we figured this out, we stopped everything we were doing. We stopped for about 5 minutes. RN-C couldn't find the paper POLST in the chart so she looked in PCC (facility electronic medical record (EMR)) PCC stated DNR/DNI. The paramedics arrived around 6:40 a.m. and were asking the nurse details about the resident. The nurse had the chart to get information about the resident and came across the POLST that read Full Code. Upon this new information the paramedics and nursing team resumed CPR. There was a 5 minute lapse between stopping CPR and resuming CPR. They did this for 15 minutes with no sign of life. The resident expired around 7:00 a.m. R1's facility internal investigation dated [DATE], indicated that R1 was admitted to the facility on [DATE] and on [DATE] SW-B met with R-1 and confirmed that R-1 wished to be full code. SW-B completed the new POLST with R1 and faxed it to nurse practitioner (NP)-J. NP-J returned the signed POLST and SW-B uploaded the POLST into the EMR. NP signed the form and sent it back to writer (SW-B), and writer uploaded the form into PCC (EMR), and it was unknown to writer that resident had a DRN/DNI order in PCC, which he came with to the hospital, that is why writer did not call for a change of POLST from DNR/DNI to full code in PCC. The form was uploaded, however, the physician orders [REDACTED]. When interviewed on [DATE], at 1:25 p.m. RN-H stated that when a POLST (advanced directive with a provider's order) is completed the practice is to place the POLST in the front of the resident's chart and to verify that it matches the resuscitation status order in electronic medical record (EMR) and if it does not, to clarify with the provider. RN-H indicated that when helping a resident with a new POLST a provider's signature is immediately obtained. RN-H stated that when a resident is found pulseless and not breathing, code status is immediately checked by looking for the POLST in the front of the chart and if indicated, then CPR is initiated. When interviewed on [DATE], at 3:05 p.m. RN-E stated that when a POLST is completed with a resident, the POLST is immediately sent to the provider for signature and when that is obtained, the POLST is placed in the front of the resident's chart. RN-E stated on completion of the POLST it is verified that the POLST matches the resuscitation status listed in the EMR. RN-E stated that when a resident is found pulseless and not breathing, code status is immediately confirmed by looking for the POLST in the front of the resident's chart and starting CPR if indicated. The facility policy Cardiopulmonary Resuscitation revised, ,[DATE], directed, A POLST form will be completed on admission by the nurse manager or designee and (reviewed) upon readmission, quarterly, and as needed (such as when a resident is transferred from one care setting or level of care to another; when there is a substantial change in the resident's health status; when the resident's treatment preferences change; for when a primary medical care provider changes). When an emergency occurs, the nurse and/or clinical team will guide care provided, according to the resident and/or resident's representative identified preferences indicated on the physician's orders [REDACTED]. CPR is not discontinued until qualified help arrives, resident pulse and respirations return, or resident is pronounced dead by a qualified personnel such as Paramedic and gives orders to stop CPR. The facility policy POLST Documentation, updated, [DATE], included, under Purpose, The Resident and/or Resident Representative's decision will be entered into the the individualized plan of care/electronic medical record, and will be communicated throughout the facility, so that staff know immediately what action to take or not take when an emergency arises. The facility Addendum to POLST Documentation Policy, dated [DATE], directed, Admitting nurse to review code status with resident immediately upon readmission. The nurse will complete code status order in PCC-and will be reflected automatically in E-MAR. The paper copy of the POLST form shall be placed in the resident's physical chart at the back of the front cover of the chart. POLST form will be reviewed and completed by a licensed professional nurse. Social workers may only facilitate and coordinate meetings with residents, responsible parties and the nurse completing the POLST. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions. The facility had conducted a full house audit on [DATE], to ensure POLST and EMR matched resident current wishes. The facility ensured every nurse had a current CPR certification on [DATE]. The facility updated their POLST policy and addendum on [DATE], to include a nurse would be responsible to initiate a POLST and have the POLST signed by the provider and then the nurse would update the POLST in the EMR. All nurses were educated prior to working their next shift which was initiated on [DATE]. Audits were to continue and the facility incorporated their action plan into the facility wide quality assurance program. Verification of corrective action was confirmed on [DATE], by interviews of licensed staff, unlicensed staff, and administration, as well as document review including training provided and an audit of medical records.

Based on interview and document review, the facility failed to ensure medications were administered without error for 1 of 3 residents (R1) reviewed. R1 sustained harm when scheduled [MED] was not administered consistent with physician orders. Although harm occurred, the facility had implemented appropriate corrective action prior to the onsite investigation so the deficiency is being cited at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified R1 was cognitively intact, received [MED] seven days a week and had a [DIAGNOSES REDACTED]. The corresponding Care Area Assessment (CAA) dated [DATE], identified R1 had a potential for impaired communication, was usually understood by others, but English was his second language with [LANGUAGE] being his primary language. The CAA indicated an interpreter was available as needed. A Brief Interview for Mental Status (BI[CONDITION]) score dated [DATE], identified a score of 13 indicating little to no impairment with R1's cognition. R1 was not available for interview during the investigation. R1's care plan indicated R1 had an abnormality in blood glucose (BG), and BG later stabilized, when resident had something to eat. Interventions were listed as: If abnormal BG readings are obtained, physician will be contacted and modifications to [MED] administration orders can be considered; Monitor resident for signs/symptoms of hyper and [DIAGNOSES REDACTED]; Monitor resident's BG as ordered; and Administer scheduled and sliding scale [MED] as ordered, all with date of [DATE]. Additional interventions included: Monitor and check resident's BG, before and after meals, with a date of [DATE]. R1's history and physical (H&P) from [DATE] indicated R1 had a significant history of [DIAGNOSES REDACTED] with arrest in the past. The H&P indicated in [DATE], R1 had experienced an out of hospital pulseless electrical activity (PEA) arrest that was attributed to profound [DIAGNOSES REDACTED]. R1's physician orders [REDACTED]. In addition, directions indicated [MEDICATION NAME] helped control blood sugar spikes that happen when a person eats, indicating as a person eats, the blood sugar naturally goes up or spikes. [MEDICATION NAME], a fast-acting [MED] was identified to work to manage those blood sugar spikes which could keep the blood sugar levels in balance. [MEDICATION NAME] peaks in about one hour and keeps working for two to four hours. Other orders included: Detemir Sol 100 unit/ml 4 U at bedtime also prescribed to treat diabetes. The package insert directions indicated Detemir ([MEDICATION NAME]) was a long [MEDICATION NAME]used to treat diabetes which begins to work within one to four hours, and peaks between four and 12 hours, and keeps working evenly up to 24 hours. [MED] [MEDICATION NAME] Solution injection as per sliding scale : if blood sugar was ,[DATE] give one unit subcutaneous (SQ), ,[DATE] = 2 units SQ, ,[DATE] = 3 units SQ, ,[DATE] = 4 units SQ, ,[DATE] = 5 units SQ, and ,[DATE] = 6 units - call provider. Blood glucose monitoring four times a day (QID) before meals and at bedtime. Call physician or nurse practitioner for blood glucose less than [AGE] or greater than 400, dated [DATE]. Review of R1's Medication Administration Record [REDACTED] In addition, R1's MAR indicated [REDACTED].M., the MAR indicated [REDACTED]. Registered Nurse (RN)-B was interviewed [DATE], at 3:54 p.m. RN-B stated although the sliding scale [MED] was administered, no other [MED] had been administered at 6:00 p.m. or 8:00 p.m. A progress note written at 2:20 a.m. on [DATE], included: At 0145 (1:45 a.m.), the assigned CNA (certified nursing assistant) called writer to inform writer that resident was having a [MEDICAL CONDITION]. When writer got to resident room, he was shaky, sweaty, groaning, jerky, grabbing his pillow and staff hand. Writer checked his blood sugar, it was 30, 1 ,[DATE] tubes of oral glucose gel was given, 911 called. He was still seizing when the paramedics came. The [MEDICAL CONDITION] lasted for about ,[DATE] minutes before the paramedics arrived. When they checked his blood sugar, it was 19 and they stayed with R1 until he became stable. During their assessment/intervention, R1's blood glucose got up to 150 but dropped back to 124. R1 was currently seated on his bed, eating sandwich, drinking milk and able to recognize writer and other staff. Resident will be monitored all through the shift. Further, the progress note indicated the assistant director of nursing (ADON) and administrator would be updated via text message by staff and the oncoming shift would be updated during shift exchange in the morning. The nursing progress note from 3:12 a.m. [DATE], indicated the writer re-checked R1's blood glucose and it had dropped to 90, so 120 cc orange juice was given. The note included, Will continue to monitor resident and blood glucose all through the night shift. The nursing progress note from 4:38 a.m. [DATE], indicated R1's blood glucose had increased to 149 and included, Will continue to monitor resident. The nursing progress note from 7:11 a.m. [DATE], indicated report had been provided to morning shift regarding an update to R1's status. Resident sleeping currently. He does not show any signs of hypoglycemic or hyperglycemic currently. The nursing progress note from 3:00 p.m. on [DATE], indicated R1 was experiencing low blood sugars during the night. Resident's BG during the morning was 371 to 5[AGE]. Writer paged on-call and received an okay to send resident into the hospital for evaluation if BG increases after receiving [MED]. Resident left the unit and was unable to receive BG re-check with [MED] at this time. Writer will locate resident to administer and monitor. The nursing progress note from 3:34 p.m. on [DATE] included, Writer found resident in day room and staff translated all information from the Dr. (doctor) and that another BG check was needed. Resident was reluctant. BG was now 264. Writer paged on-call (doctor) with the updated number and was told to continue to administer [MED] as scheduled and there was no longer a need to send into the hospital. A grievance/concern report from 2:00 p.m. [DATE], indicated R1 had reported via an interpreter, that on [DATE] at 7:00 p.m., R1 was headed down to dinner and on his way he'd stopped at the nurses' station to ask the nurse for his 5 units of [MED] to be administered before mealtimes. R1 stated that the nurse RN-B, was behind the desk talking with the ladies. R1 said that he told the nurse what he needed but the nurse was too busy talking to the ladies and did not honor his request for [MED], therefore he had just proceeded to head to the dining room to eat dinner. The report indicated when R1 had come back to the floor after dinner, he'd noticed the nurse was still talking to the ladies. R1 reported he went back to his room and the nurse did not come, so after waiting a couple of minutes he put on his call light. A CNA came into the room and stated he would get the nurse. Still the nurse did not come, R1 then went down to the second floor to ask the RN-E if he would give him his [MED]. R1 reported RN-E had told him RN-B, the third floor nurse, needed to give him his [MED] and R1 should go back to the third floor. R1 also reported RN-E had told him he would call RN-B and tell RN-B that he (R1) was requesting his [MED]. R1 stated once on the third floor RN-B had stated, So you went downstairs to get your medications. R1 stated he and RN-B went to his room and his blood sugar was 591. R1 reported he received his [MED] at 11:30 p.m. R1 reported feeling sweaty and itchy. After this, R1 only remembered people trying to hold on to his arms and reported that he did not feel right in his body. R1 reported waking up at 3:00 a.m. on [DATE] with paramedics, police, and staff around him. R1 stated that the paramedics told him his blood sugar was 19 when they checked it. R1 stated he received something to eat and began to feel better as his blood sugars stabilized. R1 reported having told the paramedics he was 'okay' and did 'not want to go to the hospital'. R1 stated his doctor was notified and had agreed he would be ok to remain in the facility as long as the staff monitored his blood sugars to ensure they remained stable. R1 reported he believed RN-B had purposefully given him extra [MED] because he'd gone to the second floor nurse and requested his medication. A Medication Error Reconciliation form was filled out on [DATE] at 3:00 p.m. The description indicated an error had occurred [DATE], and included: After investigation, it was determined that this was not a medication error, it was a document error. Resident refused PM (evening) medications. Investigation proved to be a documentation error. Resident refused PM medications. Documentation indicated a statement made by RN-B on [DATE], via phone (no name of staff member taking the statement), indicated an incident happened on [DATE]. RN-B indicated in his statement that all night he asked R1, are you ready for your [MED]? RN-B's statement indicated R1 had kept ignoring him and refusing to take his [MED]. R1 then went down and told RN-E he needed his [MED]. At this time RN-E called up to RN-B and said R1 needed his [MED] as his orders read. When RN-B was asked why all of his meds were not charted on - he was refusing all his medications. I didn't chart on them and that's on me, but he did refuse all of them. You can ask the staff that were on that night, they all witnessed R1 refuse his medications. Documentation indicated a written statement made by RN-E on [DATE], regarding the incident that occurred on [DATE] with R1. RN-E's statement indicated, at 10:30 p.m. R1 came downstairs and complained that he had been asking for his [MED] since before dinner. RN-E stated he'd asked R1 if he got his blood sugar checked and R1 had said yeah. RN-E stated, I called the nurse, (RN-B) and said you have a resident down here who wants his [MED]. RN-B said to send him up. R1 was highly upset. RN-E stated he could not understand all that R1 was saying, but could tell R1 was not happy. RN-E verified having told R1 he did not have access to his medications and R1 would have to go upstairs. RN-E reported R1 had asked if RN-E could take his blood sugar. RN-E had said he would, and R1's blood sugar was 411. RN-E stated, The overnight shift was there. RN-E was on second floor during shift change and R1 was still upset but left. RN-E stated, I do not remember who was working. I worked Sunday, ([DATE]) with CNA-B. CNA-B came to me and told me R1 was upset with me because I did not take over from (RN-B). A written statement was also provided by CNA-B regarding the [DATE] incident. CNA-B's statement, dated [DATE], indicated on [DATE], he was working on fourth floor and R1 was on third floor. (R1) liked to come to talk to me because we spoke the same language. CNA-B stated he always stopped to say Hi to R1. The following day (Sunday) [DATE], I went to the TV room to say Hiand R1 wanted to cry. R1 told me They wanted to kill me yesterday. I asked him about what happened. Do you remember that guy you were talking with? R1 was referencing RN-B, he took my blood sugar and it was 200 plus. I asked RN-B for [MED]. RN-B just ignored me and was talking to the 'ladies.' R1 came up after dinner and asked for his [MED]. RN-B ignored me again. At 10:30 p.m., R1 indicated he felt like his body was not good so he went to second floor to RN-E. I wanted to come to you for help but you weren't there? R1 asked RN-E for [MED] and RN-E asked R1 if anyone was upstairs. R1 got mad and said wouldn't be down here if there was someone. They took his blood sugar and it was 500 plus. R1 went upstairs and went to bed to die. RN-B finally came and gave me wrong [MED] and I died . RN-F came by today and R1 told me she has come to kill me too. R1 now thinks everyone wants to kill him. Anytime they think he refused cares it's because he didn't understand what they were trying to do. You must speak slowly with him. R1 doesn't understand he doesn't refuse cares or treatments. CNA-A's statement was reviewed for the incident on [DATE]. The statement was made on [DATE]. CNA-B and I , CNA-A worked together on third floor. RN-B was the nurse. R1 wanted meds while RN-B was on break. Only heard them (staff) talking about the incident. CNA-A indicated she did not know R1. I know that CNA-B goes into R1's room frequently. We left at 10:30 p.m. and R1 seemed to be ok. LSW-A was interviewed on [DATE], at 11:24 a.m. about the incident on [DATE] with R1. LSW-A explained that an interpreter and LSW-A met with R1 and R1 indicated he felt he was not being paid attention to by nursing. R1 stated he asked for [MED] and got no response from the nurse on the evening shift, [DATE]. R1 then went down for his evening meal. After the meal, R1 went to his room and put on his call light. The CNA responded and asked what he needed. R1 indicated he needed his [MED]. The CNA went to get the nurse. After no response from the nurse, R1 went to second floor and that nurse directed him to go back to see his third floor nurse. When R1 got back to third floor his nurse said so you asked the second floor nurse for your medications. The resident went to his room. R1 indicated he was given [MED] around 10:30 p.m. Ten minutes after receiving the medication he felt funny. He wet to sleep and woke up to people touching his arms and things like that. Paramedics were there and other people. Paramedics told R1 he had been given too much [MED]. LSW-A identified R1 talked about the incident out of concern for self and others. R1 was afraid the nurse had given too much [MED]. The director of nursing (DON) was interviewed on [DATE] at 12:26 p.m. and indicated he was off work during the time of the incident. The DON indicated his knowledge was that R1 had been approached by the nurse several times so see if he wanted [MED]. Resident had sought out nurse at one point and nurse was on break. R1 went to second floor. The second floor nurse sent the resident back to his nurse on third floor, RN-B. The second floor nurse, RN-E tried to contact the second floor nurse. Later RN-E was educated by management that he could have administered [MED] that was on third floor. This may have happened around 9:00 p.m. on [DATE]. The administrator was interviewed on [DATE] at 12:54 p.m. The administrator indicated that she had been notified of the incident on [DATE] involving R1. R1 had requested a translator on [DATE]. The LSW-A arranged for the meeting. There were no incident reports filled out on [DATE] for R1. The expectation was that medication errors were to be reported right away and to notify the medical doctor. The administrator indicated she was informed of the medication error around 3:00 p.m. on [DATE]. RN-B had indicated that R1 had refused medication. RN-B had approached resident 3 times and resident refused. RN-B approached resident one more time at end of shift and resident refused medication [MED]. RN-B agreed that resident did not get his dinner [MED]. RN-B agreed the BS was 400 plus. R1's doctor should have been notified. There was no documentation of the refusals. R1's progress notes were reviewed from ,[DATE] through [DATE] and there was no documentation that staff had updated MD/NP with blood sugar readings that were above 400 or less than [AGE] mg/dl. During interview on [DATE], at 2:15 p.m. the administrator, verified that there was no documentation of the provider being updated of blood sugars being above 400 or less than [AGE] mg/dl for R1. RN-B was interviewed on [DATE] at 3:45 p.m. RN-B indicated that he was back working after he had been suspended for the incident on [DATE] for R1. RN-B stated he returned back to work on [DATE] to work the evening shift. RN-B stated that on [DATE] he approached the resident multiple times to check his BG but resident refused both BG checks, [MED], and all other medications. RN-B stated he forgot to document this information. RN-B stated he administered [MED] at 9:00 p.m. If was his bedtime dose. RN-B could not state what [MED] he had given. The provider/physician was not called for R1's 400 plus BG because he had given the proper dose of [MED]. The provider was not called about the the missed 6:00 p.m. dose of [MED] and oral medication not given. RN-B indicated it was a mistake, an oversight. RN-B agreed it was a significant medication error, confirmed the resident was on [MEDICAL TREATMENT], [MED] affects kidney function. RN-B indicated no incident report was filed and indicated after 3 missed doses the provider should be called. RN-B indicated that R1 had limited English when asked about residents rights. RN-B stated residents needed to be treated with respect, had a right to their opinions, treated with dignity, right to be treated fair, safe, and right to refuse or accept care. RN-B stated he had been re-educated on re-approaching, proper documenting and informing the provider. RN-B was asked what neglect meant to him and RN-B responded it was intentionally doing something to hurt someone, not care for them the way they should be cared for and refusing their rights. RN-B acknowledged he did not try to explain to the R1 risk and benefits of refusing medications and cares. R1 allowed the second floor nurse to take his BG. The BG was not documented when the second floor nurse did his BG. RN-B stated that he gave the medication as marked. RN-B confirmed not giving R1 his scheduled [MED] at 6:00 p.m. and 8:00 p.m. were significant medication errors. RN-B also confirmed R1 did not get his other medications that evening. RN-B confirmed the evening medications had not been documented as not given and/or refused. RN-B confirmed a supervisor was not notified of R1 not receiving his medications or refusal of medications. Interview with CNA-B on [DATE] , at 9:45 a.m. CNA-B indicated that R1 spoke [LANGUAGE] and when he was working he would stop in to talk to R1. CNA-B explained that on [DATE], CNA-B stopped in to talk to R1 and R1 said these people wanted to kill me. I asked him who and he told me the nurse, I had been talking to on third floor, a male nurse. I asked him what happened and R1 said he had asked the nurse for [MED] and he didn't respond. R1 said this guy was not listening and the resident went to sleep. After 10 p.m. R1 started feeling sick and went to the second floor and asked that nurse to give him his [MED]. The nurse on second floor checked R1's BG and it was 500 plus. The resident then went back to third floor. R1 asked RN-B twice about his [MED] and there was no response from RN-B. R1 went back to his room. R1 told CNA-B I thought, let me go to bed and die. After a few minutes the nurse came in and gave him [MED]. He overdosed me and gave me the wrong [MED]. After 30 minutes I was sweaty and died . R1 woke up at 3:00 a.m. and police and paramedics were there asking if he was ok. R1 said he was and gave this information to the Social Worker. RN-E was interviewed on [DATE] at 10:40 a.m. RN-E stated he was the second floor nurse on [DATE] during the evening shift. RN-E stated, (R1) came down to my floor and voiced he was frustrated that he had not received his [MED]. This was around 10:00 p.m. I am not sure which [MED] he meant, (R1) was not specific. I assumed it was his dinner dose. I picked up the phone and called 3rd floor. (RN-B) answered the phone. I told (RN-B) his resident was asking for [MED]. (RN-B) told me to send him up. RN-E stated he informed the resident his nurse had requested he go back to his floor. RN-E then stated, It sounds like (R1) had a [MEDICAL CONDITION] because he bottomed out. At the staff meeting, when we discussed the incident, it was said (RN-B) had misunderstood (R1). The nurse was notified after resident was having a [MEDICAL CONDITION]. The administrator was interviewed on [DATE] at 11:00 a.m., and stated RN-B was suspended on [DATE]. The administrator acknowledged RN-B was working at a 'sister' facility on [DATE] where he was called and notified of his suspension. In addition to the significant medication error, record review revealed the physician orders [REDACTED]. The order dated [DATE], identified blood glucose monitoring four times a day (QID)- before meals and at bedtime, and to call physician or nurse practitioner (NP) for BG levels less than [AGE] and greater then 400. R1's BG levels from [DATE] included BG levels greater than 400 on 6 occasions, in both November and [DATE], R1 had BG levels greater than 400 on 5 occasions. BG levels less than [AGE] had been recorded 6 times in [DATE], and 2 times in each November and [DATE]. However, there was no documentation to identify the physician or NP had been notified when R1's BS readings were outside the identified parameters. R1's physician/medical director (MD) of the facility was interviewed on [DATE] at 2:00 p.m. The incident on [DATE] was reviewed with R1's physician and he indicated he had not been notified of the incident when it happened and would have expected a phone call. The physician orders [REDACTED]. The physician confirmed he was not consistently being notified of BG's that were outside of the parameters listed in R1's orders. R1's physician also confirmed he should have been notified when R1 had not received his scheduled [MED] at 6:00 p.m. and 8:00 p.m. In addition, R1's physician stated any low BG was risky and he would under treat due to the primary rule Do No Harm. He stated, safety was the primary goal. In addition, MD identified that R1 could make his needs known and did did not like to have an interpreter. MD stated when R1, or any other resident, did not receive medications as scheduled that would be considered a medication error and residents' physicians should be notified. MD was not aware that in addition to R1 not receiving [MED] that R1 did not receive oral medications for hypertension, end stage [MEDICAL CONDITION], [MEDICAL CONDITIONS], pain, and anxiety and depression. MD acknowledged this was a big problem for R1 and confirmed R1 had a negative episode following the evening shift when R1 did not receive his medications as ordered. The facility's Diabetic-Clinical Protocol, revised ,[DATE], For resident with confirmed diabetes, the nurse shall assess and document/report the following during initial assessment: a. Resident's age and sex; b. Level of consciousness, change in orientation; c. Dose and time of most recent anti-hyperglycemic given; d. All other current medications; e. any signs or symptoms of infection (urine, skin/wound, upper respiratory, etc.) or other acute illnesses; f. Usual patterns of eating and drinking; g. Approximate intake over last 24 hours; h. Recent change in intake/thirst; i. Resident's blood sugar history over 24 hours; j Unusual patterns (fluctuations, trends) of blood sugar over recent months; k. Onset, duration of any changes; and l. Recent labs. The Diabetes - Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff would incorporate such parameters into the Medication Administration Record [REDACTED]. The facility's policy on Medication Administration, revised ,[DATE], Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the mediation. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [REDACTED]. The Charting and documentation policy, revised ,[DATE], indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information was to be documented in the resident medical record: a. Objective observations b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress towards or changes in the care plan goals and objectives. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual (s) who provided the care c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting Refusal of Cares/Interventions, Risk and Benefits Policy The facility's Refusal of Cares/Interventions, Risk and Benefits Policy, ,[DATE], indicated it was the policy of the [ENTITY] management that the resident will be informed regarding risk/s benefits of necessary care and services, and given opportunity regarding decisions in the plan of care. To follow the Patient Bill of Rights, and give resident(s) opportunity to participate in decisions related to necessary care and services. 1. The resident (or Responsible designee) will be informed of necessary care, interventions and services, including information regarding risks and benefits. 2. When cares/interventions are refused, the resident will be reapproached ,[DATE] times by the person assigned to give cares/interventions. 3. If the resident still refuses cares/interventions, the person assigned to give care/interventions will report to their supervisor. 4. If the resident refuses cares/interventions, documentation on the Refusal of Care Interventions Risk & Benefit form will be completed. 5. Refusal of Care Interventions Risk & Benefit form will be reviewed with resident and /or Responsible designee, including risks, potential negative outcomes and alternatives offered. 6. The Nurse Manager will update resident's plan of care. 7. The Refusal of care Interventions Risk & Benefit form will reviewed with resident and /or Responsible designee quarterly. The facility identified the deficient practice on [DATE] when R1 filed a grievance. RN-B was suspended [DATE], and the facility conducted an investigation regarding the significant medication error(s). Corrective action was immediately implemented including education provided to licensed and unlicensed staff regarding giving medications as ordered, and notifying the physician of resident's BG levels per order. The facility's corrective action was verified during the onsite survey on [DATE] as having been implemented as of [DATE] therefore, this deficient practice is being cited at Past Non-compliance.

Based on interview and document review, the facility failed to assess/identify the risk of elopement, and provide adequate supervision for 1 of 1 resident (R209) reviewed for missing person/elopement. In addition, the facility failed to follow the facility's plan to locate R209, when R209 left the facility premises without staff knowledge, and did not return. This resulted in an immediate jeopardy (IJ) for R209 who was known to have left the faciity on [DATE]. In addition, the facility failed to provide adequate assessment and supervision that was not an IJ for 3 of 7 additional residents (R113, R34, R60), and who left the facility premises without staff notification. The IJ began on 12/15/17, when facility staff were aware R209 was not in the facility, were unaware of the resident's location, failed to notify administration and failed to begin a search for R209. On 12/19/17, at 12:01 p.m. the administrator and regional director of operations were informed of the IJ situation. The immediate jeopardy was removed on 12/20/17, at 1:00 p.m. but noncompliance remained at the lower scope and severity of E - pattern, scope and severity level which indicated no actual harm with the potential for more than minimal harm that was not an immediate jeopardy. Findings include: R209's Face Sheet indicated R209 was admitted to the facility on [DATE], and included [DIAGNOSES REDACTED]. R209's Hospital Discharge Summary dated 12/12/17, noted R209 had right eye [MEDICAL CONDITION], substance abuse, and was admitted to the hospital on [DATE], with increase difficulty with right eye, had chronic vision loss in left eye, and was found to have a stroke, and also uncontrolled type 2 diabetes. An Admit/Initial Data Collection form dated 12/12/17, at 4:40 p.m. indicated R209 needed set up transfer assistance and had impairment on one upper extremity side, and one lower extremity side. An Incident Review and Analysis form dated 12/12/17, noted R209 had experienced a fall while ambulating. The Fall Risk Evaluation dated 12/12/17, at 3:01 p.m. indicated R209 ambulated independently but could not see well and had one side paralysis. The note further indicated R209 had gotten lost earlier and was located on the second unit, but had been found by staff, and was brought back to his room. An untitled and undated form in R209's medical record indicated R209 had a TAB alarm (alarm that would alert staff when R209 moved away from bed or chair) on his bed and utilized his wheel chair. R209's initial care plan dated effective as of 12/13/17, indicated R209 needed limited assistance of one staff member for bathing, dressing, and mobility. The care plan noted R209 had right sided weakness, utilized a cane for mobility, and was at risk for falls. The care plan indicated R209 was blind in the left eye due to detached retina, had [MEDICAL CONDITION] in both eyes, and that his vision fluctuated in his right eye due to recent stroke. The care plan lacked evidence if R209 could leave the facility independently or not. R209's physician orders [REDACTED]. pen 10 units three times a day (TID). Review of R209's Medication Administration Record [REDACTED].m During review of R209's medical record progress notes revealed the following: On 12/12/17, at 9:19 p.m. R209 was admitted and was alert and oriented. On 12/14/17, at 2:49 p.m. R209 was not feeling well, had episodes of emesis and loose stools and R209's blood sugars for the day were 90 (in the morning) and 462 at 2:30 p.m. R209 was sent to the hospital at 2:40 p.m. On 12/14/17, at 8:30 p.m. R209 returned from the hospital who noted R209 was dehydrated. On 12/15/17, at 11:24 p.m. R209 had not been at facility for entire shift and left without signing out. Staff attempted to call R209's wife but was unable to make contact with her or leave a message. On 12/16/17, at 5:48 a.m. R209 had not come back to the facility and a phone call was made to his wife which was unanswered. On 12/17/17, at 7:01 p.m. R209 had been gone since Friday night, without his insulin to treat his diabetes. The phone number for his wife was not open to messages and up to this time R209 had not called facility to advise them where he might be. On 12/17/17, at 8:57 p.m. R209 had not been at the facility for two days and the nurse practitioner and director of nursing were updated and made aware. On 12/18/17, at 10:06 a.m. a social service note indicated an initial social service visit was attempted on 12/15/17, but R209 was not available and was going attempt next week. On 12/18/17, at 11:10 a.m. the director of nursing (DON) wrote she called R209's wife and alerted her of R209 being gone from the facility since 12/15/17. R209's wife had not seen or talked to R209 since last week Tuesday or Wednesday. R209's wife was informed of the admission with a therapy focus and medication management with intent to help R209 find placement if needed for discharge. R209's wife stated R209 needed a stable place to live and did not live with her. The DON informed wife if R209 was not in the facility by midnight he would be considered discharged from the facility. The sign out book located on the third floor indicated R209 was signed out on 12/15/17, location was documented as unknown LOA (leave of absence), with no time out noted, and was not signed by the resident. R209's medical review lacked evidence of an assessment to identify whether R209 was able to leave the facility independently and the care plan lacked information regarding whether R209 was able to leave the facility independently. During interview on 12/18/17, at 7:36 p.m. the administrator stated he was aware R209 was a relatively new admission and had been made aware that R209 was not in the building since 12/15/17, on the morning of 12/18/17. The administrator stated the facility needed to call to locate R209. The administrator stated normally if the facility was unaware of a resident's whereabouts the facility would inform the police and request a wellness check. The administrator also stated a resident needed to sign out (and back in) prior to leaving the facility and inform staff who they could contact in case of an emergency. The administrator stated if the resident was intending to be gone over 24 hours staff needed to be aware and have the resident sign a bed hold form. The administrator stated if a resident was not back by midnight he expected staff to attempt to call family members/emergency contact phone numbers and if that was unsuccessful he expected staff to notify administration and/or the director of nursing. The administrator stated an elopement risk assessment should be completed for residents on admission, and if it was not a formal assessment, then a progress note should indicate the resident's elopement risk. The administrator acknowledged their facility missing person/elopement procedure and policy was not followed by staff in R209's instance. The administrator stated staff had received education on the policy in the last two weeks. On 12/19/17, at 8:12 a.m. the administrator stated an elopement risk was completed and dated as of 12/18/17 (after the concern was brought to the staffs' attention during survey), which indicated R209 was not an elopement risk. The administrator stated hospitals and jail rosters had been checked on that date and they were unable to locate R209. The administrator also stated the police had done a wellness check at R209's listed address and were unable to locate him. The administrator stated he recently implemented a midnight census, because we have to keep track of our residents. The administrator stated the process was to check if residents were in their bed at midnight and take further action if not. On 12/19/17, at 8:57 a.m. the DON stated she was on-call the weekend of 12/15-12/17/17. The DON stated she did had not received any notifications regarding R209 not being at the facility. The DON stated if she was called in regards to the incident she would have questioned how long R209 had been gone and would have had staff call the responsible contact listed on his chart. The DON stated she expected notification right away after midnight census was completed if a resident was not there and staff did not know the whereabouts. The DON stated R209 was fairly new to the facility so he should not have been gone over a midnight time frame and at the end of every shift staff should be aware where the residents are in and outside of the facility. On 12/19/17, at 1:12 p.m. licensed practical nurse (LPN)-C stated R209 was admitted to facility on 12/12/17. LPN-C could not recall the exact date but stated R209 fell shortly after his admission, approximately the next morning, as he felt dizzy and was sent to the emergency room due to not feeling well, but returned later that same evening. LPN-C stated when she returned to work on the evening shift on 12/15/17, she'd observed facility staff cleaning R209's room and floor but was unaware where R209 was. LPN-C stated she attempted to call the number on the chart but was unsuccessful at getting hold of anyone, and was unable to leave a message. LPN-C stated she had called the DON on her cell phone on that date but failed to mention R209 was not in facility nor knew his whereabouts. LPN-C stated she informed LPN-D (night shift nurse) if R209 did not return to facility by midnight to call the director of nursing. LPN-C then came back to the assigned area on Sunday 12/17/17, and did not see R209 through her shift but did not take any further actions. LPN-C stated the facility process to locate a resident was to first attempt to find them within facility, attempt to contact the resident's listed personnel, and then contact management. LPN-C stated an assessment should be completed to inform staff if the resident was safe to go outside in the community independently. LPN-C stated R209 did not sign out but LPN-C wrote in the sign out book that R209 was not in the facility on 12/15/17. LPN-C denied knowing if R209 could be outside independently or if assessments had been completed upon admission. On 12/19/17, at 2:22 p.m. the registered nurse (RN)-A stated she was not familiar with R209. However, RN-A was unaware of the process to determine if a resident could leave the facility independently. RN-A stated she did not feel two days were adequate to assess a resident to make the determination if they could go outside independently. RN-A stated prior to leaving the facility the resident needed to sign out so staff are aware in case something happened. RN-A stated if a resident did not sign out staff would try to try locate the resident, and report that to the supervisor, authorities, and police. RN-A stated if a resident did not come back by midnight staff need to start the missing resident process. On 12/19/17, at 2:29 p.m. trained medication aide (TMA)-A stated she'd worked the morning shift the weekend of 12/15-12/17/17. TMA-A stated she had seen R209 at approximately 12:30 p.m. (mid-day) on 12/15/17, when he was in his wheel chair on the unit. TMA-A stated R209 was in his wheel chair because he had fallen the second day he was at the facility. TMA-A also stated when she returned on 12/16/17, resident disappeared. TMA-A stated if she'd known R209 was going to leave the building she would have advised him not to go outside as it was cold, and would have gotten the nurse. On 12/19/17, at 2:40 p.m. LPN-D stated he worked the night shift on 12/16/17. LPN-D was unaware if R209 was in the facility. LPN-D stated he was the nurse over the third and fourth floor but only went to the third floor if he was called for assistance. LPN-D stated he did not receive any calls from the third floor during his shift that night. On 12/19/17, at 4:04 p.m. RN-C stated she worked on the 12/16/17, and 12/17/17, during the morning (a.m.) shifts. RN-C stated she did not know R209, and was not aware he was not in the facility on 12/16/17, a.m. RN-C stated she was unaware whether R209 was safe to be outside independently and if the resident needed to be assessed prior to leaving. RN-C also stated R209 would need a physician's orders [REDACTED]. RN-C stated an elopement risk assessment was usually completed upon admission. RN-C stated if a resident was unable to be located staff need to attempt to call family and were to notify the supervisor. RN-C stated if a resident was out of the facility longer than 24 hours the police needed to be notified. The facility's policy titled, Missing Resident/Elopement dated 7/04, indicated Monarch Healthcare Management was committed to provide a safe environment for all residents. The policy noted that each resident was to be assessed on an ongoing basis and have appropriate safety precautions in place. The policy defined an elopement for a resident as: if a resident was found outdoors and the care plan did not indicate if that was appropriate and if a resident left the property without supervision. The policy also indicated each resident was assessed upon admission and with significant change for elopement using the elopement risk assessment. The policy further indicated if a resident was missing staff were to note when the resident was determined to be missing and to alert the person in charge at the facility, person in charge of the facility to check sign out book and initiate search of building using the intercom, residents photo to be viewed by all staff, complete resident profile form, start missing resident check list, and do the search. The policy also indicated if the resident was not found within the search, the charge nurse had to call the police, family, director of nursing, and administrator and report resident missing. R209's record lacked evidence of an Elopement Risk Evaluation for R209 upon admission. The immediate jeopardy that began on 12/15/17, was removed on 12/20/17, at 1:00 p.m., when the facility had assessed residents for elopement risk, developed care plan interventions for residents at risk, and had educated staff on pertinent areas including: resident elopement risk assessment, the facility's Missing Resident/ Elopement Policy, facility LOA (leave of absence) procedures, and on the facility's Abuse Prevention/ Vulnerable Adult Plan. The facility also initiated an investigation into R209's absence from the facility and reported the incident to the State agency. R113's Admission Record dated 12/6/17, indicated [DIAGNOSES REDACTED]. R113's admission Minimum Data Set (MDS), Care Area Assessment and care plan were not completed. R113's progress note dated 12/6/17, indicated R113 was admitted to the facility from the hospital, was able to make her needs known and was in the facility for weakness. R113's medical record review revealed a skin and smoking assessment was done on 12/6/17, however no elopement risk assessment was found in the electronic medical record and paper chart during record review. R113's progress note by social services dated 12/7/17, indicated R113 was educated on the smoking, substance abuse and bed hold policy and was given a copy of the policies. The progress note per nursing staff dated 12/10/17, indicated, (R113) is leaving AMA (against medical advice). Received call from her friend. She stated she was safe and will no longer be returning. There were no progress notes entries between 12/7/17, and 12/10/17. Review of the facility's sign out book revealed R113 was not signed out on 12/10/17. R113's progress note per social services dated 12/11/17, indicated R113's daughter was called at 10:10 a.m. and R113's daughter was not aware of where her mother was. In the same progress note, at 12:00 p.m., R113's daughter called the facility back and indicated that she had removed the resident from the facility on 12/10/17 at noon. R113's daughter indicated she was unhappy with care facility provided and that no one noticed right away that resident was gone. During the interview on 12/21/17, at 9:38 a.m., licensed social worker (LSW) stated she called R113's daughter to report to her she was missing and daughter indicated she had no idea where R113 was and that she would talk to her brother and her mom's friends to see if they had seen her. R113's daughter also told LSW that she was not greeted when she entered the facility and complained that strangers could come into the facility. LSW stated after an initial conversation with R113's daughter, the daughter had called her back and stated she'd had her mom all along. The LSW then filed a vulnerable adult report, updated adult protection and informed them she was safe and at the daughter's house. When asked about facility process for locating residents who were missing she stated the facility would try to call the resident, call the police if needed and go through the facility's missing resident check list. In regards to resident being able to go on a leave of absence (LOA), LSW indicated there had to be an assessment if they could go on their own. In regards to families taking residents on LOA, LSW stated, families can pretty much take them and they ask them to sign residents in and out. During an interview on 12/21/17, at 9:54 a.m., licensed practical nurse (LPN)- E stated an elopement assessment was supposed to done as soon as a resident was admitted . LPN-E further stated it can be hard to tell if they are an elopement risk but should fill it out anyway. During an interview on 12/21/17, at 2:42 p.m. the DON stated residents should be assessed upon initial meeting on admission and the first shift were supposed to do the initial assessment which included resident's level of consciousness and baseline vitals which also included the smoking and elopement assessment. The DON further indicated an elopement assessment should be completed during the first twenty-four hours of admission. No elopement assessment was found for R113 in the medical records and the facility was unable to provide any documentation of such. A facility policy titled, Missing Resident/Elopement indicated, Each resident is assessed upon admission and with significant change for elopement potential using Elopement Risk Assessment. Once identified as an elopement risk, the resident should be assessed annually thereafter. All others are assessed as needed. R34's Admission Record indicated R34 was admitted to facility on 10/20/17. R34's electronic physician's orders [REDACTED]. R34's medical record review reveled no elopement risk assessment was completed for R34 at the time of admission or since R34's admission. The progress note dated 12/5/17, at 12:14 a.m. indicated R34 had been gone from facility since the beginning of the evening shift on 12/4/17, (from approximately 3 p.m.). There was no evidence of attempts to locate R34. The progress note from administration dated 12/6/17, at 11:50 a.m. indicated on 12/5/17, attempts to locate R34 had been made without success. The LOA book was reviewed and showed R34 did not sign out. The progress note dated 12/6/17, indicated R34 returned to facility on 12/6 at 7:00 p.m. On 12/20/17, at 10:46 a.m. LPN-B stated residents needed to sign out in the LOA book if they wanted to leave the facility. LPN-B explained it was not okay for residents to leave on an LOA unless there was a written physician orders [REDACTED]. LPN-B further explained that administration or the director of nursing needed to be notified right away if a resident was suspected to be missing. LPN-B also stated that staff need to immediately search the facility to locate the resident and make phone calls to family, hospitals, jails in order to attempt to locate resident. LPN-B explained staff would be expected to document in the residents progress notes. LPN-B was not aware if a missing resident documentation was filled out for R34. On 12/20/17, at 12:14 p.m. R34 stated he had been educated on the LOA policy and needed to use the sign out book if he was going to leave the facility. On 12/20/17, at approximately 3:15 p.m. the corporate consultant stated that a missing resident checklist had not been completed for R34 for 12/4/17, when R34 was noted missing. R34's documentation review indicated an elopement assessment had not been completed until 12/18/17, (only after the concern was brought into the facility's attention during the survey). An order that R34 could leave the facility on an LOA was dated 12/19/17, (also during the survey). A facility's Missing Resident/Elopement policy revised dated 7/04, indicated elopement was interpreted as a resident who was in a location that was not indicated for that resident. Prevention measures included an elopement assessment which should be completed upon admission. Elopement procedures included starting a missing resident checklist and notifying administration, police, director of nursing and family if resident is not found after a facility and ground search. R60's closed record was reviewed on 12/20/17, at 2:30 p.m. R60's Admission Record indicated R60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admit/Initial Data Collection (2017) dated 9/15/17, indicated the resident required one person physical assist with transfers and used a walker for walking. The data collection also indicated R60 was able to understand, was understood and able to communicate her needs. The Discharge Summary from(NAME)Northwest Hospital dated 9/15/17, noted R60 was to see a psychiatrist at next available appointment. There was no evidence of an elopement risk assessment having been completed. R60's progress notes from 9/16/17, at 12:16 p.m. indicated R60 was out of the building. At 12:39 p.m. R60 was back in her room. The progress notes on 9/16/17, at 4:44 p.m. noted R60 was in the building, however, R60 was not in the building at 6:16 p.m. The progress notes dated 9/17/17, indicated at 7:21 a.m. R60 was in the building and at 9:21 p.m. R60 was out of the building and according to the medical record, remained on LOA. There was no evidence in R60's medical record of staff knowing where R60 was or attempts to locate her. There was no evidence of R60 having signed in or out of the building at the time of her arrivals or departures. In addition, there was no evidence of a medical doctor, medical director, DON, or administrator having been informed of R60 leaving the facility and not returning. There was no record of her having left AMA. The progress records indicated on 9/18/17, at 11:48 a.m. the mental health program coordinator placed a call to R60's mother, called R60's cell number and did call 911, and filed a missing person report. At 12:03 p.m., the mental health program coordinator attempted to locate R60 on campus and did not find her. On 9/18/17, at 12:06 p.m. the record indicated R60 did call the facility and would return the next afternoon. Review of the record indicated R60 remained on LOA and the last entry for this resident in the record was dated 9/18/17, at 10:57 p.m. that R60 was on LOA. During a joint interview on 12/20/17, at 2:44 p.m. the social services (SS)-B stated she did not know R60 and had not met her. The mental health program coordinator verified that he had attempted to reach the resident for signatures for bed hold, smoking and substance use polices on 9/18/17, at 12:03 p.m. but was unable to locate her on campus. The mental health program coordinator was not able to locate an elopement risk assessment. During an interview on 12/21/17, at 12:02 p.m. the medical director (MD) stated he would expect the facility to follow their standards of care, practices, protocol, and policies related to residents who leave the facility, leave AMA or discharge without notice. He also stated that he would expect policies to be followed for notifications of doctors and the MD. He stated that the facility is expected to complete assessments for the resident per the standards of practice and standards of care. The MD explained that in some cases, the sooner a notification was made, the better it was for the patient and that this does depend on the resident, but that the facility needs to follow their own polices and protocols.

Based on interview and documentation review the facility neglected to supervise, and failed to prevent abuse of two of six residents, (R1 and R2), reviewed when R2 assaulted R1 and then R1 retaliated assaulting R2. R1 was taken to the hospital and diagnosed with [REDACTED]. The assault occurred during the third altercation in 24 hours between R1 and R2. Findings include: R1's medical record was reviewed. R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1 used a wheelchair for mobility. R1's plan dated [DATE], indicated that R1 was independent with locomotion, required two staff for toileting, and set up assistance for activities of daily living. The care plan indicated that R1 required unspecified monitoring related to complications due to multiple medications and daily use of antidepressants. The care plan dated [DATE], indicated that R1 had incidents of verbal aggression towards other residents. Interventions included, de-escalate, redirect resident from situation, separate R1 from other residents, call for assistance, and notify physician of behaviors that are potentially harmful. R2's medical record was reviewed. R2 was admitted to the facility [DATE]. R2's [DIAGNOSES REDACTED]. An incident report dated [DATE], indicated that during an argument R2 grabbed another resident (roommate) by the head and shook the other resident's head. After the incident staff moved R2's roommate to a new room. R2's care plan dated [DATE], indicated that R2 required the assistance of one staff person for all activities of daily living, and uses a power scooter for mobility. R2 took antidepressants and antianxiety medication. An incident report dated [DATE], at 4:30 p.m. indicated that R2 and R1 had a verbal altercation and threatened to kill each other. R2 was verbally harassing, and running at R1 with his/her power scooter. R2 called R1 derogatory racial slurs. Both residents were using foul language, making threats, and yelling at each other. Both were placed on 15 minute visual checks for the evening and the night shift. The residents did not touch each other during this altercation. An incident report dated [DATE], written at 1:15 a.m., indicated that on the evening of [DATE], an unnamed resident pushed another resident to the ground outside on the patio. This resident reported to staff that an unnamed resident had pushed him/her to the ground outside on the patio. The resident that pushed this resident to the ground was not named in the incident report or the nurses notes regarding the incident, dated [DATE]. There were no changes to this residents care plan and no interventions were implemented to keep this resident, or other residents, safe. An incident report dated [DATE] at 1:15 a.m., indicated that R1 and R2 were arguing with each other in the evening of [DATE]. R1 and R2 were making accusation at each other, name-calling, yelling, and using foul language. R2 refused to discuss an event that took place on the patio where R2 pushed another resident to the ground. R2 appeared intoxicated, the staff were unable to deescalate the situation. Staff called the police and the police de-escalate R2's mood. The facility resumed 15-minute visual checks for the second time on both residents. There were no changes to either residents' care plans, and no increased supervision for the safety of either resident. No new interventions were implemented to prevent an altercation between R1 and R2. Nurses' notes dated [DATE], at 2:28 p.m., and 2:39 p.m., indicated that R1 and R2 were yelling at each other at the nurse's station and staff directed the residents away from each other. R1 informed staff that he had issues with R2 the evening before, R2 kept coming into R1's room and starting issues, and R2 was escalating issues against R1. R1 appeared tearful and shaky. The notes did not detail the issues. Staff advised both residents to avoid each other. There were no changes to either residents' care plans, and no increased supervision for the safety of either resident. No new interventions were implemented to prevent an altercation between R1 and R2. An incident report dated [DATE], written at 1:11 a.m. indicated that staff were called to the 4th floor at approximately 11:15 p.m. R2 assaulted R1 with a heavy black object wrapped in tape. Staff found R1 sitting in his wheelchair in the hallway and R1 said, Look what he did to my eye. R1's left eye was swollen to the size of golf ball, a large amount of blood was dripping from his face, and his left arm appeared deformed. As staff were assisting R1, R2 came out of his room yelling that R1 was lying, parked his wheelchair in front of R1. Then R1 pulled out a heavy black object wrapped in tape from behind his back and struck R2 three times in the back of the head. Staff separated the residents, called the police, and sent R1 to the hospital. Hospital records dated [DATE], indicated that R1 suffered a left ulna fracture, left eye swelling and left eye abrasions. R1 remains in the hospital at this time, and his bed hold expired at the facility. During an interview on [DATE], at 11:56 a.m., NA-D stated that R2 was verbally abusive to another resident. NA-D stated that the other resident reported that R2 had pushed her/him to the ground on the patio during the evening of [DATE], incident report dated [DATE], and afterwards R1 and R2 had an argument regarding that incident. At that time R2 spat into R1's face several times. NA-D stated that afterwards R1 and R2 were on 15 minute checks to ensure the safety of both residents, staff visually checked the residents location to confirm that the residents ere not together, document, and sign each check. During an interview on [DATE], 11:27 a.m. Licensed Practical Nurse (LPN)-J stated that on [DATE], at approximately 11:00 a.m. a staff person called her to assist with an argument between R1 and R2. LPN-J sent R2 to his room and then R1 stated that he was afraid of what R2 might do to R1. LPN-J called the Director of Nursing (DON), left a voice message, and sent a text message regarding R2's statement. LPN-J did not get a return call from the DON. Both residents agreed to avoid each other at that time. Staff continued visual 15-minute checks on both residents. No new interventions were implemented to prevent an altercation between R1 and R2. During an interview on [DATE], at 12:52 p.m., DON-M stated that she she was not aware of an altercation between R1 and R2 on [DATE], in the afternoon at approximately 11:00 a.m. DON-M stated that she did not receive a voicemail or text from staff regarding R1's statement of fear after the altercation with R2 during the day at approximately 11:00 a.m. on [DATE]. DON-M stated that if she had been made aware of an altercation on [DATE], in the afternoon she would have made sure that R1 and R2 were safe. DON-M stated that she would have implemented one to one supervision for the residents. The policy titled Abuse Prevention/Vulnerable Adult dated ,[DATE], provided by the facility indicated that the policy is to ensure that residents are not subjected to abuse by anyone including other residents, to identify and remedy any abusive situations, and to prevent injuries. The facility has no policy related to supervision of residents.